evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
 The modifier QG PRESCRIBED AMOUNT OF STATIONARY OXYGEN WHILE AT REST IS GREATER THAN 4 LITERS PER MINUTE (LPM); HHAs use revenue code 0603. The monthly payment amount for stationary oxygen is increased by 50 percent.    The modifier QR PRESCRIBED AMOUNTS OF STATIONARY OXYGEN FOR DAYTIME USE WHILE AT REST AND NIGHTIME USE DIFFER AND THE AVERAGE OF THE TWO AMOUNTS IS GREATER THAN 4 LITERS PER MINUTE (LPM); HHAs use revenue code 0603. The monthly payment amount for stationary oxygen is increased by 50 percent.   If the prescribed amount of oxygen is greater than 4 LPM and portable oxygen is prescribed, suppliers use either of the following modifiers with both the stationary and portable oxygen HCPCS code:    The modifier QF PRESCRIBED AMOUNT OF STATIONAY OXYGEN WHILE AT REST EXCEEDS 4 LITERS PER MINUTE (LPM) AND PORTABLE OXYGEN IS PRESCRIBED; HHAs use revenue code 0604. If the prescribed flow rate differs between stationary and portable oxygen equipment, the flow rate for the stationary equipment is used. The monthly payment for stationary oxygen is increased by the higher of 50 percent of the monthly stationary oxygen payment amount, or the fee schedule amount for the portable oxygen add- on. A separate monthly payment is not allowed for the portable equipment. Effective April 1, 2017, the modifier QF must be used with both the stationary and portable oxygen equipment codes.    The modifier QB PRESCRIBED AMOUNTS OF STATIONARY OXYGEN FOR DAYTIME USE WHILE AT REST AND NIGHTTIME USE DIFFER AND THE AVERAGE OF THE TWO AMOUNTS EXCEEDS 4 LITERS PER MINUTE (LPM) AND PORTABLE OXYGEN IS PRESCRIBED; HHAs use revenue code 0604. If the pres cribed flow rate differs between stationary and portable oxygen equipment, the flow rate for the stationary equipment is used. The monthly payment for stationary oxygen is increased by the higher of 50 percent of the monthly stationary payment amount, or t he fee schedule amount for the portable oxygen add- on. A separate monthly payment is not allowed for the portable equipment. Effective April 1, 2018, the modifier Q?? must be used with both the stationary and portable oxygen equipment codes. The stationa ry and portable oxygen equipment QB fee schedule amounts will be added to the DMEPOS fee schedule file effective 4/1/2018.
(Medicare Claims Processing Manual)
The stationary oxygen QF and QB fee schedule amounts on the DMEPOS fee schedule file represent 100 percent of the stationary oxygen allowed fee schedule amount. The portable oxygen equipment add- on QF and QB fee schedule amount on the file by state represent the higher of:   1. 50 percent of the monthly stationary oxygen payment amount (codes E0424, E0439, E1390 or E1391); or   2. The fee schedule amount for the portable oxygen add- on (codes E0431, E0433, E0434, E1392 or K0738).  D. Conserving Device Modifier  The HHA's and suppliers must indicate if an oxygen conserving device is being used with an oxygen delivery system by using HCPCS modifier QH.  E. DME MACs Only  For all States that have licensure/certification requirements for the provision of oxygen and/or oxygen related products, DME MACs shall process claims for oxygen and oxygen related products only when an oxygen specialty code is assigned to the DMEPOS supplier by the NSC and is forwarded to the DME MACs from the NSC. This specialty shall be licensed and/or certified by the State when applicable.  This specialty shall bill for Medicare -covered services and/or products when State law permits such entity to furnish oxygen and/or oxygen related products.  130.6.1 - Oxygen Equipment and Contents Billing Chart  (Rev. 1, 10- 01-03) The following chart indicates what oxygen fee schedule component is billable/payable under various transaction scenarios for providers and suppliers:  1. Situation:  Beneficiary Uses a Stationary System Only  a. Rental Cases (Beneficiary Uses a Stationary System Only)  Type of System  Stationary Monthly Payment  Oxygen Content Fee  Portable Add-On Portable Contents Fee  Concentrator  Yes No No No Type of System  Stationary Monthly Payment  Oxygen Content Fee  Portable Add-On Portable Contents Fee   E1377  E1378 E1379 E1380 E1381 E1382 E1383 E1384 E1385 E1400 E1401 E1402 E1403 E1404 E1405 E1406       Type of System  Stationary Monthly Payment  Oxygen Content Fee  Portable Add-On Portable Contents Fee  Gaseous  Yes No No No
(Medicare Claims Processing Manual)
Type of System  Stationary Monthly Payment  Oxygen Content Fee  Portable Add-On Portable Contents Fee  Gaseous  Yes No No No  E0424    Liquid Yes No No No  E0439    b. Purchase Cases (Beneficiary Uses a Stationary System Only)  Type of System  Stationary Monthly Payment  Oxygen Content Fee  Portable Add-On Portable Contents Fee  Concentrator  No No No No Gaseous  No Yes No No   E0441   Liquid No Yes No No   E0442   2. Situation:  Beneficiary Uses Both a Stationary and Portable System    a. Rents Stationary/Rents Portable  Type of System  Stationary Monthly Payment  Oxygen Content Fee  Portable Add-On Portable Contents Fee  Concentrator  Yes No Yes No  E1377  E1378 E1379 E1380 E1381 E1382 E1383 E1384 E1385 E1400 E1401 E1402 E1403 E1404  E1405 E1406   E0431 E0434  Gaseous  Yes No Yes No  E0424  E0431  Liquid Yes No Yes No  E0439  E0434     b. Rents Stationary/Owns Portable  Type of System  Stationary Monthly Payment  Oxygen Content Fee  Portable Add-On Portable Contents Fee  Concentrator  Yes No No No  E1377  E1378 E1379 E1380 E1381 E1382 E1383 E1384 E1385 E1400 E1401 E1402 E1403 E1404 E1405 E1406     Gaseous  Yes No No No  E0424    Liquid Yes No No No  E0439       c. Owns Stationary/Owns Portable  Type of System   Stationary Monthly Payment  Oxygen Content Fee  Portable Add-On Portable Contents Fee  Concentrator  No No No Yes     E0443  E0444  Gaseous  No Yes No No   E0441   Liquid No Yes No No   E0442   d. Owns Stationary/Rents Portable  Type of System  Stationary Monthly Payment  Oxygen Content Fee  Portable Add-On Portable Contents Fee  Concentrator  No No Yes Yes    E0431  E0434  E0443  E0444  Gaseous  No Yes Yes No   E0441 E0431  Liquid No Yes Yes No
(Medicare Claims Processing Manual)
E0431  E0434  E0443  E0444  Gaseous  No Yes Yes No   E0441 E0431  Liquid No Yes Yes No   E0442 E0434  3. Situation:  Beneficiary Uses a Portable System Only  a. Rents Portable System (Beneficiary Uses a Portable System Only)  Type of System  Stationary Monthly Payment  Oxygen Content Fee  Portable Add-On Portable Contents Fee  Gaseous  No No Yes Yes    E0431 E0443 Type of System  Stationary Monthly Payment  Oxygen Content Fee  Portable Add-On Portable Contents Fee  Liquid No No Yes Yes    E0434 E0444 b. Owns Portable System (Beneficiary Uses a Portable System Only)  Type of System  Stationary Monthly Payment  Oxygen Content Fee  Portable Add-On Portable Contents Fee  Gaseous  No No No Yes     E0443 Liquid No No No Yes     E0444  NOTE:   For HHAs revenue codes 0601, 0602, 0603, and 0604 may apply when billing for oxygen under the situations in this chart.  130.7 - Billing for Maintenance and Servicing (Providers and Suppliers)  (Rev. 1, 10- 01-03)  A3-3629   General   Payment is not made for maintenance and servicing if the beneficiary rents the equipment since payment for maintenance and servicing are included in the rental payments.  An exception to this is the 6- month service fee for capped rental items that the beneficiary has elected not to purchase (see 40.2 and 130.5).   Where purchase is permitted (including "Capped Rental Items" and where the beneficiary elects to purchase), payment for reasonable and necessary maintenance and servicing is made for such purchased equipment.  Coding to Identify Maintenance and Servicing   Capped Rental   If the service is capped rental, suppliers that bill the DME MAC for the maintenance and servicing fee (see 40.2) use modifier - MS with the HCPCS code for the equipment to show that parts and labor which are not covered under any manufacturer or supplier warranty.   The HHAs that bill the A/B MAC (HHH) for maintenance and servicing of capped rental items  use revenue code 0299 along with the appropriate HCPCS code for the equipment.   Not Capped Rental   Suppliers that bill the DME MACs for maintenance and servicing indicate the HCPCS code of the item serviced and the modifier - RP, replacement or repair.
(Medicare Claims Processing Manual)
Not Capped Rental   Suppliers that bill the DME MACs for maintenance and servicing indicate the HCPCS code of the item serviced and the modifier - RP, replacement or repair.   The HHAs that bill A/B MACs (HHH) for maintenance and servicing use revenue code 0299 and the appropriate HCPCS code for the equipment serviced.   Hospitals  report revenue code 0274 along with one of the following HCPCS codes: L4205, L4210, L7500, L7510, or L7520 when billing the A/B MAC (A) for maintenance and servicing of prosthetics and orthotics.   130.8 - Installment Payments (Rev. 1, 10- 01-03)  A3-3629   Where a beneficiary is purchasing an item through installments, the total price of the equipment item is reported  on the first bill.  Monthly payments are made (by the A/B MAC (A), (B), (HHH), or DME MAC).  The monthly amount is equivalent to the rental fee schedule amount and is paid until the fee schedule purchase price or actual charge has been reached, whichever comes first.   130.9 - Showing Whether Rented or Purchased  (Rev.  4052, Issued: 05- 17-18, Effective: 10- 01-18, Implementation: 10- 01-18)
(Medicare Claims Processing Manual)
130.9 - Showing Whether Rented or Purchased  (Rev.  4052, Issued: 05- 17-18, Effective: 10- 01-18, Implementation: 10- 01-18)   Claims must specify whether equipment is rented or purchased. For purchased equipment, the itemized bill or claim must also indicate whether equipment is new or used. If the provider or supplier fails to indicate on an assigned claim whether equipment was new or used, the MAC processing the claims assumes purchased equipment is used and process the claim accordingly, i.e., they pay on the basis of the used purchase fee. If an unassigned purchase claim does not specify whether the item was new or used, MACs develop the claim with the supplier. The following table indicates the HCPCS modifiers which are added to the equipment code to indicate its status: Modifier  Status  -BP  The beneficiary has been informed of the purchase and rental options and has elected to purchase the item  -BR  The beneficiary has been informed of the purchase and rental options and has elected to rent the item  -BU  The beneficiary has been informed of the purchase and rental options and after 30 days has not informed the supplier of his/her decision  -KH  DMEPOS item, initial claim, purchase or first month rental (no longer required for purchased (NU modifier claims) on or after 10/1/18)  -KI  DMEPOS item, second or third month rental  -KJ  DMEPOS item, PEN pump or capped rental months four to fifteen  -NR  New when rented (use the 'NR' modifier when an item that was new at the time of rental is subsequently purchased)  -NU  New equipment  -RR  Rental (use the 'RR' modifier when DME is to be rented)  -UE  Used durable medical equipment (no longer requires the KH modifier for claims submitted on or after 10/1/18)     HHAs report the appropriate modifier using the ASC X12 837 institutional claim format, or Form CMS -1450 following the appropriate HCPCS code.  A/B MACs (HHH) accept 7 positions in this field for data entry purposes.   140 - Billing for Supplies  (Rev. 1, 10- 01-03)
(Medicare Claims Processing Manual)
140 - Billing for Supplies  (Rev. 1, 10- 01-03)    140.1 - Billing for Supplies and Drugs Related to the Effective Use of DME  (Rev. 10236, Issued: 07 -31-2020, Effective: 08 -31-2020, Implementation: 08- 31-2020)    Suppliers and providers bill supplies that are necessary for the effective use of DME, including drugs, with the appropriate HCPCS code identifying the supply.  HHAs must also report revenue code 0294, "Supplies/Drugs for DME Effectiveness."   Suppliers and providers, other than HHAs, bill supplies and drugs (not including drugs that are necessary for the effective use of implanted DME) that are necessary for the effective use of DME to the DME MACs.  HHAs bill the A/B MACs (HHH).   Suppliers and providers, other than HHAs, bill for drugs that are necessary for the effective use of implanted DME (HCPCS codes E0751, E0753, E0782, and E0783) to the A/B MAC (B).  HHAs bill the A/B MAC (HHH).   The A/B MACs (HHH) contact the DME MAC or A/B MAC (B) as necessary to determine drug prices.   The DME MACs must:    accept NDC codes for all drugs billed in the NCPDP format;    accept NDC codes for oral anti -cancer drugs billed in the ASC X12 837 professional claim format, NCPDP format, and paper Form CMS -1500;    accept HCPCS for all other drugs billed in the ASC X12 837 professional claim format  and paper Form CMS -1500 and   return as unprocessable claims submitted with an invalid NDC using the appropriate Remittance Advice Remark Code..   See the official Washington Publishing Company website for a current list of the Remittance Advice Remark Codes.   140.1.1 - Supplier Payment Under Medicare Part B for Insulin Furnished Through Durable Medical Equipment  (Rev. 12013; Issued: 05- 02-23; Effective: 07 -01-23; Implementation: 07 -03-23)
(Medicare Claims Processing Manual)
140.1.1 - Supplier Payment Under Medicare Part B for Insulin Furnished Through Durable Medical Equipment  (Rev. 12013; Issued: 05- 02-23; Effective: 07 -01-23; Implementation: 07 -03-23)  Section 1833(b) of the Social Security Act (the Act) is amended by Section 11407 of the Inflation Reduction Act, which waives the Medicare Part B deductible beginning July 1, 2023 for insulin furnished through an item of durable medical equipment covered under section 1861(n) of the Act. Also, Section 1833(a) of the Act is amended by Section 11407 of the Inflation Reduction Act, which requires that beneficiary coinsurance for a months supply of insulin furnished through an item of durable medical equipment  is not to exceed $35 beginning July 1, 2023. The supplier payment is to be adjusted as necessary so that Medicare pays for the rest of the amount for the months supply of insulin.   Effective July 1, 2023, to ensure the appropriate coinsurance is applied all claims billing for insulin administered through an item of DME must have a modifier appended to identify if the supply is for one month or a three month supply.  Claims submitted for insulin administered through an item of DME that do not include one of the modifiers listed below will be returned to the supplier as un- processable.   JK - Short Descriptor: Drug supply 1 month or less;  Long Descriptor: One month supply or less of drug or biological  or JL- Short Descriptor: Drug 3 month supply;  Long Descriptor: Three month supply of drug or biological    140.2 - Billing for HHA Medical Supplies  (Rev. 1, 10- 01-03) HHA- 206.4, HHA -219.1, HHA -461 (partial), HO -228.3, SNF -260.3   Medical supplies are items that, due to their therapeutic or diagnostic characteristics, are essential in enabling personnel to carry out effectively the care the physician has ordered for the treatment or diagnosis of the patient's illness or injury.  Medical supplies fit into two categories.  They are classified as:    Routine because they are used in small quantities for patients during the usual course of most home visits; or
(Medicare Claims Processing Manual)
 Routine because they are used in small quantities for patients during the usual course of most home visits; or    Nonroutine because they are needed to treat a patient's specific illness or injury in accordance with the physician's plan of care and meet further conditions discussed in more detail below.   Both routine and non- routine medical supplies are included in the home health PPS rate and are not separately payable if the beneficiary is under a home health plan of care.  The CMS publishes a list of these medical supplies annually, identified by HCPCS code.  If no home health plan of care is in place, non- routine medical supplies are reported separately on the bill and the supplies are payable on 34x bills.   140.3 - Billing DME MAC  for Home Dialysis Supplies and Equipment  (Rev. 1, 10- 01-03) B3-3045.7  See Chapter 8 for claims processing instructions for Method II for suppliers and DME MACs.   150 - Institutional Provider Reporting of Service Units for DME and Supplies  (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)  Provider outpatient departments report service units using the ASC X12 837 institutional claim format or on the Form CMS 1450 the number of items being billed for orthotic and prosthetic devices.   For purchased DMEPOS items (excluding items requiring frequent and substantial servicing, capped rental items, and oxygen which cannot be purchased) HHAs report service units using the ASC X12 837 institutional claim format or on the  Form CMS -1450 the num ber of purchased items billed.  For rental DME items, including oxygen equipment, HHAs report a separate line for each month billed indicating "1" on the ASC X12 837 institutional claim format or in the service units field on the Form CMS -1450.
(Medicare Claims Processing Manual)
For oxygen contents (HCPCS codes E0441, E0442, E0443, and E0444), the HHAs report the number of feet or pounds as described by the HCPCS code.  160 - Billing for Total Parenteral Nutrition and Enteral Nutrition  (Rev. 1, 10- 01-03) A3-3660.6   All providers and suppliers billing for parenteral and enteral nutrition covered as a Part B prosthetic device benefit bill the DME MACs.  Medicare pays for no more than a one -month supply of parenteral or enteral nutrients for any one prospective billing period.  Claims submitted retroactively may include multiple months.   160.1 - Billing for Total Parenteral Nutrition and Enteral Nutrition Furnished to Part B Inpatients  (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)
(Medicare Claims Processing Manual)
Inpatient Part A hospital or SNF care includes total parenteral nutrition (TPN) systems and enteral nutrition (EN).  For inpatients for whom Part A benefits are not payable (e.g., benefits are exhausted or the beneficiary is entitled to Part B only), total parenteral nutrition (TPN) systems and enteral nutrition (EN) delivery systems are covered by Medicare as prosthetic  devices when the coverage criteria are met.  When these criteria are met, the medical equipment and medical supplies (together with nutrients) being used comprise covered prosthetic devices for coverage purposes rather than durable medical equipment.  How ever, reimbursement rules relating to DME continue to apply to such items.  When a facility supplies TPN or EN systems that meet the criteria for coverage as a prosthetic device to an inpatient whose care is not covered under Part A, the facility must bill one of the DME MACs.  Additionally, HHAs, SNFs, and hospitals that provide PEN supplies, equipment and nutrients as a prosthetic device under Part B must use the ASC X12 837 professional claim format or if permissible the Form CMS -1500 paper form to bill the appropriate DME MAC.  The DME MAC is determined according to the residen ce of the beneficiary.  Refer to 10 for jurisdiction descriptions.  A/B MACs (A) and (HHH) return claims containing PEN charges for Part B services where the bill type is 12x, 13x, 22x, 23x, 32x, 33x, or 34x with instructions to the provider to bill the DME MAC.  160.2 - Special Considerations for SNF Billing for TPN and EN Under Part B  (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 HCPCS code and any appropriate modifiers are required.  SNFs bill the DME MAC for TPN and EN under Part B, using the ASC X12 837 professional claim format, or the Form CMS -1500 paper claim if applicable.
(Medicare Claims Processing Manual)
The following HCPCS codes apply.  B4034  B4035  B4036  B4081  B4082  B4083  B4084  B4085  B4150  B4151  B4152  B4153  B4154  B4155  B4156  B4164  B4168  B4172  B4176  B4178  B4180  B4184  B4186  B4189  B4193  B4197  B4199  B4216  B4220  B4222  B4224  B5000  B5100  B5200  B9000  B9002  B9004  B9006  E0776XA B9098  B9099   For SNF billing for PEN, a SNF includes the charges for PEN items it supplies beneficiaries under Part A on its Part A bill.  The services of SNF personnel who administer the PEN therapy are considered routine and are included in the basic Part A payment f or a covered stay.  SNF personnel costs to administer PEN therapy are not covered under the Part B prosthetic device benefit.   If TPN supplies, equipment and nutrients qualify as a prosthetic device and the stay is not covered by Part A, they are covered by Part B.  Part B coverage applies regardless of whether the TPN items were furnished by the SNF or an outside supplier.  The P art B TPN bill must be sent to the DME Medicare Administrative Contractor regardless of whether supplied by the SNF or an outside supplier.   Enteral nutrients provided during a stay that is covered by Part A are classified as food and included in the routine Part A payment sent to the SNF.  (See the Medicare Provider Reimbursement Manual, 2203.1E.)  Parenteral nutrient solutions provided during a covered Part A SNF stay are classified as intravenous drugs.  The SNF must bill these services as ancillary charges.  (See the Medicare Provider Reimbursement Manual, 2203.2.)   170 - Billing for Splints and Casts  (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)
(Medicare Claims Processing Manual)
The cost of supplies used in creating casts are not included in the payment amounts for the CPT codes for fracture management and for casts and splints.  Thus, for settings in which CPT codes are used to pay for services that include the provision of a cas t or splint, supplies maybe billed with separate CPCS codes.  The work and practice expenses involved with the creation of the cast or splint are included in the payment for the code for that service .  For claims with dates of service on or after July 1, 2001, jurisdiction for processing claims for splints transferred from the DME MACs to the A/B MAC (B).  The A/B MACs (B) have jurisdiction for processing claims for splints and casts, which includes codes for splints that may have previously been billed to the DME MACs.   Jurisdiction for slings is jointly maintained by the A/B MACs (B) (for physician claims) and the DME MACs (for supplier claims).  Notwithstanding the above where the beneficiary receives the service from any of the following providers claims jurisdiction is with the A/B MAC (A).  An exception to this is hospital outpatient services and hospital inpatient Part B services, which are in cluded in the OPPS payment and are billed to the A/B MAC (A) using the ASC X12 837 institutional claim format or Form CMS - 1450).   Other providers and suppliers that normally bill the A/B MAC (A) for services bill the A/B MAC (B) for splints and casts.