evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The A/B MAC (A) also performs the following edit routines on any XX5 type bills received:    Pass all initial bill edits, including duplicate checks.    Must not be for any of: Inpatient PPS ancillaries, inpatient accommodations in any facility, services on the same day as outpatient surgery subject to the ASC payment limitation, or ESRD services included in the composite rate.  These are rejected back to the hospital with the message, This change requires an XX7 debit -only or XX8 cancel -only request from you.  Late charges are not acceptable for inpatient PPS ancillaries, inpatient accommodations in any facility, services on the same day as outpatient surgery subject to the ASC payment limitation, or ESRD services included in the composite rate.    When an XX5 suspends as a duplicate, (dates of service equal or overlapping, provider ID equal, HICNs equal, and patient surname equal), the A/B MAC (A) must determine the status of the original paid bill.  If it is denied, the A/B MAC (A) must deny the la te charge bill.    If an xx5 does not suspend as a potential duplicate, the A/B MAC (A) rejects it back to the provider with the message, No original bill paid.  Please combine and submit a single original bill (XX1).    If the original bill was approved and paid, the A/B MAC (A) compares the revenue codes on the original paid bill with the associated late charge bill:    For all providers (any bill type), if any are the same, and are revenue codes 041x, 042x, 043x, 044x, 063x, 076x, or 091x, the A/B MAC (A) or (HHH) rejects the bill back to the provider with the message,  You must submit an adjustment (7) to the original paid bill.  Revenue codes subject to utilization review are duplicated on the late charge bill.
(Medicare Claims Processing Manual)
 For HHAs (bill type 32X, 33X, or 34X), the A/B MAC (HHH) must apply the same logic for the following additional revenue codes.  If any are the same and are revenue codes 0291, 0293, 055x, 056x, 057x, 058x, 059x, 060x, 066x, the A/B MAC (HHH) rejects the bi ll back to the provider with the message,  "You must submit an adjustment (xx7) to the original paid bill.  Revenue codes subject to utilization review are duplicated on the late charge bill."    For hospital outpatient services (bill type 13X only), the A/B MAC (A) must apply the same logic for the following additional revenue codes.  If any are the same and are revenue codes 0255, 032x, 033x, 034x, 035x, 040x, 062x, 073x, 074x, 092x, or 0943, the  A/B MAC (A) rejects the bill back to the hospital with the message,  "You must submit an adjustment (xx7) to the original paid bill.  Revenue codes subject to utilization review are duplicated on the late charge bill."    For RDFs (bill type 72X or 73X), the A/B MAC (A) must apply the same logic for the following additional revenue codes; if any are the same and are revenue codes 0634, 0635, 082x, 083x, 084x, 085x, or 088x, the A/B MAC (A) rejects the bill back to the provi der with the message, You must submit an adjustment (XX7) to the original paid bill.  Revenue codes subject to utilization review are duplicated on the late charge bill.    If the late charges bill relates to two or more "original" paid bills, and one of these is denied, the A/B MAC (A) must suspend and investigate the late charge bill.
(Medicare Claims Processing Manual)
 If the late charges bill relates to two or more "original" paid bills, and one of these is denied, the A/B MAC (A) must suspend and investigate the late charge bill.   The A/B MAC (A) must compare total charges on the original paid bill with those on the associated late charge bill, and suspend and investigate any XX5 bill type with total charges in excess of those on the original paid bill.  This edit suggests the provi der may have rebilled the already paid services.   The A/B MAC (A) may decide to perform additional edits on late charge bills.   60 - Swing -Bed Services  (Rev. 11396, Issued:05- 04-22, Effective:10 -01-22, Implementation:10- 03-22)  Swing -bed services must be billed separately from inpatient hospital services. Swing- bed hospitals use one provider number when billing for hospital services to identify hospital swing- bed SNF bills. The following alpha letters identify hospital swing -bed SNF bills (for CMS use only, effective May 23, 2007, providers are required to submit only their NPI. NOTE: The swing- bed NPI will be mapped to the 6- digit alpha -numeric CMS Certification Number (CCN.)   "U" = short -term/acute care hospital swing -bed; "W" = long -term hospital swing -bed;  "Y" = rehabilitation hospital swing -bed; and  Z=CAH swing -bed.  Note that CAHs are exempt from the SNF PPS and instead are paid based on 101 percent of reasonable cost for swing -bed services. CAHs are subject to the hospital bundling requirements at section 1862(a)(14) of the Social Security Act and 42 CFR  411.15(m), and therefore, all services provided to a CAH swing-bed patient must be included on the  CAH swing -bed bill (subject to the exceptions at 42 CFR  411.15(m)(3)).  Certified registered nurse anesthetist services paid on a pass -through basis are also to be included on the CAH swing-bed bill.  A. - Inpatient Hospital Services in a Swing -Bed
(Medicare Claims Processing Manual)
A. - Inpatient Hospital Services in a Swing -Bed  The patient status code of 03 is inserted on the claim when the beneficiary swings from acute to SNF level of care.  (This constitutes a discharge for purposes of Medicare payment for inpatient hospital services under PPS.) The A/B MAC (A) indicates in the  Statement Covers Through Date  the last day of care at the hospital level.   If the beneficiary is discharged from a Medicare swing -bed and remains in the hospital, there is no need for a no-pay bill.  However, if a beneficiary continues to receive care after completing their stay in a SNF swing-bed, in a NF swing- bed, the hospital  must submit covered claims to Medicare.   B. - SNF Services in a Swing -Bed  Services are billed, in accordance with Chapter 25 with the following exceptions:    The date of admission on the swing- bed SNF bill is the date the patient began to receive SNF level of care services;    State level agreements may call for varying types of bill coding Type of Bill.  The CMS does not perform edits on type of bill coding on bills with 8 in the 2nd digit (bill classification), in FL 18 of the CWF inpatient record if the record is identified  in FL 1 as hospital or SNF. Therefore, the A/B MAC (A) accepts, with subsequent conversion, any bill type agreed to at the State level to identify swing-bed billing, i.e., 18X or 21X. It must be sure the record identification of CWF FL 1 is consistent wit h the provider number shown.    70 - All-Inclusive Rate Providers (Rev. 1, 10- 01-03) A3-3660.4   70.1 - Providers Using All -Inclusive Rates for Inpatient Part A Charges  (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)
(Medicare Claims Processing Manual)
Some providers have been approved to bill a flat fee charge for inpatient services based on either a daily basis or total stay basis for services furnished.  This is an "All -Inclusive Rate."  These charges may cover room and board, including ancillary services, or room and board only.  These instructions explain the essential data entries that must be made using the ASC X12 837 institutional claim format or on the Form CMS -1450 by providers that use all -inclusive rates as charges.  All -inclusive rate providers are identified by one of the following charge structures:    One total all- inclusive charge rate for both accommodations and ancillary services, including the cost of blood in the rate;    One total all- inclusive charge rate for both accommodations and ancillary services, not including the cost of blood in the rate;    One all -inclusive charge rate for accommodations and another for ancillary services, including the cost of blood in the all -inclusive rate; or    One all -inclusive charge rate for accommodations and another for ancillary services, not including the cost of blood in the all -inclusive rate.   Providers follow these special instructions for completing of the billing format or form.   A. - Accommodations   Revenue Codes  - Codes that identify the accommodations furnished, ancillary services provided or billing calculation are entered in this field.  The code indicates whether the rate includes charges for ancillary services or only room and board.   If the patient was furnished more than one type of accommodation, the loops or lines for each type of accommodation are completed.  This is necessary whether or not the provider charges an all -inclusive rate according to accommodations.   Where the all -inclusive rate varies with the type of accommodation, the Remarks field is annotated for a five -or-more bed accommodation showing the reason for the accommodation.  Unit of Service - A quantitative measure for services furnished, by revenue category, to or for the patient which includes items such as the number of accommodation days, pints of blood, or renal dialysis treatments, is entered.   Total Charges  - The total charges pertaining to the related revenue code for the current billing period is entered.   Noncovered Charges  - The total non- covered charges pertaining to the related revenue code for the current billing period is entered.
(Medicare Claims Processing Manual)
Total Charges  - The total charges pertaining to the related revenue code for the current billing period is entered.   Noncovered Charges  - The total non- covered charges pertaining to the related revenue code for the current billing period is entered.   B. - Ancillary Services   One All- Inclusive Charge Rate - Hospitals with one all- inclusive charge rate, including ancillary services, are reflected in the revenue code.  The total charge reflects the charge for both accommodations and ancillary services.   Separate Ancillary All -Inclusive Rate -  Some providers segregate charges for ancillary services for billing purposes.  Where a separate flat rate charge for ancillary services is incurred either on a daily or total stay basis, the provider enters separate codes for the services.  These codes indicate whether the total charge includes only ancillary cost or includes other costs (i.e., blood).   If applicable, the following additional billing instructions are applied:    Blood  Whenever whole blood is furnished the patient, value codes and amounts are completed.  If the all -inclusive rate does not include the charge for whole blood or packed cells, revenue codes, rates, service dates, units, and total charges are completed in the  same way a provider not using all -inclusive rates would complete them.  When the provider discounts its customary charges for unreplaced blood to which the deductible is applicable, it shows the charges before the discount.  If the all -inclusive rate covers the cost of providing blood whenever a patient needs it, the number of pints furnished, replaced, not replaced, and the estimated cost per pint is entered in value codes and amounts.  No amount can be shown in the Total Cha rges column since the rate includes the cost of blood.  It is not necessary to show the cost for any replaced blood.   All-Inclusive Charges According to Disease, Injury, or Type of Treatment   Providers that have a charge system based on the patient's illness or injury or type of treatment complete the applicable loops or line(s) for type of accommodation furnished showing number of days, rate, and total charges.  The rate amount and total amounts must be the same.  Blood entries are indicated as above.    Physician's Component   As with providers having a schedule of charges for individual services, the amount of any physician's component included in the all -inclusive charge is removed from the total covered charges before applying the inpatient deductible or coinsurance.    Combined Billing
(Medicare Claims Processing Manual)
As with providers having a schedule of charges for individual services, the amount of any physician's component included in the all -inclusive charge is removed from the total covered charges before applying the inpatient deductible or coinsurance.    Combined Billing   CMS does not encourage the all -inclusive rate provider to combine bill.  However, if it does, it must develop the capability and indicate in the Remarks field, the number and type of each service it is combined billing.  To identify such cases, the remark "Combined Billing" must be written in the Remarks field.  NOTE: Combined billing was eliminated with Outpatient PPS.   80 - Hospitals That Do Not Charge  (Rev. 1, 10- 01-03)  A3-3660.5   Participating hospitals that do not charge individuals and also meet the exceptions to the law that normally exclude payment for expenses paid for directly or indirectly by a governmental entity, may be reimbursed the reasonable cost of furnishing covered services to Medicare beneficiaries.  The following special procedures apply to their bills.    Part A Services   Computing Medicare Billing Rate  The Medicare billing rate per day is determined by the following equation:   Total allowable inpatient cost = cost per day per patient   Total inpatient days   Thus, the billing rate that appears is the average inpatient cost per day per inpatient as calculated from entries on the latest cost settlement report approved by Medicare.  Where this is the provider's first year in the program, the A/B MAC (A) determine s this rate based on the provider's books and records the appropriate billing rate for services rendered to Medicare beneficiaries.   Computing Medicare Billing Rate (Inpatient)   The Medicare billing rate is determined in the following manner:   Total available inpatient cost = Cost per day per patient   Total inpatient days   The A/B MAC (A) multiplies the cost per day per patient by 93 percent for short -term hospitals and by 98 percent for long- term hospitals.  (See 2208.lE of the Provider Reimbursement Manual, Part I, for definitions of "short -term" and "long -term" hospitals .)  Then it applies the following fixed percentages.  The result is the Medicare billing rate.   Computing Medicare Billing Rate (Outpatient)   The Medicare billing rate is determined by the following equation:   Total allowable outpatient cost = average cost per visit   Total visits (occasions of service)
(Medicare Claims Processing Manual)
Computing Medicare Billing Rate (Outpatient)   The Medicare billing rate is determined by the following equation:   Total allowable outpatient cost = average cost per visit   Total visits (occasions of service)   Thus, the billing rate is the average cost per outpatient visit as calculated from entries on the latest cost settlement report approved by Medicare.  Where this is the provider's first year in the program, the A/B MAC (A) determines this rate based on the  provider's books and records the appropriate billing rate for services rendered to Medicare beneficiaries.   80.1 - Medicare Summary Notice (MSN) for Services in Hospitals That Do Not Charge  (Rev. 1, 10- 01-03)  A3-3660.5.A   Where the hospital does not charge for outpatient services, the A/B MAC (A) does not send the individual an MSN.  This avoids confusion and the appearance that the beneficiary is liable for services received.   90 - Billing Transplant Services  (Rev. 1571; Issued:  08-07- 08; Effective Date:  08 -01-08; Implementation Date:  08-15-08)  Medicare covers the following organ transplants:  kidney, heart, lung, heart/lung, liver, pancreas, pancreas/kidney, and intestinal/multi- visceral.  Medicare also covers stem cell transplants for certain conditions.  On March 30, 2007, the Department of Health and Human Services (DHHS) established a regulation authorizing the survey and certification of organ transplant programs. The Centers for Medicare & Medicaid Services (CMS) is the Federal agency responsible for m onitoring compliance with the Medicare conditions of participation. All hospital transplant programs covered by the regulation (does not include stem cell transplants), whether currently approved by CMS or seeking initial approval, must submit a request for approval under the new regulations to CMS by December 26, 2007 (180 days from the effective date of the regulation.)  http://www.cms.hhs.gov/CertificationandComplianc/20_Transplant.asp#TopOfPage
(Medicare Claims Processing Manual)
Transplant hospitals should review the above Web site and send applications to the following address:  Centers for Medicare and Medicaid Services  Survey and Certification Group 7500 Security Blvd. Mailstop: S2 -12-25 Baltimore, MD 21244  The A/B MACs (A) may choose to review claims if data analysis deems it a priority.   90.1 - Kidney Transplant - General  (Rev. 1341, Issued: 09- 21-07, Effective: 06-28-07, Implementation: 10-22-07)  A3-3612, HO-E414  A major treatment for patients with ESRD is kidney transplantation.  This involves removing a kidney, usually from a living relative of the patient or from an unrelated person who has died, and surgically placing the kidney into the patient.  After the beneficiary receives a kidney transplant, Medicare pays the transplant hospital for the transplant and appropriate standard acquisition charges.  Special provisions apply to payment.  For the list of approved Medicare certified transplant facilities, refer to  the following Web site:  http://www.cms.hhs.gov/CertificationandComplianc/20_Transplant.asp#TopOfPage   A transplant hospital may acquire cadaver kidneys by:   Excising kidneys from cadavers in its own hospital; and   Arrangements with a freestanding organ procurement organization (OPO) that provides cadaver kidneys to any transplant hospital or by a hospital based OPO.  A transplant hospital that is also a certified organ procurement organization may acquire cadaver kidneys by:   Having its organ procurement team excise kidneys from cadavers in other hospitals;    Arrangements with participating community hospitals, whether they excise kidneys on a regular or irregular basis; and    Arrangements with an organ procurement organization that services the transplant hospital as a member of a network.   When the transplant hospital also excises the cadaver kidney, the cost of the procedure is included in its kidney acquisition costs and is considered in arriving at its standard cadaver kidney acquisition charge.  When the transplant hospital excises a kid ney to provide another hospital, it may use its standard cadaver kidney acquisition charge or its standard detailed departmental charges to bill that hospital.   When the excising hospital is not a transplant hospital, it bills its customary charges for services used in excising the cadaver kidney to the transplant hospital or organ procurement agency.
(Medicare Claims Processing Manual)
When the excising hospital is not a transplant hospital, it bills its customary charges for services used in excising the cadaver kidney to the transplant hospital or organ procurement agency.   If the transplanting hospital's organ procurement team excises the cadaver kidney at another hospital, the cost of operating such a team is included in the transplanting hospital's kidney acquisition costs, along with the reasonable charges billed by the other hospital of its services.   90.1.1 - The Standard Kidney Acquisition Charge  (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)   There are two basic standard charges that must be developed by transplant hospitals from costs expected to be incurred in the acquisition of kidneys:    The standard charge for acquiring a live donor kidney; and    The standard charge for acquiring a cadaver kidney.  The standard charge is not a charge representing the acquisition cost of a specific kidney; rather, it is a charge that reflects the average cost associated with each type of kidney acquisition.  When the transplant hospital bills the program for the transplant, it shows its standard kidney acquisition charge on revenue code 081X. Kidney acquisition charges are not considered for the IPPS outlier calculation.  Acquisition services are billed from the excising hospital to the transplant hospital.  A billing form is not submitted from the excising hospital to the FI.  The transplant hospital keeps an itemized statement that identifies the services furnished, the c harges, the person receiving the service (donor/recipient), and whether this is a potential transplant donor or recipient.  These charges are reflected in the transplant hospital's kidney acquisition cost center and are used in determining the hospital's s tandard charge for acquiring a live donor's kidney or a cadaver's kidney.  The standard charge is not a charge representing the acquisition cost of a specific kidney.  Rather, it is a charge that reflects the average cost associated with each type of kidney acquisition.  Also, it is an all- inclusive charge for all services required in acquisition of a kidney, i.e., tissue typing, post -operative evaluation.   A. - Billing For Blood And Tissue Typing of the Transplant Recipient Whether or Not Medicare Entitlement Is Established
(Medicare Claims Processing Manual)
A. - Billing For Blood And Tissue Typing of the Transplant Recipient Whether or Not Medicare Entitlement Is Established   Tissue typing and pre -transplant evaluation can be reflected only through the kidney acquisition charge of the hospital where the transplant will take place.  The transplant hospital includes in its kidney acquisition cost center the reasonable charges it pays to the independent laboratory or other hospital which typed the potential transplant recipient, either before or after his entitlement.  It also includes reasonable charges paid for physician tissue typing services, applicable to live donors and recipients (during the pre -entitlement period and after entitlement, but prior to hospital admission for transplantation).   B. - Billing for Blood and Tissue Typing and Other Pre -Transplant Evaluation of Live Donors   The entitlement date of the beneficiary who will receive the transplant is not a consideration in reimbursing for the services to donors, since no bill is submitted directly to Medicare.  All charges for services to donors prior to admission into the hospi tal for excision are "billed" indirectly to Medicare through the live donor acquisition charge of transplanting hospitals.   C. - Billing Donor And Recipient Pre -Transplant Services (Performed by Transplant Hospitals or Other Providers) to the Kidney Acquisition Cost Center   The transplant hospital prepares an itemized statement of the services rendered for submittal to its cost accounting department.  Regular Medicare billing forms are not necessary for this purpose, since no bills are submitted to the A/B MAC (A) at this point.  The itemized statement should contain information that identifies the person receiving the service (donor/recipient), the health care insurance number, the service rendered and the charge for the service, as well as a statement as to whether this is a potential transplant donor or recipient.  If it is a potential donor, the provider must identify the prospective recipient.   EXAMPLE:   Mary Jones  Health care insurance number  200 Adams St. Anywhere, MS   Transplant donor evaluation services for recipient:   John Jones  Health care insurance number  200 Adams St. Anywhere, MS