evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
There must be no requirement that all claims for power wheelchairs include the make and model name/number of the wheelchair separate from the claim or the CMN.   The CMN, an OMB approved information collection form, can be used to collect this information.  Specifically, DME MACs can require that the make and model name/ number of the power wheelchair be included in Section C of the CMN.  Section C requires the supplier to include a narrative description of the items, options and accessories ordered.   3. Power wheelchair additional documentation requirements re: functional abilities   There must be no requirement for suppliers to submit additional documentation to describe a beneficiary's medical condition and functional abilities when the supplier bills for a higher level of equipment than previously supplied.  While it is appropriate to avoid paying for duplicate equipment, it is inappropriate to require this documentation for all claims for "higher level equipment."  DME MACs may choose to perform pre - or post - payment probe samples to review these types of cla ims individually in order to determine medical necessity.  If DME MACs choose to conduct such investigations, they must follow the guidelines in the Program Integrity Manual, Chapter 3.   100.4 - Reporting the Ordering/Referring NPI on Claims for DMEPOS Items Dispensed Without a Physicians Order  (Rev. 1368:  Issued:  11- 02-07; Effective:  05 -23-08; Implementation:  04 -07-08)  Chapter 5, section 5.2.1 of the Medicare Program Integrity Manual (PIM) states that, in order for Medicare to make payment for an item of Durable Medical Equipment Prosthetic, and Orthotic Supplies (DMEPOS), the DMEPOS supplier must obtain a prescription f rom the   For Coordination of Benefit purposes, DMEPOS suppliers shall use the modifier EY (no physician or other licensed health care provider order for this item or service) and report their own name and National Provider Identifier (NPI) in the Ordering/Referring Provider Name fields on claims submitted on or after May 23, 2008 to secure a Medicare denial.   If the supplier has obtained a physician order for some, but not all, of the items provided to a particular beneficiary, the supplier must submit a separate claim for the items with no physician order.
(Medicare Claims Processing Manual)
If the supplier has obtained a physician order for some, but not all, of the items provided to a particular beneficiary, the supplier must submit a separate claim for the items with no physician order.   110 - General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies  (Rev. 330, Issued: 10- 22-04, Effective: 01 -01-05, Implementation: 04- 04-05)  Part B suppliers and providers other than Home Health Agencies (HHAs) must bill DMEPOS to the DME MAC, except claims for implanted DME.  Implanted DME and supplies for the implanted equipment are billed to the A/B MAC (B).   Suppliers and providers must have a supplier billing number issued by the National Supplier Clearinghouse (NSC) prior to billing the DME MAC.  Institutional providers bill their A/B MAC (A) for prosthetics and orthotics devices and supplies.  Generally, Medicare does not pay for DME in a facility.  For hospital outpatient DME, bills go to the appropriate DME MAC.  DMEPOS provided under a home health plan of care may be billed either by the HHA or by the supplier (including the HHA with a supplier number if the HHA prefers to bill that way) to the DME MAC.  If the HHA chooses to bill to the A/B MAC (HHH), the HHA includes the DME on the PPS claim (32x or 33x).  If the beneficiary is not under a plan of care and receives DMEPOS from a HHA, the agency uses bill type 34x.  Beneficiary Submitted Claims must contain an enrolled Medicare Supplier Number.   110.1 - Billing/Claim Formats (Rev. 2993, Effective: ASC X12 -  01-01-12, ICD -10 - Upon Implementation of ICD -10; Implementation: ASC X12 -  08-25-14, ICD -10 - Upon Implementation of ICD -10)  The DME MAC and the A/B MAC (B) are billed on the ASC X12 837 professional claim format or if permissible Form CMS -1500.
(Medicare Claims Processing Manual)
The DME MAC and the A/B MAC (B) are billed on the ASC X12 837 professional claim format or if permissible Form CMS -1500.  The A/B MAC (A) (including the A/B MAC (HHH)) is billed on the ASC X12 837 institutional claim format or if permissible Form CMS -1450.   Note that the ASC X12 formats support reporting of the CMNs in the FRM segment   The National Council for Prescription Drug Programs (NCPDP) Telecommunications Standard Version D0 and Batch Standard 1.2 is the HIPAA standard for electronic retail pharmacy drug claims and related coordination of benefits (COB).   This standard will be used by all DME MACs that process retail pharmacy drug transactions.  All other claims submitted to the DME MAC by pharmacies, other than retail pharmacy drug claims, must be sent in the ASC X12 837 professional claim format.   110.1.1 - Requirements for Implementing the NCPDP Standard  (Rev. 1, 10- 01-03) Retail pharmacies will be identified by a value of A5 in the specialty code as received by the National Supplier Clearinghouse.  Only DME MAC  suppliers with an A5 specialty code may use the NCPDP standard.  The DME MACs , their EDI submitters, and their other trading partners are required to transmit the NDCs in the NCPDP standards for identification of prescription drugs dispensed through a retail pharmacy.  NDCs replace the drug HCPCS codes for retail pharmacy drug transactions billed to DME MACs  via the N CPDP standards.  110.1.2 - Certificate of Medical Necessity (CMN)  (Rev. 867, Issued: 02- 17-06, Effective: 04 -01-06, Implementation: 04- 03-06)  The CMN for Parenteral Nutrition (Form CMS -852) is required.  The DME MAC  Information Form for Immunosuppressive Drugs (Form DMERC -08.02) is not required when billing for immunosuppressive drugs with dates of service on or after April 1, 2006.  As with other electronic formats, CMN data must be submitted within the valid transaction.   For claims submitted on the Form CMS -1500, retail pharmacies will continue to supply hard copy CMNs when required.
(Medicare Claims Processing Manual)
For claims submitted on the Form CMS -1500, retail pharmacies will continue to supply hard copy CMNs when required.   110.1.3 - NCPDP Companion Document  (Rev. 1, 10- 01-03)  The DME MACs are to provide the NCPDP companion document, found at: http://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/Downloads/NCPDPD0CG.pdf  to retail pharmacy drug claim submitters (either provider, billing agent, or clearinghouse) that will submit retail pharmacy drug claims to Medicare electronically.   110.2 - Application of DMEPOS Fee Schedule  (Rev. 1, 10- 01-03)  Services that are paid under the DME fee schedule are identified in the DMEPOS fee schedule file available free on the CMS Web Site at: http://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS -Fee-Schedule.html   The DMEPOS fee schedule applies to claims to A/B MACs (A) and (HHH)  as follows.   BILL TYPE/  DEFINITION  ORTHOTICS/ PROSTHETICS  DME/  OXYGEN 12X (Hospital inpatient Part B)  Subject to fee schedule  Not covered, therefore, not subject to fee schedule  13X (Hospital Outpatient)  Subject to fee schedule  Subject to fee schedule  22X (SNF inpatient Part B)  Subject to fee schedule  Not covered, therefore, not subject to fee schedule  23X (SNF outpatient)  Subject to fee schedule  Subject to fee schedule  *32X (HHA visits under Part B Plan of Care)  Subject to fee schedule  Subject to fee schedule  *33X (HHA visits under Part A Plan of Care)  Subject to fee schedule  Subject to fee schedule  34X (HHA visits not under a Plan of Care)  Subject to fee schedule  Subject to fee schedule  71X Rural health clinics (Provider -based only)  Subject to fee schedule  Subject to fee schedule  74X (Outpatient PT)  Subject to fee schedule  Subject to fee schedule  75X (CORF)  Subject to fee schedule  Subject to fee schedule  **83X ASC  Subject to fee schedule  Subject to fee schedule  85X RPCH  Subject to fee schedule  Subject to fee schedule
(Medicare Claims Processing Manual)
* HCPCS codes A4214, A4310 through A4455, A4481, A4622, A4623, A4625, A4626, A4629, and A5051 through A5149 are excluded from the fee schedule when billed by a HHA to its A/B MAC (HHH) under these bill types.  Also, when billed on type of bill 32x or 33, c atheter and ostomy supplies are considered non- routine supplies and are billed with revenue code 027x.   ** HCPCS codes A4214, A4310 through A4330, A4338 through A4359, and A5102 through A5114 are excluded from the fee schedule when billed by a non- OPPS hospital with an ASC service under this bill type.  In addition, HCPCS codes A5119 through A5131 can be excluded or included in the fee schedule depending on the procedure in which they are associated.   NOTE:   Bill types not listed are not subject to the fee schedule for either orthotics/-prosthetics or DME/oxygen with the exception of provider -based Federally Qualified Health Centers (FQHCs).  Orthotics/prosthetics and DME/oxygen furnished by provider -based F QHCs are subject to the fee schedule.  However, bill type 73X is not reflected in the above chart since FQHCs use the bill type for the parent provider (usually 13x).  Bill types listed above are billed to the A/B MAC (A) or (HHH) for orthotics/prosthetics.   Providers other than HHAs bill the DME MAC for DME/oxygen.  HHAs bill their A/B MAC (HHH) for DME/oxygen.   DME billing is not required on Home Health PPS claims.  Home Health Agencies retain the option to bill services to A/B MAC (HHH) or have services provided under arrangements with a supplier that bills the DME MAC.   110.3 - Pre-Discharge Delivery of DMEPOS for Fitting and Training (Rev. 1, 10- 01-03) B3-3011
(Medicare Claims Processing Manual)
110.3 - Pre-Discharge Delivery of DMEPOS for Fitting and Training (Rev. 1, 10- 01-03) B3-3011  The following are CMS policy and billing procedures regarding the circumstances under which a supplier may deliver durable medical equipment, prosthetics, and orthotics -  but not supplies -  to a beneficiary who is in an inpatient facility that does not qualify as the beneficiary's home.   110.3.1 - Conditions That Must Be Met  (Rev. 1, 10- 01-03)  In some cases, it would be appropriate for a supplier to deliver a medically necessary item of durable medical equipment (DME), a prosthetic, or an orthotic -  but not supplies -to a beneficiary who is an inpatient in a facility that does not qualify as the  beneficiary's home.  The CMS will presume that the pre -discharge delivery of DME, a prosthetic, or an orthotic (hereafter "item") is appropriate when all the following conditions are met:   1. The item is medically necessary for use by the beneficiary in the beneficiary's home.   2. The item is medically necessary on the date of discharge, i.e., there is a physician's order with a stated initial date of need that is no later than the date of discharge for home use.  3. The supplier delivers the item to the beneficiary in the facility solely for the purpose of fitting the beneficiary for the item, or training the beneficiary in the use of the item, and the item is for subsequent use in the beneficiary's home.  4. The supplier delivers the item to the beneficiary no earlier than two days before the day the facility discharges the beneficiary.
(Medicare Claims Processing Manual)
5. The supplier ensures that the beneficiary takes the item home, or the supplier picks up the item at the facility and delivers it to the beneficiary's home on the date of discharge.  6. The reason the supplier furnishes the item is not for the purpose of eliminating the facility's responsibility to provide an item that is medically necessary for the beneficiary's use or treatment while the beneficiary is in the facility.  Such items ar e included in the Diagnostic Related Group (DRG) or Prospective Payment System (PPS) rates.  7. The supplier does not claim payment for the item for any day prior to the date of discharge.   8. The supplier does not claim payment for additional costs that the supplier incurs in ensuring that the item is delivered to the beneficiary's home on the date of discharge.  The supplier cannot bill the beneficiary for redelivery.   9. The beneficiary's discharge must be to a qualified place of service (e.g., home, custodial facility), but not to another facility (e.g., inpatient or skilled nursing) that does not qualify as the beneficiary's home.   110.3.2 - Date of Service for Pre -Discharge Delivery of DMEPOS  (Rev. 1, 10- 01-03)  For DMEPOS, the general rule is that the date of service is equal to the date of delivery.  However pre -discharge delivery of items intended for use upon discharge are considered provided on the date of discharge.  The following three scenarios demonstrate  both the latter rule (when the date of service is the date of discharge) and related exceptions.
(Medicare Claims Processing Manual)
1.  If the supplier leaves the item with the beneficiary two days prior to the date of discharge, and if the supplier, as a practical matter, need do nothing further to effect the delivery of the item to the beneficiary's home (because the beneficiary or a  caregiver takes it home), then the date of discharge is deemed to be the date of delivery of the item.  Such date must be the date of service for purposes of claims submission.  (This is not an exception to the general DMEPOS rule that the date of service must be the date of delivery.  Rather, it recognizes the supplier's responsibility -  per condition five above -  to ensure that the item is actually delivered to the beneficiary's home on the date of discharge.)  No one may bill for the days prior to the date of discharge.   2. If the supplier fits the item to the beneficiary, or trains the beneficiary in its use while the beneficiary is in the facility, but thereafter removes the item and subsequently delivers it to the beneficiary's home, then the date of service must be the  date of actual delivery of the item, provided such date is not earlier than the date of discharge.   3. If the supplier leaves the item at the facility and the beneficiary does not take the item home, or a third party does not send it to the beneficiary's home, or the supplier does not otherwise (re)deliver the item to the beneficiary's home on or before the date of discharge, the date of service must not be earlier than the actual date of delivery of the item, i.e., the actual date the item arrives, by whatever means, at the beneficiary 's home.    110.3.3 - Facility Responsibilities During the Transition Period  (Rev. 1, 10- 01-03)  1. A facility remains responsible for furnishing medically necessary items to a beneficiary for the full duration of a beneficiary's stay.  The DRG and PPS rates cover such items.
(Medicare Claims Processing Manual)
1. A facility remains responsible for furnishing medically necessary items to a beneficiary for the full duration of a beneficiary's stay.  The DRG and PPS rates cover such items.   2. A facility may not delay furnishing a medically necessary item for the beneficiary's use or treatment while the beneficiary is in the facility.  A facility may not prematurely remove a medically necessary item from the beneficiary's use or treatment on the basis that a supplier delivered a similar or identical item to the beneficiary for the purpose of fitting or training.   3. A facility may not, through a stratagem of relying upon a supplier to furnish such items, improperly shift its costs for furnishing medically necessary items to a beneficiary who is a resident in the facility to Medicare Part B.   Nevertheless, beginning two days before the beneficiary's discharge, a facility may take reasonable actions to permit a supplier to fit or train the beneficiary with the medically necessary item that is for subsequent use in the beneficiary's home.  These actions may include the substitution of the supplier -furnished item, in whole or in part, for the facility-furnished item during the beneficiary's last two inpatient days provided the substitution is both reasonable and necessary for fitting or training and the item is intended for subsequent use at the beneficiary's home.   4. For prosthetic and orthotic (P&O) items, the above restrictions apply to residents in a covered Part A stay.  For DME, the above restrictions apply in a covered Part A or a Part B stay.   110.4 - Frequency of Claims for Repetitive Services (All Providers and Suppliers)  (Rev. 1, 10- 01-03)  HHAs include DMEPOS on bill types 32x or33x with home health visits bill at the freqency required for the home health.  See Chapter 10 for home health billing requirements.
(Medicare Claims Processing Manual)
HHAs include DMEPOS on bill types 32x or33x with home health visits bill at the freqency required for the home health.  See Chapter 10 for home health billing requirements.   Other providers and suppliers, including home health agencies billing the A/B MAC (HHH) on bill type 34x, submit claims on a monthly basis unless  another policy that allows billing at a different frequency applies.  For example suppliers may bill for more than one month's diabetic test strips.  Claims are submitted in sequence where there are cases of known continuous periods of service over an extended period (e.g., capped rental equipment or therapies).  When there is a break in service (e.g. interruption of capped rental as the result of an ex tensive inpatient stay), suppliers should continue sequential billing when the services resume.   The purpose of these requirements is to avoid CMS operational expenditures, and at the same time simplify the review process   110.5 - DME MACs Only - Appeals of Duplicate Claims  (Rev. 2993, Effective: ASC X12 -  01-01-12, ICD -10 - Upon Implementation of ICD -10; Implementation: ASC X12 -  08-25-14, ICD -10 - Upon Implementation of ICD -10)  The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) must afford appeal rights for the initial determination of an item or service only, unless the supplier is appealing whether or not the denied item is actually a duplicate.  If a claim is denied as a duplicate, the DME MACs must not afford appeal rights based on coverage, medical necessity, pricing, or any basis on which the supplier can otherwise appeal.  The DME MAC may only afford appeal rights on claims denied as duplicates if the supplier is appealing because the claim is not, in fact, a duplicate.  If a supplier appeals a denied duplicate claim on the basis that the claim is not, in fact a duplicate, the DME MAC shall adjudicate the claim in accordance with all other Medicare rules and regulations.  The DME MACs must use the following Medicare Summary Notice (MSN) and ASC X12 835 remittance messages when denying duplicate claims:
(Medicare Claims Processing Manual)
 MSN 7.3 -  This service/item is a duplicate of a previously processed service.  No appeal rights are attached to the denial of this service except for the issue as to whether the service is a duplicate.  Disregard the appeals information on this notice unle ss you are appealing whether the service is a duplicate.    Spanish -  Este servicio/artculo es un duplicado de otro servicio procesado previamente.  No tiene derechos de apelacin de este servicio, excepto si cuestiona que este servicio es un duplicado.  Haga casa omiso a la informacin sobre apelaciones en esta n otification, en relacin a sus derechos de apelacin, a menos que este apelando si el servicio fue duplicado.   Claim adjustment r eason code 18: - Duplicate claim/service   Remittance advice remark code N111 -  This service was included in a claim that was previously billed and adjudicated.  No appeal rights attached except with regard to whether the service/item is a duplicate.   120 - DME MACs - Billing Procedures Related To Advanced Beneficiary Notice (ABN) Upgrades  (Rev. 2993, Effective: ASC X12 -  01-01-12, ICD -10 - Upon Implementation of ICD -10; Implementation: ASC X12 -  08-25-14, ICD -10 - Upon Implementation of ICD -10)  This section provides the DME MACs billing instructions regarding the use of ABNs and claims modifiers for upgrades for items of DMEPOS.  Federal Regulations at 42 CFR 411.408 and Chapter 30 of this manual establishes the basis for a supplier to issue an ABN to a beneficiary.  The purpose of the ABN is to inform a Medicare beneficiary, before he or she receives an item that Medicare will probably not pay for that particular item on that particular occasion.  The ABN allows the beneficiary to make an informed consumer decision on whether to accept an item for which he or she may have to pay out of pocket or through supplementary insurance.
(Medicare Claims Processing Manual)
Under existing policy, suppliers may collect from a beneficiary a payment amount greater than Medicares allowed payment amount if the beneficiary, by signing an ABN, agrees to pay extra for a DMEPOS item because the beneficiary prefers an item with featur es or upgrades that are not medically necessary.  This policy applies to both assigned and unassigned claims.  When a beneficiary does not sign an ABN, a supplier that accepts assignment cannot hold the beneficiary liable for the cost of medically unnecess ary equipment or upgrades unless there is other acceptable evidence that the beneficiary knew or could reasonably have been expected to know that Medicare would not pay for the medically unnecessary equipment or upgrades.  With respect to unassigned claims , a signed ABN is necessary to hold the beneficiary liable.   The instructions in this section apply to situations where the ABN is being used for upgrades and applies to both assigned and unassigned claims.  An upgrade is an item with features that go beyond what is medically necessary.  An upgrade may include an excess component.  An excess component may be an item feature or service, which is in addition to, or is more extensive and/or more expensive than the item that is reasonable and necessary under Medicares coverage requirements.  When a DMEPOS supplier knows  or believes that the DMEPOS item does or may not meet Medicares reasonable and necessary rules under specific circumstances, it is the responsibility of the supplier to notify the beneficiary in writing via an ABN if the supplier wants to collect money f rom a beneficiary if an item is denied.   When a supplier furnishes an upgraded item of DMEPOS and the supplier expects Medicare to reduce the level of payment based on a medical necessity partial denial of coverage for additional expenses attributable to the upgrade, the supplier must give an ABN to the beneficiary for signature for holding the beneficiary liable for the additional expense.  Optional ABN forms are available at:  http://www.cms.gov/Medicare/Medicare -General -Information/BNI/ABN.html .