evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Total Charges   The hospice enters the total charge for the service described on each revenue code line.  This information is being collected for purposes of research and will not affect the amount of reimbursement.  Non-Covered Charges   The hospice enters a charge amount equal to the Total Charges for any revenue code line with a Service Date within a non -covered period (e.g., an occurrence span code 77 period).   Payer Name   The hospice identifies the appropriate payer(s) for the claim.   National Provider Identifier  Billing Provider   The hospice enters its own National Provider Identifier (NPI).   Principal Diagnosis Code   The hospice enters diagnosis coding as required by ICD-9- CM / ICD -10-CM Coding Guidelines.  CMS accepts only HIPAA approved ICD-9- CM or ICD -10-CM/ICD -10-PCS codes, depending on the date of service.  The official ICD-9-CM codes, which were updated annually through October 1, 2013, are posted at http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html  The official annual updates to ICD-10-CM and ICD-10- PCS codes are posted at http://www.cms.gov/Medicare/Coding/ICD10/index.html. Use full diagnosis codes including all applicable digits, up to five digits for ICD-9- CM and up to seven digits for ICD-10- CM.  The principal diagnosis listed is the diagnosis most contributory to the terminal prognosis.  Non-reportable Principal Diagnosis Codes to be returned to the provider for correction:    Hospices may not report ICD-9CM v- codes and ICD -10-CM z -codes as the principal diagnosis on hospice claims.  Hospices may not report debility, failure to thrive, or dementia codes classified as unspecified as principal hospice diagnoses on the hospice claim.  Hospices may not report diagnosis codes that cannot be used as the principal diagnosis according to ICD-9- CM or ICD -10-CM Coding Guidelines or require further compliance with various ICD-9- CM or ICD -10-CM coding conventions, such as those that have principal diagnosis code sequencing guidelines.
(Medicare Claims Processing Manual)
Other Diagnosis Codes  The hospice enters diagnosis coding as required by ICD-9-CM and ICD-10-CM Coding Guidelines.  Hospices will report all diagnoses identified in the initial and comprehensive assessments on hospice claims, whether related or unrelated  to the terminal prognos is of the individual effective October 1, 2015. This will also include the reporting of any mental health disorders and conditions that would affect the plan of care.  Attending Provider Name and Identifiers   The hospice enters  the National Provider Identifier (NPI) and name of  the physician currently  responsible  for certifying  the terminal illness , and signing the  individuals  plan  of care for medical  care and treatment.   The hospice shall enter the NPI and name of the attending physician designated by the patient as having the most significant role in the determination and delivery of the patients medical care. If there is no attending physician listed, then the hospice s hall report the certifying MD.  Other Provider Name and Identifiers   If the attending physician is a nurse practitioner or physician assistant, the hospice enters the NPI and name of the nurse practitioner or physician assistant. The hospice enters the NPI and name of the hospice physician responsible for certifying that the patient is terminally ill, with a life expectancy of 6 months or less if the disease runs its normal course.  Note:  Both the attending physician and other physician fields should be completed unless the patients designated attending physician is the same as the physician certifying the terminal illness.  When the attending physician is also the physician certifying the terminal illness, only the attending physician is required to be reported. NOTE:  for electronic claims, this information is reported in Loop ID 2310F  Referring Provider Name.
(Medicare Claims Processing Manual)
Hospices shall report the NPI of any nursing facility, hospital, or hospice inpatient facility where the patient is receiving hospice services, regardless of the level of care provided when the site of service is not the billing hospice.  The billing hospi ce shall obtain the NPI for the facility where the patient is receiving care and report the facilitys name, address and NPI on the 837 Institutional claim format in loop 2310 E Service Facility Location.  When the patient has received care in more than on e facility during the billing month, the hospice shall report the NPI of the facility where the patient was last treated.  Failure to report this information for claims reporting place of service HCPCS Q5003 (long term care nursing facility), Q5004 (skilled nursing facility), Q5005 (inpatient hospital), Q5007 (long term care hospital) and Q5008 (inpatient psychiatric facility) will result in the claim being returned to the provider.     30.4 - Claims From Medicare Advantage Organizations  (Rev. 2258, Issued: 07- 29 -11, Effective: 01-01-12, Implementation: 01-03-12)  Federal regulations require that Medicare fee -for-service A/B MACs (HHH) maintain payment responsibility for managed care enrollees who elect hospice.  These regulations are found at 42 CFR Part 417, Subpart P:go to http://www.gpo.gov/fdsys/browse/collectionCfr.action; select the applicable year, and scroll down to Part  417, and go to 42 CFR 417.585 Special Rules: Hospice Care (b) ; and  also at 42 CFR 417.531 Hospice Care Services (b)  which can be located in the same manner .  Medicare Fee for Service retains payment responsibility for all hospice and non-hospice related claims beginning on the date of the hospice election.  A. Covered Services   While a hospice election is in effect, certain types of claims may be submitted by either a hospice provider, or a provider treating an illness not related to the terminal condition, to a fee -for-service A/B MAC (A), (B), or (HHH) of CMS.  These claims are  subject to the usual Medicare rules of payment, but only for the following services:  1. Hospice services covered under the Medicare hospice benefit if billed by a Medicare hospice;
(Medicare Claims Processing Manual)
2. Services of the enrollees attending physician if the physician is not employed by or under contract to the enrollees hospice;   3. Services not related to the treatment of the terminal condition while the beneficiary has elected hospice; or   4. Services furnished after the revocation or expiration of the enrollees hospice election until the full monthly capitation payments begin again.  Monthly capitation payments will begin on the first day of the month after the beneficiary has revoked their hospice election.   B. Billing of Covered Services   Medicare hospices bill the Medicare fee- for-service A/B MAC (HHH) for beneficiaries who have coverage through Medicare Advantage just as they do for beneficiaries with fee-for-service coverage.  Billing begins with a notice of election for an initial hospi ce benefit period, and followed by claims with types of bill 81X or 82X.  If the beneficiary later revokes election of the hospice benefit, a final claim indicating revocation, through use of occurrence code 42, should be submitted as soon as possible so t hat the beneficiarys medical care and payment is not disrupted.  Medicare physicians may also bill the Medicare fee- for-service A/B MAC (HHH) for beneficiaries who have coverage through Medicare Advantage as long as all current requirements for billing for hospice beneficiaries are met.  These claims should be submitted  with a GV or GW modifier as applicable.  A/B MACs (HHH) process these claims in accordance with regular claims processing rules.  When these modifiers are used, A/B MAC (HHH) are instructed to use an override code to assure such claims have been reviewed and should be approved for payment by the Common Working File in Medicare claims processing systems.   As specified above, by regulation, the duration of payment responsibility by fee -for-service A/B MACs (HHH) extends through the remainder of the month in which hospice is revoked by hospice beneficiaries.  MA plan enrollees that have elected hospice may revoke hospice election at any time, but claims will continue to be paid by fee -for-service A/B MACs (HHH) as if the beneficiary were a fee -for-service beneficiary until the first day of the month following the month in which hospice was revoked.
(Medicare Claims Processing Manual)
30.5  Hospice Claims for Vaccine Services (Rev. 3621, Issued: 10- 07-16, Effective: 10- 01-16, Implementation:  10-03-16)  For dates of service on or after October 1, 2016, services for the vaccines provided by a hospice may be billed on an institutional claim to the hospices Medicare contractor.  Since these services are not part of the Medicare hospice benefit, they must be billed on a separate claim that includes only the vaccines and their administration.  For information on coding and payment of vaccine services, see chapter 18, section 10 of this manual.  40 - Billing and Payment for Hospice Services Provided by a Physician  (Rev. 1, 10- 01-03) HSP-406, B3 -4175, B3- 2020, B3- 15513  40.1 - Types of Physician Services  (Rev. 1, 10- 01-03) HSP-406  Payment for physician services provided in conjunction with the hospice benefit is made based on the type of service performed.   40.1.1 - Administrative Activities  (Rev.4280, Issued: 04- 19-2019, Effective: 07 -21-19, Implementation: 07- 21-19)  Payment  for physicians  administrative  and general  supervisory activities  is included in  the hospice  payment  rates.   These activities  include  participating  in the establishment,  review  and updating of  plans  of care,  supervising care and services  and establishing  governing policies.   These activities  are generally  performed  by the  physician  serving as  the medical  director  and the physician member  of the interdisciplinary  group (IDG).  Nurse practitioners or physician assistants may not serve as or replace the medical director or physician member of the IDG.   40.1.2 - Hospice Attending Physician Services  (Rev. 4280, Issued: 04- 19-2019, Effective: 07 -21-19, Implementation: 07- 21-19)
(Medicare Claims Processing Manual)
40.1.2 - Hospice Attending Physician Services  (Rev. 4280, Issued: 04- 19-2019, Effective: 07 -21-19, Implementation: 07- 21-19)  Under the Medicare hospice benefit, an attending physician is defined as a doctor of medicine or osteopathy or a nurse practitioner or physician assistant (for professional services related to the terminal illness that are furnished on or after December 8,  2003 and January 1, 2019, respectively) who is identified by the  patient,  at the time  he/she  elects  hospice  coverage,  as having the  most  significant  role in the determination  and delivery  of his or her medical  care.  Payment  for physicians, nurse practiti oners, or physician assistants serving as the attending physician, who provide direct  patient  care services  and who are hospice  employees  or working under  arrangement  with  the hospice , is made in  the following manner:    Hospices  establish  a charge and  bill the  A/B MAC (HHH)  for these services under Medicare Part A.    The A/B MAC (HHH)  pays the hospice at the lesser of the actual charge or 100 percent of the Medicare physician fee schedule for physician services or 85 percent of the fee schedule amount for nurse practitioner or physician assistant services.  This payment is in addition to the daily hospice rates.    Payment for  attending physician services  is counted with  the payments  made at  the daily  payment  rates  to determine  whether  the overall  hospice  cap amount  has been  exceeded.    No payment  is made for attending physician services  furnished voluntarily.  However,  some  attending physicians may seek payment for certain services while furnishing other services on a volunteer basis.  Payment may be made for services not furnished voluntarily if the hospice is obligated to pay the attending physician for the services.  An attending physician must treat Medicare patients on the same basis as other patients in the hospice and may  not designate  all services  rendered  to non- Medicare patients  as volunteer  and at the same time  bill the  hospice  for services  rendered  to Medicare patients.
(Medicare Claims Processing Manual)
 EXAMPLE: Dr. Jones has an agreement with a hospice to serve as its medical director on a volunteer basis.  Dr. Jones does not furnish any direct patient care services on a volunteer basis.  A Medicare beneficiary enters the hospice and designates Dr. Jones  as her attending physician.  When he furnishes a direct service to the beneficiary, he bills the hospice for this service and the hospice in turn bills the A/B MAC (HHH) and is paid for the service.  Dr. Jones may not bill Medicare Part B as an independen t attending physician because as a volunteer he is deemed to be a hospice employee.    No payment is made for nurse practitioner services that can be performed by a registered nurse, nor is payment made for nurse practitioner services that are performed outside of the attending physician role.   40.1.3 - Independent Attending Physician Services  (Rev. 4280, Issued: 04- 19-2019, Effective: 07 -21-19, Implementation: 07- 21-19)  When  hospice  coverage is  elected,  the beneficiary  waives  all rights  to Medicare Part  B payments  for professional services  that are related  to the treatment  and management  of his/her  terminal illness  during any  period his/her  hospice  benefit  election  is in force,  except  for professional  services  of an independent  attending physician, who is not an employee of the designated hospice nor receives compensation from the hospice for those services.  For purposes of administering the hospice benefit  provisions, an  attending physician means  an individual  who:    Is a doctor  of medicine or  osteopathy, or    A nurse practitioner (for professional services related to the terminal illness and related conditions that are furnished on or after December 8, 2003), or    A physician assistant (for professional services related to the terminal illness and related conditions  that are furnished on or after and January 1, 2019; and   Is identified  by the  individual, at  the time  he/she  elects  hospice  coverage,  as having the  most  significant  role in the determination  and delivery  of their  medical  care.   Hospices should reiterate with patients that they must not see independent physicians for care related to their terminal illness other than their independent attending physician unless the hospice arranges it.
(Medicare Claims Processing Manual)
Hospices should reiterate with patients that they must not see independent physicians for care related to their terminal illness other than their independent attending physician unless the hospice arranges it.   Even  though a  beneficiary  elects  hospice  coverage,  he/she  may  designate  and use  an independent attending physician, who  is not employed by nor receives compensation from the  hospice  for professional  services  furnished, in  addition to  the services  of hospice-employed physicians.  The  professional  services  of an independent attending physician that  are reasonable and  necessary  for the  treatment  and management  of a hospice  patients  terminal illness  are not  considered Medicare Part A  hospice  services.  Where the  service is  related to the hospice patients terminal illness, but was furnished by someone other than the designated attending physician [or a physician substituting for the attending physician] the physician or other provider must look to the hospice for payment.  Professional services related to the hospice patients terminal condition that were furnished by an independent attending physician are billed to the A/B MAC (B) through Medicare Part B.  When the independent attending physician furnishes a service related to the patients terminal illness and related conditions that includes both a professional and technical component (e.g., x-rays), he/she bills the professional component of such services to the A/B MAC (B) on a professional claim and looks to the hospice for payment for the technical component.  Likewise, the independent attending physician would look to the hospice for payment for services furnished that have no professional component (e.g., clinical lab tests). The remainder of this section explains thi s in greater detail.
(Medicare Claims Processing Manual)
When a Medicare beneficiary elects hospice coverage he/she may designate an attending physician, not employed by the hospice, in addition to receiving care from hospice-employed physicians.  The professional services of a non-hospice affiliated attending physic ian for the treatment and management of a hospice patients terminal illness and related conditions are not considered Medicare Part A hospice services.  These independent attending physician services are billed through Medicare Part B to the A/B MAC (B), provided they were not furnished under a payment arrangement with the hospice.  The independent attending physician codes services with the GV modifier Attending physician not employed or paid under agreement by the patients hospice provider when billing his/her professional services furnished for the treatment and management of a hospice patients terminal condition. The A/B MAC (B) makes payment to the independent attending physician based on the payment and deductible rules applicable to each covered service.   Payments for the services of an independent a ttending physician are not  counted  in determining  whether  the hospice  cap amount  has been  exceeded  because Part B  services  provided by an  independent  attending physician are  not part of the hospices  care.   Services  provided by an independent  attending physician must  be coordinated with  any direct  care services  provided by hospice  physicians.  Only  the direct professional  services of an  independent  attending physician, to a  patient  may be billed; the  costs  for services  such  as lab or x-rays are not to be included  in the bill.  If another physician covers for a hospice patients designated attending physician, the services of the substitute physician are billed by the designated attending physician under either the reciprocal billing or fee -for-time compensation arrangement (formerly referred to as Locum Tenens Arrangements) instructions.  In such instances, the attending physician bills using the GV modifier in conjunction with either the Q5 or Q6 modifier.   When services related to a hospice patients terminal condition are furnished under a payment arrangement with the hospice by the designated attending physician, the attending physician must look to the hospice for payment.  In this situation the physicians services are Part A hospice services and are billed by the hospice to its A/B MAC (HHH).
(Medicare Claims Processing Manual)
The CWF response contains the periods of hospice entitlement. This information is a permanent part of the notice and is furnished on all CWF replies and automatic notices. A/B MACs (B) use the CWF reply for validating dates of hospice coverage and to resea rch, examine and adjudicate services coded with the GV or GW modifiers.   40.1.3.1 - Care Plan Oversight  (Rev. 4280, Issued: 04- 19-2019, Effective: 07 -21-19, Implementation: 07- 21-19)  Care plan oversight (CPO) exists where there is physician supervision of patients under care of hospices that require complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans. Implicit in the conce pt of CPO is the expectation that the physician has coordinated an aspect of the patients care with the hospice during the month for which CPO services were billed.   For a physician or NP employed by or under arrangement with a hospice agency, CPO functions are incorporated and are part of the hospice per diem payment and as such may not be separately billed.  For information on separately billable CPO services by the attending physician, nurse practitioner, or physician assistant, see Chapter 12, 180 of this manual.  40.2 - Processing Professional Claims for Hospice Beneficiaries  (Rev.10485, Issued: 11- 19-20, Effective: 09 -07-2020, Implementation: 12- 01-2020)   Professional services of attending physicians, who may be nurse practitioners or physician assistants, furnished to hospice beneficiaries are coded with modifier GV: Attending physician not employed or paid under arrangement by the patients hospice provider.  This modifier must be retained and reported to CWF.   A/B MACs (B) processing professional claims shall presume that hospice benefits are not involved unless the biller codes services on the claim to indicate that the patient is a hospice enrollee (e.g. the GV modifier is billed by the attending physician, or  the GW modifier is billed for services unrelated to the patients terminal condition) or the trailer information on the CWF reply shows a hospice election.  The A/B MAC (B) shall use the hospice enrollment trailer information on the CWF reply to examine a nd validate the claim information.
(Medicare Claims Processing Manual)
For beneficiaries enrolled in hospice, A/B MACs (B) shall deny any services on professional claim that are submitted without either the GV or GW modifier.  A/B MACs (A) and (B) or DME MACs, shall deny claims for all other services related to the patients terminal condition furnished by individuals or entities other than the designated attending physician.  Such claims include bills for any DME, supplies  or independently practicing  speech -language pathologists  or physical  therapists  that are related  to the terminal condition.  These services  are included in  the hospice  rate and  paid  through the  institutional claim.   DME MACs shall make determinations of relatedness in the same way the A/B MACs Part B do today  based entirely on the presence of the GW modifier and not based on diagnosis coding.  In the event that the claim exceeds the number of allowable modifiers, the DME MAC shall instruct the supplier to use modifier 99 on the line to indicate additional modifiers are reported in the remarks field.  The supplier must include the GW modifier in the claim remarks. Claims that do not contain the GW modifier shall be denied.   40.2.1 - Claims After the End of Hospice Election Period  (Rev. 2258, Issued: 07-  29-11, Effective: 01 -01-12, Implementation: 01- 03-12)  Upon revocation of Medicare coverage of hospice care for a particular election period, an individual resumes Medicare coverage of the benefits waived when hospice care was elected. After revocation, A/B MACs (B) process and pay professional claims for cove red Part B services that hospice employed physicians may furnish.   50 - Billing and Payment for Services Unrelated to Terminal Illness  (Rev. 4280, Issued: 04- 19-2019, Effective: 07 -21-19, Implementation: 07- 21-19)