evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
While we recognize that inadvertent errors may occasionally occur in the course of furnishing such information, an SNF should not only make a good faith effort to furnish accurate information to its supplier, but must reimburse the supplier once such an er ror is called to its attention.  If, in the scenario at issue, the SNF refuses to pay the supplier for the service even after being apprised of the inaccuracy of its initial information, the SNF would not be in compliance with consolidated billing requirem ents.  As discussed previously, having supporting documentation in place for the disputed service would not only help to ensure compliance with the consolidated billing requirements, but should also provide a vehicle for resolving the dispute itself.  Of course, the SNF can often prevent such disputes from arising to begin with, simply by ensuring that the supplier receives accurate and timely information about the status of a residents Medicare -covered SNF stay.  The SNFs responsibility to communicat e accurate and timely resident information to its suppliers is especially important in those instances where a particular portion of an otherwise bundled service remains separately billable to Part B (for example, the professional component that represents  a physicians interpretation of an otherwise bundled diagnostic test).  Problem Scenario 2:  A resident temporarily departs from the SNF on a brief leave of absence, typically accompanied by a relative or friend.  While briefly offsite, the resident (or the relative or friend, acting on the residents behalf) obtains services that are subject to the consolidated billing requirement, but fails to notify the SNF.  The SNF refuses to pay for the offsite services, and the supplier bills the beneficiary/family member directly.
(Medicare Claims Processing Manual)
As in the previous scenario, the SNF remains responsible for any services included in the SNF bundle of services subject to consolidated billing that are furnished to the resident by an outside entity, even in the absence of a valid arrangement with the SNF.  The SNFs can act to prevent such problems from arising by ensuring that each resident (and, if applicable, his or her representative) is fully aware of the applicable requirements.  For example, while the Medicare law at 1802 of the Act guarantees a benef iciarys free choice of any qualified entity that is willing to furnish services to the beneficiary, in selecting a particular SNF, the beneficiary has effectively exercised this right of free choice with respect to the entire package of services for which  the SNF is responsible under the consolidated billing requirement, including the use of any outside suppliers from which the SNF chooses to obtain such services.  SNF staff need to communicate these requirements to beneficiaries and family members upon ad mission.  Further, in providing such advice periodically throughout each residents stay, the SNF should take particular care to include any resident who is about to leave the facility temporarily, in order to ensure that the resident (and, if applicable, the residents representative) understands the need to consult the SNF before obtaining any services offsite.
(Medicare Claims Processing Manual)
Moreover, while the SNF itself should take reasonable steps to prevent such problems from arising, the supplier in this scenario is also responsible for being aware of and complying with the consolidated billing requirements.  This means that prior to furnishing services to a Medicare beneficiary, the supplier should routinely ascertain whether the beneficiary is currently receiving any comprehensive Medicare benefits (such as SNF or home health benefits) for which Medicare makes a bundled payment that could potentially include the suppliers services.  If the supplier ascertains that a particular beneficiary is, in fact, a resident of an SNF with which the supplier does not have a valid arrangement in place, then the supplier should contact the SNF before actually furnishing any services to that beneficiary that are subject to the consolidated billing provision.  Further, under the regulations at 42 CFR 489.21(h), the beneficiary cannot be charged for the bundled services.  20 - Services Included in Part A PPS Payment Not Billable Separately by the SNF  (Rev. 2573, Issued: 10- 26-12, Effective: 04-01-13, Implementation: 04 -01-13)
(Medicare Claims Processing Manual)
For cost reporting periods beginning on and after July 1, 1998, SNF services paid under Part A include posthospital SNF services for which benefits are provided under Part A, and all items and services which, prior to July 1, 1998, had been paid under Part B but furnished to SNF residents during a Part A covered stay regardless of source, except for the exclusions listed in the annual SNF consolidated billing update files.  Annual update files, as well as subsequent quarterly updates to the annual update, for SNF consolidated billing can be found at http://www.cms.hhs.gov/SNFConsolidatedBilling/.  This file lists services by HCPCS code, short descriptors, and the major category under which the HCPCS falls.  HCPCS added or removed by subsequent quarterly update transmittals will be listed under the respective years annual update at the above link.  The respective years annual update file will be updated to add or remove the HCPCS listed in the quarterly updates.  A general explanation of the five major categories can also be found at the above link.  NOTE:  It is important for MACs/providers to understand the major categories for SNF CB.  Some major categories exclude services by revenue code (see section 20.1.2.2 for emergency room exclusion) as well as bill types (see section 20.2.1.2 on coding for renal dialysis facilities and 20.2.2 for hospice facilities).   Services paid under Part A cannot be billed under Part B.  Any service paid under Part A that is billed separately will not be paid separately, or payment will be recovered if already paid at the time of the SNF billing.  The following subsections list the  types of services that can be billed under Part B for SNF residents for whom Part A payment is made.   20.1 - Services Beyond the Scope of the Part A SNF Benefit  (Rev. 846, Issued:  02- 10-06; Effective:  12 -15-05; Implementation:  03 -13-06)
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20.1 - Services Beyond the Scope of the Part A SNF Benefit  (Rev. 846, Issued:  02- 10-06; Effective:  12 -15-05; Implementation:  03 -13-06)  The following services are beyond the scope of the SNF Part A benefit and are excluded from payment under Part A SNF PPS and from the requirement for consolidated billing.  These services must be paid to the practitioner or provider that renders them and a re billed separately by the rendering provider/supplier/practitioner to the A/B MAC (A) or (B).  The SNF may not bill excluded services separately under Part B for its inpatients entitled to Part A benefits.  HCPCS procedure codes representing these excepted services for services billed to the A/B MACs (A), (B), (HHH), and DME MACs  are updated as frequently as quarterly on the CMS Web site at :  https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/  Physicians, non-physician practitioners, and suppliers billing the A/B MAC (B) should consult the above link for lists of separately billable services.
(Medicare Claims Processing Manual)
Physicians, non-physician practitioners, and suppliers billing the A/B MAC (B) should consult the above link for lists of separately billable services.    Note :  There are separate Annual Update files for service billed to A/B MACs (B)/DME MACs and services billed to A/B MACs (A) or (HHH) posted to the Web site mentioned above.  20.1.1 - Physicians Services and Other Professional Services Excluded From Part A PPS Payment and the Consolidated Billing Requirement  (Rev. 12283, Issued:10- 05-23, Effective:01-08-24, Implementation:01-08-24)  Except for the therapy services (see 20.5), physicians professional services and services of certain nonphysician providers listed below are excluded from Part A PPS payment and the requirement for consolidated billing, and must be billed separately by the practitioner to the A/B MAC (B).  See below for Rural Health Clinic (RHC)/Federally Qualified Health Center (FQHC) instructions.  For this purpose physician service means the professional services of the physician as defined under the Medicare physician Fee Schedule.  For services that contain both a technical component and a professional component, the technical component, if any, must be billed by the SNF for its Part A inpatients.  The A/B MAC (B) will pay only the professional component to the physician.  For example, the technical component of a diagnostic radiology test (representing the performance of the procedure itself) is subject to SNF CB, whereas the professional component (representing the physicians interpretation of the test results) is excluded and, thus, remains separately billable under Part B.     Physicians services other than physical, occupational, and speech language pathology services furnished to SNF residents;     Physician assistants, working under a physicians supervision;     Nurse practitioners and clinical nurse specialists working in collaboration with a physician;     Certified nurse -midwives;     Qualified psychologists ;   Marriage and family therapists;   Mental health counselors; and    Certified registered nurse anesthetists.    SNF CB excludes the categories of practitioner services described above, and this exclusion applies specifically to those professional services that ordinarily require performance by the practitioner personally (see the regulations at  42 CFR 411.15(p)(2)(i)
(Medicare Claims Processing Manual)
and 415.102(a)(3) ).  This means, for example, that an otherwise bundled task (such as a routine blood draw) cannot be converted into an excluded physician service merely by having a physician perform it personally, as such a task does not ordinarily require performance by t he physician.  This exclusion also does not encompass services  that are performed by someone else as an incident to the practitioners professional service.  Such incident to services remain subject to SNF CB and, accordingly, must be billed to Medicare by the SNF itself (see 10.3).    Providers with the following specialty codes assigned by CMS upon enrollment with  Medicare are considered physicians for this purpose.  Some limitations are imposed by 1861(q) and (r)  of the Act.  These providers may bill their A/B MAC (B) directly.
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Physician Specialty Codes  01  General Practice  02  General Surgery  03  Allergy/Immunology  04  Otolaryngology  05  Anesthesiology  06  Cardiology  07  Dermatology  08  Family Practice  10  Gastroenterology  11  Internal Medicine  Physician Specialty Codes  12  Osteopathic Manipulative Therapy  13  Neurology  14  Neurosurgery  16  Obstetrics Gynecology  18  Ophthalmology  19  Oral Surgery (Dentists only)  20  Orthopedic Surgery  22  Pathology  24  Plastic and Reconstructive Surgery  25  Physical Medicine and Rehabilitation  26  Psychiatry  28  Colorectal Surgery (formerly Proctology)  29  Pulmonary Disease  30  Diagnostic Radiology  33  Thoracic Surgery  34  Urology  35  Chiropractic  36  Nuclear Medicine  37  Pediatric Medicine  38  Geriatric Medicine  39  Nephrology  40  Hand Surgery  41  Optometry  44  Infectious Disease  46  Endocrinology  48  Podiatry  66  Rheumatology  69  Independent Labs  70  Multi specialty Clinic or Group Practice  76  Peripheral Vascular Disease  77  Vascular Surgery  78  Cardiac Surgery  79  Addiction Medicine  81  Critical Care (Intensivists)  82  Hematology  83  Hematology/Oncology  84  Preventive Medicine  85  Maxillofacial Surgery  86  Neuropsychiatry  90  Medical Oncology  91  Surgical Oncology  92  Radiation Oncology  93  Emergency Medicine  94  Interventional Radiology  98  Gynecological/Oncology  Nonphysician Provider Specialty Codes   99  Unknown Physician Specialty  42  Certified Nurse Midwife  43  Certified Registered Nurse Anesthetist,  Anesthesia Assistants (effective 1/1/89)  50  Nurse Practitioner  62  Clinical Psychologist  (billing independently)  68  Clinical Psychologist  89  Certified Clinical Nurse Specialist  97  Physician Assistant      NOTE:   Some HCPCS codes are defined as all professional components in the fee schedule.  Fee schedule definitions apply for this purpose.  Effective July 1, 2001, the Benefits Improvement and Protection Act (BIPA) established payment method II, in which CAHs can bill and be paid for physician services billed to their A/B MAC (A).  CAHs must bill the professional fees using revenue codes 96x, 97x, or 98x on an 85x type of bill (TOB).  Like professional services billed to the A/B MAC (B), the specific line items containing these revenue codes for professional services are excluded from the requirement for consolidated billing.  RHC/FQHC Instructions:
(Medicare Claims Processing Manual)
Effective January 1, 2005, section 410 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) amended the SNF consolidated billing law to specify that when a SNFs Part A resident receives the services of a physician (or another type of practitioner that the law identifies as being excluded from SNF consolidated billing) from a RHC or a FQHC, those services are not subject to CB merely by virtue of being furnished under the auspices of the RHC or FQHC.  Accordingly, under section 410 of the MMA, services otherwise included within the scope of RHC and FQHC services that are also described in clause (ii) of section 1888(e)(2)(A) are excluded from consolidated billing, effective with services furnished on or after January 1, 2005.  Only this subset of RHC/FQHC services may be covered and paid separately when furnished to SNF residents during a covered Part A stay (see the regulations at 42 CFR  411.15(p)(2)(xvii) and 405.2411(b)(2)).  Use TOBs 71x and 73x, respectively, to bill for these RHC/FQHC services.  See Pub. 100-02, Medicare Benefit Policy Manual, chapter 13 for additional information on Part B coverage of RHC/FQHC services.   20.1.1.2 - Hospitals Facility Charge in Connection with Clinic Services of a Physician  (Rev. 3230, Issued: 04- 03-15, Effective: 06-15-15, Implementation: 06-15-15)
(Medicare Claims Processing Manual)
As noted above in section 20.1.1, physician services are excluded from Part A PPS payment and the requirement for consolidated billing.  When a beneficiary receives clinic services from a hospital -based physician, the physician in this situation would bill his or her own professional services directly to the A/B MAC (B) and would be reimbursed at the facility rate of the Medicare physician fee schedule - which does not include overhead expenses.  The hospital historically has submitted a separate Part B facility charge for the associated overhead expenses to its A/B MAC (A).  The hospitals facility charge does not involve a separate service (such as a diagnostic test) furnished in addition to the physicians professional service; rather, it represents solely the overhead expenses associated with furnishing the professional service itself.  Accordingly, hospitals bill for facility charges under the physician evaluation and management (E&M) codes in the range of 99201-99245 and G0463 (for hospitals paid under the Outpatient Prospective Payment System).   E&M codes, representing the hospitals facility charge for the overhead expenses associated with furnishing the professional service itself, are excluded from SNF CB.  Effective for claims with dates of service on or after January 1, 2006, the CWF will bypass CB edits when billed with revenue code 0510 (clinic visit) with an E&M HCPCS code in the range of 99201- 99245 and, effective January 1, 2014 with HCPCS code G0463.  NOTE:   Unless otherwise excluded in one of the Five Major Categories for billing services to A/B MACs (A) , physician services codes are to be billed to the A/B MAC (B)  by the physician.  Facility charges associated with the physicians clinic visit must be reported as explained above.  20.1.2 - Other Excluded Services Beyond the Scope of a SNF Part A Benefit  (Rev. 4409, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19)
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The following services are not included in Part A PPS payment when furnished in a Medicare participating hospital or CAH and may be paid to the provider rendering them.  This exception does not apply if the service is furnished in an ambulatory surgical center  (ASC) or other independent (non- hospital) facility, because it specifically addresses those services that are so far beyond the normal scope of SNF care as to require the intensity of the hospital setting  in order to be furnished safely and effectively.  In transmittals for Part A and B institutional billing providing the annual update list of HCPCS codes affected by SNF consolidated billing, such services are referre d to as  Major Category I of SNF consolidated billing editing.  Note that of the types of services listed, only ambulatory surgeries are listed as inclusions, rather than exclusions, to consolidated billing.   Certain  cardiac catheterizations;    Certain computerized axial tomography (CT) scans;    Certain magnetic resonance imaging (MRIs);    Certain ambulatory surgeries involving the use of a hospital operating room or comparable hospital facilities (i.e., the use of a gastrointestinal (GI) suite or endoscopy suite for the insertion of a percutaneous esophageal gastrostomy (PEG) tube).  For Part A inpatients, the professional portion of these services is billed by the rendering practitioner to the A/B MAC (B).  Any hospital outpatient charges are billed to the A/B MAC (A).    Certain radiation therapies;   Certain angiographies, and lymphatic and venous procedures;    Emergency services; and    Ambulance services when related to an excluded service within this list (see 20.3 for ambulance transportation related to dialysis services).
(Medicare Claims Processing Manual)
 Certain angiographies, and lymphatic and venous procedures;    Emergency services; and    Ambulance services when related to an excluded service within this list (see 20.3 for ambulance transportation related to dialysis services).   These relatively costly services are beyond the general scope of care in SNFs, and their receipt has the effect of temporarily suspending a beneficiarys status as a SNF resident for CB purposes with respect to such services.  Even though it may be medic ally appropriate for a beneficiary to be cared for in a SNF while receiving radiation therapy, the SNF is not responsible for paying for excluded radiation therapy itself when the beneficiary receives it as a hospital outpatient.  Similarly, angiography codes and codes for some lymphatic and venous procedures are considered beyond the general scope of services delivered by SNFs.  The hospital or CAH must bill the A/B MAC (A) for the services.  Excluded services provided to Medicare beneficiaries in swing be ds subject to SNF PPS are to be billed on TOB 13x by the swing bed hospital (see 100.1).  Services directly related to these services, defined as services billed for the same place of service and with the same line item date of service as the services listed below, are also excluded from SNF CB, with exceptions as listed below.  This language a ddresses excluding as directly related those items and services that are so closely associated with the excluded procedure that it would actually be impossible to perform the excluded procedure itself without them, such as the anesthesia for an excluded ambulatory surgical procedure under 20.1.2.1, or an otherwise bundled diagnostic test when needed to identify the cause of (and appropriate course of treatment for) a medical emergency under 20.1.2.2.   Note that anesthesia, drugs incident to radiology and supplies will be bypassed by enforcement edits when billed with CT Scans, Cardiac Catheterizations, MRIs, Radiation Therapies, or Angiographies or surgeries.
(Medicare Claims Processing Manual)
In general, bypasses also allow CT Scans, Cardiac Catheterization, MRI, Radiation Therapy, Angiography, and Outpatient Surgery HCPCS codes 0001T  0021T, 0024T  0026T, or 10021 -  69990 (except those HCPCS codes listed in Major Category I. F.) to process and pay.  This includes all other revenue code lines on the incoming claim that have the same line item date of service (LIDOS).   20.1.2.1 Outpatient Surgery and Related Procedures - INCLUSION  (Rev. 3612, Issued: 09- 16-16, Effective: 10 -18-16, Implementation: 10- 18-16)  Inclusions, rather than exclusions, are given in this one case, because of the great number of surgical procedures that are excluded and can only be safely performed in a hospital operating room setting.  It is easier to automate edits around the much shorter list of inclusions under this category, representi ng minor procedures (such as debriding a mycotic toenail) that, while technically considered surgery, can nevertheless be safely performed at bedside in the SNF itself.  Additionally, this was the approach originally taken in the regulation to present this information.    Note that anesthesia, drugs, supplies and lab services will be bypassed by enforcement edits when billed with outpatient surgeries excluded  from SNF CB.  The bypass is implemented for these services when the line item date of service matches the line item date of service for the excluded surgery.  For revenue codes not requiring a line item date of service (i.e., pharmacy and supplies), the bypass will be implemented when no line item date of service is present.   See 10.1 above for the link to where transmittals providing current lists of HCPCS codes used for Major Category I SNF consolidated billing editing can be found.  20.1.2.2 - Emergency Services  (Rev. 2573, Issued: 10- 26-12, Effective: 04-01-13, Implementation: 04-01-13)
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Emergency room services performed in hospitals, including CAHs, are excluded from SNF CB for beneficiaries that are in skilled Part A SNF stays.  Hospitals report emergency room (ER) services under the 045X (Emergency Room - x represents a varying third digit) revenue code with a line item date of service (LIDOS) indicating the date the patient entered the ER.  Services related to the ER encounter are also excluded from the SNF CB provision.  Emergency services are defined in the regulations at 42 CFR 42 4.101 as . . . services that are necessary to prevent death or serious impairment of health and, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services.  In this context, fal se alarm situations may occasionally arise, in which the initial assessment of a beneficiarys condition as life-threatening subsequently proves to be unfounded (for example, where a patients chest pain and shortness of breath initially appear to be symptoms of a heart attack, but upon subsequent examination turn out to be merely a bad case of indigestion).  Such situations still qualify for the emergency services exclusion from SNF CB as long as the initial symptoms provided a reasonable basis for assuming the onset of a medical emergency, even though this assumption ultimately was not borne out by subsequent events.   Where services related to the ER encounter span more than one service date, hospitals must identify those services by appending a modifier ET (Emergency Services) to those line items.  The reporting of the ET modifier will alert CWF that these are related ER services performed on subsequent dates so the SNF CB edits in CWF will be bypassd.  20.2 - Services Excluded from Part A PPS Payment and the Consolidated Billing Requirement on the Basis of Beneficiary Characteristics and Election  (Rev. 2573, Issued: 10- 26-12, Effective: 04-01-13, Implementation: 04-01-13)  SNF -516