evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Although an additional allowance for the administration of a renal -related injection to a dialysis patient may not be made, the patients MCP physician or a physician other than the MCP physician may submit claims and be paid for the drug itself as well as supplies, e.g., needles and syringes, used to administer the drug.   EXAMPLE:   Dr. Jones is Mr. Whites MCP physician.  Dr. Jones is unable to furnish the regular EPO injections his patient needs three times a week.  It is Dr. Jones responsibility to compensate the physician who administers the injections.  The administering physi cian submits claims for the injectable and necessary supplies.  In this case, the A/B MAC (B) makes a reasonable monthly allowance, e.g., $3 for the cost of supplies (i.e., syringes and needles).   20.5.9 - Annual Update of AWP Payment Allowance Limit for Vaccines (Rev. 1357, Issued: 10- 26-07, Effective: 09 -01-07, Implementation: 11- 26-07)  The payment allowance limits for influenza, Pneumococcal and Hepatitis B vaccines are 95 percent of the AWP as reflected in the published compendia except where the vaccine is furnished in a hospital outpatient department.  Where the vaccine is administered in the hospital outpatient department, the vaccine is paid at reasonable cost.  Medicare contractors will be receiving subsequent annual updates of the vaccine payment allowance limits for influenza and pneumococcal vaccines communicated by a Recurring U pdate Notification.   30 - A/B MAC (B)  Distribution of Limit Amounts  (Rev. 1, 10- 01-03)  The A/B MACs (A) get drug prices from the A/B MAC (B) for drugs not listed on the SDP.  A/B MACs (B) prepare a list of the drug payment allowance limits updates (or new file depending upon local requirements) to the claims system.   A/B MACs (B) distribute, free of charge, the updated limits in an agreed upon format directly to the A/B MACs (A) in their jurisdiction.
(Medicare Claims Processing Manual)
A/B MACs (B) distribute, free of charge, the updated limits in an agreed upon format directly to the A/B MACs (A) in their jurisdiction.   A/B MACs (B) should contact each A/B MAC (A) to determine the preferred method of transmission.  A/B MACs (B) are to send this information to all A/B MACs (A) they routinely deal with.  If this method of obtaining payment allowance updates does not work for any A/B MAC (A), the A/B MAC (B) must contact the appropriate RO office.   40 - Discarded Drugs and Biologicals  (Rev: 12067;  Issued: 06 -02-23; Effective: 01 -01-23; Implementation: 07 -03-23)  The CMS encourages physicians, hospitals and other providers and suppliers to care for and administer drugs and biologicals to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner.   When a billing provider or supplier must discard the remainder of a single -dose container or single -use package after administering a dose to a Medicare patient, the program provides payment for the amount of drug or biological discarded as well as the dos e administered, up to the amount of the drug or biological as indicated on the vial or package label.   Effective January 1, 2017 when processing claims for drugs and biologicals local contractors shall require the use of the JW modifier to identify unused and discarded amounts (hereafter, discarded amounts) of drugs or biologicals from single -dose containers or single -use packages.   The discarded amount is any amount that is not part of the prescribed dose and not intended to have a therapeutic effect in the patient. Even if certain amounts are extracted from the vial or are required to be in the vial to administer the prescribed dose , we do not consider them to be used if they are not intended for therapeutic effect as part of the prescribed dose.  Generally, the discarded amount is the labeled amount on the single -dose container (or containers if more than one is required) minus the dose (the dose being the prescribed amount of drug administered to the patient).
(Medicare Claims Processing Manual)
The JW modifier, billed on a separate line, provides payment for the amount of discarded drug or biological. For the administered amount, one claim line shall include the billing and payment code (such as a HCPCS code) describing the given drug, no modifie r, and the number of units administered in the unit field. For the discarded amount, a second claim line shall include the same billing and payment code as used for the administered amount, the JW modifier, and the number of units discarded in the units field.   For example, if a provider or supplier uses a single -dose container that is labeled to contain 100 units of a drug to administer 95 units to the patient and 5 units are discarded. The 95-unit dose is billed on one line, while the discarded 5 units shall be  billed on another line with the JW modifier. Both line items would be processed for payment. Providers must record the discarded amounts of drugs and biologicals in the patients medical record.   Effective July 1, 2023, local contractors shall require the use of the modifier JZ to attest that there are no amounts of drugs or biologicals from single -dose containers or single -use packages were unused and discarded. For the administered amount, the cl aim line should include the billing and payment code (such as HCPCS code) describing the given drug, the JZ modifier (attesting that there were no discarded amounts), and the number of units administered in the units field.
(Medicare Claims Processing Manual)
The JW modifier is only applied to the amount of drug or biological that is discarded. A situation in which the JW modifier is not permitted is when the actual dose of the drug or biological administered is less than the billing unit. For example, one bill ing unit for a drug is equal to 10mg of the drug in a single use vial. A 7mg dose is administered to a patient while 3mg of the remaining drug is discarded. The 7mg dose is billed using one billing unit that represents 10mg on a single line item. The singl e line item of 1 unit would be processed for payment of the total 10mg of drug administered and discarded. Billing another unit on a separate line item with the JW modifier for the discarded 3mg of drug is not permitted because it would result in overpayme nt. Therefore, when the billing unit is equal to or greater than the total actual dose and the amount discarded, the use of the JW modifier is not permitted. For dates of service beginning July 1, 2023, the JZ modifier shall be used in this circumstance.   In general, the JW and JZ modifier policy applies to all drugs separately payable under Medicare Part B that are described as being supplied in a single -dose container or single -use package based on FDA -approved labeling.  The use of these modifiers is  not appropriate for drugs that are from multiple -dose containers.  The JW and JZ modifier policy does not apply for drugs that are not separately payable, such as packaged OPPS or ASC drugs, or drugs administered in the FQHC or RHC setting.   The JW and JZ modifiers are not required for vaccines described under section 1861(s)(10) of the Act that are furnished from single -dose containers. Since the influenza, pneumococcal, and COVID 19 vaccines specified in section 1861(s)(10) of the Act are of ten roster billed by mass immunizers, and roster billing cannot accommodate modifiers, it would be impractical to require the JW and JZ modifiers for such vaccines. Such a requirement would likely result in substantial operational issues for mass immunizers and impair patient access to these vaccines.
(Medicare Claims Processing Manual)
The JW modifier is not used on claims for CAP drugs. For CAP drugs, see subsection 100.2.9 - Submission of Claims With the Modifier JW, Drug or Biological Amount Discarded/Not Administered to Any Patient, for additional discussion of the discarded remainder of a vial or other packaged drug or biological in the CAP. Note that the CAP is postponed effective January 1, 2009.   40.1 - Discarded Erythropoietin Stimulating Agents for Home Dialysis  (Rev. 1581; Issued:  08- 29-08; Effective/Implementation Date:  12 -01-08)  Multiuse vials are not subject to payment for discarded amounts of drug or biological, with the exception of self administered erythropoietin stimulating agents (ESAs) by Method I home dialysis patients.  The renal facility must bill the program using the modifier JW for the amount of ESAs appropriately discarded if the home dialysis patient must discard a portion of the ESA supply due to expiration of a vial, because of interruption in the patients plan of care, or unused ESAs on hand after a patients de ath.  Specific instructions are found in chapter 8 of this manual, 60.4.4.1 Self Administered EPO Supply, and 60.7.4 Darbepoetin Alfa (Aranesp) Furnished to Home Patients.  This applies only to home dialysis patients who meet the Method I conditions described in Pub 100- 2 Benefits Policy Manual, chapter 11, 90 Epoetin (EPO), and does not apply to Method II home dialysis patients.   Supplies of ESAs for self administration are billed according to the pre -determined plan of care schedule provided to home dialysis patients that meet the criteria for self administered ESAs discussed in chapter 8 of this manual, 60.4 Epoetin Alfa (EPO) For ESRD Patients and 60.7 Darbepoetin Alfa (Aranesp) for ESRD Patients.  The renal facility, through the amounts prescribed in the plan of care, shall ensure the patients ESA on hand at any time does not exceed a 2 -month supply.  CMS expects the faci lity to minimize excess dispensing of the ESAs for self administration based on the patients plan of care.
(Medicare Claims Processing Manual)
50 - Assignment Required for Drugs and Biologicals  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  A. A/B MACs (B)   Under 114 of the Benefits Improvement Act of 2000, effective for claims with dates of service on or after February 1, 2001, payment for any drug or biological covered under Part B of Medicare may be made only on an assignment -related basis.  Therefore, no  charge or bill may be rendered to anyone for these drugs and biologicals for any amount except for any applicable unmet Medicare Part B deductible and coinsurance amounts.  All entities (including physicians, nonphysician practitioners, pharmacies and suppliers) that bill Medicare for drugs and biologicals must take assignment on all claims for drugs and biologicals furnished to any beneficiary enrolled in Medicare Part B.  Contractors apply this policy to all items paid based on the lower of the actual charge on the claim or 95 percent of the AWP.  See 20 for a description of the AWP.  Mandatory assignment does not apply to HCPCS code E0590, which represents the dispensing fee for nebulizer drugs.   A/B MACs (B) process all claims for drugs and biologicals with a date of service on or after February 1, 2001, as though the physician or nonphysician practitioner had taken assignment.  If only drugs and biologicals are billed on the claim, and the claim was submitted as unassigned, contractors change the claim to assigned and process as an assigned claim.  If a physician or nonphysician practitioner submits an unassigned claim that contains both codes for drugs or biologicals and codes for other services, A/B MACs (B) split the claim into two claims.  The first claim will be an unassigned claim for services other than drugs or biologicals, and the second will be an assigned claim for drugs or biologicals furnished on or after February 1, 2001.  The followi ng messages apply when an A/B MAC (B) has changed the claim to assigned status (regardless of whether the contractor had to split the claim):
(Medicare Claims Processing Manual)
The contractor shall use the following remittance advice messages and associated codes when adjusting payment under this policy. The RARC below is not included in the CAQH CORE Business Scenarios.  Group Code: N/A  CARC: N/A  RARC: MA72  MSN: 16.50  Additional appropriate message for physicians, suppliers, and beneficiaries should be added as necessary.   B. DME MACs   Under 114 of BIPA, DMEPOS suppliers must accept assignment on all claims for drugs and biologicals that they bill to the DME MACs.  A supplier may not render a charge or bill to anyone for these drugs and biologicals for any amount other than the Medicare  Part B deductible and coinsurance amounts.  Mandatory assignment does not apply to HCPCS code E0590, which represents the dispensing fee for nebulizer drugs.   The DME MACs must inform suppliers on their Web sites and in their next bulletins that they must accept assignment on claims for drugs and biologicals furnished on or after February 1, 2001.   The DME MACs must deny any claims a beneficiary submits for drugs and biologicals with dates of service on or after February 1, 2001.  The DME MACs must notify beneficiaries that suppliers must accept assignment on claims for drugs and biologicals, and the refore, the beneficiaries may not submit claims for drugs and biologicals.  When denying beneficiary- submitted claims, DME MACs use the following Medicare Summary Notice (MSN) messages:   MSN 16.6 (English):  This item or service cannot be paid unless the provider accepts assignment.   MSN 16.6 (Spanish):  Este artculo o servicio no se pagar a menos de que el proveedor acepte asignacin.   MSN 16.7 (English):  Your provider must complete and submit your claim.   MSN 16.7 (Spanish):  Su proveedor debe completar y someter su reclamacin.   MSN 16.34 (English):  You should not be billed for this service.  You do not have to pay this amount.
(Medicare Claims Processing Manual)
MSN 16.34 (English):  You should not be billed for this service.  You do not have to pay this amount.   MSN 16.34 (Spanish):  Usted no debera ser facturado por este servicio.  Usted no tiene que pagar esta cantidad.   MSN 16.36 (English):  If you have already paid it, you are entitled to a refund from this provider.   MSN 16.36 (Spanish):  Si usted ya lo ha pagado, tiene derecho a un reembolso de su proveedor.   If a supplier submits an unassigned claim with a date of service on or after February 1, 2001, to the DME MAC for a drug or biological, the DME MAC must process the claim as though the supplier accepted assignment.  It is possible that a supplier may bill drugs and other items on the same claim, which would result in a claim with some assigned and some nonassigned items.  In the event that a supplier bills an unassigned claim to a DME MAC that contains both codes for drugs or biologicals and codes for other items, the DME MACs must replicate the claim.  This will result in two claims in the DME MAC system: an unassigned cla im for items other than drugs or biologicals, and an assigned claim for drugs and biologicals furnished on or after February 1, 2001.  When a DME MAC changes an unassigned drug claim to an assigned claim, the contractor shall use the following remittance advice messages and associated codes when adjusting payment under this policy. The RARC below is not included in the CAQH CORE Business Scenarios
(Medicare Claims Processing Manual)
Group Code: N/A  CARC: N/A  RARC: MA72  MSN:  N/A  Suppliers that bill the DME MACs for drugs for use with DMEPOS must have a pharmacy license to dispense drugs.  When a DME MAC denies a claim for a drug because the National Supplier Clearing House (NSC) records do not show that the supplier has a pharmacy license, the DME MAC must also deny any equipment, accessories, and supplies related to the drug, when the supplier bills the drug on the same claim as the equipment.  (Suppliers should bill drugs for use with DMEPOS on the same claim as the equipment itself, if they are also providing and billing for the equipment.)  In situations when a supplier bills unassigned drugs and equipment, ac cessories, or supplies on the same claim, the DME MAC and VMS Shared System Maintainer must ensure that they apply nonlicensed pharmacy equipment, accessory and supply edits and denials before they replicate the claim.  Even if the system denies a line due  to the nonlicensed pharmacy edit prior to replicating the claim, the system must still replicate any unassigned claims for drugs and biologicals and change the assignment indicator.    The contractor shall use the following remittance advice messages and associated codes when adjusting payment under this policy. The RARC below is not included in the CAQH CORE Business Scenarios.  Group Code: N/A  CARC: N/A  RARC: MA72  MSN:  N/A  OR  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: B7  RARC: M143  MSN: N/A  Or
(Medicare Claims Processing Manual)
Group Code: CO  CARC: B7  RARC: M143  MSN: N/A  Or   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.  Group Code: CO  CARC: 107  RARC: N/A  MSN: N/A  The DME MACs must work together to create and maintain a list of HCPCS drug codes that suppliers must bill on an assigned basis.  This will enable VMS shared system maintainer and the DME MACs to implement the necessary edits in their systems.  Finally, th e four DME MACs must work together to create a list of drug and equipment codes to which the nonlicensed pharmacy edit would apply in this situation.  For this second list, the DME MACs need add only drugs that are used with equipment, and the equipment, a nd related supplies and accessories, that use those drugs, as opposed to all drugs that are subjected to the licensure edit.  The DME MACs must share these lists with VMS shared system maintainer and CMS Central Office.   60 - DMEPOS Suppliers Require a License to Dispense Drugs  (Rev. 1, 10- 01-03)  Regulations at 42 CFR 424.57(b)(4)  (supplier standards) state that a supplier that furnishes a drug used as a Medicare -covered supply with durable medical equipment or prosthetic devices must be licensed by the State to dispense drugs.  (A supplier of drugs must bill and receive payment f or the drug in its own name.  A physician, who is enrolled as a DMEPOS supplier, may dispense, and bill for, drugs under this standard if authorized by the State as part of the physicians license.)   Therefore, suppliers may not bill the DME MACs for any Medicare -covered drugs unless they have a State license to dispense the drugs, regardless of whether or not the drugs require a prescription.  Similarly, a physician may not dispense Medicare -covered p rescription or nonprescription drugs unless he or she is authorized by the State to dispense such drugs as part of his or her physicians license.
(Medicare Claims Processing Manual)
The DME MACs must deny claims for prescription drugs, and related equipment when billed on the same claim, if the National Supplier Clearinghouses (NSC) records show the supplier was not licensed to dispense the drug on the DOS (date of service).   In effect, for DOS on or after December 11, 2000, the DME MACs must deny claims for all Medicare - covered drugs dispensed by a supplier or physician who is not licensed to dispense the drug.  If the DME MACs feel that it is necessary, they may coordinate t o develop a list of drugs and related equipment that should be subjected to the licensure edit.  Note that these provisions do not apply to EPO.  Method I beneficiaries must obtain their EPO through their dialysis facilities, and Method II beneficiaries must receive EPO from the same supplier that provides all their other dialysis supplies.  60.1 - Prescription Drugs Billed by Suppliers Not Licensed to Dispense Them  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  Medicare does not cover a drug used as a supply with DME or a prosthetic device if the drug is dispensed by an entity that is not licensed to dispense the drug.  The drug is not considered to be reasonable and necessary because CMS cannot be assured of its  safety and effectiveness unless it is dispensed by an entity that has a State license that qualifies it to dispense the drug.  The equipment used with the drugs dispensed by a nonlicensed entity is also considered to be not reasonable and necessary becaus e of the related safety and efficacy concerns.  Physicians are considered to have been deemed the right to dispense prescription drugs, and therefore do not require a pharmacy license.   The DME MACs should deny claims for a prescription drug (and related equipment when billed on the same claim as the drug) when the National Supplier Clearinghouses (NSCs) files show the supplier is or was not licensed to dispense the drugs on the date of  service (DOS).   An exception to this general policy is oxygen claims.  Messages for Assigned Claims:
(Medicare Claims Processing Manual)
An exception to this general policy is oxygen claims.  Messages for Assigned Claims:   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: B7  RARC: M143  MSN: 8.50  Messages for Nonassigned Claims:   MSN:  This item or service is not covered when performed or ordered by this provider.  (MSN #12.18)   Appeals should be addressed according to the instructions in Chapter 29.
(Medicare Claims Processing Manual)
MSN:  This item or service is not covered when performed or ordered by this provider.  (MSN #12.18)   Appeals should be addressed according to the instructions in Chapter 29.   70 - Claims Processing Requirements  General  (Rev. 11427; Issued: 05- 20-22; Effective: 01 -01-23; Implementation: 01 -03-23) NOTE: CMS seeks to reduce burden and modernize processes to ensure a reduction in improper payments and an increase in customer satisfaction. The Certificate of Medical Necessity (CMN) form and DME Information Form (DIF) were originally required to help document the medical necessity and other coverage criteria for selected Durable Medical Equipment, Prosthetics, Orthotics , and Supplies (DMEPOS) items. In the past, a supplier received a signed CMN from the treating physician or created and signed a DIF to submit with the claim. Due to improvements in claims processing and medical records management, the information found on CMNs or DIFs is available either on the claim or in the medical record and is redundant. Therefore, to reduce burden and increase customer satisfaction, providers and suppliers no longer need to submit these forms for services rendered after January 1, 2023.  For claims with dates of service on or after January 1, 2023  providers and suppliers no longer need to submit CMNs or DIFs with claims. Due to electronic filing requirements, claims received with these forms attached will be rejected and returned to the provider or supplier.   For claims with dates of service prior to January 1, 2023  processes will not change and if the CMN or DIF is required, it will still need to be submitted with the claim, or be on file with a previous claim.  This statement applies throughout the Program Integrity Manual wherever CMNs and DIFs are mentioned.  A/B MACs (B) are billed with the ASC X12 837 professional claim format or, if approved, with the paper form CMS -1500.  A/B MACs (A) are billed with the ASC X12 837 institutional claim format or, if approved, with the paper Form CMS -1450.