evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The IHS providers are paid by the A/B MAC (A) for covered drugs and biologicals provided during a clinic vi sit.  All charges are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (IHS/tribal hospitals and hospital -based clinics) or TOB 85X (CAHs). Payment is made to IHS providers under the AIR. Payment is made to IHS CAHs based upon 101 pe rcent of the all inclusive facility specific per visit rate.   The IHS hospital swing- bed providers are paid according to the SNF PPS payment methodology for covered drugs and biologicals provided during the IHS hospital swing -bed stay. Services are itemized and billed with the appropriate revenue code that describes the service on TOB 18X.   Payment to IHS CAH swing -bed providers for covered drugs and biologicals provided during an IHS CAH swing -bed stay is included in the all inclusive facility specific per  diem rate.   Supply fees are also due when multi -day supplies of any of the following self -administered drugs are provided to IHS hospital outpatients or patients of a provider -based clinic:  oral anti -cancer drugs, oral anti -emetic drugs, or immunosuppressive drugs. Following the same procedures that apply to non- IHS facilities, these multi- day supplies must be billed to the appropriate DME MAC in order to collect the supplying fee.  The supplying fee must be billed on the same claim as the drug itself. For a 1 day supply of the above mentioned drugs, there is no supplying fee, the facility bills the designated A/B MAC (A) and is paid the AIR for the outpatient visit.  For an IHS CAH, payment for a 1 day supply of the drug is based on 101 percent of the all inclusive fa cility specific per visit rate.  A/B MACs (A) will also make payment for multi- day supplies of these particular drugs when provided to a beneficiary in an inpatient Part B stay in an IHS hospital, CAH, or SNF.   For additional information regarding billing for drugs and associated supplying fees, see Chapter 17, 80.7 of Pub. 100- 04, Medicare Claims Processing Manual.
(Medicare Claims Processing Manual)
For additional information regarding billing for drugs and associated supplying fees, see Chapter 17, 80.7 of Pub. 100- 04, Medicare Claims Processing Manual.   100.16 - A/B MAC (A) --Payment for Telehealth Services to Indian Health Service/Tribal Facilities and Practitioners  (Rev. 1776, Issued: 07- 24-09, Effective: 01- 01-09, Implementation: 01- 04-10)  For background on the telehealth benefit, see Chapter 12, 190.1 in this manual.  For more information on the payment of Telehealth services, see Chapter 15 of the Benefit Policy Manual.  Telehealth servi ces fall into two categories: an originating site facility service in which the beneficiary is presented to the distant site practitioner, and a distant site service which is generally some type of professional consultation.  100.16.1 - A/B MAC (A) - Teleh ealth Originating Site Facility Fee - Medicare Part B - Payment Policy  (Rev. 1776, Issued: 07- 24-09, Effective: 01- 01-09, Implementation: 01- 04-10)  Effective January 1, 2009, IHS providers, including CAHs are paid separately from the AIR for the Telehealth Originating Site Facility Fee.  HCPCS code Q3014 (telehealth originating site facility fee) is a Part B benefit.  The fee is updated each calendar year by the Medicare Economic Index announced in the annual Physician Fee Schedule Final Regulat ion.  IHS providers are paid for HCPCS code Q3014 at the fee schedule payment, not the providers usual all -inclusive payment methodology (e.g., inpatient DRG or AIR or CAH per diem).  For CAHs, the payment amount is 80 percent of the fee, not 101 percent of cost.  The Medicare Part B deductible and coinsurance apply to the Telehealth Originating Site Facility Fee, but are waived by the IHS.   100.16.2 - A/B MAC (A) - Telehealth Originating Site Facility Fee - Medicare Part B - Claims Processing  (Rev. 1776, Issued: 07 -24-09, Effective: 01- 01-09, Implementation: 01- 04-10)
(Medicare Claims Processing Manual)
The Telehealth Originating Site Facility Fee is reported on TOB 12X, 13X or 85X along with the revenue code 0780 and HCPCS code Q3014 as described in Chapter 12, Section 190 of Pub. 100- 04, Medicare Claims Processing Manual.   No clinic visit shall be billed if this is the only service received.  There is no requirement that a practitioner present the patient for interactive telehealth services.   The MSN is suppressed.   100.16.3 - A/B MAC (A) -- Payment for Distant Site Practitioner Services  (Rev. 1776, Issued: 07- 24-09, Effective: 01- 01-09, Implementation: 01- 04-10)  Distant site services are listed in 190.3 in Chapter 12 of this manual.  These services are payable only by the A /B MAC (A) to a Method II CAH.  Payment is based on 80 percent of the MPFS.  Deductible and coinsurance apply, but are waived by IHS.   The MSN is suppressed.   110 - Audit  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  110.1 - Audit of IHS Cost Reports  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  All IHS hospitals that convert to CAH status are subject to audit by the A/B MAC (A). CMS audit policy can be found in Chapter 8, Contractor Procedure s for Provider Audit, of Pub. 100- 06, Medicare Financial Management Manual.   The CAHs are reimbursed under the Medicare Principles of Reasonable Costs. These principles are set forth in the Provider Reimbursement Manual 15- 1.  For IHS hospitals that do not  convert to CAH status, their cost reports are not subject to audit by Medicare.   110.2 - Method E Cost Reports  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)
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110.2 - Method E Cost Reports  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  The IHS has used the Method E cost report since it began filing cost reports with CMS in 1998. Method E is the method of cost apportionment which is used to calculate the all inclusive outpatient per visit rate and the all inclusive inpatient ancillary per  diem rate. Both of these rates are paid under Part B of the Medicare Program. For a more detailed explanation see the Provider Reimbursement Manual 15- I, Chapter 22, 2208.  The Method E cost report filed by the IHS is a modified cost report that is appli cable to AIR no charge structure hospitals. The modified cost report does not use all the worksheets of the regular hospital cost report form (Form CMS - 2552). The worksheets filed by IHS are worksheet S -Part I &II, S -2, S-3, A, A -6, A-8, A-8-1, B-Part I, B -Part III, and B -1. For more detailed information see Provider Reimbursement Manual 15- II, Chapter 36.  110.3 - Critical Access Hospitals  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)
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110.3 - Critical Access Hospitals  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  All IHS hospitals that elect CAH status , and are certified as such, are reimbursed under the reasonable cost method of reimbursement. The all inclusive inpatient per diem rate, the all inclusive outpatient per visit rate, and the all inclusive inpatient ancillary per diem rate are calculated based upon the individual CAHs cost report filed with the A/B MAC (A). These rates are facility specific rates and are not to be confused with the AIRs published in the Federal Register by the IHS for each calendar year. A CAH cost report is subject to audi t by its A/B MAC (A). The A/B MAC (A) can disallow costs if those costs did not comply with the Principles of Cost Reimbursement published in the Provider Reimbursement Manual 15- 1. Any costs disallowed are subject to appeal by the CAH. There is also a fin al settlement of an IHS CAH cost report. A final settlement necessitates the issuance of a Notice of Program Reimbursement (NPR) by the A/B MAC (A). The NPR advises the CAH if a balance is due the hospital or the program is due repayment. The NPR also advi ses the CAH of any cost disallowance, its appeal and reopening rights. It should be noted that an IHS hospital that is not a CAH does not receive an NPR and does not have a final settlement.   Effective for cost reporting periods beginning on or after Janua ry 1, 2004, payment for inpatient services, other than a distinct part unit, is 101 percent of the reasonable costs. Effective for cost reporting periods beginning on or after January 1, 2004, payment for outpatient services is 101 percent of the reasonabl e costs. For a detailed explanation concerning payments to CAHs, see 42 CFR, 413.70. For cost reimbursement principles see 42 CFR Part 413 and Provider Reimbursement Manual 15- 1. For Cost Reports see the Provider Reimbursement Manual 15- II, the chapter on hospital cost reports.
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120 - Payment to Non -Indian Health Service Physicians by Indian Health Service (IHS) Providers for Teleradiology Interpretations  (Rev. 1643, Issued: 12- 05-08, Effective: 01- 01-07, Implementation: 03- 09-09)  The IHS providers may choose to purchase or otherwise contract for teleradiology interpretation from non- IHS practitioners.  Two options are available for payment for these services.   (1) Contractual Reassignment -  Under this provision, non- IHS physicians can reassign their benefit s to the IHS hospital where the technical component is performed.  Non- IHS practitioners providing these services shall enroll with the designated A/B MAC contractor for IHS and complete a Form CMS -855-R form for each IHS hospital performing the test.  Bec ause of IHS status, state licensure and location of the physicians is not an issue and the designated A/B MAC contractor shall make payment based on the Medicare locality in which services are rendered in accordance with current jurisdictional pricing guid elines (see 80.2, paragraph 6 of this Chapter).   Purchased Test - The purchased test method is available for all purchased diagnostic tests including radiology, and the requirements are found in Chapter 1.  Payment for teleradiology interpretations under the purchased test option does not require non- IHS physicians enrollment with the designated A/B MAC contractor for IHS.  All general jurisdictional and pricing rules apply for payment for these services.  Transmittals Issued for this Chapter   Rev #  Issue  Date  Subject  Impl Date  CR#  R11427CP  05/20/2022  Claims Processing Manual  Update - Pub. 100-04 for Elimination of Certificates of Medical Necessity (CMNs) and Durable Medical Equipment Forms (DIFs)   01/03/2023  12734  R11414CP  05/12/2022  Claims Processing Manual Update - Pub. 100-04 for Elimination of Certificates of Medical Necessity (CMNs) and Durable Medical Equipment Forms (DIFs) -  Rescinded and replaced by Transmittal 11427   06/13/2022  12734  R3897CP  10/27/2017  Pulmonary Rehabilitation (PR) Services Addition to Chapter 19, Indian Health Services (IHS)
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04/02/2018  10276  R3049CP  08/25/2014  Update to Pub. 100 -04, Chapter 19 to Provide Language -Only Changes for ICD -10 and ASC X12  09/23/2014  8646  R2895CP  03/07/2014  Update to Pub. 100 -04, Chapter 19 to Provide Language -Only Changes for ICD -10 and ASC X12  Rescinded and replaced by Transmittal 3049  10/01/2014  8646  R2102CP  11/19/2010  Systems Changes Necessary to Implement Technical Correction Related to Critical Access Hospital Services, Section 3128 of the Affordable Care Act, Pub. 118 -148 04/04/2011  7219  R2075CP  10/28/2010  Implementation of Section 2902 of the Patient Protection and Affordable Care Act (the Affordable Care Act) for Indian Health Service (HIS) Part B Services and All Inclusive Rate (AIR) Billing for Return Visits  01/28/2011  6908  R1957CP  04/28/2010  Update to the HCPCS Codes for Payment of Surgical Dressings to Indian Health Service (HIS) Providers  10/04/2010  6909  R1776CP  07/24/2009  Telehealth Services in Indian Health Service (HIS) or Tribal Providers  01/042010  6493  Rev #  Issue  Date  Subject  Impl Date  CR#  R1643CP  12/05/2008  Indian Health Service (IHS) Provider Payment to Non-IHS Physicians for Teleradiology Interpretations  03/09/2009  6162  R1511CP  05/23/2008  Indian Health Service (HIS) Hospital Payment for Calendar Year 2008  06/23/2008  6063  R1446CP  02/08/2008  Update to Common Working File (CWF) Edits 7284 and 7548  07/07/2008  5907  R1325CP  08/29/2007  Testing and Implementation of 2008 Ambulatory Surgical Center (ASC) Payment System Changes  01/07/2008  5680  R1308CP  07/20/2007  Testing and Implementation of 2008 Ambulatory Surgical Center (ASC) Payment System Changes  Replaced by Transmittal 1325  01/07/2008  5680  R1040CP  08/25/2006  Clarifications and Additions to Chapter 19, Indian Health Services (IHS) - Replaces Rev. 1027  09/11/2006  5230
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Transmittal 1325  01/07/2008  5680  R1040CP  08/25/2006  Clarifications and Additions to Chapter 19, Indian Health Services (IHS) - Replaces Rev. 1027  09/11/2006  5230  R1027CP  08/11/2006  Clarifications and Additions to Chapter 19, Indian Health Services (IHS) - Replaced by Rev. 1040  09/11/2006  5230  R706CP  10/07/2005  Payment Methodology for Rehabili tation Services in IHS/Tribally Owned and/or Operated Hospitals and Hospital -Based Facilities  01/03/2006  3934  R681CP  09/16/2005  Guidelines For  Payment of Vaccines (Pneumococcal Pneumonia Virus (PPV), Influenza Virus, And Hepatitis B Virus) and Their Administration Provided By Indian Health Service (IHS) Tribally Owned and/or Operated Hospitals and Hospital Based Facilities  01/03/2006  3967  R633CP  08/03/2005  Guidelines For Payment of Vaccines (Pneumococcal Pneumonia Virus (PPV), Influenza Virus, And Hepatitis B Virus) and Their Administration Provided By Indian Health Service (IHS) Tribally Owned and/or Operated Hospitals and Hospital Based Facilities  01/03/2006  3967  R611CP  07/22/2005  Payment Methodology for Rehabilitation Services in IHS/Tribally Owned and/or 01/03/2006  3934  Rev #  Issue  Date  Subject  Impl Date  CR#  Operated Hospitals and Hospital -Based Facilities  R461CP  02/04/2005  Processing Durable Med ical Equipment (DME) Orthotics, Prosthetics, Drugs, and Surgical Dressing Claims for Indian Health Services (IHS) and Tribally Owned and Operated Hospitals for Hospital Based Facilities including Critical Access Hospitals (CAHs)  07/05/2005  3674  R430CP  01/14/2005  Mandatory Assignment for MMA 630 Claims  07/05/2005  3587  R241CP  07/23/2004  Expansion of the s cope of items and services for which payment may be made to IHS facilities and suppliers  01/03/2005  3288  R201CP  06/10/2004  Initial Publication of Chapter  Not Applicable  3302  Back to top of Chapter
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Medicare Claims Processing Manual  Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)   Table of Contents  (Rev. 12437;  Issued: 12- 28-23)  (Rev. 1 2423;  Issued: 12 -20-23)
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Transmittals for Chapter 20  01 - Foreword  10 - Where to Bill DMEPOS and PEN Items and Services  10.1 -  Definitions  10.1.1 -  Durable Medical Equipment (DME)  10.1.2 -  Prosthetic Devices -  Coverage Definition 10.1.3 -  Prosthetics and Orthotics (Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes) - Coverage Definition  10.1.4 -  Payment Definition Variances  10.1.4.1 -  Prosthetic Devices  10.1.4.2 -  Prosthetic and Orthotic Devices (P&O)  10.2 -  Coverage Table for DME Claims  10.3 -  Beneficiaries Previously Enrolled in Managed Care Who Return to Traditional Fee for Service (FFS)  20 - Calculation and Update of Payment Rates  20.1 -  Update Frequency  20.2 -  Locality  20.3 -  Elimination of "Kit" Codes and Pricing of Replacement Codes  20.4 -  Contents of Fee Schedule File  20.5 -  Online Pricing Files for DMEPOS  20.6 -  Phase- in For Competitive Bid Rates in Areas Not in a Competitive Bid Area  30 - General Payment Rules  30.1 -  Inexpensive or Other Routinely Purchased DME  30.1.1 -  Used Equipment  30.1.1.2  Used Rental Equipment  30.1.2 -  Transcutaneous Electrical Nerve Stimulator (TENS)  30.2 -  Items Requiring Frequent and Substantial Servicing  30.2.1 -  Daily Payment for Continuous Passive Motion (CPM) Devices  30.3 -  Certain Customized Items  30.4 -  Other Prosthetic and Orthotic Devices  30.5 -  Capped Rental Items  30.5.1-  Capped Rental Fee Variation by Month of Rental  30.5.2 -  Purchase Option for Capped Rental Items  30.5.3 -  Additional Purchase Option for Electric Wheelchairs  30.5.3.1 -  Exhibits  30.5.4 -  Payments for Capped Rental Items During a Period of Continuous Use 30.5.5 -  Payment for Power -Operated Vehicles that May Be Appropriately Used as Wheelchair  30.6 -  Oxygen and Oxygen Equipment  30.6.1 -  Adjustments to Monthly Oxygen Fee  30.6.2 -  Purchased Oxygen Equipment  30.6.3 -  Contents Only Fee  30.6.4 -  DMEPOS Clinical Trials and Demonstrations  30.7 -  Payment for Parenteral and Enteral Nutrition
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-  Adjustments to Monthly Oxygen Fee  30.6.2 -  Purchased Oxygen Equipment  30.6.3 -  Contents Only Fee  30.6.4 -  DMEPOS Clinical Trials and Demonstrations  30.7 -  Payment for Parenteral and Enteral Nutrition (PEN) Items and Services  30.7.1 -  Payment for Parenteral and Enteral Pumps  30.7.2 -  Payment for PEN Supply Kits  30.8 -  Payment for Home Dialysis Supplies and Equipment  30.8.1 -  DME MAC and A/B MAC (A)  Determination of ESRD MethodSelection  30.8.2 -  Installation and Delivery Charges for ESRD Equipment  30.8.3 -  Elimination of Method II Home Dialysis  30.9 -  Payment of DMEPOS Items Based on Modifiers  30.9.1  Processing of Expatriate Beneficiary DMEPOS Claims for Purchased Items Submitted with the EX Modifier  40 - Payment for Maintenance and Service of Equipment  40.1 -  General  40.2 -  Maintenance and Service of Capped Rental Items  40.3 -  Maintenance and Service of PEN Pumps  50 - Payment for Replacement of Equipment  50.1 -  Payment for Replacement of Capped Rental Items  50.2 -  A/B MAC (A) or (HHH) Format for Durable Medical Equipment, Prosthetic, Orthotic and Supply Fee Schedul e 50.3 -  Payment for Replacement of Parenteral and Enteral Pumps  50.4 -  Payment for Replacement of Oxygen Equipment in Bankruptcy Situations  50.5  Payment of a Part of a DMEPOS Item  60 - Payment for Delivery and Service Charges for Durable Medical Equipment  80 - Penalty Charges for Late Payment Not Included in Reasonable Charges or Fee Schedule Amounts  90 - Payment for Additional Expenses for Deluxe Features  100 -  General Documentation Requirements  100.1 -  Written Order Prior to Delivery  100.1.1 -  Written Order Prior to Delivery -  HHAs  100.2 -  Certificates of Medical Necessity (CMN)  100.2.1 -  Completion of Certificate of Medical Necessity Forms  100.2.2 -  Evidence of Medical Necessity for Parenteral and Enteral Nutrition (PEN) Therapy  100.2.2.1 -  Scheduling and Documenting Certifications and Recertifications of Medical Necessity for PEN  100.2.2.2 -  Completion of the Elements of PEN CMN  100.2.2.3 -  DME MAC  Review of Initial PEN Certifications  100.2.3.1 -  Scheduling and Documenting
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of Medical Necessity for PEN  100.2.2.2 -  Completion of the Elements of PEN CMN  100.2.2.3 -  DME MAC  Review of Initial PEN Certifications  100.2.3.1 -  Scheduling and Documenting Recertifications of Medical Necessity for Oxygen  100.2.3.2 -  HHA Recertification for Home Oxygen Therapy  100.2.3.3 -  A/B MAC (A) or (HHH)  Review of Oxygen Certifications  100.3 -  Limitations on DME MAC  Collection of Information 100.4 -  Reporting the Ordering/Referring NPI on Claims for DMEPOS Items Dispensed Without a Physician's Order  110 -  General Billing Requirements -  for DME, Prosthetics, Orthotic Devices, and Supplies  110.1 -  Billing/Claim Formats  110.1.1 -  Requirements for Implementing the NCPDP Standard 110.1.2 -  Certificate of Medical Necessity (CMN)  110.1.3 -  NCPDP Companion Document  110.2 -  Application of DMEPOS Fee Schedule  110.3 -  Pre-Discharge Delivery of DMEPOS for Fitting and Training 110.3.1 -  Conditions That Must Be Met  110.3.2 -  Date of Service for Pre -Discharge Delivery of DMEPOS  110.3.3 -  Facility Responsibilities During the Transition Period  110.4 -  Frequency of Claims for Repetitive  Services (All Providers and Suppliers)  110.5 -  DME MACs Only -  Appeals of Duplicate Claims  120 -  DME MACs -  Billing Procedures Related To Advanced Beneficiary Notice (ABN) Upgrades  120.1 -  Providing Upgrades of DMEPOS Without Any Extra Charge  130 -  Billing for Durable Medical Equipment (DME) and Orthotic/Prosthetic Devices  130.1 -  Provider Billing for Prosthetic and Orthotic Devices  130.2 -  Billing for Inexpensive or Other Routinely Purchased DME  130.3 -  Billing for Items Requiring Frequent and Substantial Servicing 130.4 -  Billing for Certain Customized Items  130.5 -  Billing for Capped Rental Items (Other Items of DME)  130.6 -  Billing for Oxygen and Oxygen Equipment  130.6.1 -  Oxygen Equipment and Contents Billing Chart  130.7 -  Billing for Maintenance and Servicing  (Providers and Suppliers)  130.8 -  Installment Payments  130.9 -  Showing Whether Rented or Purchased  140 -  Billing for Supplies  140.1 -  Billing for Supplies and Drugs Related to
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Equipment and Contents Billing Chart  130.7 -  Billing for Maintenance and Servicing  (Providers and Suppliers)  130.8 -  Installment Payments  130.9 -  Showing Whether Rented or Purchased  140 -  Billing for Supplies  140.1 -  Billing for Supplies and Drugs Related to the Effective Use of DME
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140.1.1 -  Billing of Insulin Furnished through DME  140.2 -  Billing for HHA Medical Supplies  140.3 -  Billing DME MAC  for Home Dialysis Supplies and Equipment  150 -  Institutional Provider Reporting of Service Units for DME and Supplies  160 -  Billing for Total Parenteral Nutrition and Enteral Nutrition  160.1 -  Billing for Total Parenteral Nutrition and Enteral Nutrition Furnished to Part B Inpatients  160.2 -  Special Considerations for SNF Billing for TPN and EN Under Part B  170 -  Billing for Splints and Casts  180 -  Billing for Home Infusion Therapy Services   181  Lymphedema Compression Treatment Benefit  190 -  A/B MAC (A), (B), (HHH), or DME MAC  Application of Fee Schedule and Determination of Payments and Patient Liability for DME Claims  200 -  Automatic Mailing/Delivery of DMEPOS  210 -  CWF Crossover Editing for DMEPOS Claims During an Inpatient Stay 211 - SNF Consolidated Billing and DME Provided by DMEPOS Suppliers  211.1 -  General Information  211.2 -  Partial Month Stays For Capped Rental Equipment  212 -  Home Health Consolidated Billing and Supplies Provided by DMEPOS Suppliers  213- Billing for Home IVIG Items and Services  220 -  Appeals  230 -  DME MAC  Systems  300 -  New Systems Requirements  01 - Foreword  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    This chapter provides general instructions on billing and claims processing for durable medical equipment (DME), prosthetics and orthotics (P&O), parenteral and enteral nutrition (PEN), and supplies.  Coverage requirements are in the Medicare Benefit Polic y Manual and the National Coverage Determinations Manual.    These instructions are applicable to services billed to the A/B MAC (A), (B), and (HHH), and DME MAC unless otherwise noted.    The DME, prosthetic/orthotic devices (except customized devices in a SNF), supplies and oxygen used during a Part A covered stay for hospital and skilled nursing facility (SNF) inpatients are included in the inpatient prospective payment system (PPS) and a re not separately billable.