(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 12 - Physicians/Nonphysician Practitioners   Table of Contents  (Rev.  12461; Issued: 01-18-24)    Transmittals for Chapter 12   10 - General  20 - Medicare Physicians Fee Schedule (MPFS)  20.1 - Method for Computing Fee Schedule Amount 20.2 - Relative Value Units (RVUs)  20.3 - Bundled Services/Supplies 20.4 - Summary of Adjustments to Fee Schedule Computations 20.4.1 - Participating Versus Nonparticipating Differential  20.4.2 - Site of Service Payment Differential  20.4.3 - Assistant at Surgery Services  20.4.4 - Supplies 20.4.5 - Allowable Adjustments  20.4.6 - Payment Due to Unusual Circumstances (Modifiers -22 and - 52) 20.4.7 -  Technical Component Payment Reduction for X-Rays and Other Imaging Services 20.5 - No Adjustments in Fee Schedule Amounts 20.6- Update Factor for Fee Schedule Services  20.7 - Comparability of Payment Provision of Delegation of Authority by CMS to Railroad Retirement Board  20.8 - Payment for Teleradiology Physician Services Purchased by Indian Health Services (IHS) Providers and Physicians 30 - Correct Coding Policy 30.1 - Digestive System (Codes 40000 - 49999) 30.2 - Urinary and Male Genital Systems (Codes 50010 - 55899) 30.3 - Audiology Sevices 30.4 - Cardiovascular System (Codes 92950-93799) 30.5 - Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions 30.6 - Evaluation and Management Service Codes - General (Codes 99202 - 99499) 30.6.1 - Selection of Level of Evaluation and Management Service  30.6.1.1 - Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV)  30.6.2 -  Billing for Medically Necessary Visit on Same Occasion as Preventive Medicine Service  30.6.3 -  Payment for Immunosuppressive Therapy Management  30.6.4 -  Evaluation and Management (E/M) Services Furnished Incident to Physicians Service by Nonphysician Practitioners  30.6.5 -  Physicians in Group Practice  30.6.6 -  Payment for Evaluation and Management Services Provided During Global Period of Surgery  30.6.7 -  Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99202 -  99215)  30.6.8 -  Payment for Hospital Observation Services and Observation or Inpatient Care Services (Including Admission and Discharge Services)  30.6.9 -  Payment for Inpatient Hospital Visits -  General  30.6.9.1 -  Payment for Initial Hospital Inpatient or Observation  Care Services and  Hospital Inpatient or Observation or Inpatient Care Services (Including Admission and Discharge Services)  30.6.9.2 -  Subsequent Hospital Inpatient or Observation Care Visit and Hospital  Inpatient or Observation Discharge Day Management Services (Codes 99231 -  99239)  30.6.10 -  Consultation Services  30.6.11 -  Emergency Department Visits (Codes 99281 -  99288)  30.6.12 -  Critical Care Visits and Neonatal Intensive Care (Codes  99291 -  99292)               30.6.12.1 -  Definition              30.6.12.2 -  Critical Care by a Single Physician or NPP  30.6.12.3 -  Critical Care Visits Furnished Concurrently by Different  Specialties  30.6.12.4 -  Critical Care Furnished Concurrently by Practitioners in the  Same Specialty and Same Group (Follow -Up Care)  30.6.12.5 -  Split (or Shared) Critical Care Visits  30.6.12.6 -  Critical Care and Other Same -Day Evaluation and  Management (E/M) Visits  30.6.12.7 -  Critical Care Visits and Global Surgery  30.6.12.8 -  Medical Record Documentation  30.6.13 -  Nursing Facility Services  30.6.14 -  Home or Residence Services (Codes 99341  99350)     30.6.14.1   Home or Residence Services (99341  99350) When     Performed in Place of Service 12 (Home)    30.6.15 -  Prolonged Services , Standby Services (Codes 99354 -  99360)  and                              Evaluation and Management service for Power Mobility Devices (PMDs) (G0372)  30.6.15.1 -  Prolonged Services  General Rules  30.6.15.2 -  Prolonged Office/Outpatient E/M Visits  30.6.15.3 -  Prolonged Other E/M Visits  30.6.15.4 - Power Mobility Devices (PMDs) (Code G0372)                          30.6.17  Physician Management Associated with Superficial Radiation                                      Treatment                30.6.18 -  Split (or Shared) Visits    30.6.19  Office/Outpatient Evaluation and Management  (O/O E/M) Complexity    Add-on Payment (Code G2211)  40 - Surgeons and Global Surgery  40.1 -  Definition of a Global Surgical Package  40.2 -  Billing Requirements for Global Surgeries  40.3 -  Claims Review for Global Surgeries  40.4 -  Adjudication of Claims for Global Surgeries  40.5 -  Postpayment Issues  40.6 -  Claims for Multiple Surgeries  40.7 -  Claims for Bilateral Surgeries  40.8 -  Claims for Co -Surgeons and Team Surgeons  40.9 -  Procedures Billed With Two or More Surgical Modifiers  50 - Payment for Anesthesiology Services  60 - Payment for Pathology Services  70 - Payment Conditions for Radiology Services  80 - Services of Physicians Furnished in Providers or to Patients of Providers  80.1 -  Coverage of Physicians Services Provided in Comprehensive Outpatient Rehabilitation Facility  80.2 -  Rural Health Clinic and Federally Qualified Health Center Services  80.3 -  Unusual Travel (CPT Code 99082)  90 - Physicians Practicing in Special Settings  90.1 -  Physicians in Federal Hospitals  90.2 -  Physician Billing for End- Stage Renal Disease Services  90.2.1 -  Inpatient Hospital Visits With Dialysis Patients  90.3 -  Physicians Services Performed in Ambulatory Surgical Centers (ASC)  90.4 -  Billing and Payment in Health Professional Shortage Areas (HPSAs)  90.4.1 -  Provider Education 90.4.1.1 -  A/B MAC (B)  Web Pages  90.4.2 -  HPSA Designations  90.4.3 -  Claims Coding Requirements  90.4.4 -  Payment  90.4.5 -  Services Eligible for HPSA and Physician Scarcity Bonus Payments  90.4.6 -  Reserved for Future Use  90.4.7 -  Post -payment Review  90.4.8 -  Reporting 90.4.9 - HPSA Incentive Payments for Physician Services Rendered in a Critical Access Hospital  90.4.10 -  Administrative and Judicial Review  90.4.11 -  Health Professional Shortage Areas (HPSA) Surgical Incentive Payment Program (HSIP) for Surgical Services Rendered in HPSAs  90.4.11.1 -  Overview of the HSIP  90.4.11.2 -  HPSA Identification  90.4.11.3 -  Coordination with Other Payments  90.4.11.4 - General Surgeon and Surgical Procedure Identification for Professional Services Paid Under the Physician Fee Schedule (PFS)  90.4.11.5 -  Claims Processing and Payment  90.5 -  Billing and Payment in a Physician Scarcity Area  90.5.1 -  Provider Education 90.5.2 -  Identifying Physician Scarcity Area Locations  90.5.3 -  Claims Coding Requirements  90.5.4 -  Payment  90.5.5 -  Services Eligible for the Physician Scarcity Bonus  90.5.5.1 -  Remittance Messages  90.5.6 -  Post -payment Review  90.5.7 -  Administrative and Judicial Review  90.6 -  Indian Health Services (IHS) Provider Payment to Non- IHS Physicians for Teleradiology Interpretations  90.7 -  Bundling of Payments for Services Provided in Wholly Owned and Wholly Operated Entities (including Physician Practices and Clinics): 3 -Day Payment Window  90.7.1 -  Payment Methodology: 3- Day Payment Window in Wholly Owned or Wholly Operated Entities (including Physician Practices and Clinics)  100 -  Teaching Physician Services  100.1 -  Payment for Physician Services in Teaching Settings Under the MPFS  100.1.1 -  Evaluation and Management (E/M) Services  100.1.2 -  Surgical Procedures  100.1.3 -  Psychiatry  100.1.4 -  Time -Based Codes  100.1.5 -  Other Complex or High- Risk Procedures  100.1.6 -  Miscellaneous  100.1.7 -  Assistants at Surgery in Teaching Hospitals  100.1.8 -  Physician Billing in the Teaching Setting 100.2 -  Interns and Residents  110 -  Physician Assistant (PA) Services Payment Methodology 110.1 -  Global Surgical Payments  110.2 -  Limitations for Assistant- at-Surgery Services Furnished by Physician Assistants  110.3 -  Outpatient Mental Health Treatment Limitation  110.4 -  PA Billing to the A/B MAC (B)  120 - Nurse Practitioner (NP) And Clinical Nurse Specialist (CNS) Services  Payment Methodology 120.1 -  Limitations for Assistant- at-Surgery Services Furnished by Nurse Practitioners and Clinical Nurse Specialists  120.2 -  Outpatient Mental Health Treatment Limitation  120.3 -  NP and CNS Billing to the A/B MAC (B)  130 -  Nurse -Midwife Services  130.1 -  Payment for Certified Nurse -Midwife Services  130.2 -  Global Allowances  140 -  Qualified Nonphysician Anesthetist Services  140.1 -  Qualified Nonphysician Anesthetists  140.2 -  Entity or Individual to Whom Fee Schedule is Payable for Qualified Nonphysician Anesthetists  140.3 -  Anesthesia Fee Schedule Payment for Qualified Nonphysician Anesthetists  140.3.1 -  Conversion Factors Used on or After January 1, 1997 for Qualified Nonphysician Anesthetists  140.3.2 -  Anesthesia Time and Calculation of Anesthesia Time Units  140.3.3 -  Billing Modifiers  140.3.4 -  General Billing Instructions  140.4 -  Qualified Nonphysician Anesthetist Special Billing and Payment Situations  140.4.1 -  An Anesthesiologist and Qualified Nonphysician Anesthetist Work Together  140.4.2 -  Qualified Nonphysician Anesthetist and an Anesthesiologist in a Single Anesthesia Procedure  140.4.3 -  Payment for Medical or Surgical Services Furnished by CRNAs   140.5-- Payment for Anesthesia Services Furnished by a Teaching CRNA  150 -  Clinical Social Worker (CSW) Services  160 -  Independent Psychologist Services  160.1 -  Payment  170 -  Clinical Psychologist Services  170.1 -  Payment  180 -  Care Plan Oversight Services  180.1 -  Care Plan Oversight Billing Requirements  190 -  Medicare Payment for Telehealth Services  190.1 -  Background  190.2 -  Eligibility Criteria  190.3 -  List of Medicare Telehealth Services  190.3.1 -  Telehealth Consultation Services, Emergency Department  or Initial Inpatient versus Inpatient Evaluation and Management (E/M) Visits  190.3.2 -  Telehealth Consultation Services, Emergency Department  or Initial Inpatient Defined  190.3.3 -  Follow -Up Inpatient Telehealth Consultations Defined  190.3.4  Payment for ESRD -Related Services as a Telehealth Service  190.3.5  Payment for Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services  190.3.6  Payment for Diabetes Self -Management Training (DSMT) as a Telehealth Service