evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The distance between the CAH or entity and the other provider or supplier of ambulance services will be determined as the shortest distance in miles measured over improved roads between the CAH or the entity and the site at which the vehicles of the neares t provider or supplier of ambulance services are garaged.  An improved road is any road that is maintained by a local, State, or Federal government entity and is available for use by the general public.  An improved road includes the paved surface up to the front entrance of the CAH and the front entrance of the garage.   40 - Billing Coverage and Utilization Rules for PPS and Non -PPS Hospitals (Rev. 2388, Issued: 01- 20-12, Effective: 04 -22-12, Implementation: 04- 22-12)  A. - General   Days of utilization are charged based upon actual days of coverage including grace and waiver days.  The number of covered days used are maintained by CMS to track the beneficiary's eligible days in a benefit period.  The hospital collects the coinsurance, if applicable, for only the number of days charged against the beneficiary's utilization record maintained by CMS.  For example, if the mean length of stay for a DRG is 10 days and the beneficiary is discharged after 3, only 3 days of utilization is charged.  In a like situation, if the DRG mean length of stay is 10 days and the beneficiary is discharged after 15, the 15 days are charged against the utilization record.   NOTE:   There are some exceptions to this rule under LTCH PPS.  See 150.4.  Coinsurance, if applicable, is payable by the beneficiary for the number of days used.  The hospital subtracts the coinsurance amount from the DRG payment.  Days after benefits are exhausted are not charged against the beneficiary's utilization even though the hospital may receive the full DRG payment.   The basic prospective payment amount will be paid if:    There is at least l day of utilization left at the time of admission and that day is also a day of entitlement (e.g., a day before the beneficiary discontinued voluntary Part A entitlement by not paying the premium).
(Medicare Claims Processing Manual)
 There is at least l day for which payment may be made under the guarantee of payment.  (If benefits are exhausted prior to admission and no payment may be made under guarantee of payment, only Part B benefits are available.)    The beneficiary becomes entitled after admission.  The hospital may not bill the beneficiary or other persons for days of care preceding entitlement except for days in excess of the outlier threshold.  Utilization is not counted for any days treated as noncovered, except as described below:    Utilization is not counted for any nonentitlement days, or days after benefits are exhausted (including guarantee of payment days), even if those days are treated as covered for outlier calculation or treated as Medicare patient days for the cost report.    The length of stay exceeds the day/cost outlier threshold (Day outliers were discontinued at the end of FY 1997), utilization is counted for medically unnecessary days which are noncovered but for which the hospital may not charge the beneficiary because t he requirements of 40.2 were not met.  See 40.2.2 for identification of these days.    If the adjusted cost of the stay exceeds the cost outlier threshold, utilization is counted for any medically unnecessary days on which all Part A services are treated as noncovered under 40.2.B  and for which the hospital may not charge the beneficiary.  (Where only ancillary services are denied, all days are counted as covered.)   Lifetime reserve days (LTR) for an inpatient hospital stay for which prospective payment may be made is subject to the following:   If the beneficiary had one or more regular benefit days (full or coinsurance days) remaining in the spell of illness when admitted, there is no advantage in using lifetime reserve days.  The beneficiary is deemed to have elected not to use lifetime reserve days for the nonoutlier (Day outliers were discontinued at the end of FY 1997) portion of the stay.  IPPS uses Occurrence Span code 70 for the covered non -utilization period after regular benefit days are exhausted or when only LTR days are exhausted.  For example:
(Medicare Claims Processing Manual)
EXAMPLE 1: No Cost Outlier, only LTR Days available and Exhaust prior to discharge  Dates of Service  01/05 - 01/16  Medically necessary days  11 Benefit days available VC 83  1 LTR  Covered days VC 80  1 Noncovered days VC 81  10 Cost report days  11 OC A3  01/15(includes covered non -utilization period)  OSC 70  01/06 - 01/15  Room & Board revenue code   11 Total & Covered units  Medicare approved revenue codes  Charges in covered  Reimbursement  Full DRG payment, no cost outlier  Beneficiary Liability:  LTR copayment amoun t  EXAMPLE 2: No Cost Outlier, Coinsurance Days available and Exhaust prior to discharge  Dates of Service  01/05 - 01/16  Medically necessary days  11 Benefit days available VC 82  3 Coinsurance  Covered days VC 80 3 Noncovered days VC 81  8 Cost report days  11 OSC 70  01/08 - 01/15  Room & Board revenue code  11 Total & Covered units  Medicare approved revenue codes  Charges in covered  Reimbursement  Full DRG payment, no cost outlier  Beneficiary Liability  Coinsurance copayment amount   After regular benefits have been exhausted, lifetime reserve days will be used automatically for outlier days unless the beneficiary elects not to use them, or the average daily charges for outlier days to be reimbursed as lifetime reserve days do not exceed the lifetime reserve day coinsurance amount.  (In the latter case the beneficiary is deemed to have elected not to use lifetime reserve days for outlier days.) An election not to use lifetime reserve for outlier days applies to all outlier days in an ad mission.    If the beneficiary had no regular benefit days remaining when admitted, available lifetime reserve days are used automatically for each day of the stay.  Exceptions exist if the beneficiary elects not to use lifetime reserve days, or the charges for which the beneficiary is liable, if electing not use lifetime reserve days, do not exceed the charges for which the beneficiary would be liable if the lifetime reserve days were used.  Using lifetime reserve days, the beneficiary would be responsible for the sum
(Medicare Claims Processing Manual)
of the coinsurance amounts for the lifetime reserve days that would be used plus the total charges for outlier days, if any, for which no lifetime reserve days are available.  (In the latter case the beneficiary will be deemed to have elected not to use any lifetime reserve days.)   An election by the beneficiary not to use lifetime reserve days applies to the entire stay and precludes any payment for the stay.  A deemed election not to use lifetime reserve days applies to the entire stay and precludes any payment for the stay unless payment may be made under the guarantee of payment.   The number of days for which utilization is charged may be different from the number used in Pricer to compute outlier status or the number of Medicare patient days shown on the cost report.   40.1 - "Day Count" Rules for All Providers  (Rev. 1, 10- 01-03)  A3-3620   See 40.2.A  for general rules on counting days.  A. - Day of Admission   For all hospitals, the A/B MAC (A) counts the day of admission for the cost report and for utilization.  For PPS hospitals, it counts the day of admission for Pricer purposes unless the rules for same day transfer apply.   B. - Day of Discharge, Death, or Beginning a Leave of Absence   The A/B MAC (A) does not count the day of discharge or death for cost report, utilization or Pricer purposes unless the admission and discharge day are the same day.  Where admission and discharge occur on the same day, it counts one day for cost report, utilization and Pricer purposes.  If the patient is admitted with the expectation that the patient will remain overnight, but is discharged or dies before midnight, it counts the day for the cost report, utilization and Pricer.  It does not count any days i n a leave of absence (occurrence span code 74), for cost report, utilization or Pricer purposes.  C. - Same Day Transfer From Participating Hospital to Nonparticipating Hospital or Nonparticipating Distinct Part of Hospital
(Medicare Claims Processing Manual)
If the beneficiary is admitted to a PPS hospital with the expectation that the beneficiary will remain overnight, but is transferred to a nonparticipating provider or a nonparticipating distinct part of the same provider before midnight, the A/B MAC (A) counts the day for the cost report, utilization and Pricer.  If the beneficiary is admitted to a non- PPS hospital with the expectation that the beneficiary will remain overnight, but is transferred to a nonparticipating hospital or a nonparticipating distinc t part of a hospital before midnight, the A/B MAC (A) counts the day for cost report and utilization purposes.  D. - Same Day Transfer From Participating Hospital to Participating Hospital   If the beneficiary is transferred to a participating hospital or distinct part of a participating hospital, the A/B MAC (A) counts the day, if it is determined to be covered, for the cost report and for Pricer at both hospitals.  However, it charges utilization on the bill only for the later admission to avoid charging the beneficiary twi ce for the same day.  The earlier admission, for which the A/B MAC (A) does not charge utilization, can be recognized by condition code 40 (same day transfer), and the same date entered in the "From" and "Through" dates in CWF.   E. - Guarantee of Payment Days   There can be up to fourteen guarantee of payment days (8 days plus weekends and Federal holidays) beginning with the date in occurrence code 20.  The A/B MAC (A) does not charge utilization, as the beneficiary has no days remaining, but counts guarantee of  payment days for the cost report and Pricer.   F. - Provider Liability Issue
(Medicare Claims Processing Manual)
F. - Provider Liability Issue   When the A/B MAC (A) or the QIO finds the provider liable, the A/B MAC (A) or the QIO determines the cause for provider liability prior to making any decision regarding utilization.  If the provider is technically liable, i.e., liable for reasons other tha n custodial care or medical necessity of the services, the A/B MAC (A) shows the dates of provider liability in occurrence span code 77, and counts the days for utilization, but not for cost report or Pricer purposes.  If the provider is liable because ser vices were not medically necessary or were custodial care, the A/B MAC (A) shows the dates of provider liability in occurrence span code 79 and does not count the days for cost report, utilization or Pricer purposes.   G. - Special Rules Which Differ for PPS and Other Providers   If Part A payment may be made for a hospital stay under PPS (i.e., there is at least one Medicare patient day, guarantee of payment day, or day for which the program is liable to the hospital under the limitation of liability provision), the A/B MAC (A) tr eats all days as covered for cost report purposes, except as provided below.  It applies this same rule when per diem payments are made to a transferring PPS hospital, whether for all or part of a stay, or when a PPS hospital requests outlier payment, whet her or not such payment is made.  For non- PPS hospitals, PPS exempt units and SNFs, it counts the number of days available to the beneficiary for all purposes.   Where outlier status is involved and there are either pre -entitlement days or days after benefits were exhausted, the A/B MAC (A) reduces cost report days by the lesser of the number of pre -entitlement/post-benefits exhausted days or the number of days in the stay in excess of the outlier threshold.  1. Length of Stay Does Not Exceed the Day Outlier Threshold (Day outliers discontinued after FY 97)
(Medicare Claims Processing Manual)
The A/B MAC (A) counts all days (including day of admission, but not the day of discharge or death, unless it is also the day of admission) as covered for cost report and Pricer purposes.  It does not count those medically unnecessary days for which the pr ovider meets notice requirements and other conditions for charging the beneficiary.  (See 40.2.2 C and D .)  It does not count those medically unnecessary days for cost report or Pricer purposes.  It counts the actual number of days available to the beneficiary for utilization.   2. Length of Stay Exceeds the Day Outlier Threshold (Day outliers discontinued after FY 97)   The A/B MAC (A) counts all days (including the day of admission, but not the day of discharge or death unless it is also the day of admission) in the stay for cost report and Pricer purposes except as follows:   a. Pre-entitlement Days   The A/B MAC (A) does not count pre -entitlement days for the cost report or for utilization in non- PPS hospitals, exempt units or SNFs.  For PPS hospitals, it does not count pre -entitlement days for utilization or for Pricer.  The number of days counted as noncovered for the cost report is limited to the number of days in the stay in excess of the day outlier threshold.  To determine which preentitlement days are counted as noncovered, the A/B MAC (A) begins at the end of the stay (the day before the day of discharge, death, etc.) and working backward, counts off days identified as pre -entitlement days until it has counted all preentitlement days or, until the number of days counted equals the total number of days in excess of the outlier threshold.  b. Post-Exhaustion of Benefit Days   The A/B MAC (A) treats post -exhaustion of benefit days exactly like pre -entitlement days.   To resolve any Medicare Secondary Payor (MSP) issues, see the Medicare Secondary Payer Manual.   40.2 - Determining Covered/Noncovered Days and Charges  (Rev. 1231; Issued:  04- 27-07; Effective:  12 -03-07; Implementation:  12 -03-07)
(Medicare Claims Processing Manual)
40.2 - Determining Covered/Noncovered Days and Charges  (Rev. 1231; Issued:  04- 27-07; Effective:  12 -03-07; Implementation:  12 -03-07)  The CMS must record a day or charge as either covered or noncovered because of the following:   Beneficiary utilization is recorded based upon days during which the patient received hospital or SNF accommodations, including days paid by Medicare and days for which the provider was held liable for reasons other than medical necessity or custodial care .  Days denied as not medically necessary or as custodial care are not charged against a beneficiary's utilization record when the provider is determined to be liable.   The provider may claim credit on its cost report only for covered accommodations, days and charges for which actual payment is made, i.e., provider liable days and charges are not included.  Data from the bill payment process are used in preparing the cost  report.   The number of days and charges provided to the Pricer program affects the day and cost outlier determinations and the DRG payment amount.  Non- PPS provider days are excluded from Pricer consideration.  It is possible to use a different number of days on a single bill for each of the above purposes, although the same number of days will generally apply in actual practice.  For example, if the beneficiary had at least 1 day of eligibility remaining at admission, days that occur after benefits are exhausted up through the day outlier threshold for the applicable DRG are counted for cost reporting purposes under IPPS (see section190.12.1 for IPF and section 150.17 for LTCH benefits exhaust claims processing).   A. - General Rule on Counting of Days   These following are general rules for counting days.  However, these rules are also subject to special rules for determining day of admission, discharge, death, beginning a leave of absence, same day transfer, guarantee of payment days, provider liability issues and outlier days for PPS outliers.  See 40.1 and 40.1.G  for an explanation of these special rules.
(Medicare Claims Processing Manual)
The provider calculates and enters on the bill the number of claimable Medicare patient days on the cost report.  (Medicare patient days always refer to cost report days.)  For PPS facilities the A/B MAC (A) counts, for the cost report, utilization and Pricer purposes, all days for which Part A payment may be made to the hospital.  This includes days for which the provider is not liable under the limitation of liability provision.  It does not count days for which no Part A payment may be made for cost report, utilization or Pricer purposes.   For non- PPS providers, the A/B MAC (A) does not count the days for Pricer purposes, because DRG payment or outlier calculations are not made.  B. - Medically Unnecessary Days for Which the Provider May Charge the Beneficiary   Days on which the hospital furnished no covered Part A services are not charged to utilization and are not counted as Medicare patient days.   If the hospital or SNF stay includes any medically unnecessary days for which the provider has met the requirements of 40.2.2 C or D  for charging the beneficiary, the A/B MAC (A) counts those days as noncovered under Part A for cost report, utilization and Pricer purposes.   Since the provider may not be aware of the date benefits are exhausted or when the outlier threshold is reached, the A/B MAC (A) verifies the provider's counts.  If, for any reason, the A/B MAC (A) or the QIO determines fewer days are claimable (e.g., if t he A/B MAC (A) or the QIO indicates that benefits are exhausted), the A/B MAC (A) will adjust cost report days for its PS&R system.  If the A/B MAC (A) or the QIO determines fewer days are claimable for the cost report, it determines the proper number of d ays of utilization to charge the beneficiary and the proper number of days for the length of stay used by Pricer.  It uses the factors in 40.1 and 40.1G  to make these calculations.   C. - Medically Unnecessary Outlier Costs for Which the Hospital May Not Charge
(Medicare Claims Processing Manual)
C. - Medically Unnecessary Outlier Costs for Which the Hospital May Not Charge   If the hospital requests payment for cost outlier, and the Medicare covered charges converted to cost exceed the cost outlier threshold, the services which are not reasonable and necessary (or constitute custodial care) which are noncovered, but for which the hospital may not charge the beneficiary are determined as follows:    The hospital determines the lesser of the following:    The cost of the medically unnecessary services (converting the charges for the medically unnecessary services to cost); or    The amount by which the adjusted cost of the stay exceeds the cost outlier threshold.  Ancillary services, which are not required to be furnished on an inpatient basis, are treated as medically unnecessary, but nevertheless may be covered under Part B.    If the costs in excess of  the outlier threshold exceed the cost of the medically unnecessary services, the cost of all of the medically unnecessary services are treated as noncovered costs.  If these costs exceed the costs in excess of the cost outlier threshold, beginning with the cost of the last medically unnecessary service in the stay, the hospital must identify, and add on, in reverse order, the cost of other medically unnecessary services until the total cost of medically unnecessary services reaches the costs in excess of the cost outlier threshold.  If the cost of the last service to be added on in this manner brings the cost of medically unnecessary services over the amount of costs in excess of the cost outlier threshold, only the portion of the cost of that last medicall y unnecessary service (in the order of the addition) needed to bring the total of the medically unnecessary costs up to the costs in excess of the cost outlier threshold is added on.  In this case, the costs in excess of the cost outlier threshold are treated as the noncovered costs.   Once the costs of medically unnecessary services to be treated as noncovered are determined, convert them to charges for each applicable service/revenue category, e.g., accommodations, radiology, pharmacy, by dividing the costs treated as not medically nec essary in each category by 72 percent.  The medically unnecessary charges determined are treated as noncovered charges.  Days for which all costs are found to be noncovered are treated as noncovered days.
(Medicare Claims Processing Manual)
 The hospital determines which medically unnecessary services and days treated as noncovered are services and days for which the beneficiary can be charged under 40.2.2C  or E.  The remainder of the services and days are the medically unnecessary services and days treated as noncovered even though the hospital may not charge the beneficiary.  However, the distinction between medically unnecessary services and days for which the hospital may charge, and those for which it may not, will not be reflected in the charges shown on the inpatient hospital billing.  Both are combined and shown as noncovered services and days.  The determination of medically unnecessary cost outliers is not affected by non- entitlement days or days after benefits are exhausted.  If the stay is covered or treated as covered, the beneficiary is treated as entitled to Part A, and as having benefits a vailable throughout the stay.  40.2.1 - Noncovered Admission Followed by Covered Level of Care  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD -10: Upon Implementation of ICD- 10, Implementation: ICD -10: Upon Implementation of ICD -10, ASC X12: September, 23 2014)   Where a beneficiary receives noncovered care at admission, and is notified as such, but subsequently is furnished covered level of care during the same hospital stay, the admission is deemed to have occurred when covered services became medically needed an d rendered.  This is applicable to PPS and non- PPS billings.   The following billing entries identify this situation:   Admission date (not the deemed date).    Occurrence code "31" and the date the hospital provided notice to the beneficiary.    Occurrence span code 76 indicates the noncovered span from admission date through the day before covered care started.    Value code 31 is used to indicate the amount which was charged the beneficiary for noncovered services.    Noncovered charges related to the noncovered services.   The principal diagnosis is shown as the diagnosis that caused the covered level of care.    Only procedures performed during the covered level of care are shown on the bill.  If a no payment bill for the noncovered level of care has been processed, the hospital prepares and forwards a new initial bill.