evekhm/cms_iom_500 huggingface dataset:
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In addition to the annual update at the beginning of each calendar year, we also update the OPPS on a quarterly basis to account for mid- year changes such as adding new pass -through drugs and/or devices, adding new treatments and procedures to the new technology APCs, removing procedures from the inpatient list, and recognizing new HCPCS codes that may be added during the year.  The quarterly updates are issued as Recurring Update Notifications.  The quarterly Recurring Update Notifications can be found in Pub. 100-21, Recurring Update Notification, which can be accessed at the following Web si te:  http://www.cms.gov/Regulations- and-Guidance/Guidance/Manuals/Internet- Only -Manuals -IOMs.html  10.10 - Biweekly Interim Payments for Certain Hospital Outpatient Items and Services That Are Paid on a Cost Basis, and Direct Medical Education Payments, Not Included in the Hospital Outpatient Prospective Payment System (OPPS)  (Rev. 1, 10-03-03) A-01-32  For hospitals subject to the OPPS, payment for certain items that are not paid under the OPPS, but which are reimbursable in addition to OPPS, are made through biweekly interim payments subject to retrospective adjustment based on a settled cost report.  These payments include:   Direct medical education payments;   Costs of nursing and allied health programs;   Costs associated with interns and residents not in an approved teaching program as described in 42 CFR 415.202;   Teaching physicians costs attributable to Part B services for hospitals that elect cost- based reimbursement for teaching physicians under 42 CFR 415.160;   CRNA services;    For hospitals that meet the requirements under 42 CFR 412.113(c) , the reasonable costs of anesthesia services furnished to hospital outpatients by qualified nonphysician anesthetists (i.e., certified registered nurse anesthetists and anesthesiologists assistants) employed by the hospital or ob tained under arrangements;    Bad debts for uncollectible deductibles and coinsurance;   Organ acquisition costs paid under Part B.
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 Bad debts for uncollectible deductibles and coinsurance;   Organ acquisition costs paid under Part B.   For hospitals that are paid under the OPPS, interim payments for these items attributable to both hospital outpatients, as wel l as inpatients whose services are paid under Part B of the Medicare program are made on a biweekly basis.  The A/B MAC (A) determines the amount of the biweekly payment by estimating a hospitals reimbursement amount for these items for the cost reporting  period by using:    Medicare principles of cost reimbursement for cost -based items; and    Medicare rules for determining payment for graduate medical education for direct medical education, and dividing the total annual estimated amount for these items into  26 equal biweekly payments.   The estimated annual amount is based on the most current data available.  Biweekly interim payments are reviewed and, if necessary, adjusted at least twice during the reporting period, with final settlement based on a submitte d cost report.   Because hospitals subject to the OPPS have not received payment for these items attributable to services furnished on or after August 1, 2000, the date the OPPS was implemented, the first payment to each hospital included all the payments due to the hospital retroactive to August 1, 2000.  Thereafter, A/B MACs (A) continue to make payment on a biweekly basis.  Each payment is made two weeks after the end of a biweekly period of services.  The A/B MAC (A) was required to make retroactive paym ents and begin making biweekly interim payments to all hospitals that are due these payments no later than 60 days after March 8, 2001.
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These biweekly payments may be combined with the inpatient biweekly payments that the A/B MAC (A) makes under 2405.2 o f the Medicare Provider Reimbursement Manual (CMS Pub.15- I).  However, if a single payment is made, for purposes of final cost report settlement, they must maintain records to separately identify the amount of the hospitals combined payment that is paid out of the Part A or Part B trust fund.  10.11 - Calculation of Overall Cost -to-Charge Ratios (CCRs) for Hospitals Paid Under the Outpatient Prospective Payment System (OPPS) and Community Mental Health Centers (CMHCs) Paid Under the Hospital OPPS  (Rev. 1445, Issued:  02- 08-08; Effective:  01- 01-08; Implementation:  03 -10-08)  10.11.1 - Requirement to Calculate CCRs for Hospitals Paid under OPPS and for CMHCs  (Rev. 2296, Issued: 09- 02-11, Effective: 10- 01-11, Implementation: 10- 03-11)  Medicare contractor s must calculate overall cost -to-charge ratios for hospitals paid under OPPS and for CMHCs using the providers most recent full year cost reporting period, whether tentatively settled or final settled, in accordance with the instructions in 10.11.7, 10.11.7.1, 10.11.8, 10.11.8.1 or 10.11.9 as applicable. The contractor must calculate a provider overall CCR whenever a more recent full year cost report becomes available. If a CCR is calculated based on the tentatively settled cost report, the contractor must calculate another overall CCR when the cost report is final or when a cost report for a subsequent cost reporting period is tentatively settled, whichever occurs first. If a CCR is based on a final settled cost report, the contractor must calculate the CCR when a cost report for a subsequent cost reporting period is tentatively settled.   10.11.2 - Circumstances in Which CCRs are Used  (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)
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10.11.2 - Circumstances in Which CCRs are Used  (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)  The contractors must apply CCRs prospectively to calculate outlier payments (for hospitals paid under OPPS and CMHCs), Transitional Outpatient Payment System (TOPS) payments (for hospitals paid under OPPS), device pass -through payments (for hospitals paid under OPPS), and items and servi ces paid at charges adjusted to cost (for hospitals paid under OPPS).    10.11.3 - Selection of the CCR to be Used  (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)   Contractors will use the CCR calculated for the most recent perio d of time, whether based on a tentatively settled cost report or a final settled cost report.  For example, if the CCR being used is the tentatively settled CCR for FY 2008, and a tentatively settled CCR for FY 2009 is determined before the final settled C CR for FY 2008, then the contractor uses the CCR based on the tentatively settled 2009 cost report.  10.11.3.1 - CMS Specification of Alternative CCR (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)
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Effective January 1, 2009, t he central office may direct Medicare contractors to use an alternative CCR if CMS believes this will result in a more accurate CCR.  Also, if the Medicare contractor finds evidence that indicates that using data from the latest settled or tentatively settled cost report would not result in the most accurate CCR, then the Medicare contractor shall notify the CMS central office and CMS regional office to seek approval to use a CCR -based on alternative data.  For example, CCRs may be revised more often if a change in a hospital or CMHCs operations occurs which materially affects a hospital or CMHCs costs and charges.  The central and regional offices must approve the Medicare contractors request before the Medicare contractor may use a CCR -based on alternative data.  Revised CCRs are applied prospectively to all OPPS claims processed after the update.  Medicare contractors shall send notification to the central office via the following address and e- mail address:   CMS  C/O Division of Outpatient Care - OPPS O utlier Team  7500 Security Blvd.  Mail Stop C4 -05-17 Baltimore, MD 21244 outliersopps@cms.hhs.gov  10.11.3.2 - Hospital or CMHC Request for Use of a Different CCR  (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)
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10.11.3.2 - Hospital or CMHC Request for Use of a Different CCR  (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)   Effective January 1, 2009, CMS (or the Medicare contractor) may specify an alternative CCR if it believes that the CCR being applied is inaccurate.  In addition, a hospital or CMHC has the opportunity to request that a different CCR be applied for outlier payment calculation in the event it believes the CCR being applied is inaccurate.  The hospital or CMHC is required to present substantial evidence supporting its request.  Such evidence should include documentation regarding its costs and charges that demonstrate its claim that an alternative ratio is more accurate.  After the Medicare contractor has evaluated the evidence presented by the hospital or CMHC, the Medicare contractor notifies the CMS central office and CMS  regional office of any such request.  The CMS central and regional offices approve or deny any request by the hospital (or CMHC) or Medicare contractor for use of a different CCR.  Medicare contractors shall send requests to the CMS central office using the address and e-mail address provided above.  10.11.3.3 - Notification to Hospitals Paid Under the OPPS of a Change in the CCR  (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)   The Medicare contractor shall notify a hospital or CMHC whenever it makes a change to its CCR.  When a CCR is changed as a result of a tentative settlement or a final settlement of the cost report, the change to the CCR can be included in the notice that is issued to each provider after a tentative or final settlement is completed.  Medicare contractors can also issue separate notification to a hospital about a change to its CCR(s).    10.11.4 - Use of CCRs in Mergers, Acquisitions, Other Ownership Changes, or Errors Related to CCRs (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)  The contractors use the CCR for the surviving provider in cases of provider merger, acquisition or other such changes.
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The contractors use the CCR for the surviving provider in cases of provider merger, acquisition or other such changes.   Effective for hospitals experiencing a change of ownership after January 1, 2007, that have not accepted assignment of an existing hospital's provider agreement in accordance with 42 CFR 489.18, and do not yet have a Medicare cost report, the contractor may use the default S tatewide CCR to determine cost -based payments until the hos pital has submitted its first Medicare cost report.  See 10.11.10 for the location of the Statewide CCRs and the upper limit above which the contractor must use the Statewide CCR.  For purposes of identifying a CCR for payment, Medicare contractors may apply a Statewide average to hospitals receiving a new provider number, such as hospitals converting from non- IPPS to IPPS status.  Also, for purposes of identifying a CCR for payment, hospitals receiving a new provider number may request use of a different CCR based on substantial evidence.  Use of an alternative CCR is subject to the approval of the CMS central and regional offices as discussed in 10.11.3.2.  For hospitals experiencing a change of ownership prior to January 1, 2007, the contractor should use the prior hospital's CCR.   In instances where errors related to CCRs and/or outlier payments are discovered, the Medicare contractor shall contact the CMS central office to seek further guidance.  Medicare contractors may contact the CMS central office via the address and e -mail address listed in 10.11.3.1 of this chapter.   If a cost report is reopened after final settlement and as a result of this reopening, there is a change to the CCR, Medicare contractors should contact the CMS regional and central office for further instructions.  Medicare contractors may contact the CMS central office via the address and email address listed in 10.11.3.1.  10.11.5 - New Providers and Providers with Cost Report Periods Less Than a Full Year  (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)  The contractors must calculate a hospital CCR using the most recent full -year cost report if a hospital or CMHC has a short period cost report.
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The contractors must calculate a hospital CCR using the most recent full -year cost report if a hospital or CMHC has a short period cost report.   The contractors must use the Statewide CCR for all inclusive rate hospitals paid under OPPS, or when a new provider does not have a full years cost report and has no cost report history.   See 10.11.10 for the location of the Statewide CCRs.   10.11.6 - Substitution of Statewide CCRs for Extreme OPPS Hospi tal Specific CCRs  (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)  The contractors must use the applicable Statewide average urban or rural hospital default ratio if the CCR calculated for a hospital paid under OPPS is greater than the upper limit CCR in the file of overall OPPS hospital CCR limits on the CMS Web site.   In addition to the circumstances listed in 10.11.6, 10.11.5, and 10.11.4 of this chapter, a Medicare contractor also should use a Statewide average CCR if it i s unable to determine an accurate overall ancillary CCR for a hospital for whom accurate data with which to calculate an operating CCR is not available.  Further, the policies of 10.11.3.1 and 10.11.3.2 can be applied as an alternative to the Statewide a verage.   See 10.11.10 for the location of the Statewide CCRs and the upper limit above which the contractor must use the Statewide CCR.    10.11.7 - Methodology for Calculation of Hospital Overall CCR for Hospitals That Do Not Have Nursing and Paramedical E ducation Programs for Cost Reporting Periods Beginning Before  May 1, 2010, Under Cost Report Form 2552- 96 (Rev. 2296, Issued: 09- 02-11, Effective: 10- 01-11, Implementation: 10- 03-11)  10.11.7.1 - Methodology for Calculation of Hospital Overall CCR for Hos pitals That Do Not Have Nursing and Paramedical Education Programs for Cost Reporting Periods Beginning On or After May 1, 2010, Under Cost Report 2552 -10 (Rev. 2296, Issued: 09- 02-11, Effective: 10- 01-11, Implementation: 10- 03-11)
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In calculating the hosp itals costs or charges, do not include departmental CCRs and charges for services that are not paid under the OPPS such as physical, occupational and speech language therapies, clinical diagnostic laboratory services, ambulance, rural health clinic servic es, non- implantable DME, etc. See 10.11.10 for the location of the list of exact cost centers that shall be included in the calculation of the overall CCR.   Step 1 -  Determining Overall Costs:   Calculate costs for each cost center by multiplying the departmental CCR for each cost center (and subscripts thereof) that reflect services subject to the OPPS from Form CMS 2552- 10, Worksheet C, Part I, Column 9 by the Medicare outpatient charges for tha t cost center (and subscripts thereof) from Worksheet D, Part V, Columns 2, 3, and 4,. Sum the costs calculated for each cost center to arrive at Medicare outpatient cost of services subject to OPPS.   Step 2 -  Determining Overall Charges: Calculate charges by summing the Medicare outpatient charges from Form CMS 2552- 10, Worksheet D, Part V, Columns 2, 3, and 4, (and for each cost center (and subscripts thereof) that reflect services subject to the OPPS.   Step 3 -  Calculating the Overall CCR: Divide the c osts from Step 1 by the charges from Step 2 to calculate the hospitals Medicare outpatient CCR.   10.11.8 - Methodology for Calculation of Hospital Overall CCR for Hospitals That Have Nursing and Paramedical Education Programs for Cost Reporting Periods Beginning Before May 1, 2010, Under Cost Report Form 2552- 96 (Rev. 2296, Issued: 09- 02-11, Effective: 10- 01-11, Implementation: 10- 03-11)  10.11.8.1 - Methodology for Calculation of Hospital Overall CCR for Hospitals That Have Nursing and Paramedical Education Programs for Cost Reporting Periods Beginning On or After May 1, 2010, Under Cost Report 2552 -10 (Rev.  2296, Issued: 09- 02-11, Effective: 10- 01-11, Implementation: 10- 03-11)
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Do not include departmental CCRs and charges for services not subject to the OPPS (such as physical, occupational and speech language therapies, clinical diagnostic laboratory services, ambulance, rural health clinic services, non -implantable DME, etc.) in calculating the hospitals costs or charges.  See 10.11.10 for the location of the list of the exact cost centers that should be included in the overall CCR.   Step 1 -- Determining  costs for each department:   From Worksheet B, Part 1 -  Column 26, deduct the nursing and paramedical education costs found on the applicable line in Columns - 20, and 23 of Worksheet B, Part I to calculate a cost for each cost center.   Exception: The costs for 9200 are not calculated on this worksheet. For cost center 9200,  Observation Beds (Non -Distinct Part), use the cost reported on Worksheet D-1, Part IV, line 89, and deduct the nursing and paramedical education costs found on Worksheet D-1, Part IV, line 93 and subscripts, column 5. See Step 3 below.   Step 2 - Determining charges for each department: From worksheet C, Part 1 - Column 8 (sum of columns 6 and 7), identify total charges.
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Step 3 - Determining the CCRs for each department without nursing and paramedical education costs: For each line, divide the costs from Step1 by the charges from Step 2 to acquire CCRs for each line, without inclusion of nursing and paramedical education costs. Exception: For cost center 9200,  Observation Beds (Non -Distinct Part), use the cost reported on Worksheet D-1, Part IV, line 89, and deduct the nursing and paramedical education costs found on Worksheet D-1, Part IV, line 93 and subscripts, column 5.   Step 4 - Determining Overall Costs: Multiply the CCR in step 3 by the Medicare outpatient charges for that cost center (and subscripts thereof) from Worksheet D Part V, Columns 2, 3, and 4,. Sum the costs calculated for each cost center to arrive at Medicare outpatient cost of services subject to OPPS.   Step 5 - Determining Overall Charges: Calculate charges by summing the Medicare outpatient charges from Form CMS 2552-10, Worksheet D, Part V, Columns 2, 3, and 4, for each cost center (and subscripts thereof) that reflect service subject to the OPPS.   Step 6 - Calculating the Overall CCR: Divide the costs from Step 4 by the charges from step 5 to calculate the hospitals Medicare outpatient CCR.   10.11.9 - Methodology for Calculation of CCR for CMHCs  (Rev. 10869; Issued: 07-14-21; Effective: 08-13-21; Imp lementation: 08 -13-21)  Calculate the CMHCs CCR using the providers most recent full year cost report, Form CMS 2088-92, and Medicare cost and charges from Worksheet C, Page 2. Divide costs from line 39.01, Column 3 by charges from line 39.02, Column 3 t o calculate the CCR.   Calculate the CMHCs CCR using the providers most recent full year cost report, Form CMS 2088-17, and Medicare cost and charges from Worksheet C.  Divide costs from line 50, Column 5, by charges from line 50, Column 4, to calculate t he CCR .
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If the CCR is above 1.0 enter the appropriate Statewide average urban or rural hospital default ratio that is in the OPSF for the CMHC.  There is no lower limit for CMHC CCRs.  Use the CCR you calculate and do not substitute the Statewide average urban or rural hospital default ratio in cases where the CCR is below 1.0.  Note that CCR reporting requirements in 10.11 apply to both hospitals paid under OPPS and to CMHCs.  10.11.10 - Location of Statewide CCRs, Tolerances for Use of Statewide CCRs in  Lieu of Calculated CCRs and Cost Centers to be Used in the Calculation of CCRs (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)  The file of OPPS hospital upper limit CCRs and the file of Statewide CCRs are located on the CMS Web site at www.cms.hhs.gov/HospitalOutpatientPPS/  under Annual Policy Files.  A spreadsheet li sting the Statewide CCRs also  can be found in the file containing the preamble tables that appears in the most recent OPPS/ASC final rule.  The contractors must always use the most recent Statewide CCR.   The file of standard and nonstandard cost centers to be used in the calculation of hospital outpatient CCRs is also found on the CMS Web site at www.cms.hhs.gov/HospitalOutpatientPPS/ under Revenue Code to Cost Center Crosswalk.   10.11.11 - Reporting of CCRs for Hospitals Paid Under OPPS and for CMHCs (Rev.  2111, Issued: 12- 03-10, Effective: 04- 01-11, Implementation: 04- 04-11 )
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The contractors shall report the OPPS hospital overall or CMHC CCR they calculate, or the Statewide CCR they sel ect, for each provider to the Outpatient Provider Specific File (OPSF; see 50.1 of this chapter) within 30 days after the date of the calculation or selection of the Statewide CCR for the provider.  If a cost report reopening results in adjustments that w ould change the CCR that is currently in effect, the contractor shall calculate and enter the CCR in the OPSF within 30 days of the date that the reopening is finalized.  In such an instance, contractors must create an additional record in the OPSF for the  provider.  The contractor entries in the OPSF shall include the effective date of the CCR being entered.  Entries in the OPSF shall not replace a pre- existing entry for the provider. The only instances a Medicare contractor retroactively changes a field i n the PSF is to update the CCR when using the FISS Lump Sum Utility for outlier reconciliation or otherwise specified by the CMS Regional Office or Central Office.   10.12 - Payment Window for Outpatient Services Treated as Inpatient Services  (Rev. 3238, Is sued: 04 -22-15,  Effective: 04 -01-15 Implementation: 04 -06-15)  The policy for the payment window for outpatient services treated as inpatient services is discussed in chapter 3  40.3 of this manual.  The policy requires payment for certain outpatient services provided to a beneficiary on the date of an inpatient admission or during the 3 calendar days (or 1 calendar day for a non-IPPS hospital) prior to the date of an inpatient admission to be bundled (i.e., included) with the Medicare Part A payment f or the beneficiarys inpatient admission if those outpatient services are provided by the admitting hospital or an entity that is wholly owned or wholly operated by the admitting hospital.  The policy applies to all diagnostic outpatient services (includin g non- patient laboratory tests) and non -diagnostic services (i.e., therapeutic) that are related to the inpatient stay.  Ambulance and maintenance renal dialysis services are not subject to the payment window.