evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Beneficiaries are protected from liability for the period from the delivery of the expedited notice, usually two days before the end of coverage, to the end of the covered period written on the notice if the beneficiary requests an expedited determination timely.  If the beneficiary does not request the determination timely, or if the determination process at the QIO is delayed, the beneficiary may be liable for services provided from the day after the end of the covered period until the date of the actual discharge.   In cases where the beneficiary may be liable, in addition to reporting condition code C4 providers must also report occurrence span code 76, defined as patient liability period, along with the days of liability that have been incurred.  Line items with dates of service falling within this patient liability period are reported with noncovered charges and, if they require HCPCS coding, with modifier TS.  Intermediaries will deny these lines and hold the beneficiary liable.  In certain cases, an Advance Beneficiary Notice (ABN) may be issued simultaneously or immediately following the issuance of an expedited determination notice.  These ABNs would pertain to continued services that the beneficiary wishes to receive despite the providers intent to discharge the beneficiary.  Any required physician orders continue to be needed for the services to continue.  If these ABN situations result in a beneficiarys request for a demand bill to Medicare regarding continuing services after the QIO/QIC has upheld the discharge, providers must report condition code C4 on the demand bill.  The demand bill must otherwise be prepared according to all other applicable instructions.  B  Reporting of QIO/QIC Decisions Not Upholding a Discharge   When providers are notified of QIO/QIC decisions that authorize continued Medicare coverage and do not specify a coverage ending date, they must submit a continuing claim for the current billing or certification period according to all claims instructions for the applicable type of bill, plus a single additional data element.  Providers must annotate these claims with condition code C7, which is defined QIO extended authorization. This indicator will alert FIs/RHHIs that coverage of the services on the claim has already been subject to review.
(Medicare Claims Processing Manual)
In the circumstance, expected to be rare, when providers are notified of QIO/QIC decisions which authorize continued Medicare coverage only for a limited period of time, they must submit claims as follows:   If the time period of coverage specified by the QIO/QIC extends beyond the end of the normal billing or certification period for the applicable type of bill, providers submit a continuing claim for that period according to all applicable claims instructions plus two additional data elements.  Providers must annotate these claims with condition code C3, which is defined QIO partial approval and with occurrence span code M0, which is defined QIO approved stay dates, along with the following dates the be ginning date of the coverage period provided by the QIO/QIC, and the statement through date of the claim.    If the time period of coverage specified by the QIO/QIC does not extend to the end of the normal billing or certification period for the applicable type of bill, providers submit a discharge claim according to all applicable claims instructions plus two additional data elements.  Providers must annotate these claims with condition code C3, which is defined QIO partial approval and with occurrence span code M0, which is defined QIO approved stay dates and the dates provided by the QIO/QIC.   NOTE:   Regarding any decision that does not uphold a discharge, QIO/QIC decisions authorizing extended coverage cannot authorize delivery of services if there are not also the required physician orders needed to authorize the care.   C  Billing Beneficiaries in Cases Subject to Expedited Determinations   Providers should note a significant difference between the use of expedited determination notices and the use of ABNs.  As described in Claims Processing Manual, Chapter 1, section 60.3.1, in ABN or HHABN situations, all providers other than SNFs can bill beneficiaries for services subject to a demand bill while awaiting a Medicare determination on the coverage of the services.  The same is not true in expedited determination situations.  When a beneficiary requests an expedited determination timely, no funds may be collected until the provider receives notification of the QIO/QIC decision.  D  Reporting Provider Liability Situations   Providers may be liable as a result of two specific situations in the expedited review process:   (1) if the provider is not timely in giving information to the QIO; and
(Medicare Claims Processing Manual)
D  Reporting Provider Liability Situations   Providers may be liable as a result of two specific situations in the expedited review process:   (1) if the provider is not timely in giving information to the QIO; and   (2) if the provider does not give valid notice to the beneficiary.   Since both these events occur after the point the provider has already determined discharge is imminent, there may be no actual liability, since there may be no medical need for additional care.  However if services are required, and either of these liabil ity conditions apply, such services should be billed as noncovered line items using the GZ modifier, which indicates the provider is liable, consistent with Section 60.4.2 of this chapter.   160 - Identifying Institutional Providers  (Rev. 11794, Issued:01- 19-23, Effective: 04 -01-23, Implementation:04- 03-23)  Since May 23, 2007, Medicare institutional providers submit only the ten position numeric National Provider Identifier (NPI) as their provider identifier.    References to the six position alpha -numeric CMS Certification Number (CCN) (previously called the OSCAR number) found throughout the chapters of the Medicare Claims Processing Manual, on an ongoing basis, are supplied only for the purpose of CMS internal processing.  Therefore, these references are documented as for CMS use only.  160.1 - Reporting of Taxonomy Codes (Institutional Providers)  (Rev.11794, Issued:01- 19-23, Effective: 04 -01-23, Implementation:04- 03-23)  Institutional providers may submit a taxonomy code on claims they submit to Medicare.  Medicare does not use the taxonomy code for matching a providers NPI to the appropriate legacy identifier.  Medicare uses other claims data for this purpose.  Medicare does not use the taxonomy code for any other claims processing purpose.  Payers other than Medicare may have requirements for taxonomy codes.  Medicare will pass any taxonomy code submitted on a Medicare claim to our trading partners on crossover claims, to allow for the possibility that those payers may use it.
(Medicare Claims Processing Manual)
If an institutional provider chooses to submit taxonomy codes, the following table supplies the crosswalk from Medicares CMS Certification Number (CCN) to the appropriate taxonomy code based on the providers facility type:  Provider Type  CCN Coding  Taxonomy Code  Short -term (General and Specialty) Hospitals  0001-0879  *Positions 3-6 282N00000X Critical Access Hospitals  1300 -1399 *  282NC0060X  Long -Term Care Hospitals  2000 -2299 *  282E00000X  Hospital Based Renal Dialysis Facilities  2300-2499* 261QE0700X Independent Renal Dialysis Facilities  2500-2899* 261QE0700X Rehabilitation Hospitals  3025 -3099 *  283X00000X  Childrens Hospitals  3300 -3399 *  282NC2000X  Hospital Based Satellite Renal Dialysis Facilities  3500-3699 Type of Bill code 72X + 261QE0700X + different zip code than any renal dialysis facility that is located on that hospitals campus  Psychiatric Hospitals  4000-4499 * 283Q00000X Organ Procurement Organization (OPO)  P in third Position 335U00000X Psychiatric Unit M or S in third Position 273R00000X Rehabilitation Unit  R or T in third Position 273Y00000X Swing -Bed Unit  U, W, Y, or Z in third Position  Type of Bill Code X8X (swing bed) with one of the following taxonomy codes to define the type of facility in which the swing bed is located  275N00000X if unit in a short-term hospital (U),  282E00000X if unit in a long-term care hospital (W), 283X00000X if unit in a rehab facility (Y),  282NC0060X if unit in a critical access hospital (Z)  170 - Payment Bases for Institutional Claims  (Rev. 1526, Issued: 05- 30-08, Effective: 07 -01-08, Implementation: 07- 07-08)
(Medicare Claims Processing Manual)
170 - Payment Bases for Institutional Claims  (Rev. 1526, Issued: 05- 30-08, Effective: 07 -01-08, Implementation: 07- 07-08)  There are many different payment mechanisms that apply to institutional claims.  Among these are reasonable cost, prospective payment systems, all of which require at least some bundling of services, and various fee schedules.  170.1 - Services Paid on the Medicare Physician Fee Schedule (MPFS)  (Rev. 1526, Issued: 05- 30-08, Effective: 07 -01-08, Implementation: 07- 07-08)  The following chart shows for selected Types of Bill (TOB) those revenue codes containing (some) services payable on the MPFS .  Services Payable on the MPFS               TOB by Revenue Code                Rev codes                                  12x IHS 12x  13x IHS 13x 22x 23x 34x 72x 74x 75x 76x 81x 82x 85x IHS 85x 030x          X                     031x          X                     032x          X X                   033x          X X                   034x          X X                   036x          X X                   0401, 0403  X   X   X X               X X 0410, 0412, 0419          X X       X           042x  X X X X X X X   X X           043x  X X X X X X X   X X           044x  X X X X X X X   X X           046x          X X                   471 X X X X X X                   048x          X X                   0550, 0559                    X           056x                    X           061x          X X                   657                       X X     070x          X X                   073x          X X                   074x          X X                   075x          X X                   771 X X X X X X X X    X       X X                                                                  Services Payable on the MPFS               TOB by Revenue Code (continued)                 12x IHS 12x  13x IHS 13x 22x 23x 34x 72x 74x 75x 76x 81x 82x 85x HIS 85x 078x  X X X X                   X X 090x          X X       X           091x          X X       X           092x          X X                   0940, 0942, 0949          X X       X           096x                            X X 097x                            X X 098x                            X X
(Medicare Claims Processing Manual)
170.1.1  Payments on the MPFS for Providers With Multiple Service Locations  (Rev. 3454, Issued: 02- 04-16, Effective: 07 -01-16, Implementation: 07- 05-16)  Services that are paid subject to the Medicare Physician Fee Schedule (MPFS) are adjusted based on the applicable payment locality.  Medicare systems determine which locality applies using ZIP codes.  In cases where the provider has only one service locati on, the payment locality used to calculate the fee amount is determined using the ZIP code of the master address contained in the Medicare contractors provider file.   Increasingly, hospitals operate off -site outpatient facilities.  Other institutional outpatient service providers, including rehabilitation agencies and Comprehensive Outpatient Rehabilitation Facilities, may operate multiple sites.  In some cases, these a dditional locations are in a different payment locality than the parent provider.  In order for MPFS payments to be accurate, the nine -digit ZIP code of the satellite facility is used to determine the locality in these cases.   Medicare outpatient service providers report the nine -digit ZIP code of the service facility location in the 2310E loop of the 837 Institutional claim transaction.  Direct Data Entry submitters also are required to report the nine -digit ZIP code of the service facility location for off-site or multiple satellite office outpatient facilities.  Paper submitters report this information in Form Locator (FL) 01 on the paper claim form.  Medicare systems us e this service facility ZIP code to determine the applicable payment locality whenever it is present.   180  Denial of Claims Due to Violations of Physician Self -Referral Prohibition  (Rev. 1578, Issued: 08- 15-08, Effective: 01 -01-09, Implementation: 01 -05-09)  180.1  Background and Policy  (Rev. 1578, Issued: 08- 15-08, Effective: 01 -01-09, Implementation: 01- 05-09)
(Medicare Claims Processing Manual)
180.1  Background and Policy  (Rev. 1578, Issued: 08- 15-08, Effective: 01 -01-09, Implementation: 01- 05-09)  Under Section 1877 of the Social Security Act (the Act) (42 U.S.C. 1395nn), a physician may not refer a Medicare patient for certain designated health services (DHS) to an entity with which the physician (or an immediate family member of the physician) ha s a financial relationship, unless an exception applies.  Section 1877 of the Act also prohibits the DHS entity from submitting claims to Medicare, the beneficiary, or any entity for DHS that are furnished as a result of a prohibited referral.  The followi ng services are DHS: clinical laboratory services; radiology and certain other imaging services (including MRIs, CT scans and ultrasound); radiation therapy services and supplies; durable medical equipment and supplies; orthotics, prosthetics, and prosthet ic devices; parenteral and enteral nutrients, equipment and supplies; physical therapy, occupational therapy, speech- language pathology services; outpatient prescription drugs; home health services and supplies; and inpatient and outpatient hospital services.  A financial relationship includes both ownership/investment interests and compensation arrangements (for example, contractual arrangements between a hospital and a physician for physician services).  The statute and regulations enumerate various exc eptions to the physician self -referral prohibition.  Violations of the statute are punishable by denial of payment for all DHS claims, refunds of amounts collected for DHS claims, and civil money penalties for knowing violations of the prohibition.  Applic able regulations are published at 42 C.F.R. Part 411, Subpart J.  180.2  Denial Code  (Rev. 1578, Issued: 08- 15-08, Effective: 01 -01-09, Implementation: 01- 05-09)
(Medicare Claims Processing Manual)
Prior to the publication of the new CARC #213, there was no specific code to describe claims that are denied based on a violation of the physician self -referral statute at Section 1877 of the Act.  A specific code is appropriate so both the providers of DH S and the industry know that claims are being denied based on the non compliance with the physician self -referral prohibitions.  This code should be used any time a claim is denied because the physician (or an immediate family member of the physician) has a financial interest in a DHS provider and fails to meet one of the exceptions available in 42 C.F.R. 411.355- 411.357.  190  Payer Only Codes Utilized by Medicare  (Rev. 11571, Issued:08- 25-22, Effective: 09 -27-22, Implementation: 09- 27-22)  This section contains the listing of payer codes designated by the National Uniform Billing Committee to be assigned by payers only. Providers shall not submit these codes on their claims forms. The definitions indicating Medicares usage for these systema tically assigned codes are indicated next to each code value.  Condition Codes  12-14  Not currently used by Medicare.  15  Clean claim is delayed in CMS Processing System.  16  SNF Transition exception.   62  PIP Bill.  63  Bypass CWF edits for incarcerated beneficiaries. Indicates services rendered to a prisoner or a patient in State or local custody meets the requirement of 42 CFR 411.4(b) for payment.   64  Other Than Clean Claim.  65  Non -PPS Bill.  98  Data Associated With DRG 468 Has Been Validated.  EY  Lung Reduction Study Demonstration Claims.  M0  All -Inclusive Rate for Outpatient - Used by a Critical Access Hospital electing to be paid an all -inclusive rate for outpatient services.
(Medicare Claims Processing Manual)
M1  Roster Billed Influenza Virus Vaccine or Pneumococcal Pneumonia Vaccine (PPV). Code indicates the influenza virus vaccine or pneumonia vaccine (PPV) is being billed via the roster billing method by providers that mass immunize.  M2  Allows Home Health claims to process if provider reimbursement > $150,000.00. HHA Payment Significantly Exceeds Total Charges. Used when payment to an HHA is significantly in excess of covered billed charges.  M3  SNF 3 Day stay bypass for NG/Pioneer ACO waiver.  M4  Presence of infected wound or wound with morbid obesity  M5  Not currently used by Medicare   M6  PA Rural Health Model  M7-M9  Not currently used by Medicare.  MA  GI Bleed. (Bill Type 072x)  MA  Managed Care Enrollee (Bill Type 012x, 013x, and 076x)  MB  Pneumonia. (Bill Type 072x)  MC  Pericarditis. (Bill Type 072x)  MD  Myelodysplastic Syndrome. (Bill Type 072x)  ME  Hereditary Hemolytic and Sickle Cell Anemia. (Bill Type 072x)  MF  Monoclonal Gammopathy. (Bill Type 072x)  MG  Grandfathered Tribal Federally Qualified Health Centers.  MH-MN  Not currently used by Medicare.  MO  MAC Override Appeal Timeliness.  MP  PHP claim contains initial admit week  MQ  PHP claim contains final discharge week  MR-MU  Not currently used by Medicare.  MV  20 hours for partial PHP subsequent week not met  MW  20 hours for partial PHP initial week net met MX  Wrong Surgery on Patient (Inpatient)  MY  Surgery Wrong Body Part (Inpatient)  MY  Outlier Cap Bypass (CMHC)  MZ  Surgery Wrong Patient (Inpatient)  MZ  IOCE error code bypass (Outpatient)  UU  Not currently used by Medicare.   Z0-Z9  Not currently used by Medicare.   ZA  No Positive COVID- 19 test result in M/R   ZB  Expanded Access approval   ZC  Clinical Trial of a different product   ZD-ZZ  Not currently used by Medicare.   Occurrence Codes  23  Date of Cancellation of Hospice Election period.  48  Not currently used by Medicare.  49  Original Notice of Election (NOE) receipt date.
(Medicare Claims Processing Manual)
ZD-ZZ  Not currently used by Medicare.   Occurrence Codes  23  Date of Cancellation of Hospice Election period.  48  Not currently used by Medicare.  49  Original Notice of Election (NOE) receipt date.   AA-AZ  Not currently used by Medicare.  Occurrence Span Codes  79  Verified non -covered stay dates for which the provider is liable.  Z0-Z9  Not currently used by Medicare.  ZA-ZZ  Not currently used by Medicare.  Value Codes  17  Operating Outlier Amount  The A/B MAC (A) reports the amount of operating outlier payment amount made (either cost or day (day outliers have been obsolete since 1997)) in CWF with this code. It does not include any capital outlier payment in this ent ry.   18  Operating Disproportionate Share Amount  The A/B MAC (A) REPORTS THE OPERATING DISPROPORTIONATE SHARES AMOUNT APPLICIALBE. It uses the amount provided by the disproportionate share field in PRICER. It does not include any PPS capital IME adjustment e ntry.  19  Outpatient Use.  The Medicare shared system will display this payer only code on the claim for low volume providers to identify the amount of the low volume adjustment being included in the providers reimbursement. This payer only code 19 is also use d for IME on hospital claims. This instruction shall only apply to ESRD bill type 72x and must not impact any existing instructions for other bill types.  19  Inpatient Use.  Operating Indirect Medical Education Amount  The A/B MAC (A) reports operating indirect medical education amount applicable. It uses the amount provided by the indirect medical education field in PRICER. It does not include any PPS capital IME adjustment in this entry.  20  Total payment sent provider for capital under PPS, including HSP, FSP, outlier, old capital, DSH adjustment, IME adjustment, and any exception amount.  62  On Type of Bill 032x: HH Visits - Part A - The number of visits determined by Medicare to be payable from the Part A trust fund to reflect the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Security A ct.
(Medicare Claims Processing Manual)
62  On Type of Bills 081x 0r 082x: Number of High Routine Home Care Days -  Days that fall within the first 60 days of a routine home care hospice claim.   63  On Type of Bill 032x: HH visits  Part B - The number of visits determined by Medicare to be payable from the Part B trust fund to reflect the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Security Act.   63  On Type of Bills 081x 0r 082x: Number of Low Routine Home Care Days -  Days that come after the first 60 days of a routine home care hospice claim.  64  HH Reimbursement  Part A - The dollar amounts determined to be associated with the HH visits identified in a value code 62 amount. This Part A payment reflects the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) o f the Social Security Act.  65  HH Reimbursement  Part B - The dollar amounts determined to be associated with the HH visits identified in a value code 63 amount. This Part B payment reflects the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) o f the Social Security Act.  70  Interest Amount  The contractor reports the amount of interest applied to this Medicare claim.  71  Funding of ESRD Networks - The A/B MAC (A) reports the amount the Medicare payment was reduced to help fund ESRD networks.  72  Flat Rate Surgery Charge  The standard charge for outpatient surgery where the provider has such a charging structure.  73  Sequestration adjustment amount.  74  Low volume hospital payment amount   75  Prior covered days for an interrupted stay.   76  Providers Interim Rate  Providers percentage of billed charges interim rate during this billing period. This applies to all outpatient hospital and skilled nursing facility (SNF) claims and home health agency (HHA) claims to which an interim rate i s applicable. The contractor reports to the left of the dollar/cents delimiter. An interim rate of 50 percent is entered as follows: 50.00.   77  Medicare New Technology Add -On Payment  Code indicates the amount of Medicare additional payment for new technology.