evekhm/cms_iom_500 huggingface dataset:
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Section 1833(t)(1)(B)(i) of the Act allows CMS to define the services for which payment under the OPPS is appropriate and the Secretary has determined that the services designated to be inpatient only services are not appropriate to be furnished in a hospital outpatient department. Inpatient only services are ge nerally, but not always, surgical services that require inpatient care because of the nature of the procedure, the typical underlying physical condition of patients who require the service, or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged. An example of an inpatient only service is CPT code 33513, Coronary artery bypass, vein only; four coronary venous grafts. The designation of services to be inpatient -only is open to public comment each year as part of the annual rulemaking process. Procedures removed from the inpatient only list may be appropriately furnished in either the inpatient or outpatient settings and such procedures continue to be payable when furnished in the inpat ient setting.  There is no payment under the OPPS for services that CMS designates to be inpatient -only services. These services have an OPPS status indicator of C in the OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule. For th e most current Addendum B and for Addendum E published with the OPPS notices and regulations, see http://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/HospitalOutpatientPPS/index.html.  Excluding the handful of exceptions discussed below, CMS does not pay for an inpatient -only service furnished to a person who is registered in the hospital as an outpatient and reports the service on the outpatient hospital bill type (TOB 13X). CMS also does not pay for all other services on the same day as the inpatient only procedure.  There are two exceptions to the policy of not paying for outpatient services furnished on the same day with an inpatient -only service that would be paid under the OPPS if the inpatient service had not been furnished:  Exception 1: If the inpatient -only service is defined in CPT to
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furnished on the same day with an inpatient -only service that would be paid under the OPPS if the inpatient service had not been furnished:  Exception 1: If the inpatient -only service is defined in CPT to be a separate procedure and the other services billed with the inpatient -only service contain a procedure that can be paid under the OPPS and that has an OPPS SI=T on the same date as the inpatient -only procedure or OPPS SI = J1 on the same claim as the inpatient -only procedure, then the inpatient -only service is denied but CMS makes payment for the separate procedure and any remaining payable OPPS services. The list of separate procedures is available with the Integrated Outpatient Code Editor (I/OCE) documentation. See http://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/. Exception 2: If an inpatient -only service is furnished but the patient expires before inpatient admission or transfer to another hospital and the hospital reports the inpatient only service with modifier CA, then CMS makes a single payment for all se rvices reported on the claim, including the inpatient only procedure, through one unit of APC 5881, (Ancillary outpatient services when the patient dies.) Hospitals should report modifier CA on only one procedure.  As of January 1, 2020, procedures that have been removed from the inpatient -only (IPO) list are exempt from certain medical review activities related to compliance with the 2 -midnight rule, which states that generally services are considered appropriate for inpatient hospital admission and payment under Medicare Part A when the physician expects the patient to require a stay that crosses at least 2 midnights and admits the patient to the hospital based upon that expectation (78 FR 50913 through 50954).    Specifically, procedures that have been removed from the IPO list are not eligible for referral to Recovery Audit Contractors (RACs) for noncompliance with the 2- midnight rule within the 2 -calendar years following their removal from the IPO list. These procedures will not be considered by the Beneficiary and Family- Centered Care Quality Improvement Organizations (BFCC -QIOs) in determining whether a provider exhibits persistent noncompliance with the 2-
(Medicare Claims Processing Manual)
their removal from the IPO list. These procedures will not be considered by the Beneficiary and Family- Centered Care Quality Improvement Organizations (BFCC -QIOs) in determining whether a provider exhibits persistent noncompliance with the 2- midnight rule for purposes of referral to the RAC nor wi ll these procedures be reviewed by RACs for patient status within the 2 -calendar years following their removal from the IPO list.  During the 2- year exemption period, BFCC -QIOs will have the opportunity to review claims for procedures that have been recently removed from the IPO list in order to provide education for practitioners and providers regarding compliance with the 2-midnight  rule, but claims identified as noncompliant with the 2 -midnight rule will not be denied with respect to the site -of-service under Medicare Part A.  190  Payer Only Codes Utilized by Medicare  (Rev. 4391, Issued: 09- 06-19, Effective: 07 -01-19, Implementation: 07- 01-19)
(Medicare Claims Processing Manual)
This section contains the listing of payer codes designated by the National Uniform Billing Committee to be assigned by payers only.  Providers shall not submit these codes on their claims forms.  The definitions indicating Medicares usage for these syste matically assigned codes are indicated next to each code value.   Condition Codes   12-14 - Not currently used by Medicare.   15  Clean claim is delayed in CMS Processing System.   16  SNF Transition exception.  60  Operating Cost Day Outlier.   61  Operating Cost Outlier.   62  PIP Bill.   63  Bypass CWF edits for incarcerated beneficiaries. Indicates services rendered to a prisoner or a patient in State or local custody meets the requirement of 42 CFR 411.4(b) for payment.   64  Other Than Clean Claim.   65  Non -PPS Bill.   98  Data Associated With DRG 468 Has Been Validated.   EY  Lung Reduction Study Demonstration Claims.  M0  All -Inclusive Rate for Outpatient -  Used by a Critical Access Hospital electing to be paid an all -inclusive rate for outpatient services.   M1  Roster Billed Influenza Virus Vaccine or Pneumococcal Pneumonia Vaccine (PPV). Code indicates the influenza virus vaccine or pneumonia vaccine (PPV) is being billed via the roster billing method by providers that mass immunize.   M2  Allows Home Health claims to process if provider reimbursement > $150,000.00. HHA Payment Significantly Exceeds Total Charges. Used when payment to an HHA is significantly in excess of covered billed charges.   M3  SNF 3 Day stay bypass for NG/Pioneer ACO waiver.   M4  Presence of infected wound or wound with morbid obesity    M5  Not currently used by Medicare   M6  PA Rural Health Model   M7-M9  Not currently used by Medicare.  MA  GI Bleed. (Bill Type 72x)   MA  Managed Care Enrollee (Bill Type 12x, 13x, and 76x)   MB  Pneumonia. (Bill Type 72x)   MC  Pericarditis. (Bill Type 72x)   MD -  Myelodysplastic Syndrome. (Bill Type 72x)   ME -  Hereditary Hemolytic and Sickle Cell Anemia. (Bill Type 72x)   MF -  Monoclonal Gammopathy. (Bill Type 72x)   MG  Grandfathered Tribal Federally Qualified Health Centers.
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ME -  Hereditary Hemolytic and Sickle Cell Anemia. (Bill Type 72x)   MF -  Monoclonal Gammopathy. (Bill Type 72x)   MG  Grandfathered Tribal Federally Qualified Health Centers.   MH-MO  Not currently used by Medicare.   MP  PHP claim contains initial admit week   MQ  PHP claim contains final discharge week    MR-MW  Not currently used by Medicare.   MX  Wrong Surgery on Patient (Inpatient)   MY  Surgery Wrong Body Part (Inpatient)   MY  Outlier Cap Bypass (CMHC)   MZ  Surgery Wrong Patient (Inpatient)   MZ  IOCE error code bypass   UU  Not currently used by Medicare.   Occurrence Codes   23 - Date of Cancellation of Hospice Election period.  48 - Date hospice face- to-face encounter was untimely   49  Original Notice of Election (NOE) receipt date   Occurrence Span Codes   79 - Verified non- covered stay dates for which the provider is liable.   Value Codes   17- Operating Outlier Amount  The A/B MAC (A) reports the amount of operating outlier payment amount made (either cost or day (day outliers have been obsolete since 1997)) in CWF with this code.  It does not include any capital outlier payment in this entry.  18  Operating Disproportionate Share Amount  The A/B MAC (A) REPORTS THE OPERATING DISPROPORTIONATE SHARES AMOUNT APPLICIALBE.  It uses the amount provided by the disproportionate share field in PRICER.  It does not include any PPS capital IME adjustment  entry.   19  The Medicare shared system will display this payer only code on the claim for low volume providers to identify the amount of the low volume adjustment being included in the providers reimbursement.  This payer only code 19 is also used for IME on hos pital claims.  This instruction shall only apply to ESRD bill type 72x and must not impact any existing instructions for other bill types.   19 - Operating Indirect Medical Education Amount  The A/B MAC (A) reports operating indirect medical education amount applicable.  It uses the amount provided by the indirect medical education field in PRICER.  It does not include any PPS capital IME adju stment in this entry.
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20  Total payment sent provider for capital under PPS, including HSP, FSP, outlier, old capital, DSH adjustment, IME adjustment, and any exception amount.  62   On Type of Bill 032x:  HH Visits -  Part A -  The number of visits determined by Medicare to be payable from the Part A trust fund to reflect the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Securi ty Act.  On Type of Bills 081x 0r 082x: Number of High Routine Home Care Days -  Days that fall within the first 60 days of a routine home care hospice claim.  63  On Type of Bill 032x:  HH visits  Part B -  The number of visits determined by Medicare to be payable from the Part B trust fund to reflect the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Securit y Act.  On Type of Bills 081x 0r 082x: Number of Low Routine Home Care Days -  Days that come after the first 60 days of a routine home care hospice claim.  63  On Type of Bills 081x 0r 082x: Number of Low Routine Home Care Days - Days that come after the first 60 days of a routine home care hospice claim.   64 - HH Reimbursement  Part A -  The dollar amounts determined to be associated with the HH visits identified in a value code 62 amount.  This Part A payment reflects the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3)  of the Social Security Act.   65 - HH Reimbursement  Part B -  The dollar amounts determined to be associated with the HH visits identified in a value code 63 amount.  This Part B payment reflects the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Security Act.   70 - Interest Amount -  The contractor reports the amount of interest applied to this Medicare claim.   71 - Funding of ESRD Networks -  The A/B MAC (A) reports the amount the Medicare payment was reduced to help fund ESRD networks.   72- Flat Rate Surgery Charge -  The standard charge for outpatient surgery where the provider has such a charging structure.
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72- Flat Rate Surgery Charge -  The standard charge for outpatient surgery where the provider has such a charging structure.   73- Sequestration adjustment amount.  74  Low volume hospital payment amount   75- Prior covered days for an interrupted stay.   76  Providers Interim Rate Providers percentage of billed charges interim rate during this billing period.  This applies to all outpatient hospital and skilled nursing facility (SNF) claims and home health agency (HHA) claims to which an interim rate is applicable.  The contractor reports to the left of the dollar/cents delimiter. An interim rate of 50 percent is entered as follows: 50.00.  77 - Medicare New Technology Add- On Payment -  Code indicates the amount of Medicare additional payment for new technology.  78  Off-site Zip Code - When the facility zip (Loop 2310E N403 Segment) is present for the following bill types: 12X, 13X, 14X, 22X, 23X, 34X, 72X, 74X, 75X, 81X, 82X, and 85X.  The ZIP code is associated with this value and is used to price MPFS HCPCS and Anesthesia Services for  CAH Method II.   79  Total payments for services applicable to the ESRD -  The Medicare shared system will display this payer only code on the claim.  The value represents the dollar amount for Medicare allowed payments applicable for the calculation in determining an outlier payment.   Q0  Pioneer Accountable Care Organization (ACO) non-model payment or Next Generation ACO non- model payment   Q1  Pioneer ACO model payment amount including reduction or NG ACO payment amount including reduction   Q2  Hospice claim paid from Part B Trust Fund   Q3  Prior Authorization 25% Penalty  Q4  PA Rural Model Exclusion - Physician Service Claim Reimbursement   Q5  EHR   Q6  PQRS               Q7  Islet Isolation Add -on payment amount   Q8 - Transitional Drug Add- On Payment Adjustment (TDAPA)   Q9  Medicare Performance Adjustment (MPA)   QA-QC  Not used by Medicare   QD  Device Credit   QE-QL  Not used by Medicare   QM  MIPS adjustment amount   QN  First APC pass- through device offset   QO  Second APC pass -through device offset   QP  Third APC pass -through device offset   QQ  Terminated procedure with device offset
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QM  MIPS adjustment amount   QN  First APC pass- through device offset   QO  Second APC pass -through device offset   QP  Third APC pass -through device offset   QQ  Terminated procedure with device offset   QR  First APC pass- through drug or biological offset   QS  Second APC pass -through drug or biological offset   QT  Third APC pass -through drug or biological offset   QU Device credit with device offset   QV  Value -based purchasing adjustment amount   QW  Placeholder reserved for future use   QX-QZ  Not used by Medicare   200 - Special Services for OPPS Billing  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  200.1 - Billing for Corneal Tissue  (Rev. 3425, Issued: 12- 18-15, Effective: 01 -01-16, Implementation: 01- 04-16)  Corneal tissue will be paid on a cost basis, not under OPPS, only when it is used in a corneal transplant procedure described by one of the following CPT codes: 65710, 65730, 65750, 65755, 65756, 65765, 65767, and any successor code or new code describing a new type of corneal transplant procedure that uses eye banked corneal tissue.  In all other procedures cornea tissue is packaged.  To receive cost based reimbursement hospitals must bill charges for corneal tissue using HCPCS code V2785.   200.2 - Hospital Dialysis Services For Patients With and Without End Stage Renal Disease (ESRD)  (Rev.  2455, Issued: 04- 26-12, Effective: 10 -01-12, Implementation; 10- 01-12)
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Effective with claims with dates of service on or after August 1, 2000, hospital -based End Stage Renal Disease (ESRD) facilities must submit services covered under the ESRD benefit in 42 CFR 413.174 (maintenance dialysis and those items and services direct ly related to dialysis such as drugs, supplies) on a separate claim from services not covered under the ESRD benefit.  Items and services not covered under the ESRD benefit must be billed by the hospital using the hospital bill type and be paid under the O utpatient Prospective Payment System  (OPPS) (or to a CAH at reasonable cost).  Services covered under the ESRD benefit in 42 CFR 413.174 must be billed on the ESRD bill type and must be paid under the ESRD PPS.  This requirement is necessary to properly pay only unrelated ESRD services (thos e not covered under the ESRD benefit) under OPPS (or to a CAH at reasonable cost).   Medicare does not allow payment for routine or related dialysis treatments, which are covered and paid under the ESRD PPS, when furnished to ESRD patients in the outpatient department of a hospital. However, in certain medical situations in which the ESRD outpatient cannot obtain her or his regularly scheduled dialysis treatment at a certified ESRD facility, the OPPS rule for 2003 allows payment for non- routine dialysis treatments (which are not covered under the ESRD benefit) furnished to ESRD outpatients in the outpatient department of a hospital.  Payment for unscheduled dialysis furnished to ESRD outpatients and paid under the OPPS is limited to the following circumstances:    Dialysis performed following or in connection with a dialysis -related procedure such as vascular access procedure or blood transfusions;    Dialysis performed following treatment for an unrelated medical emergency; e.g., if a patient goes to the emergency room for chest pains and misses a regularly scheduled dialysis treatment that cannot be rescheduled, CMS allows the hospital to provide and bill Medicare for the dialysis treatment; or    Emergency dialysis for ESRD patients who would otherwise have to be admitted as inpatients in order for the hospital to receive payment.
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 Emergency dialysis for ESRD patients who would otherwise have to be admitted as inpatients in order for the hospital to receive payment.   In these situations, non- ESRD certified hospital outpatient facilities are to bill Medicare using the Healthcare Common Procedure Coding System (HCPCS) code G0257 (Unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not certified as an ESRD facility).    HCPCS code G0257 may only be reported on type of bill 13X (hospital outpatient service) or type of bill 85X (critical access hospital) because HCPCS code G0257 only reports services for hospital outpatients with ESRD and only these bill types are used to report services to hospital outpatients.  Effective for services on and after October 1, 2012, claims containing HCPCS code G0257 will be returned to the provider for correction if G0257 is reported with a type of bill other than 13X or 85X (such as a 12x inpatient claim).   HCPCS code 90935 (Hemodialysis procedure with single physician evaluation) may be reported and paid only if one of the following two conditions is met:   1) The patient is a hospital inpatient with or without ESRD and has no coverage under Part A, but has Part B coverage.  The charge for hemodialysis is a charge for the use of a prosthetic device.  See Benefits Policy Manual 100- 02 Chapter 15 section 120.  A.  The service must be reported on a type of bill 12X or type of bill 85X.  See the Benefits Policy Manual 100- 02 Chapter 6 section 10 ( Medical and Other Health Services Furnished to Inpatients of Participating Hospitals)  for the criteria that must be met fo r services to be paid when a hospital inpatient has Part B coverage but does not have coverage under Part A; or   2) A hospital outpatient does not have ESRD and is receiving hemodialysis in the hospital outpatient department.  The service is reported on a type of bill 13X or type of bill 85X.
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2) A hospital outpatient does not have ESRD and is receiving hemodialysis in the hospital outpatient department.  The service is reported on a type of bill 13X or type of bill 85X.    CPT code 90945 (Dialysis procedure other than hemodialysis (e.g. peritoneal dialysis, hemofiltration, or other continuous replacement therapies)), with single physician evaluation, may be reported by a hospital paid under the OPPS or CAH method I or method II on type of bill 12X, 13X or 85X.   200.3 - Billing Codes for Intensity Modulated Radiation Therapy (IMRT) and Stereotactic Radiosurgery (SRS)  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  200.3.1 - Billing Instructions for IMRT Planning and Delivery  (Rev. 3685, Issued: 12- 22-16, Effective: 01 -01-17, Implementation: 01- 03-17)  Payment for the services identified by CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT  code 77301 (IMRT planning). These codes should not be reported in addition to CPT  code 77301 when provided prior to or as part of the development of the IMRT  plan.  In addition, CPT codes 77280- 77290 (simulation- aided field settings) should not be reported for verification of the treatment field during a course of IMRT.     200.3.2 - Billing for Multi- Source Photon (Cobalt 60 -Based) Stereotactic Radiosurgery (SRS) Planning and Delivery (Rev. 3941; Issued: 12- 22-17; Effective: 01 - 01-18; Implementation: 01 -02-18)  Effective for services furnished on or after January 1, 2014, hospitals must report  SRS planning and delivery services using only the CPT codes that accurately describe  the service furnished.  For the delivery services, hospitals must report CPT code  77371, 77372, or  77373.
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CPT  Code  Long  Descriptor  77371 Radiation treatment delivery, stereotactic radiosurgery (srs),  complete course of treatment of cranial lesion(s) consisting of 1 session;  multi-  source cobalt 60  based  77372 Radiation treatment delivery, stereotactic radiosurgery (srs),  complete course of treatment of cranial lesion(s) consisting of 1 session;  linear accelerator  based  77373 Stereotactic body radiation therapy, treatment delivery, per fraction to  1 or more lesions, including image guidance, entire course not to exceed 5 fractions
(Medicare Claims Processing Manual)
As instructed in the CY 2014 OPPS/ASC final rule, CPT code 77371 is to be used only for single session cranial SRS cases performed with a Cobalt -60 device, and CPT  code 77372 is to be used only for single session cranial SRS cases performed with a  linac - based device.  The term cranial means that the pathological lesion(s) that are the  target  of the radiation is located in the patients cranium or head.  The term single  session means that the entire intracranial lesion(s) that comprise the patients diagnosis  are treated in their e ntirety during a single treatment session on a single day.  CPT  code 77372 is never to be used for the first fraction or any other fraction of a fractionated SRS treatment.  CPT code 77372 is to be used only for single session cranial linac -based  SRS treatment.  Fractionated SRS treatment is any SRS delivery service requiring more than  a single session of SRS treatment for a cranial lesion, up to a total of no more than five fractions, and one to five sessions (but no more than five) for non -cranial lesions.   CPT code 77373 is to be used for any fraction (including the first fraction) in any series  of fractionated treatments, regardless of the anatomical location of the lesion or  lesions being radiated.  Fractionated cranial SRS is any cranial SRS that exceeds one treatment session and fractionated non- cranial SRS is any non -cranial SRS, regardless of  the number of fractions but never more than five.  Therefore, CPT code 77373 is  the exclusive code (and the use of no other SRS treatment delivery code is permitted) for  any and all fractionated SRS treatment services delivered anywhere in the body, including, but not limited to, the cranium or head.  77372 is not to be used for the first fraction of  a fractionated cranial SRS treatment series and must only be used in cranial SRS  when  there is a single treatment session to treat the patients entire  condition.