evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The DME MACs identify instances where revisions to DMEPOS fees are needed and forward requests to CMS via email to the Division of Data Systems. The information must be contained in an ASCII file.  The requests must include a narrative description.   The following file specifications are 2003 examples, the actual file names may change each year:   Data Set Name  DMEREV1A.TXT  First Quarter Submission   DMEREV1B.TXT  Second Quarter Submission  DMEREV1C.TXT  Third Quarter Submission  DMEREV1D.TXT  Fourth Quarter Submission Record Format  Field Name  PIC Position  Comment  HCPCS Code  X(5)  1 - 5  Filler  X(1)  6 - 6 Set to Spaces  First Modifier  X(2)  7 - 8  Filler  X(1)  9 Set to Spaces  Second Modifier  X(2)  10 - 11  Filler  X(2)  12 - 13 Set to Spaces  State  X(3)  14 - 16  Filler  X(1)  17 Set to Spaces  Field Name  PIC Position  Comment  Revised Base Fee  S9(5)V99 18 - 26 1992 level for surgical dressings;  1995 level for PEN;  2013 level for Splints & Casts;  2012 level for certain IOLs;  1989 for all other categories  Filler  X(1)  27 Set to Spaces  Capped Rental Rebasing Indicator  X(1)  28 For Capped Rental Services Only:  0 - IR not applied to original base fee and base fee in effect prior to 1991, base fee is subject to rebasing adjustment  1 - IR applied to original base fee or base fee not in effect prior to 1991, base fee is exempted from rebasing adjustment  Filler  X(1)  29 Set to Spaces  Nature of Fee Revision X(1)  30 0 = Correction 1 = IR Revision 2 = Other -  Please submit supporting documentation. Filler  X(1)  31  Set to Spaces  IR - Effective Date  9(8) 32 - 39 Field is applicable only to those records where the fee has changed due to an inherent reasonableness decision and the previous field contains a value of 1.  Format is YYYYMMDD
(Medicare Claims Processing Manual)
The CMS will recalculate current year fee schedule amounts as appropriate and release the entire file in the record layout described in 60.1.  An indicator in the record field (Pricing Change Indicator) will identify those instances where pricing amounts have changed.  The CMS will also issue instructions for implementing the revised fee schedule amounts with the fee schedule.   60.5  Rural ZIP Code Claim Record Layout for Medicare Contractors Processing Rural DMEPOS Fee Schedule Claims  (Rev. 3350, Issued: 09- 11-15, Effective: 01 -01-16, Implementation: 01- 04-16)  This file contains rural area, as defined in 42 CFR 414.202, ZIP codes within the contiguous United States for use processing claims subject to the adjusted fee schedule methodology required by Section1834(a)(1)(F) of the Social Security Act.  The CMS wil l provide the specific file names when the rural ZIP code files are released.   Field Name  Pic Position  Comment  Effective Date  9(8) 1 - 8 Effective date that ZIP code considered rural  (CCYYMMDD).  Expiration Date  9(8) 9 - 16 Final date for considering a ZIP code rural. Field will be filled with 99999999s if an end- date has not been established.  Discontinued rural ZIP codes will be end dated as of the end of the quarter it was last an active rural ZIP. File Format is CCYYMMDD.  ZIP Code  X(5)  17 - 21 5-digit ZIP code considered rural  State  X(2)  22 - 23  Filler  X(17)  24 -40 Set to spaces   70 - Parenteral and Enteral Nutrition (PEN) Fee Schedule  (Rev. 1, 10- 01-03) PM B -01-54, AB -02-152  The Balanced Budget Act of 1997 4315 authorized the Secretary to implement a fee schedule for parenteral and enteral nutrition (PEN) items and services.  These items were previously paid on a reasonable charge basis.  The DME MACs will make payment based on the new PEN fee schedule effective for claims with dates of service on or after January 1, 2002.  The file layout for the PEN fee schedule is consistent with that of the DMEPOS fee schedule in 60.1 above except that Region, Ceiling, and Floor fields are not applicable and will be zero filled.
(Medicare Claims Processing Manual)
The CMS issues instructions for implementing an annual PEN fee schedule along with the DMEPOS fee schedule instructions.  The PEN fee schedule is provided to DME MACs and the Pricing, Data Analysis, and Coding Contractor (PDAC) via CMS mainframe telecommu nication system.   70.1 - Record Layout for PEN Fee Schedule  (Rev. 3350, Issued: 09- 11-15, Effective: 01 -01-16, Implementation: 01- 04-16)  Field Name  Pic Position  Comment  Year  X(4)  1 - 4 Applicable Update Year  Field Name  Pic Position  Comment  HCPCS Code  X(5)  5 - 9 All current year active and deleted codes  1st Modifier  XX 10 - 11  2nd Modifier  XX 12 - 13  Jurisdiction  X 14 D = DME MAC Jurisdiction  Category  XX 15 - 16 PE = Parenteral and Enteral Nutrition.   HCPCS Action  X 17 Indicates active/delete status in HCPCS file A = Active Code  D = Deleted Code, price provided for grace period processing only  Filler  XX 18 - 19 Value = 00  State  XX 20 - 21  Original Base Fee  9(5)V99  22 - 28 This amount is not used for pricing claims.  It is on file for informational purposes.  Beginning January 1, 2016, this field will include the Competitive Bidding Rural Fee Amount for specific HCPCS codes.  A new indicator field (RURAL FEE INDICATOR) shall be populated with a value of R when the Rural Fee is present in this field.  Filler  9(5)V99  29 - 35 This field is zero filled.  Filler  9(5)V99  36 - 42 This field is zero filled.  Updated Fee Schedule Amount  9(5)V99  43 - 49 Amount used for pricing.  Gap-Fill Indicator  X 50 0 = No Gap -filling required.  1 = A/B MAC (B) Needs to Gap -fill Original Base Year Amount.  Pricing Change Indicator  X  51 0 = No change to the updated fee schedule amount since previous release.  1 = A change has occurred to the updated fee schedule amount since the previous release.  Rural Fee Indicator  X(01)  52 R = Rural Fee is present in the Original Base Fee field  Filler  X(8)  53 - 60
(Medicare Claims Processing Manual)
80 - Reasonable Charges as Basis for A/B MAC (B)/DME MAC Payments  (Rev. 1, 10- 01-03) B3-5000, AB -01-118, AB -02-136, B -02-089  Effective with services furnished on or after January 1, 1992, A/B MACs (B) pay for physicians services based on a fee schedule.  Nonphysician services are also paid based on a percentage of fee schedule amounts depending on the type of nonphysician and s ervice rendered.  Other services and supplies (e.g., DMEPOS) are paid under the fee schedule designed specifically for those services.  Beginning in 1992, only the services listed below are paid under the reasonable charge methodology.  Where payment continues to be made on a reasonable charge basis for items and services, other than ambulance and laboratory services, A/B MACs (B) compute customary and prevailing charge updates at the beginning of each fee screen year (the 12- month period beginning January), using available statistics on charges for services from claims processed or services rendered during the 12 month period ending June 30 immediately preceding the start of the fee screen year.  For example, the customary and prevailing charge rates established for fee screen year 2003 (January 1, 2003, through December 31, 2003) are based on the charges made from July 1, 2001, through June 30, 2002.  Instructions regarding payment for ambulance and for laboratory services still subject to reasonable charges are found in Medicare Claims Processing Manual, Chapter 15, Ambulance, and Chapter 16, Laboratory Services from Independent Labs, Physicians, and Providers.  Additional instructions regarding payment for dialysis supplies and equipment are provided in the Medicare Claims Processing Manual, Chapter 8, Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims.   See specific year Program Memorandum instructions for a list of codes that are subject to the inflation -indexed charge (IIC) each year.  A/B MACs (B) compute each years IIC screen, by increasing the appropriate previous years screen by the percentage amount specified in annual Program Memorandum instructions.  A/B MA Cs (B)  must not compute IIC screens for items paid using gap- filled payment amounts in the previous year.  See specific year Program Memorandum instructions for any variances to these rules and for each years specific increase percentage.
(Medicare Claims Processing Manual)
Services paid on a reasonable charge basis continue to be paid for under the rules in this section.  A/B MACs (B)/DME MACs have the primary responsibility for determining reasonable charges.  The following guidelines are intended to assure overall consiste ncy among A/B MACs (B)/DME MACs with respect to the concepts applied in making reasonable charge determinations.   80.1 - Criteria for Determining Reasonable Charge  (Rev. 1, 10- 01-03) B3-5002, B -03-007  There are two criteria in 1842 of the Act that must be considered in determining the reasonable charge for a service.  They are:    The customary charges for similar services generally made by the physician or other person furnishing such services; and    The prevailing charges in the locality for similar services.   Therefore, the reasonable charge for a specific service in the absence of unusual medical complications or circumstances, may not exceed the lowest of:    The customary charge for that service;   The prevailing charge made for similar services in the locality; or   The actual charge for the service.  (See 80.8.)   The law also provides that the reasonable charge for a service not exceed the charge applicable for a comparable service under comparable circumstances to the contractors policyholders or subscribers.  (See 80.7.)  The A/B MAC (B) or DME MAC also determines if the charge for the specific item or service is inherently reasonable.   The income of an individual patient may not be considered in determining the amount of the reasonable charge.   Public Law 96- 499 requires that reasonable charge payments be based on customary and prevailing charge screens in effect on the date the service is rendered.  However, if the service was rendered at any time prior to the current fee year, payment is based on the screens in effect during the preceding fee screen year.   To implement this provision, the A/B MAC (B) must complete the following activities:   Retain the prior years pricing files in the system so that reasonable charge pricing data is available for two years.  As of July 1, 2003, all A/B MACs (B) operating the MCS system must retain at least five pricing files (current period plus four prior periods); and    Price the service based on the date of service on the claim using pricing files in effect for the same year as the date of service.
(Medicare Claims Processing Manual)
 Price the service based on the date of service on the claim using pricing files in effect for the same year as the date of service.   80.2 - Updating Customary and Prevailing Charges  (Rev. 1, 10- 01-03) B3-5003  A/B MACs (B)/DME MACs update customary and prevailing charge limits at the beginning of each fee screen year (the 12 -month period beginning January), using available statistics on charges for services from claims processed or services rendered during the 12-month period ending June 30 immediately preceding the start of the fee screen year.  For example, the limits used during fee screen year 2003 (January 1, 2003, through December 31, 2003) were based on the charges made from July 1, 2001, through June 30, 2002.  Customary and prevailing charge screens for a fee screen year are not changed except for the following reasons:    In individually identified and highly unusual situations where equity clearly indicates that the increases are warranted and requested by the entity furnishing the service;   To correct erroneous calculations; or   To establish screens for new services.   A/B MACs (B)/DME MACs must ensure that all data on the frequency of services, all data files and customary and prevailing charge files used to establish reasonable charge screens are retained and are available for use.   80.3 - The Customary Charge  (Rev. 1, 10- 01-03) B3-5010, B3- 5205  The customary charge is the amount that best represents the actual charges made for a given medical service or by other persons who supply other medical and health services to the general public.  Therefore, obtain information on the customary charges from the following sources:    Physicians and other persons not only from the Medicare program;   Any other available sources;   Other contractor programs;   Other insurance programs;   Federal Employee Health Benefit Program;   TriCare;   Any studies conducted by State or local medical societies;   From public agencies;   Any data volunteered from other sources.   Where circumstances warrant, MACs may also ask physicians or other persons for their charges for services rendered to the public in general.  MACs should validate any information on charges obtained from sources against claims.  A. Charges for Rare or Unusual Procedures
(Medicare Claims Processing Manual)
Where circumstances warrant, MACs may also ask physicians or other persons for their charges for services rendered to the public in general.  MACs should validate any information on charges obtained from sources against claims.  A. Charges for Rare or Unusual Procedures   A/B MACs (B) may incur situations where a new or rare procedure is performed and information on customary and prevailing charges is difficult to obtain.  In such situations, in order to make the reasonable charge determination:   a. Obtain data, if possible, on the charges made for the unusual or rare procedure in other areas similar to the locality in which the service was rendered; or   b. Consult with the local medical society regarding the appropriate charge to be made for this procedure.   A relative value scale may be used together with available information about the physicians customary charges and about the prevailing charges for more frequently performed services in the locality in order to fill gaps in the data available.  Where there  is insufficient information, consult with any medical authority that would be helpful, such as the medical personnel within the A/B MAC (B), the local or State medical society, or hospital medical personnel.  In assessing the value of the procedure, the m edical personnel should take into consideration:   a. Its complexity;  b. The time needed to perform the procedure; and  c. The prevailing charges in the locality for other procedures of comparable complexity.  A/B MACs (B) then determine reasonable charge for a given service on the best available medical opinion and information on customary and prevailing charges.   80.3.1 - Calculating Customary Charge  (Rev. 1, 10- 01-03) B3-5010.1, B3- 5213  A/B MACs (B) and DME MACs use to the extent possible, the actual charges for services rendered during the year ending June 30 immediately preceding the start of the fee screen year.  Use data either from claims processed or from claims for services rendered during that 12- month period.
(Medicare Claims Processing Manual)
The A/B MAC (B) or DME MAC arrays each charge the physician, supplier, or another entity made for a service in ascending order.  The lowest actual charge which is high enough to include the median of the arrayed charge data is then selected as the physicia ns or other persons customary charge for the service.  Include charges made to a class of patients (such as members of a Preferred Provider Organization) in the array of charges used to compute the customary charge.   Customary charges may be established using price lists when there is inadequate charge data.  In this case, use only the fees charged and the price lists in effect as of December  31 of the data base year.  The intent is to use a price list which reasonably  replicates the median of the prices charged by the supplier for his items and services during the data base year.   Where the MAC permitted an increase in a customary charge under the equity provision (see 80.3.1.1 below), the increased amount is recognized as the customary charge for the next fee screen year if it exceeds the median of charges made by the physician or other person for the service during the 12 months ending June 30 immediately preceding the start of that fee screen year.  The increased amount is the correct customary charge for use in the appropriate prevailing charge calculation(s).   A. Inclusion of Sales Taxes in Reasonable Charges   Sales taxes where appropriate were included in the calculation of reasonable charges computed.  They were also accounted for in the calculation of the base fee schedules for DME and orthotic/prosthetic devices.  The Consumer Price Index used to update fee schedules also accounts for sales tax.  Therefore, MACs do not make any additional payment for sales taxes and do not make adjustments in fees to reflect local changes in tax rates.   80.3.1.1 - Equity Adjustments in Customary Charge Screens  (Rev. 1, 10- 01-03) B3-5010.2
(Medicare Claims Processing Manual)
80.3.1.1 - Equity Adjustments in Customary Charge Screens  (Rev. 1, 10- 01-03) B3-5010.2  Once the MAC establishes the customary charge screens for a fee screen year, further increases (other than to correct errors) are permitted only in individually identified and highly unusual situations where equity clearly indicates that the increases are warranted.  Requests for revisions in customary charge profiles are initiated only by physicians or other persons furnishing covered services.  Such requests are neither encouraged nor discouraged, and each request is handled on the basis of its own merits.  All of the following considerations are taken into account, as applicable, in determining whether unusual circumstances warrant a revision in a customary profile in a particular situation.    Time elapsed since last change was made in customary charge   o Identify if the last change made in a customary charge for the service was in the past two or three years.  Generally, the more time that has elapsed since the last change the stronger the case is for recognizing the current charge.   o Take into consideration that a physician or other entity did not increase fees charged for a service because of the governments request for restraint and this can be verified.  This should be taken into account in determining whether unusual circumstances  are present in a particular case.    Consider the amount of the requested increase and the relationship of the new and old charges to the customary charges of other physicians or other persons in the locality for the service.    Increases in Operating Expenses Used to Justify an Increase in Charges   o The entity must specifically prove that increases in operating expenses are substantially above those resulting from general economic factors and the situation is unique.   80.3.2 - Customary Charge Profile  (Rev. 1, 10- 01-03) B3-5010.3  A/B MACs (B)/DME MACs establish and maintain adequate data on the customary charges for specific services and procedures made by individual physicians and other persons and organizations which render covered services.  This data must be readily available.  The customary charge record for each entity rendering covered services must include a minimum of the following data:    Entity name, address, identification code, locality and specialty status;    A continuing history of the entitys charges for specific services, supplies, etc;
(Medicare Claims Processing Manual)
 Entity name, address, identification code, locality and specialty status;    A continuing history of the entitys charges for specific services, supplies, etc;    A customary charge for each specific service or item derived from the entitys history of charges for that service or item (and which is to be used as the basis for the determination of reasonable charges in conjunction with the prevailing charge criterion ); and    For a charge made under unusual circumstances, include a description of the circumstances.   A/B MACs (B)/DME MACs develop and include in the entitys profile a customary charge conversion factor for use with a relative value scale when there is insufficient data to establish the actual customary charge or when an infrequently performed service or item is involved.  80.4 - Prevailing Charge  (Rev. 1, 10- 01-03) B3-5020  Prevailing charges are those charges that fall within the range of charges most frequently and widely used in a locality for a particular procedure or service.  The top of this range establishes an overall limitation on the charges that the A/B MAC (B) acc epts as reasonable for a given procedure or service, except where unusual circumstances or medical complications warrant an additional charge.   For any fee screen year, the prevailing charge limit in a locality for a service must be calculated as the 75th percentile of the customary charges determined for that service.  Array each customary charge for the service in ascending order and weight by how often the physician or other person rendered the service (as reflected by the charge data used to calculate the customary charge.  The lowest customary charge which is high enough to include the customary charges of the physicians or other persons who r endered 75 percent of the cumulative services is then determined as the prevailing charge for the service.  The proper procedure for establishing revised prevailing charge screens based on the 75th percentile is illustrated by the following example:   Customary Charge  Number of the item/ service  rendered  Cumulative Services  $5 1402  1402  $6 1115  2517  $7 1680  4197  $8 803 5000   Total 5000
(Medicare Claims Processing Manual)
Customary Charge  Number of the item/ service  rendered  Cumulative Services  $5 1402  1402  $6 1115  2517  $7 1680  4197  $8 803 5000   Total 5000    In the above example, 75 percent of the total of 5,000 services equals 3,750 services.  The prevailing charge is, therefore, $7.  (A total of 2,517 services were rendered with $5 and $6 customary charges, and an additional 1,680 services were rendered with $7 customary charges.  T he 3,750th service was thus rendered with a $7 customary charge.)   A/B MACs (B)/DME MACs establish four customary charges as the minimum number of customary charges for the same service needed to calculate the prevailing charge for a particular service in a locality or in an A/B MAC (B) service area.   If it is necessary to establish customary charges using price lists, A/B MACs (B)/DME MACs use these customary charges to also establish the required prevailing charges.  (See 80.3.1.)  If the A/B MAC (B)/DME MAC cannot derive precise data on the frequency of services from their records, they may use any information they have about the volume of business done by various suppliers in their area in order to weight the customary charges used to calculate the prevailing charges.   If the A/B MAC (B)/DME MAC has not established a locality prevailing charge for the service by specialty or group of specialties, they select the locality prevailing charge from the remaining sources of data (items 2 through 5 below inclusive).  That seque nce must be followed in strict order except as otherwise permitted by item 6.  The first charge available in the sequence of sources of data is selected as the locality prevailing charge.  Payments must be based on the fully adjusted locality prevailing charges.   Approved Sources of Data in the Required Sequence   1 Prevailing charge by locality and by specialty or group of specialties;   2 Prevailing charge by A/B MAC (B) service area and by specialty or group of specialties;   3 Prevailing charge by locality without regard to specialty;   4 Prevailing charge by A/B MAC (B) service area without regard to specialty; and