evekhm/cms_iom_500 huggingface dataset:
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Should such evidence of potential fraud, misrepresentation, or aberrant billing patterns by a provider be found, claims are subject to medical review regardless of whether th e KX modifier was used on the claim.  Progressive corrective action (PCA) and medical review have a role in the therapy exception process. Although the services may meet the criteria for exception from the cap due to condition or complexity, they are still subject to review to determine that the services are otherwise covered and appropriately provided.  The exception is granted on the clinicians assertion that there is documentation in the record justifying that the services meet the criteria for reasonable and necessary services.  For example, the documentation must accurately represent the facts, and there shall be no evidence of patterns of aberrant billing of the services by the provider/supplier.  Services deemed medically necessary are still subject to review related to fraud or abuse. An example of inappropriate use of the process is the routine use of the KX modifier on every claim for a patient that has an excepted condition or complexity, regardless of the impact of the condition on the need for s ervices above the cap.   3.3.2.8 - MAC Articles  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs.  A. General   The MACs have the discretion to publish articles communicating certain information to providers, such as any newly developed educational materials, coding instructions or clarification of existing medical review related billing or claims policy. The MACs are required to enter articles that address LCDs, coding or medical revi ew-related billing and claims considerations into the Medicare Coverage Database (MCD).   For the purposes of this manual, the term "publish" will be used to describe any form of dissemination including posting on a Web site, distributing at a seminar, e -mailing, or printing in a hardcopy bulletin. The MAC Medical Review Departments are responsible for the development of articles associated with new or revised LCDs and for entering those articles into the Medicare Coverage Database. Other widespread educatio nal articles shall not be charged to MR.   The MAC medical review departments shall send articles to the appropriate department within the MAC for publishing. All newly created articles shall be posted on the MAC's Web site where duplicate copies can be obt ained by providers/suppliers.
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The MAC medical review departments shall send articles to the appropriate department within the MAC for publishing. All newly created articles shall be posted on the MAC's Web site where duplicate copies can be obt ained by providers/suppliers.   When NCDs or other coverage instructions issued by the CMS include specific conditions or parameters for covered services, the MACs have the discretion to develop and publish a list of covered codes associated with the covera ge provision. MACs have the discretion to automate denials for codes not included on the list without the development of a LCD if the NCD indicates or states that no other condition or parameters will be covered.   MACs also have the discretion to:    Publish definitions of procedure codes, lists of items that may be billed under a particular code, or minimum requirements that providers must meet in order to bill using a certain code.    Publish a product classification list that instructs providers about  which  specific products meet the definitional requirements of a particular HCPCS code. Developing or revising an LCD for this article is  unnecessary.   Explain which off-labeled uses of the Food and Drug Administration (FDA) approved drugs are considered r easonable and necessary within the diagnosis codes that reflect such uses.    Explain the benefit category decisions and publish a list of drugs/biologicals that are considered usually self -administered. MACs should enter their self- administered medication exclusion list into the Medicare Coverage Database. This database can be accessed at  www.cms.gov/mcd.   MACs have the discretion to explain which HCPCS code or group of codes proper ly describes a particular  service.    MACs have the discretion to publish State non-physician licensure information that governs services billed by the physician under the "incident to" provision.  The MACs shall ensure that articles do not conflict with NCDs, LCDs, policy, or coverage provisions in interpretive manuals. Although a comment and notice process is not required, MACs are encouraged to consult with stakeholders in the provider community when developing articles. MACs shall monitor comments about a rticles from clinician providers and respond to their concerns, as needed, by issuing revised or clarifying articles.   NOTE: Nothing in this section precludes the MACs or UPICs from making individual claim determinations, even in the absence of an article or LCD.
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NOTE: Nothing in this section precludes the MACs or UPICs from making individual claim determinations, even in the absence of an article or LCD.   3.3.3 - Reviewing Claims in the Absence of Policies and Guidelines  (Rev. 10365; Issued: 10-02- 20; Effective: 08 -27-20; Implementation: 08-27-20)  The MACs, CERT, Recovery Auditors, and UPICs have the discretion to review claims, in the absence of polices, whether a NCD, coverage provision in an interpretive Medicare manual, or LCD exists for that service. When making individual claim determinations, they shall determine that the service in question is covered based on whether the service meets all of the conditions listed in section 3.6.2.1.  3.4 - Prepayment Review of Claims (Rev. 902, Issued: 09-27-19, Effective: 10 -28-19, Implementation: 10-28-19)  This section applies to MACs and UPICs.  A. General   Non-random (targeted) review is defined as review conducted with a specific reason or logic to substantiate the cause for review. MACs are encouraged to initiate non- random service- specific prepayment r eview to prevent improper payments for services identified by CERT or Recovery Auditors or other sources.   The MACs shall initiate targeted provider -specific prepayment review only when there is the likelihood of a sustained or high level of improper paym ents.  B. 100% Prepayment Review and Random Review Instructions   Section 1302 of the Health Care and Education Reconciliation Act (HCERA) repealed section 1874A (h) of the Social Security Act which had placed restrictions on prepayment medical review. CMS review contractors shall comply with Section 1 random review and Section 2 100% prepayment review.   1. Random Review
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1. Random Review   Random review is defined as review conducted without a specific reason or logic to substantiate the cause for review. MACs have the discretion to conduct random reviews of services; however, CMS does not recommend random reviews. MACs shall notify the CMS Contracting Officers Representative (COR), Regional Office Technical Monitor (TM), and Business Function Lead (BFL) of its intent t o conduct random review. The MAC shall describe what the intended result of the random review will be, an estimate of the number of claims to be reviewed randomly and the rationale as to why random review would be more effective than targeted review.   2. 100% Prepayment Review   100% prepayment review is defined as review of every claim submitted by a targeted provider for a specific code (i.e., DRG, CPT, HCPCs). 100% prepayment review also includes review of every claim submitted by the targeted provider.   MACs have the discretion to conduct 100 % prepayment review of providers. CMS considers 100 % prepayment review to be appropriate when a provider has a prolonged time period of non- compliance with CMS policies. Any MAC that plans to conduct 100 % prepaymen t review shall inform the CMS COR, Regional Office TM, and BFL in advance about any provider being placed on 100 % prepayment review. In addition, the MAC shall provide    The background information on attempts to educate the provider.    The historical improp er payment rate of the provider before beginning 100% prepayment review.    The length of time the provider is expected to be on 100 % prepayment reviews.   The estimated number of claims and the dollar value of claims expected to be reviewed per month.   The criteria for removing the provider from 100 % prepayment review.  3.  UPIC Initiated Prepayment Reviews   No UPIC shall initiate a 100% prepayment review without CMS approval, except 100% prepayment reviews associated with a Payment Suspension. Therefore, t he UPIC shall provide its COR and IAG BFL a summary of the investigation, any prior history (if applicable) with the provider/supplier in question, and any other relevant information in a format agreed upon by the COR and IAG BFL.
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If the COR and IAG BFL agree that 100% prepayment review is appropriate, the UPIC shall include the case on the next case coordination meeting agenda for discussion and final approval. During the case coordination meeting, the UPIC may receive additional guidance from CMS related to subsequent actions related to these investigations.  If the UPIC has subsequent questions following the case coordination meeting, the UPIC shall coordinate with its COR and IAG BFL.  3.4.1 - Electronic and Paper Claims  (Rev. 721; Issued: 06-09- 17; Effective: 07 -11-17; Implementation: 07 -11-17)
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This section applies to MACs.  The Administrative Simplification Compliance Act (ASCA, Section 3 of Pub. L, 107-105, 42 CFR 424.32) requires that all Medicare claims be submitted electronically using the ASC X12 837 institutional or professional claim formats with few exceptions.  MACs shall not require providers to submit paper claims when they are targeted for prepayment medical record review.  The MACs shall allow providers that qualify for an ASC A mandatory electronic billing exception to submit paper claims when they are targeted for prepayment review (See IOM Pub.100-04, chapter 24, 90 for exceptions).  3.4.1.1 - Linking LCD and NCD ID Numbers to Edits  (Rev. 377, Issued: 05-27-11, Effective: 06-28-11, Implementation: 06-28-11)  The MACs shall ensure that any edit that could result in a denial based on a LCD or NCD includes the LCD or NCD ID number(s) associated with the denial. The MACs shall ensure that any edit that could result in a denial based on a lab negotiated NCD includes the NCD ID number(s) associated with the denial.  3.4.1.2 - Not Otherwise Classified (NOC) Codes  (Rev. 377, Issued: 05-27-11, Effective: 06-28-11, Implementation: 06-28-11)  This section applies to MACs.  The MAC MR sta ff should assist claims processing staff in making coverage and pricing determinations on NOC HCPCS/CPT codes. The claims processing staff will need information from the MR staff so that they can price the service in accordance with CMS pricing methodologi es described in the Claims Processing Manual (IOM Pub. 100- 04).  MACs shall keep track of pricing determinations for frequently billed services so that the claims processing staff can price future claims using established MR pricing guidelines for that ser vice.   3.4.1.3 - Diagnosis Code Requirements  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs and UPICs, as indicated.
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This section applies to MACs and UPICs, as indicated.   ICD-10-CM is used for diagnoses on inpatient discharges and for other services provided on and after the implementation of ICD -10-CM. ICD -9-CM is used for discharges and other services before the implementation of ICD -10-CM.  Section 1833(e) of the Act states that no payment should be made under this part unless there has b een furnished such information as may be necessary in order to determine the amounts due such provider or other person. MACs and UPICs should require submission of information, in accordance with the requirements below, that they deem necessary to make a claim determination and determine appropriate payment. Some provider types are required to submit diagnosis codes on all claims while other provider types are required to submit diagnosis codes only if such information is required by a LCD.   A. Claims Submit ted by Physicians or Certain Non -Physician Practitioners  Must Contain Diagnosis  Codes.   Section 1842 (p) (1) of the Act states that for each claim submitted by physicians or certain non -physician practitioners (defined in 1842(b) (18) (C) of the Act) shall include the appropriate diagnosis code (or codes). For claims submitted with invalid, truncated, or missing diagnosis codes, MACs and UPICs shall classify the claim as rejected as unprocessable within the MCS. See the Claims Processing Manuals IOM Pub.100- 04.  B. Claims Submitted by All Other Provider Types Must Contain Diagnosis Codes if re quired by a  LCD
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B. Claims Submitted by All Other Provider Types Must Contain Diagnosis Codes if re quired by a  LCD  During a service -specific review to address potential abuse or overutilization, MACs  and UPICs should require that diagnosis codes be submitted with each claim for the targeted service. The diagnosis information is used to determine if the  services are covered and correctly coded. MACs and UPICs should require that ICD diagnosis codes be submitted by all non- physician billers with every claim for a targeted service only if such a requirement appears in a LCD for that service. This outreach shall occur via Web site, bulletin articles,  etc.  For provider -specific reviews, MACs and UPICs have the discretion to require submission of diagnosis codes to support that the reasonable and necessary criteria has been met on all claims submitted by individual non- physician providers who have been targeted because of unusual billing practices, fraud referrals, etc., even if no LCD exists requiring such codes. For claims submitted with invalid, truncated, or missing diagnosis codes, reviewers shall classif y the claim as unable to be processed, and return the claim to the provider (RTP). See the Claims Processing Manual IOM Pub.100- 04.  C. Requirements for Lab  Claims   The American Medical Associations (AMA) 1998 edition of the Current Procedural Terminology (CPT) established three new and one revised Organ and Disease Oriented laboratory panels. Since these panels are composed of clinically relevant groupings of automated multichannel tests there is a general presumption of medical necessity.  If there is data or reason to suspect abuse of the panel codes, contractors may review these claims. Should contractors determine the need to develop a LCD for laboratory panel codes the MAC shall develop these policies at the panel code level. In some instances of perceived abuse of the panel codes, the contractors may review the panel and deny component tests on a case -by-case basis or evaluate the need for the component level  test.  3.4.1.4 - Prepayment Review of Claims Involving Utilization Parameters  (Rev . 721; Issued: 06- 09-17; Effective: 07 -11-17; Implementation: 07 -11-17)  This section applies to MACs.  A.  For Non -lab Claims
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This section applies to MACs.  A.  For Non -lab Claims   The MACs shall implement prepayment edits that will prevent payment to providers who have a pattern of billing for items or services that are not covered, incorrectly coded or inappropriately billed. The MACs shall respond quickly when they identify providers who seem to have egregious overutilization of a non- lab item or service and who bill for egregious amounts. The identifi cation of, and response to these providers shall be within the context of the MACs MR Strategy and prioritization of review targets.  B.  Utilization Denials   The MACs have the discretion to establish edits to automatically deny services when overutilization of a non- lab service is identified and clear policy serves as the basis for denial.   The MACs shall establish medical record review edits and make individual claim determinations when overutilization of a non- lab service is identified and there is not clear policy to serve as the basis for denial.   The MACs shall establish medical record review edits that do not involve utilization parameters and make individual claim determinations when overutilization of a lab service is identified and there is no clear policy to serve as the basis for denial.  For example, if the problem is limited to a few laboratory providers, the MAC could develop a provider -specific prepayment edit to suspend payment for all of the lab services in question from the problem providers.  If the problem is widespread, the MAC could develop a service -specific edit to suspend payment for all of the lab services in question or all of the services in question for a particular diagnosis or revenue code. Based on data analysis within each  MAC jurisdiction, the MACs shall focus the edit by provider, diagnosis, procedure code, or in any other way except by use of a utilization parameter.   3.4.1.5 - Prepayment Review Edits  (Rev. 377, Issued: 05- 27-11, Effective: 06 -28-11, Implementation: 06- 28-11)  This section applies to MACs.  A.  Automated Edits  Automated prepayment edits, designed by MAC staff, are put in place to prevent payment for non- covered, incorrectly coded, or inappropriately billed services. Most automated payment edits will be se rvice- specific.  The MAC will rarely install a provider -specific automated prepayment edit. B.  Limits on Automated Prepayment Review
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The MACs shall not install edits that result in the automatic denial of payment for items or services based solely on the  diagnosis of a progressively debilitating disease when treatment may be reasonable and necessary.  The appearance of a progressively debilitating disease on a claim or history does not permit automated denials that presume a stage of that disease that neg ates the effectiveness of treatment.  Likewise, when a beneficiary with a progressively debilitating disease experiences an illness or injury unrelated to his or her progressively debilitating disease, the provider should submit a claim with a primary diag nosis that most accurately reflects the need for the provided item or service. For instance, a claim for treatment for an acute urinary tract infection cannot be denied by automatic edit just because the beneficiary has a diagnosis of multiple sclerosis.   3.4.2  Prepayment Medical Record Review Edits  (Rev. 721; Issued: 06- 09-17; Effective: 07 -11-17; Implementation: 07 -11-17)  This section applies to MACs.  The MACs shall focus prepayment medical record review edits to suspend only claims with a high probability of aberrant billing practices.  Focused edits reduce provider burdens and increase the efficiency of MR activities.  The MACs shall ensure that edits are specific enough to identify only the services that they determine to be questionable based on da ta analysis.  MACs are encouraged to ensure that most MR edits are located in the table driven portion of the system and are not hard coded. It is important to have the flexibility to modify MR edits based on workload demands and changes in provider behavi or.  The MACs have the discretion to establish prepayment medical record review edits that are either service- specific or provider -specific.  Provider -specific edits can suspend all claims from a particular provider or focus on selected service(s), place o f service, or other parameters.   3.5 - Postpayment Medical Record Review of Claims  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)
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3.5 - Postpayment Medical Record Review of Claims  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  The MACs shall initiate targeted provider -specific or service -specific postpayment medical record review only when there is the likelihood of a sustained or high level of payment error. RACs, UPICs, and SMRC shall perform postpay review of claims as outlin ed in their SOW.   3.5.1 - Re-opening Claims  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, CERT, RACs, SMRC and UPICs, as indicated.   The MACs, CERT, RACs, SMRC, and UPICs shall adhere to the rules found in CFR 405.980 through 986 when conducting automated or postpayment medical record reviews. High error rate and/or potential overutilization, identified by data analysis, are reasons to perform postpayment review and represent sufficient cause to reopen claims in accordance with 42 CFR 405.986. See Pub. 100- 04, chapter 34 for more information on good cause for reopening.  3.5.2 - Case Selection  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to M ACs, CERT, SMRC, and UPICs, as indicated.   Case review and development provisions:   The MACs and the SMRC shall not perform postpayment review of unassigned claims. A claim submitted for a service or supply by a provider who has not accepted the Medicare fee schedule is an unassigned claim.    The MACs, SMRC, and UPICs have the discretion to select cases for postpayment  review on a claim -by-claim basis or use statistical sampling for overpayment  estimation.   o When MACs, SMRC, and UPICs conduct claim -by-claim postpayment review, they shall only collect or refund the actual overpayment or underpayment amount.
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o When MACs, SMRC, and UPICs conduct claim -by-claim postpayment review, they shall only collect or refund the actual overpayment or underpayment amount.  o When MACs, SM RC, and UPICs conduct statistical sampling  for overpayment estimation as specified in PIM chapter 8, they shall extrapolate the sampling results to the known universe of similar claims when calculating the projected overpayment or underpayment amount.   The MACs, RACs, SMRC, and UPICs have the discretion to conduct the postpayment review onsite at the provider or suppliers location.   MAC staff shall review their provider tracking system, using RAC Data Warehouse (RACDW) data,  and consult with the UPICs to ensure non- duplication during the process of selecting providers for postpayment review.    To prevent duplicate claim reviews, the MACs, SMRC, and RACs shall use the RACDW to identify, and exclude from review, claims that wer e previously reviewed, or that are under current review, by another contractor.   CERT shall duplicate another contractors review, when appropriate, if those claims are chosen as part of a statistically valid random sample to measure the improper payment rate.   This instruction does not prevent the UPICs from reviewing a claim that has been reviewed by another contractor in order to support their case development or other administrative action.    When the MACs, CERT, RACs, SMRC and UPICs choose to send the provider an ADR for a postpayment review, they shall do so in accordance with PIM chapter 3, 3.2.3.2. The contractors may grant an extension of the submission timeframes at their discretion or in accordance with their SOWs.    The MACs, CERT, RACs, SMRC and UPICs make coverage,  coding, and/or other determinations when re- adjudicating  claims.    The MACs, CERT, RACs, SMRC and UPICs shall document all incorrectly paid, denied, or under-coded (e.g., billed using a procedure/supply or other code that is lower than what is supported by medical documentation) items or  services.    Services newly denied as a result of re- adjudication shall be reported as positive values.