evekhm/cms_iom_500 huggingface dataset:
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 Extend the 5.8 percent reduction in operating costs and 10 percent reduction in capital costs (which had been due to sunset on December 31, 1999) through the first date the OPPS is implemented;     Require annual updating of the OPPS payment weights, rates, payment adjustments and groups;     Require annual consultation with an expert provider advisory panel in review and updating of payment groups;     Establish budget neutral outlier adjustments based on the charges, adjusted to costs, for all OPPS services included on the submitted outpatient bill for services furnished before January 1, 2002, and thereafter based on the individual services billed;     Provide transitional pass -through payment for the additional costs of new and current medical devices, drugs, and biologicals for at least two years but not more than three years;     Provide payment under OPPS for implantable devices including durable medical equipment (DME), prosthetics and those used in diagnostic testing;     Establish transitional payments to limit providers losses under OPPS; the additional payments are for 3 1/2 years for CMHCs and most hospitals, and permanent for the 10 cancer hospitals; and     Limit beneficiary coinsurance for an individual service paid under OPPS to the inpatient hospital deductible.    The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), which was signed into law on December 21, 2000, made a number of revisions to the Outpatient Prospective Payment System (OPPS).  These are:     Accelerated reductions of beneficiary copayments;     Increase in market basket update for 2001;     Transitional corridor provision for transitional outpatient payments (TOPs) for providers that did not file 1996 cost reports; and     Special transitional corridor treatment for childrens hospitals.
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 Transitional corridor provision for transitional outpatient payments (TOPs) for providers that did not file 1996 cost reports; and     Special transitional corridor treatment for childrens hospitals.    The Secretary has the authority under  1883(t)  of the Act to determine which services are included (with the exception of ambulance services for which a separate fee schedule is applicable starting April 1, 2002).  Medicare will continue to pay for clinical diagnostic laboratory services, orthotics, pr osthetics (except as noted above), and for take -home surgical dressings on their respective fee schedules.  Medicare will also continue to pay for chronic dialysis using the composite rate (certain CRNA services, PPV , and influenza vaccines and their admin istration, orphan drugs, and ESRD drugs and supplies are not included in the composite rate), for screening mammographies based on the current payment limitation, which changes to payment under the Medicare Physician Fee Schedule (MPFS), effective January 1, 2002, and for outpatient rehabilitation services (physical therapy including speech language pathology and occupational therapy) under the MPFS.  Acute dialysis, e.g., for poisoning, will be paid under OPPS.  The 10 cancer centers exempt from inpatient PPS are included in this system, but are eligible for hold harmless payment under the Transitional Corridor provision.    The Outpatient Prospective Payment System (OPPS) applies to all hospital outpatient departments except for hospitals that provide Part B only services to their inpatients;  Critical Access Hospitals (CAHs); Indian Health Service hospitals; hospitals located in American Samoa, Guam, and Saipan; hospitals located in the Virgin Islands; and effective January 1, 2017 non- excepted off -campus provider -based departments of a hospita l. The OPPS also applies to partial hospitalization and intensive outpatient services furnished by Community Mental Health Centers (CMHCs).    Certain hospitals in Maryland that are paid under Maryland waiver provisions are also excluded from payment under OPPS but not from reporting Healthcare Common Procedure Coding System (HCPCS) and line item dates of service.   10.1.1 - Payment Status Indicators  (Rev. 1445; Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)
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10.1.1 - Payment Status Indicators  (Rev. 1445; Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  An OPPS payment status indicator is assigned to every HCPCS code.  The status indicator identifies whether the service described by the HCPCS code is paid under the OPPS and if so, whether payment is made separately or packaged.  The status indicator may also provide additional information about how the code is paid under the OPPS or under another payment system or fee schedule.  For example, services with status indicator A are paid under a fee schedule or payment system other than the OPPS.  Services with status indicator N are paid under the OPPS, but their payment is packaged into payment for a separately paid service.  Services with status indicator T are paid separately under OPPS but a multiple procedure payment reduction applies when two or more services with a status indicator of T are billed on the same date of service.   The full list of status indicators and their definitions is published in Addendum D1 of the OPPS/ASC proposed and final rules each year.  The status indicator for each HCPCS code is shown in OPPS Addendum B.  10.2 - APC Payment Groups (Rev. 1445; Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  Each HCPCS code for which separate payment is made under the OPPS is assigned to an ambulatory payment classification (APC) group. The payment rate and coinsurance amount calculated for an APC apply to all of the services assigned to the APC.  A hospital may receive a number of APC payments for the services furnished to a patient on a single day; however, multiple surgical procedures  furnished on the same day are subject to discounting.  (See section 10.5 for discussion of multiple procedure discounting under the OPPS).
(Medicare Claims Processing Manual)
Services within an APC are similar clinically and with respect to hospital resource use. The law requires that the median cost for the highest cost service within the APC may not be more than 2 times the median cost for the lowest cost service in the APC, and the Secretary may make exceptions in unusual cases, such as low volume items and services.   This is commonly called the 2 times rule.  The median costs of services change from year to year as a result of changes in hospitals charge, changes to cost -to-charge ratios as determined from hospital cost reports, and changes in the frequency of services.  Therefore, the APC assignment of a service may change from one year to the next year as is needed to avoid a violation of the 2 times rule or to improve clinical and/or resource homogeneity of APCs.  This APC reconfiguration may result in significant changes in the payment rate for the APC and, therefore, for the service being billed.  10.2.1 - Composite APCs (Rev. 3941; Issued: 12- 22-17; Effective: 01 - 01-18; Implementation: 01 -02-18)  Composite APCs provide a single payment for a comprehensive diagnostic and/or treatment service that is defined, for purposes of the APC, as a service typically reported with multiple HCPCS codes.  When HCPCS codes that meet the criteria for payment of the composite APC are billed on the same date of service, CMS makes a single payment for all of the codes as a whole, rather than paying individually for each code.  See Addendum A at www.cms.hhs.gov/HospitalOutpatientPPS/  for the national unadjusted payment rates for these composite APCs.  10.2.2 - Cardiac Resynchronization Therapy  (Rev. 2386, Issued: 01- 13-12, Effective: 01 -01-12, Implementation: 01- 03-12)
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Effective for services furnished on or after January 1, 2012, cardiac resynchronization therapy involving an implantable cardioverter defibrillator (CRT -D) will be recognized as a single, composite service combining implantable cardioverter defibrillator p rocedures (described by CPT code 33249 (Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter -defibrillator and insertion of pulse generator  )) and pacing electrode insertion procedures (described by CPT code 33225 (Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter -defibrillator or pacemaker pulse generator (including upgrade to dual chamber system))) when performed on the same date of servi ce.  When these procedures appear on the same claim but with different dates of service, or appear on the claim without the other procedure, the standard APC assignment for each service will continue to be applied.   Medicare will make a single payment for those procedures that qualify for composite service payment, as well as any packaged services furnished on the same date of service.  Because CPT codes 33225 and 33249 may be treated as a composite service for payment purposes, CMS is assigning them status indicator Q3 (Codes that may be paid through a composite APC) in Addendum B.  Hospitals will continue to use the same CPT codes to report CRT -D procedures, and the I/OCE will evaluate every claim received to determine if payment as a composite service is appropriate. Specifically, the I/OCE will determine whether payment will be mad e through a single, composite payment when the procedures are done on the same date of service, or through the standard APC payment methodology when they are done on different dates of service.   CMS is also implementing claims processing edits that will return to providers incorrectly coded claims on which a pacing electrode insertion procedure described by CPT code 33225 is billed without one of the following CPT codes for insertion of an implantable cardioverter defibrillator or pacemaker:    33206 (Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial);    33207 (Insertion or replacement of permanent pacemaker with transvenous electrode(s); ventricular);
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 33207 (Insertion or replacement of permanent pacemaker with transvenous electrode(s); ventricular);    33208 (Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular);    33212 (Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular);    33213 (Insertion or replacement of pacemaker pulse generator only; dual chamber, atrial or ventricular);    33214 (Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator));    33216 (Insertion of a single transvenous electrode, permanent pacemaker or cardioverter -defibrillator);   33217 (Insertion of 2 transvenous electrodes, permanent pacemaker or cardioverter -defibrillator);   33221(Insertion of pacemaker pulse generator only; with existing multiple leads);    33222 (Revision or relocation of skin pocket for pacemaker);    33230 (Insertion of pacing cardioverter -defibrillator pulse generator only; with existing dual leads);    33231 (Insertion of pacing cardioverter -defibrillator pulse generator only; with existing multiple leads)    33233 (Removal of permanent pacemaker pulse generator);    33234 (Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular);    33235 (Removal of transvenous pacemaker electrode(s); dual lead system, atrial or ventricular);    33240 (Insertion of single or dual chamber pacing cardioverter -defibrillator pulse generator); or    33249 (Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter -defibrillator and insertion of pulse generator).   10.2.3 - Comprehensive APCs (Rev. 12421; Issued: 12- 21-23; Effective: 01 -01-24; Implementation: 01 -02-24)
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10.2.3 - Comprehensive APCs (Rev. 12421; Issued: 12- 21-23; Effective: 01 -01-24; Implementation: 01 -02-24)   The following services are excluded from comprehensive APC packaging:   ambulance services   brachytherapy sources (status indicator U)   diagnostic and mammography screenings   physical therapy, speech- language pathology and occupational therapy services reported on a separate facility claim for recurring services   pass -through drugs, biologicals, and devices (status indicators G or H)   preventive services defined in 42 CFR 410.2   self -administered drugs (SADs) -  drugs that are usually self -administered and do not function as supplies in the provision of the comprehensive service   services assigned to OPPS status indicator F (including certain CRNA services, Hepatitis B vaccines and corneal tissue acquisition)   services assigned to OPPS status indicator L (including influenza, pneumococcal pneumonia, and COVID -19 vaccines)   certain Part B inpatient services  Ancillary Part B inpatient services payable under Part B when the primary J1 service for the claim is not a payable Medicare Part B inpatient service (for example, exhausted Medicare Part A benefits, beneficiaries with  Part B only)    services assigned to a New Technology APC   Any drug or biological described by HCPCS code C9399 (Unclassified drugs or biologicals)   10.2.4 - Reporting for Certain Outpatient Department Services (That Are Similar to Therapy Services) (Non -Therapy Outpatient Department Services) and Are Adjunctive to Comprehensive APC Procedures  (Rev. 10541; Issued: 12-31-20; Effective: 01-01-21; Implementation: 01-04 -21)  This language was originally published in the October 2016 Update of the Outpatient Perspective Payment System (OPPS) (Transmittal R3602CP). We are updating this language based on the removal of the regulations at 42 CFR 410.59(a)(4) and 42 CFR 410.60(a)(4 ) related to functional reporting for therapy services.
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Non-therapy outpatient department services are services such as physical therapy, occupational therapy, and speech- language pathology provided during the perioperative period (of a Comprehensive APC (C -APC) procedure) without a certified therapy plan of care. These are not therapy services as described in section 1834(k) of the Act, regardless of whether the services are delivered by therapists or other non- therapist health care workers. Therapy services are those provided by therapists under a plan of care  in accordance with section 1835(a)(2)(C) and section 1835(a)(2)(D) of the Act and are paid for under section 1834(k) of the Act, subject to annual therapy caps as applicable (78 FR 74867 and 79 FR 66800), until they were repealed by Bipartisan Budget Act of 2018, effective January 1, 2018. Because these services are outpatient department services and not therapy services, the requirement for functional reporting under the regulations at 42 CFR 410.59(a)(4) and 42 CFR 410.60(a)(4) does not apply. The functional reporting requirements were applicable until January 1, 2019 at which time the regulations at 42 CFR 410.59(a)(4) and 42 CFR 410.60(a)(4) were removed (83 FR 41786 and 83 FR 59452).  The comprehensive APC payment policy packages payment for adjunctive items, services, and procedures into the most costly primary procedures under the OPPS at the claim level. When non -therapy outpatient department services are included on the same claim a s a C -APC procedure (status indicator (SI) = J1) (see 80 FR 70326) or the specific combination of services assigned to the Observation Comprehensive APC 8011 (SI = J2), these services are considered adjunctive to the primary procedure. Payment for non-therapy outpatient department services is included as a packaged part of the payment for the C -APC procedure.
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Effective for claims received on or after October 1, 2016  with dates of service on or after January 1, 2015, providers may report non -therapy outpatient department services (that are similar to therapy services) that are adjunctive to a C -APC procedure (SI = J1) or the specific combination of services assigned t o the Observation Comprehensive APC 8011 (SI = J2), in one of two ways:   1. Without using the therapy CPT codes and instead reporting these non -therapy services with Revenue Code 0940 (Other Therapeutic Services); or  2. Reporting non- therapy outpatient department services that are adjunctive to J1 or J2 services with the appropriate occurrence codes, CPT codes, modifiers, and revenue codes.   10.3 - Calculation of APC Payment Rates  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  The OPPS national unadjusted payment rates for APCs other than drugs and biologicals are calculated as the products of the scaled relative weight for the APC and the OPPS conversion factor.  Hospital specific payments for these APCs are derived after appli cation of applicable adjustment factors (e.g., multiple surgery reduction, rural sole community adjustment, etc.) and the post reclassification wage index that applies to the hospital to which payment is being made.  Payment rates for separately paid drugs  and biologicals are generally established based on a percentage of the average sales price of the drug or biological.   An APCs scaled relative weight is generally calculated based on the median cost (operating and capital) of all of the services included in the APC group.  Median costs are developed from a database of the most currently available hospital outpatient claim s using the most recently filed cost report data.   The following is a simplified description of the process used to calculate the OPPS payment rates for services for which the rate is based on the median cost.    Hospital -specific, department -specific cost -to-charge ratios are used to convert billed charges to costs for each HCPCS code;
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 Hospital -specific, department -specific cost -to-charge ratios are used to convert billed charges to costs for each HCPCS code;    For most APCs, single procedure bills (claims that contain only one separately paid procedure code) for all of the procedures within a particular APC are used to calculate the median costs on which APC payment weights are based to ensure that the median captures the full cost of the procedure when it is the only service furnished. The costs on the bill are summed to add the costs of any packaged services into the procedure with which the packaged services are packaged.  Composite APCs are an exception to this statement since the payment for them is calculated only from multiple procedure claims that meet the criteria for composite APC payment;    60 percent of the total cost is wage neutralized and the set of claims for each APC is trimmed at +/-  3 standard deviations from the geometric mean;    A median cost is calculated for each APC, using the claims for the procedures that meet the criteria for being assigned to that APC and the array of costs determined from those claims.  In some cases, a subset of single procedure bills that meet specified criteria are used to calculate the median cost for the APC.  For example, CMS uses only claims with correct device codes, no token charges for devices, no interrupted procedures, and without no cost or full credit devices to set the median cost for device- dependent APCs.  Similarly, the median costs for composite APCs are calculated using only claims that meet the criteria for the composite APC.   Median costs are converted to relative weights by dividing each APCs median cost by the median cost for the Level 3 Hospital Clinic Visit APC.    Relative weights are scaled for budget neutrality.    Scaled weights are converted to payment rates using a conversion factor which takes into account pass -through payments to be made in the coming year, changes to the wage index (see section 10.8.1), the cost of outlier payments (see section 10.7) and the annual market basket update factor.
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CMS issues a proposed rule with a 60 day comment period in the summer of the year before the year in which the proposed payment rates would be applicable.  There is a 60 day comment period, after which CMS issues a final rule with comment period to announc e the forthcoming years payment policies and rates.  The CMS OPPS Webpage at http://www.cms.hhs.gov/HospitalOutpatientPPS/  is the best source for both rules and the supporting files.  10.4 - Packaging  (Rev. 3941; Issued: 12- 22-17; Effective: 01 - 01-18; Implementation: 01 -02-18)  Under the OPPS, packaged services are items and services that are considered to be an integral part of another service that is paid under the OPPS.  No separate payment is made for packaged services, because the cost of these items and services is included  in the APC payment for the service of which they are an integral part.  For example, routine supplies, anesthesia, recovery room use, and most drugs are considered to be an integral part of a surgical procedure so payment for these items is packaged into the APC payment for the surgical procedure.   A. Packaging for Claims Resulting in APC Payments   If a claim contains services that result in an APC payment but also contains packaged services, separate payment for the packaged services is not made since payment is included in the APC.  However, charges related to the packaged services are used for outlier and Transitional Corridor Payments (TOPs) as well as for future rate setting.  Therefore, it is extremely important that hospitals report all HCPCS codes consistent with their descriptors; CPT and/or CMS instructions and correct coding principles, and all charges for all services they furnish, whether payment for the services is made separately paid or is packaged.   B. Packaging for Claims Resulting in No APC Payments   If the claim contains only services payable under cost reimbursement, such as corneal tissue, and services that would be packaged services if an APC were payable, then the packaged services are not separately payable.  In addition, these charges for the pa ckaged services are not used to calculate TOPs.