evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Other providers and suppliers that normally bill the A/B MAC (A) for services bill the A/B MAC (B) for splints and casts.    180 - Billing for Home Infusion Therapy Services                                (Rev. 4112, Issued: 08- 10-18, Effective: 01 -01-19, Implementation: 01- 07-19) Effective January 1, 2019 and until the implementation of the full home infusion therapy benefit, Medicare makes separate temporary transitional payments for Home Infusion Therapy (HIT) services to eligible home infusion suppliers (i.e., a licensed pharmac y that provides external infusion pumps and external infusion pump supplies). This payment amount covers the cost of professional services, including nursing services, training and education (not otherwise paid for as durable medical equipment), remote monitoring, and monitoring services for the provision of home infusion therapy furnished by a qualified home infusion with administration of certain transitional home infusion drugs administered through an item of DME.   Temporary transitional payments are made for HIT services based on the home infusion drug provided.  Home infusion drugs are assigned to three payment categories, determined by the Healthcare Common Procedure Coding System (HCPCS) J -code.   Each DME MAC maintains a list of drugs that are administered through an item of DME and HIT payment is made for days  on which home infusion therapy services are furnished by skilled professionals in the individuals home on the day of infusion drug administration.  Temporary Transitional Payment Categories for Home Infusion Therapy Services, by Infusion Drug (J -Code)
(Medicare Claims Processing Manual)
Category 1  J-Code  Description  J0133 Injection, acyclovir, 5 mg J0285 Injection, amphotericin b, 50 mg J0287 Injection, amphotericin b lipid complex, 10 mg J0288 Injection, amphotericin b cholesteryl sulfate complex, 10 mg J0289 Injection, amphotericin b liposome, 10 mg  J0895 Injection, deferoxamine mesylate, 500 mg J1170 Injection, hydromorphone, up to 4 mg J1250 Injection, dobutamine hydrochloride, per 250 mg J1265 Injection, dopamine hcl, 40 mg J1325 Injection, epoprostenol, 0.5 mg J1455 Injection, foscarnet sodium, per 1000 mg J1457 Injection, gallium nitrate, 1 mg  J1570 Injection, ganciclovir sodium, 500 mg  J2175 Injection, meperidine hydrochloride, per 100 mg J2260 Injection, milrinone lactate, 5 mg  J2270 Injection, morphine sulfate, up to 10 mg J2274 Injection, morphine sulfate, preservative -free for epidural or intrathecal use, 10 mg J2278 Injection, ziconotide, 1 microgram  J3010 Injection, fentanyl citrate, 0.1 mg J3285 Injection, treprostinil, 1 mg Category 2  J-Code  Description  J1555 JB  Injection, immune globulin (cuvitru), 100 mg J1559 JB  Injection, immune globulin (hizentra), 100 mg  J1561 JB  Injection, immune globulin, (gamunex- c/gammaked), non- lyophilized (e.g., liquid), 500 mg J1562 JB  Injection, immune globulin ( vivaglobin), 100 mg J1569 JB  Injection, immune globulin, (gammagard liquid), non- lyophilized, (e.g., liquid), 500 mg J1575 JB  Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immune globulin Category 3
(Medicare Claims Processing Manual)
(e.g., liquid), 500 mg J1575 JB  Injection, immune globulin/hyaluronidase, (hyqvia), 100 mg immune globulin Category 3  J-Code  Description  J9000 Injection, doxorubicin hydrochloride, 10 mg  J9039 Injection, blinatumomab, 1 microgram  J9040 Injection, bleomycin sulfate, 15 units  J9065 Injection, cladribine, per 1 mg J9100 Injection, cytarabine, 100 mg J9190 Injection, fluorouracil, 500 mg J9200 Injection, floxuridine, 500 mg J9360 Injection, vinblastine sulfate, 1 mg J9370 Injection, vincristine sulfate, 1 mg
(Medicare Claims Processing Manual)
The payment category for subsequent transitional home infusion drug additions to the Local Coverage Determinations (LCDs) and compounded infusion drugs not otherwise classified, as identified by HCPCS codes J7799 and J7999, will be determined by the DME MAC.  A single unit of payment will be made for HIT services provided in the individuals home during an infusion drug administration calendar day.   Suppliers will report the following HCPCS G -codes associated with the payment categories for the professional services furnished in the individuals home and on an infusion drug administration calendar day:   1. G0068: Professional services for the administration of anti -infective, pain management, chelation, pulmonary hypertension, and/or inotropic infusion drug(s) for each infusion drug administration calendar day in the individuals home, each 15 minutes.  Short Descriptor: Adm of infusion drug in home  2. G0069: Professional services for the administration of subcutaneous immunotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes. Short Descriptor: Adm of immune drug in home  3. G0070: Professional services for the administration of chemotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes.  Short Descriptor: Adm of chemo drug in home   In the event that multiple drugs, which are not all assigned to the same payment category, are administered on the same infusion drug administration calendar day, a single payment would be made that is equal to the highest payment category.    Providers should report visit length in 15- minute increments (15 minutes=1 unit).  See the table below for the rounding of units.  Rounding of Time Units   Unit  Time  1 <23 minutes  2 = 23 minutes to <38 minutes  3 = 38 minutes to <53 minutes  4 = 53 minutes to <68 minutes  5 = 68 minutes to <83 minutes  6 = 83 minutes to <98 minutes  7 = 98 minutes to <113 minutes  8 = 113 minutes to <128 minutes  9 = 128 minutes to <143 minutes  10 = 143 minutes to <158 minutes
(Medicare Claims Processing Manual)
Claims that include G -codes for HIT services are not required to, but may also include the HCPCS J -code for the infusion drug, the E -code for the external infusion pump, and A-codes for supplies other than the drug.  A submitted claim for HIT services is subject to a Common Working File (CWF) edit in the event that a transitional drug J -code is not found on the same claim as the billed professional HIT services, or in claims history in the previous 30 days. If a J -code  is not found on the same claim as the billed professional services, the claims processing system will recycle the G -code claim for the professional services associated with the administration of the home infusion drug, until a claim containing the J -code for the infusion drug is received in the CWF. The professional visit claim will recycle three times (with a 30 -day look back period) for a total of 15 business days. After 15 business days, if no J -code claim is found in claims history, the G -code claim wi ll be denied.  Suppliers must ensure that the appropriate drug associated with the visit is billed with the visit or no more than 30 days prior to the visit.  Visits are denied if the appropriate drug for the visit is not billed.  In the event that multiple visits occur on the same date of service, suppliers must only bill for one visit and should report the highest paying visit with the applicable drug. Claims reporting multiple visits on the same line item date of service will be returned as unprocessable.    181  Lymphedema Compression Treatment Benefit  (Rev. 12379; Issued; 11- 22-23; Effective: 01 -01-24; Implementation:01- 02-24)
(Medicare Claims Processing Manual)
181  Lymphedema Compression Treatment Benefit  (Rev. 12379; Issued; 11- 22-23; Effective: 01 -01-24; Implementation:01- 02-24)  Effective for items furnished on or after January 1, 2024, section 4133 of the Consolidated Appropriations Act (CAA), 2023, establishes a new Medicare DMEPOS benefit category for standard and custom fitted compression garments and additional lymphedema com pression treatment items for the treatment of lymphedema that are prescribed by an authorized practitioner.   Claims for lymphedema treatment items that do not have an appropriate diagnosis for lymphedema will be denied. Claim payment can be made for lymphedema compression treatment items for more than one body part/area per beneficiary. In addition, claim payment  can be made for both a daytime and nighttime garment for the same body part/area per beneficiary.   A quantity of three daytime garments or wraps per body area and two nighttime garment per body area is allowed. Any amount billed that exceeds frequency limitations will be denied unless a replacement is needed due to a change in medical need or because a garment or wrap is lost, stolen, or irreparably damaged. Replacement of the garments can only be made in accordance with the proposed frequency limitation of once every 6 months for a daytime garment or wrap and once every two years for a nighttime garment . When billing for replacement of a garment or wrap use of the RA modifier is required. .  190 - A/B MAC (A), (B), or (HHH), or DME MAC  Application of Fee Schedule and Determination of Payments and Patient Liability for DME Claims (Rev. 1, 10- 01-03) A3-3629, B3- 5102   The following instructions apply to all A/B MACs (A), (B), and (HHH), and DME MACs processing DMEPOS claims:   First the 'allowable amount' is determined.  This is the lower of the fee schedule amount or the billed charge.   The application of deductible and coinsurance are calculated as follows.   A. Claims to A/B MACs (B) or DME MACs   Any unmet deductible is subtracted from the allowed amount and 80 percent of the remainder is paid.
(Medicare Claims Processing Manual)
A. Claims to A/B MACs (B) or DME MACs   Any unmet deductible is subtracted from the allowed amount and 80 percent of the remainder is paid.   B. Claims to A/B MACs (A) or (HHH)   NOTE:   Per 42 CFR 410.2 (Follow the link, choose the applicable year, select Title 42, then open Chapter IV.  You then must choose which part to open.  To get to 410.2 you select the second choice and open it, then select Part 410 and download the pdf version.), a nominal charge provider means a provider that furnishes services free of charge or at a nominal charge, and is either a public provider or another provi der that (1) demonstrates to CMS's satisfaction that a significant portion of its patients are low -income; and (2) requests that payment for its services be determined accordingly.   1. Payment to a Provider Other Than Nominal Charge Provider   To determine the Part B payment to a provider other than nominal charge provider, A/B MACs (A) and (HHH)  subtract any unmet Part B deductible from the lower of the actual charge or the fee schedule amount for the item or service and multiply the remainder by 80 percent.  This is the final payment.  (If the item or service is furnished by a HHA and is covered  under a plan of care, the payment is determined in the same way, except that no deductible is applicable.)   2. Payment to a Nominal Charge HHA   To determine the Part B payment to a nominal charge HHA, A/B MACs (HHH) subtract any unmet Part B deductible from the fee schedule amount and multiply the remainder by 80 percent.  This is the final payment.  (If the item or service is covered under a plan of care, the payment is determined in the same way, except that no deductible is applicable.)  For these items and services, no providers other than HHAs are considered nominal charge providers.   3. Payment to a Nominal Charge Provider Other Than a Nominal Charge HHA
(Medicare Claims Processing Manual)
3. Payment to a Nominal Charge Provider Other Than a Nominal Charge HHA   To determine the Part B payment to a nominal charge provider other than a nominal charge HHA, A/B MACs (A) and (HHH)  subtract any unmet Part B deductible from the lower of the actual charge or the fee schedule amount and multiply the remainder by 80 percent.  This is the final payment.  4. Patient Liability to a HHA Other Than a Nominal Charge HHA   To determine the patient liability to a HHA other than a nominal charge HHA under Part B, A/B MACs (HHH) subtract any unmet deductible from the lower of the actual charge or fee schedule amount and multiply the remainder by 20 percent.  The result, plus the unmet deductible is the patient's liability.  If the item or service is covered under a plan of care, the deductible does not apply.  5. Patient Liability to a Nominal Charge HHA   To determine patient liability to a nominal charge HHA under Part B, A/B MACs (HHH) subtract any unmet deductible from the fee schedule amount and multiply the remainder by 20 percent.  The result, plus the unmet deductible is the patient's liability.  If the item or service is covered under a Plan of Care, the deductible does not apply.  6. Patient Liability to a Provider Other Than a HHA   To determine patient liability to a provider other than an HHA (including nominal charge providers other than a HHA), A/B MACs (A)  subtract any unmet deductible from the actual charge and multiply the remainder by 20 percent.  The result, plus the unmet deductible is the patient's liability.  Coinsurance is applied as applicable.   The following describes application of deductible and coinsurance on HHA bills by bill type:   a. Patient Under Part B Plan of Treatment (Bill Type 32X)   No deductible applicable; and  No coinsurance applicable   Exception:   Coinsurance applies on DME and orthotic/prosthetic claims.  b. Patient Under Part A Plan of Treatment (Bill Type 33X)   No deductible applicable; and  No coinsurance applicable
(Medicare Claims Processing Manual)
Exception:   Coinsurance applies on DME and orthotic/prosthetic claims.  b. Patient Under Part A Plan of Treatment (Bill Type 33X)   No deductible applicable; and  No coinsurance applicable   Exception:  Coinsurance applies on DME and orthotic/prosthetic claims.  c. Patient Not Under Plan of Treatment, Part B Medical and Other Health Services and Osteoporosis Injections (Bill Type 34X)    Deductible applies; and   Coinsurance applies   The following examples illustrate how to calculate provider payment and patient liability in various situations.  The examples, like the preceding rules for HHAs, address items and services not under a Plan of Care and, therefore, include deductible applic ation.  The Note following each HHA example addresses items and services obtained under a Plan of Care and, therefore, do not address deductible application.  EXAMPLE 1:   CLAIM CONTAINING ONLY ORTHOTIC/PROSTHETIC CHARGES   $200.00 Orthotic/prosthetic charges  $140.00 Orthotic/prosthetic fee schedule amount  $100.00 Part B deductible to be met   To determine the payment to all providers (other than nominal charge HHAs) apply the following steps:   Step 1:  Determine the lower of the actual charge or the fee schedule amount:  $140.00 (do not apply the provider's interim rate)  Step 2:  Subtract any unmet Part B deductible from the amount determined in Step 1:  $140.00 - $100.00 = $40.00  Step 3:  Apply 80% to the amount determined in Step 2:  $40.00 X 80% = $32.00   The Part B payment to the provider in this example is $32.00   To determine payment to nominal charge HHAs apply the following steps:   Step 1:  Subtract any unmet deductible from the fee schedule amount: $140.00 - $100.00 = $40.00  Step 2:  Apply 80% to the amount determined in Step 1: $40.00 x 80% = $32.00
(Medicare Claims Processing Manual)
The Part B payment to the nominal charge HHA in this example is $32.00  NOTE:   If the item or service is covered under a Home Health Plan of Care, the payment is determined the same way, except no deductible is applicable.  In the above examples the payment would be $112.00 ($140.00 x 80%).   To determine beneficiary liability to providers other than HHAs apply the following steps:   Step 1:  Subtract any unmet Part B deductible from the actual charge:  $200.00 - $100.00 = $100.00  Step 2:  Multiply the amount determined in Step 1 by 20% coinsurance: $100.00 x 20% = $20.00  Step 3:  Add the result of Step 2 to the unmet deductible: $20.00 + $100.00 = $120.00   The beneficiary's liability in this example is $120.00.  ($100.00 Part B deductible and $20.00 coinsurance.)   NOTE:   If the item of service is covered under a Home Health Plan of Care, the beneficiary's liability is determined the same way, except no deductible is applicable.  In this example, the beneficiary's liability would be $28.00 ($140.00 x 20% coinsurance).   EXAMPLE 2:   CLAIM CONTAINING ONLY ORTHOTIC/PROSTHETIC CHARGES - NEGATIVE PAYMENT   $120.00 Orthotic/prosthetic charges  $  80.00 Orthotic/prosthetic fee schedule amount  $100.00 Part B deductible to be met   To determine the payment to all providers (other than nominal charge HHAs) apply the following steps:   Step 1:  Determine the lower of the actual charge or the fee schedule amount:  $80.00 (do not apply the provider's interim rate)  Step 2:  Subtract any unmet Part B deductible from amount determined in Step 1:  $80.00 - $100.00 = -$20.00
(Medicare Claims Processing Manual)
Do not apply the 80 percent since the result of Step 2 is a negative amount.  There is no Part B payment to the provider in this example because the result equals a negative payment amount.  A/B MACs (A) or (HHH)  do not take the negative amount of ( -$20.00) from future payments to the provider.   To determine payment to nominal charge HHAs, apply the following step:   Step 1:  Subtract any unmet deductible from the fee schedule amount: $80.00 - $100.00 = -$20.00   Do not apply the 80 percent since the result of Step 1 is a negative amount.  There is no Part B payment to the nominal charge HHA in this example because the result equals a negative payment amount.  A/B MACs (HHH) do not take the negative amount of ( -$20.00) from future payments to the HHA.   NOTE:  If the item or service is covered under a Home Health Plan of Care the payment is determined in the same way, except no deductible is applicable.  In the above examples the payment would be $64.00 ($80.00 x 80%).   To determine beneficiary liability to providers other than HHAs, apply the following steps:   Step 1:  Subtract any unmet Part B deductible from the actual charge: $120.00 - $100.00 = $20.00  Step 2:  Multiply the amount in Step 1 by 20% coinsurance: $20.00 x 20% = $4.00   The beneficiary's liability in this example is $104.00 ($100.00 Part B deductible and $4.00 coinsurance).
(Medicare Claims Processing Manual)
The beneficiary's liability in this example is $104.00 ($100.00 Part B deductible and $4.00 coinsurance).   The beneficiary's liability to HHAs (nominal charge and other than nominal charge) in this example is $80.00 (the fee schedule amount for nominal charge HHAs or the lower of the fee schedule amount or the actual charge for other than nominal charge HHAs).  The HHA cannot charge the beneficiary the $100.00 deductible since it exceeds $80.00.  $80.00 is credited to the beneficiary's deductible.  The beneficiary's deductible to be met on the next claim is $20.00.  The beneficiary has no coinsurance obligation.  NOTE:  If the item or service is covered under a Home Health Plan of Care, the beneficiary's liability is determined the same way, except that no deductible is applicable.  The beneficiary's liability in this example would be $16.00 coinsurance ($80.00 x 20%).   200 - Automatic Mailing/Delivery of DMEPOS  (Rev. 1, 10- 01-03)  Suppliers/manufacturers may not  automatically deliver DMEPOS to beneficiaries unless the beneficiary, physician, or designated representative has requested  additional supplies/equipment.  The reason is to assure that the beneficiary actually needs the DMEPOS.  DME MAC review should be done on a post -pay basis.
(Medicare Claims Processing Manual)
A beneficiary or their caregiver must specifically request refills of repetitive services and/or supplies before a supplier dispenses them.  A supplier may not initiate a refill of an order.  The supplier must not automatically dispense a quantity of suppl ies on a predetermined regular basis.  A request for refill is different than a request for a renewal of a prescription.  Generally, the beneficiary or caregiver will rarely keep track of the end date of a prescription.  Furthermore the physician is not likely to keep track of this.  The suppli er is the one who will need to have the order on file and will know when the prescription will run out and a new order is needed.  It is reasonable to expect the supplier to contact the physician and ask for a renewal of the order.  This is consistent with the DME MAC Supplier Manual for the particular jurisdiction, which states: "The description of the item (on an order) may be completed by someone other than the physician (most commonly the supplier).  However, the physician must review the order and sign and date it to indicate agreement."  Again the supplier must not automatically mail or deliver the DMEPOS to the beneficiary until specifically requested.   The DME MACs inform suppliers of these procedures via their bulletins and training sessions.  These procedures will benefit suppliers by helping to maximize claims processing accuracy, and to reduce the likelihood of a postpayment claim denial because the DMEPOS were not medically necessary.   DME MACs must publish this information on their Web sites and in their bulletins on an annual basis.   210 - CWF Crossover Editing for DMEPOS Claims During an Inpatient Stay  (Rev. 2993, Effective: ASC X12 -  01-01-12, ICD -10 - Upon Implementation of ICD -10; Implementation: ASC X12 -  08-25-14, ICD -10 - Upon Implementation of ICD -10)  I. General Information   A. Background:
(Medicare Claims Processing Manual)
I. General Information   A. Background:   In general, the DMEPOS benefit is meant only for items a beneficiary is using in his or her home.  For a beneficiary in a Part A inpatient stay, an institutional provider (e.g., hospital) is not defined as a beneficiarys home for DMEPOS, and so Medicare does not make separate payment for DMEPOS when a beneficiary is in the institution.  The institution is expected to provide all medically necessary DMEPOS during a beneficiarys covered Part A stay.   EXCEPTION:  Medicare makes a separate payment for a full month for DMEPOS items, provided the beneficiary was in the home on the from date or anniversary date defined below.   For capped rental items of durable medical equipment (DME) where the DME supplier submits a monthly bill, the date of delivery (from date) on the first claim must be the from or anniversary date on all subsequent claims for the item.  For example, if t he first claim for a wheelchair is dated September 15, all subsequent bills must be dated for the 15th of the following months (October 15, November 15, etc.).   B. Policy:   If a beneficiary using DMEPOS is at home on the from date or anniversary date, Medicare pays for the DMEPOS for the entire month, even if the from date is the date of discharge from the institutional provider.  If a beneficiary using DMEPOS is in a covered Part A stay for a full month, Medicare does not make payment for the DMEPOS for that month.  For capped rental items, if the covered Part A stay overlaps the anniversary date (from date on the claim), and the beneficiary is not in the covered Part A stay for the entire month, the date of discharge becomes the new anniversary date (from date on the claim) for subsequent claims.  In this situation, the supplier must submit a new claim with the date of discharge as the new anniversary date upon the beneficiarys release from the institution.  Suppliers should annotate the claims, to indicate that the patient was in an institution, resulting in the need to establish a new anniversary date. The CWF: