evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Medical Necessity of Therapy Services (A52775)
Successful rehabilitation therapy requires the attainment of significant progress for a reasonable period of time beyond the immediate intervention. Services should not be repetitive, palliative, or simply reinforcing previously learned skills or maintaining function. In most instances, the goal of therapy is to maximize patient/caregiver abilities within the patients home environment. It is expected that the patients treatment goals and achievements during the therapy episode will reflect significant and timely progress toward this end. As a result, during the therapy episode, the emphasis of therapy will generally shift from traditional, patient-centered therapeutic services to patient/caregiver education in order to prepare the patient for a safe transition to an effective maintenance program. The expectation is that the patient/caregiver will be compliant in performing the established maintenance program to help prevent relapse. If therapeutic gains from prior therapy services are tenuous, such that additional concentrated therapy is needed for non-skilled maintenance of the patient in their usual living environment (that includes caregivers), then the goals of additional therapy would be considered to be unrealistic.Medical Necessity - MaintenanceMedicare reimburses for the development of a medically necessary individualized maintenance program to:Maximize and retain the patient's functional status achieved with therapy services;Assure patient safety within their home environment;Train the patient and/or caregiver in the maintenance activities;Prevent further decline in the patient's condition.Medicare does not reimburse for carrying out maintenance activities when:The activities do not require the skills of a qualified clinician i.e., the level of complexity and sophistication of the activities do not require the performance and/or supervision of a therapist.The condition of the patient is such that the services do not require the performance and/or supervision of a therapist.The activities can reasonably be provided by non-skilled personnel after training is completed by the qualified clinician.
Article - Billing and Coding: Medical Necessity of Therapy Services (A52775)
It is anticipated that once the maintenance program is established, updates to the program will be necessary on an infrequent basis.When additional medical necessary services are required for the same medical condition, a thorough initial evaluation should be completed for the patient who was previously discharged. Documentation for maintenance program revisions must support that any additional therapy services require the performance and/or supervision of a qualified therapist due to the complexity/sophistication of the required procedures and/or the condition of the patient. The documentation must clearly indicate why a revision of the maintenance program is necessary and what specific revision(s) are needed. Key documentation components include:Was the patient/caregiver compliant with their previously established maintenance program?Was the patient unable to complete the maintenance program? Why?Are there anynewsignificant medical and/or functional issues noted since discharge from prior therapy that necessitate revision of the maintenance program?For additional information, see the attachedBilling and Coding: Therapy Evaluation, Re-Evaluation and Formal Testingarticle in the Related Local Coverage Documents link below.SourcesCenters for Medicare and Medicaid Services (CMS) Resident Assessment Instrument Manual (RAI) Version 3, Section OCMS Inpatient Rehabilitation Facility (IRF) Training Q&A Series 4 Section V, #33IOM,Medicare Benefit Policy Manual, Publication 100-02, Chapter 1, Section 110IOM,Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Sections 220-230.
(Medicare Benefit Policy Manual)
Medicare Benefit Policy Manual  Chapter 1 - Inpatient Hospital Services Covered Under Part A
(Medicare Benefit Policy Manual)
Table of Contents (Rev. 10892, 08-06-21) Transmittals for Chapter 1  1  Definition of Inpatient Hospital Services  10 - Covered Inpatient Hospital Services Covered Under Part A  10.1 - Bed and Board  10.1.1 - Accommodations - General  10.1.2 - Medical Necessity - Need for Isolation  10.1.3 - Medical Necessity - Admission Required and Only Private Rooms Available  10.1.4 - Charges for Deluxe Private Room  10.1.5 - All Private Room Providers  10.1.6 - Wards  10.1.6.1 - Assignment Cons istent With Program Purposes  10.1.6.2 - Assignment Not Consistent With Program Purposes  10.1.7 - Charges  10.2  Hospital Inpatient Admission Order and Certification  20 - Nursing and Other Services  20.1 - Anesthetist Services  20.2 - Medical Social Services to Meet the Patient's Medically Related Social Needs  30 - Drugs and Biologicals  30.1 - Drugs Included in the Drug Compendia  30.2 - Approval by Pharmacy and Drug Therapeutics Committee  30.3 - Combination Drugs  30.4 - Drugs Specially Ordered for Inpatients  30.5 - Drugs for Use Outside the Hospital  40 - Supplies, Appliances, and Equipment  50 - Other Diagnostic or Therapeutic Items or Services  50.1 -  Therapeutic Items  50.2 -  Diagnostic Services of Psychologists and Physical Therapists  50.3 -  Diagnostic Services Furnished to an Inpatient by an Independent Clinical Laboratory Under Arrangements With the Hospital  50.4 -  Diagnostic Services Furnished a Hospital Inpatient Under Arrangement With the Laboratory of Another Participating Hospital 60 - Services of Interns or Residents -In-Training 70 - Inpatient Services in Connection With Dental Services  80 - Health Care Associated With Pregnancy  90 - Termination of Pregnancy  100 -  Treatment for Infertility  110 -  Inpatient Rehabilitation Facility (IRF) Services  110.1 -  Documentation Requirements  110.1.1 -  Required Preadmission Screening 110.1.2 -  Required Post -Admission Physician Evaluation  110.1.3 -  Required Individualized Overall Plan of Care  110.1.4 -  Required Admission Orders  110.1.5 -  Required Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF -PAI)  110.2 -  Inpatient Rehabilitation Facility Medical Necessity Criteria  110.2.1 -  Multiple Therapy Disciplines  110.2.2 -  Intensive Level of Rehabilitation Services  110.2.3 -  Ability to Actively Participate in Intensive Rehabilitation Therapy Program
(Medicare Benefit Policy Manual)
-PAI)  110.2 -  Inpatient Rehabilitation Facility Medical Necessity Criteria  110.2.1 -  Multiple Therapy Disciplines  110.2.2 -  Intensive Level of Rehabilitation Services  110.2.3 -  Ability to Actively Participate in Intensive Rehabilitation Therapy Program  110.2.4 -  Physician Supervision 110.2.5 -  Interdisciplinary Team Approach to the Delivery of Care
(Medicare Benefit Policy Manual)
110.2.6  IRF Waivers and Flexibilities During the Public Health                                Emergency for the COVID -19 Pandemic  110.3 -  Definition of Measurable Improvement  120 -  Services Rel ated to and Required as a Result of Services Which Are Not Covered Under Medicare  130 -  Religious Nonmedical Health Care Institution (RNHCI) Services  130.1 -  Beneficiary Eligibility for RNHCI Services  130.2 -  Election of RNHCI Benefits  130.2.1  Revocation of RNHCI Election 130.2.2  RNHCI Election After Prior Revocation  130.3  Medicare Payment for  RNHCI Services and Beneficiary Liability  130.4 -  Coverage of RNHCI Items Furnished in the Home  130.4.1 -  Coverage and Payment of Durable Medical Equipment Under the RNHCI Home Benefit  130.4.2 -  Coverage and Payment of Home Visits Under the RNHCI Home Benefit  1  Definition of Inpatient Hospital Services  (Rev. 1, 10-01-03)  Inpatient hospital services are defined in Title XVIII of the Social Security Act (the Act) and in the regulations (42 CFR 409.10):  A.  Subject to the conditions, limitations, and exceptions set forth in this subpart, the term "inpatient hospital or inpatient CAH services" means the following services furnished to an inpatient of a particip ating hospital or of a participating CAH or, in the case of emergency services or services in foreign hospitals, to an inpatient of a qualified hospital:  1.  Bed and board.  2.  Nursing services and other related services.  3.  Use of hospital or CAH faci lities.   4.  Medical social services.   5.  Drugs, biologicals, supplies, appliances, and equipment.  6.  Certain other diagnostic or therapeutic services.   7.  Medical or surgical services provided by certain interns or residents- in- training.   8.  Transportation services, including transport by ambulance.  B.  Inpatient hospital services does not include the following types of services:  1.  Posthospital SNF care, as described in 42 CFR  409.20 , furnished by a hospital or a critical access hospital that has a swing -bed approval.  2.  Nursing facility services, described in 42 CFR 440.155
(Medicare Benefit Policy Manual)
CFR  409.20 , furnished by a hospital or a critical access hospital that has a swing -bed approval.  2.  Nursing facility services, described in 42 CFR 440.155 that may be furnished as a Medicaid service under title XIX of the Act in a swing - bed hospital that has an approval to furnish nursing facility services.  3.  Physician services that meet the requirements of 42 CFR 415.102(a) for payment on a fee schedule basis.   4.  Physician assistant services, as defined in 1861(s)(2)(K)(i) of the Act.   5.  Nurse practitioner and clinical nurse specialist services, as defined in 1861(s)(2)(K)(ii) of the Act.   6.  Certified nurse mid -wife services, as defined in 1861(gg) of the Act.   7.  Qualified psychologist services, as defined in 1861(ii)  of the Act.   8.  Services of an anesthetist, as defined in 42 CFR 410.69.  10 - Covered Inpatient Hospital Services Covered Under Part A  (Rev.  234, Issued: 03-10-17, Effective: 01-01-16, Implementation: 06-12-17)  Patients covered under hospital insurance are entitled to have payment made on their behalf for inpatient hospital services.  (Inpatient hospital services do not include extended care services provided by hospitals pursuant to swing bed approvals.  See Pub. 100-02, Chapter 8, 10.3, "Hospital Providers of Extended Care Services.").   However, both inpatient hospital and inpatient SNF benefits are provided under Part A - Hospital Insurance Benefits for the Aged and Disabled, of Title XVIII).  Additional information concerning the following topics can be found in the following chapters of this manual:    Benefit Period is found in Chapter 3    Counting Inpatient Days is found in Chapter 3    Lifetime reserve days is found in Chapter 5    Related payment information is housed in the Provider Reimbursement Manual
(Medicare Benefit Policy Manual)
 Benefit Period is found in Chapter 3    Counting Inpatient Days is found in Chapter 3    Lifetime reserve days is found in Chapter 5    Related payment information is housed in the Provider Reimbursement Manual   Blood must be furnished on a day which counts as a day of inpatient hospital services to be covered as a Part  A service and to count toward the blood deductible.  Thus, blood is not covered under Part A and does not count toward the Part A blood deductible when furnished to an inpatient after the inpatient has exhausted all benefit days in a benefit period, or where the individual has elected not to use lifetime reserve days.  However, where the patient is discharged on their first day of entitlement or on the hospital's first day of participation, the hospital is permitted to submit a billing form with no accommo dation charge, but with ancillary charges including blood.  The records for all Medicare hospital inpatient discharges are maintained in CMS for statistical analysis and use in determining future Prospective Payment System (PPS) Diagnosis Related Group (DR G) classifications and rates.   Non-PPS hospitals do not pay for noncovered services generally excluded from coverage in the Medicare Program.  This may result in denial of a part of the billed charges or in denial of the entire admission, depending upon circumstance.  In PPS hospitals, the following are also possible:  1. In appropriately admitted cases where a noncovered procedure was performed, denied services may result in payment of a different DRG (i.e., one which excludes payment for the noncovered procedure); or   2. In appropriately admitted cases that become cost outl ier cases, denied services may lead to denial of some or all of an outlier payment.
(Medicare Benefit Policy Manual)
2. In appropriately admitted cases that become cost outl ier cases, denied services may lead to denial of some or all of an outlier payment.   The following examples illustrate this principle.  If care is noncovered because a patient does not need to be hospitalized, the A/B MAC Part A denies the admission and ma kes no Part A (i.e., PPS) payment unless paid under limitation on liability.  Under limitation on liability, Medicare payment may be made when the provider and  the beneficiary were not aware the services were not necessary and could not reasonably be expected to know that the services were not necessary.  For detailed instructions, see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 30,"Limitation o n Liability" section 20 .  If a patient is appropriately hospitalized but receives (beyond routine services) only noncovered care, the admission is denied.  NOTE:   The A/B MAC Part A does not deny an admission that includes covered care, even if noncovered care was also rendered.  Under PPS, Medicare assumes that it is paying for only the covered care rendered whenever covered services needed to treat and/or diagnose the illness were in fact provided.   If a noncovered procedure is provided along with covered nonroutine care, a DRG change rather than an admission denial might occur.  If noncovered procedures are elevating costs into the cost outlier category, outlier payment is denied in whole or in part.  When the hospital is included in PPS, most of the subs equent discussion regarding coverage of inpatient hospital services is relevant only in the context of determining the appropriateness of admissions, which DRG, if any, to pay, and the appropriateness of payment for any outlier cases.   If a patient receives items or services in excess of, or more expensive than, those for which payment can be made, payment is made only for the covered items or services or for only the appropriate prospective payment amount.  This provision applies not only to inpatient serv ices, but also to all hospital services under Parts A and B of the program.  If the items or services were requested by the patient, the hospital may charge him or her the difference between the amount customarily charged for the services requested and the amount customarily charged for covered services.
(Medicare Benefit Policy Manual)
An inpatient  is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services (see 10.2 below).  Generally, a patient is considered an inpatient if f ormally admitted as inpatient with the expectation that he or she will require hospital care that is expected to span at least two midnights and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospita l and not actually use a hospital bed overnight.  The physician or other practitioner responsible for a patient's care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient.  Physicians should use the expec tation of the patient to require hospital care that spans at least two midnights period as a benchmark, i.e., they should order admission for patients who are expected to require a hospital stay that crosses two midnights and the medical record supports that reasonable expectation.  However, the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs, the types o f facilities available to inpatients and to outpatients, the hospital's by -laws and admissions policies, and the relative appropriateness of treatment in each setting.  Factors to be considered when making the decision to admit include such things as:    The severity of the signs and symptoms exhibited by the patient;   The medical predictability of something adverse happening to the patient;   The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinaril y require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and    The availability of diagnostic procedures at the time when and at the location where the patient presents.   Admissions of particular patients are not covered or noncovered solely on the basis of the length of time the patient actually spends in the hospital.  In certain specific situations coverage of services on an inpatient or outpatient basis is determined by  the following rules:
(Medicare Benefit Policy Manual)
Admissions of particular patients are not covered or noncovered solely on the basis of the length of time the patient actually spends in the hospital.  In certain specific situations coverage of services on an inpatient or outpatient basis is determined by  the following rules:   Minor Surgery or Other Treatment  - When patients with known diagnoses enter a hospital for a specific minor surgical procedure or other treatment that is expected to keep them in the hospital for only a few hours (less than 24), they  are considered outpatients  for coverage purposes regardless of: the hour they came to the hospital, whether they used a bed, and whether they remained in the hospital past midnight.  Renal Dialysis  - Renal dialysis treatments are usually covered only as o utpatient services but may under certain circumstances be covered as inpatient services depending on the patient's condition.  Patients staying at home, who are ambulatory, whose conditions are stable and who come to the hospital for routine chronic dialys is treatments, and not for a diagnostic workup or a change in therapy, are considered outpatients.  On the other hand, patients undergoing short -term dialysis until their kidneys recover from an acute illness (acute dialysis), or persons with borderline re nal failure who develop acute renal failure every time they have an illness and require dialysis (episodic dialysis) are usually inpatients.  A patient may begin dialysis as an inpatient and then progress to an outpatient status.   Under original Medicare, the Quality Improvement Organization (QIO), for each hospital is responsible for deciding, during review of inpatient admissions on a case- by-case basis, whether the admission was medically necessary.  Medicare law authorizes the QIO to make these judgment s, and the judgments are binding for purposes of Medicare coverage.  In making these judgments, however, QIOs consider only the medical evidence which was available to the physician at the time an admission decision had to be made.  They do not take into account other information (e.g., test results) which became available only after admission, except in cases where considering the post -admission information would support a finding that an admission was medically necessary.  Refer to chapters 4 and 7 of Pub. 100-10, Quality Improvement Organization Manual with regard to initial determinations for these services.  The QIO will review the swing bed services in these PPS hospitals as well.
(Medicare Benefit Policy Manual)
with regard to initial determinations for these services.  The QIO will review the swing bed services in these PPS hospitals as well.   NOTE:   When patients requiring extended care services are admitted to beds in a hospital, they are considered inpatients of the hospital.  In such cases, the services furnished in the hospital will not be considered extended care services, and payment may not be made under the program for such services unless the services are extended care services furnished pursuant to a swing bed agreement granted to the hospital by the Secretary of Health and Human Services.   10.1 - Bed and Board (Rev. 1, 10-01-03) A3-3101.1, HO-210.1  10.1.1 - Accommodations - General  (Rev. 1, 10-01-03) A3-3101.1.A, HO-210.1.A  The program will pay the same amount for routine accommodations services whether the patient has a private room not medically necessary, a private room medically necessary (Medicare does not pay for deluxe accommodations in any case), a semiprivate room (2-, 3-, or 4-bed accommodations), or ward accommodations, if its ward accommodations are consistent with program purposes (see 10.1.6 below).  A provider having both private and semiprivate accommodations may nevertheless charge the patient a differential for a private room if:    The private room is not medically necessary; and    The patient (or relative or other person acting on their behalf) has requested the private room, and the provider informs them of the amount of charge at the time of the request.   The private room differential may not exceed the difference between the customary charge for the accommodations furnished and the most prevalent semiprivate accommodation rate at the time of the patient's admission.   Where the provider bills for a private room as a covered service, i.e., shows the charge for the room as a covered charge on the Form CMS -1450, the A/B MAC (A) will deem the private room to be medically necessary.  Where the provider, on the other hand, shows a private differential as a noncovered charge, the A/B MAC (A) will assume that the private room is not medically necessary.
(Medicare Benefit Policy Manual)
If the beneficiary (or their representative) protests a charge for the private room on the grounds that the privacy was medically necessary, such protest will, if not in written form, be reduced to writing and forwarded to the A/B MAC (A).  The A/B MAC (A) will then develop the facts and make a specific determination regarding the medical necessity of the private room.  (If an A/B MAC (A) receives many protests of this kind, the provider may need guidance on what constitutes medical necessity for privacy).  If the protest is received after the claim is processed, it will be treated as a request for reconsideration.  If at any time in the course of development (or thereafter within the period when the determination is not administratively final), the provider acknowledges that the private room was medically necessary; the A/B MAC (A) will make an immediate finding to this effect.   Where it is necessary to develop the medical necessity of a private room, the guidelines in subsections 10.1.2 and 10.1.3 below will apply.   10.1.2 - Medical Necessity - Need for Isolation  (Rev. 1, 10-01-03) A3-3101.1.B, HO-210.1.B  A private room is medically necessary where isolation of a beneficiary is required to avoid jeopardizing their health or recovery, or that of other patients who are likely to be alarmed or disturbed by the beneficiary's symptoms or treatment or subjected to infection by the beneficiary's communicable disease.  For example, communicable diseases, heart attacks, cerebra-vascular accidents, and psychotic episodes may require isolation of the patient for certain periods.  (See 10.1.3 below concerning medical necessity not based on need for isolation).