evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
To be consistent with the Medicare HPSA physician program (Publication 100- 04, Chapter 12, Section 90.4), HSIP payments will be calculated by Medicare contractors on a quarterly basis, on behalf of the qualifying 02- general surgeon for the qualifying surgi cal procedures.   250.13.2 - HPSA Identification  (Rev. 2078, Issued: 10- 28-10, Effective: 04 -01-11, Implementation: 04- 04-11)  For HSIP payments to be applicable, the 10 -  or 90 -  day global surgical procedure must be furnished in an area designated by the Secretary as of December 31 of the prior year as a HPSA.   Each year, a list of ZIP codes eligible for automatic payment of the HPSA physician bonus is published.  This list is also utilized for automatic payments of the incentive for eligible services furnished by general surgeons.  Modifier AQ is used to identif y circumstances when general surgeons furnish services in areas that are designated as HPSAs as of December 31 of the prior year, but that are not on the list of ZIP codes eligible for automatic payment.  Modifier AQ should be appended to the major surgica l procedure on claims submitted for payment for professional services furnished in a HPSA that is not recognized as such for the purpose of automatic payment.  250.13.3 - Coordination with Other Payments (Rev. 2078, Issued: 10- 28-10, Effective: 04 -01-11, Implementation: 04- 04-11)  Section 5501(b)(4) of the ACA provides payment under the HSIP as an additional payment amount for specified surgical services without regard to any additional payment for the service under section 1833(m) of the Act.  Therefore, a general surgeon may receive both a HPSA physician bonus  payment under the established program and an HSIP payment under the new program beginning in CY 2011.  250.13.4 - General Surgeon and Surgical Procedure Identification for Professional Services Paid under the Physician Fee Schedule (PFS)  (Rev. 2078, Issued: 10- 28-10, Effective: 04 -01-11, Implementation: 04- 04-11)  Qualifying general surgeons will be identified on a claim for a 10 -  or 90 -  day global surgical procedure based on the NPI listed in the operating provider field on the claim and the associated primary enrolled specialty of the operating physician of 02 -  general surgery.
(Medicare Claims Processing Manual)
Major surgical procedures are those procedures for which a 10 -  or 90 -  day global period is used for payment under the PFS.  The specific procedure codes eligible for the HSIP are identified in column U (global period) of the Physician Fee Schedule Relati ve Value Update (RVU) file located at:  http://www.cms.gov/Medicare/Medicare -Fee-for-Service -Payment/PhysicianFeeSched/PFS -Relative -Value- Files.html, with a global period designation of 10 -  or 90 day.  250.13.5 - Claims Processing and Payment  (Rev. 2078, Issued: 10- 28-10, Effective: 04 -01-11, Implementation: 04- 04-11)  A. General Overview   The HPSA physician bonus program guidelines are contained in Publication 100- 04, Chapter 12, and Section 90.4.  Refer to that manual for payment and claims processing guidance for the HPSA physician bonus program that was established in 2005.  The following guidelines pertain only to qualifying 02-  general surgeons  who have reassigned their billing rights to CAHs paid under the optional method, and who are eligible to receive the additional 10 percent HSIP payment for major surgical procedures furnished  in HPSAs from January 1, 2011 through December 31, 2015.   Contractors shall only identify eligible services with a 10 -  or 90 -  day global period rendered in eligible zip code areas based on the HPSA physician bonus program ZIP code file for the appropriate date of service.   Providers may report modifier AQ when submitting claims for major surgical procedures that were furnished in approved HPSAs, where those HPSAs are not recognized for automatic payment.  The modifier must be appended to the major surgical procedure HCPCS co de in order for the CAH paid under the optional method to be paid the 10 percent additional incentive payment for the surgical procedure on behalf of the general surgeon.   B. Method of Payment:    Calculate and pay CAHs paid under the optional method on behalf of  02-  general surgeons furnishing  10 -  and 90 -  day global surgical procedures in a recognized HPSA an additional 10 percent incentive payment based on 115 percent of the amount that would be paid for the surgeons professional services under the PFS;    Calculate the payment based on the amount actually paid for the service, not the Medicare approved amount;    Combine the additional payment with the HPSA physician bonus payment;
(Medicare Claims Processing Manual)
 Calculate the payment based on the amount actually paid for the service, not the Medicare approved amount;    Combine the additional payment with the HPSA physician bonus payment;    Accept and pay services submitted with modifier AQ and;    Revise the special incentive remittance for CAHs that is forwarded with the incentive check so that physicians can identify which type of incentive payment (HPSA physician, HSIP, or PCIP) was paid for which service.   C. Changes for Contractor Systems   The Medicare Carrier System, (MCS), Common Working File (CWF,) and National Claims History (NCH) shall be modified to accept a new HSIP and a new PCIP indicator on the claim line.   Once the type of incentive payment has been identified by the shared systems, the shared system shall modify their systems to set the indicator on the claim line as follows:  1 = HPSA;  2 = PSA;  3 = HPSA and PSA;  4 = HSIP;  5 = HPSA and HSIP  6 = PCIP;  7 = HPSA and PCIP;  Space = Not Applicable.   The contractor shared system shall send the HIGLAS 810 invoice for incentive payment invoices, including the new HSIP payment.  The contractor shall also combine the practitioners HPSA physician bonus, Physician Scarcity (PSA) bonus (if it should become available at a later date), and HSIP payment invoice per practitioner.  The contractor shall receive the HIGLAS 835 payment file from HIGLAS showing a single incentive payment per practitioner.   250.14 - Payment of Licensed Clinical Social Workers (LCSWs),  Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) in a Method II CAH  (Rev. 12477; Issued:01- 25-24; Effective: 01 -01-24; Implementation:02- 26-24)
(Medicare Claims Processing Manual)
The services of a LCSW, MFT or MHC that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is billed on type of bill 85X with revenue code (RC) 96X, 97X, and/or 98X.  In addition, the LCSW services requires an AJ modifier and the MFT or MHC must be enrolled as a MFT or MHC specialty. Under Section 1834(g)(2)(B) of the Act, outpatient professional services performed in a Method II CAH are paid 115 percent of such amounts as would otherwise be paid under the Act if the services were not included in the outpatient CAH services.   The Medicare payment for services performed by a LCSW, MFT or MHC shall be 80 percent of the lesser of the actual charges for the services or 75 percent of the amount determined for the payment of a psychologist.  Payment is calculated as follows:   ((Facility specific MPFS amount times the LCSW, MFT or MHC reduction (75%)) minus (deductible and coinsurance)) times 115%.   250.15 - Coding and Payment of Multiple Surgeries Performed in a Method II CAH  (Rev. 2333, Issued: 10- 28-11, Effective: 04 -01-12, Implementation: 04- 02-12)  Multiple surgeries rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedures are eligible and billed on type of bill 85x with revenue code (RC) 096x, 097x and/or 098x.   Multiple surgeries are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co -surgeons, surgical teams, or assistants- at-surgery may participate in performing multiple surgeries on the same patient on the same day.
(Medicare Claims Processing Manual)
Medicare pays for multiple surgeries by ranking from the highest MPFS amount to the lowest MPFS amount. When the same physician performs more than one surgical service at the same session, the allowed amount is 100% for the surgical code with the highest MPFS amount. The allowed amount for the subsequent surgical codes is based on 50% of the MPFS amount.  In addition, special endoscopic pricing rules are applied prior to the multiple surgery rules, if applicable. CAH Method II providers may review the multi ple surgery and special endoscopic pricing rules in Pub. 100- 04, Chapter 12, Section 40.6.  In addition, section 40.6.D addresses rare situations where the above payment rules may be bypassed using modifier 22. Providers shall be aware that CAH claims billed with Modifier 22 may be subject to medical review .  250.16 - Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Imaging Procedures Rendered by Physicians  (Rev. 3578, Issued:  08- 05 Effective:  01 -01-17, Implementation:  01- 03-17)  Diagnostic imaging procedures rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedures are eligible and billed on type of bill 85x with revenue code (RC) 096x, 097x and/or 098x.   The MPPR on diagnostic imaging applies when multiple services are furnished by the same physician to the same patient in the same session on the same day. Full payment is made for each service with the highest payment under the MPFS.  Effective for dates of services on or after January 1, 2012, payment is made at 75 percent for each subsequent service; and effective for dates of services on or after January 1, 2017, payment is made at 95 percent for each subsequent service.   250.17  - Payment of Global Surgical Split Care in a Method II CAH Submitted with Modifier 54 and/or 55  (Rev. 2574, Issued: 10- 26-12 , Effective:01 -01-13 , Implementation:01- 07-13)
(Medicare Claims Processing Manual)
Global surgical procedures rendered by a physician that has reassigned their billing rights to a CAH Method II provider is payable by Medicare only when billed on an 85x type of bill (TOB) with revenue code (RC) 096x, 97x, and/or 98x and modifier 54 (surgi cal care only) and/or 55 (postoperative management only).   There are occasions when more than one physician provides services included in the global surgical period, i.e., when the physician who performs the surgical procedure does not furnish the follow -up care. If this occurs, payment for the postoperative or post -discharge care should be split between the physicians when they agree on the transfer of care.   When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provides all services (except where stated policies, e.g., the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative care, result in payment that is higher than the global allowed amount).   CAH Method II providers may review the Global Surgical pricing rules in Pub. 100- 04, Chapter 12, sections 40.1 -40.5.  260 - Outpatient Partial Hospitalization Services  (Rev. 1, 10- 03-03)  A3-3661, A -01-93  Medicare Part B coverage is available for outpatient partial hospitalization services provided by hospitals, CAHs, and CMHCs.  260.1 - Special Partial Hospitalization Billing Requirements for Hospitals, Community Mental Health Centers, and Critical Access Hospitals  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01 -02-24)   Medicare Part B coverage is available for hospital outpatient partial hospitalization services.    A. Billing Requirement
(Medicare Claims Processing Manual)
Medicare Part B coverage is available for hospital outpatient partial hospitalization services.    A. Billing Requirement     Section 1861 ( http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm)  of the Act defines the services under the partial hospitalization benefit in a hospital.   Section 1866(e)(2) of the Act (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm) recognizes CMHCs as providers of services but only for furnishing partial hospitalization or intensive outpatient services.  See 261.1.1 of this chapter for CMHC partial hospitalization bill review directions.    Hospitals and CAHs report condition code 41 in FLs 18- 28 (or electronic equivalent) to indicate the claim is for partial hospitalization services.  They must also report a revenue code and the charge for each individual covered service furnished.  In addit ion, hospital outpatient departments are required to report HCPCS codes.  CAHs are not required to report HCPCS code for this benefit.    Under component billing, hospitals are required to report a revenue code and the charge for each individual covered service furnished under a partial hospitalization program.  In addition, hospital outpatient departments are required to report HCPCS codes.   Component billing assures that only those partial hospitalization services covered under 1861(ff) of the Act are paid by the Medicare program.    Effective January 1, 2017, non- excepted off -campus provider -based departments of a hospital are required to report a PN modifier on each claim line for non- excepted items and services.  The use of modifier PN will trigger a payment rate under the Medicare Physician Fee Schedule.  We expect the PN modifier to be reported with each nonexcepted item and service including those for which payment will not be adjusted, such as separately payable drugs, clinical labor atory tests, and therapy services.     Excepted off -campus provider -based departments of a hospital must continue to report existing modifier PO (Services, procedures and/or surgeries provided at off -campus provider -based outpatient departments) for all excepted items and services furnished. Use of the off -campus PBD modifier became mandatory beginning January 1, 2016.
(Medicare Claims Processing Manual)
All hospitals are required to report condition code 41 in FLs 18- 28 to indicate the claim is for partial hospitalization services.  Hospitals use bill type 13X and CAHs use bill type 85X.  The following special procedures apply.    Bills must contain an acceptable revenue code.  They are as follows:    Revenue Code Description   0250  Drugs and Biologicals   043X  Occupational Therapy   0900  Behavioral Health Treatment/Services   0904  Activity Therapy  0910  Psychiatric/Psychological Services (Dates of Service prior to October 16, 2003)   0914  Individual Therapy   0915  Group Therapy   0916  Family Therapy   0918  Behavioral Health/Testing   0942  Education/Training    Hospitals other than CAHs are also required to report appropriate HCPCS codes as follows:    Revenue Code  Descripon  HCPCS Code  043X  Occupaonal Therapy  *G0129 (PHP/IOP)  0900  Behavioral Health  Treatment/Services  ****90791 or ***** 90792, 97153, 97154, 97155, 97156, 97157, 97158  0904  Acvity Therapy   **G0176 (PHP/IOP)  0914  Individual Psychotherapy  90785, 90832, 90833, 90834,  90836, 90837, 90838, 90839, 90840, 90845, 90880, 90899   0915  Group Therapy  G0410, G0411, 90853   0916  Family Psychotherapy  90846, 90847, 90849  0918   Behavioral Health/Tesng  96112, 96116, 96130, 96131, 96132, 96133, 96136, 96137, 96138,  96139, 96146, 96156, 96158, 96161, 96164, 96167, 97151, 97152  0942  Educaon/Training  G0023, G0024, G0140, G0146, ***G0177, G0451, 96202, 96203, 97550, 97551, 97552
(Medicare Claims Processing Manual)
The A/B MAC (A) will edit to assure that HCPCS are present when the above revenue codes are billed and that they are valid HCPCS codes.  The A/B MAC (A) will not edit for matching the revenue code to HCPCS.    *The definition of code G0129 is as follows:    Occupational therapy services requiring skills of a qualified occupational therapist, furnished as a component of a partial hospitalization or intensive outpatient treatment program, per session (45 minutes or more).    **The definition of code G0176 is as follows:    Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patients disabling mental problems, per session (45 minutes or more).    ***The definition of code G0177 is as follows:    Training and educational services related to the care and treatment of patients disabling mental health problems, per session (45 minutes or more).    ****The definition of code 90791 is as follows:    Psychiatric diagnostic evaluation (no medical services) completed by a non -physician.    *****The definition of code 90792 is as follows:    Psychiatric diagnostic evaluation (with medical services) completed by a physician.    Codes G0129 and G0176 are used only for intensive outpatient programs or partial hospitalization programs.    Code G0177 may be used in intensive outpatient programs, partial hospitalization programs, and outpatient mental health settings.    Revenue code 0250 does not require HCPCS coding.  However, Medicare does not cover drugs that can be self -administered.    Edit to assure that HCPCS are present when the above revenue codes are billed and that they are valid HCPCS codes.  Do not edit for the matching of revenue code to HCPCS.    B. Professional Services
(Medicare Claims Processing Manual)
Edit to assure that HCPCS are present when the above revenue codes are billed and that they are valid HCPCS codes.  Do not edit for the matching of revenue code to HCPCS.    B. Professional Services     The professional services listed below when provided in all hospital outpatient departments are separately covered and paid as the professional services of physicians and other practitioners.  These professional services are unbundled and these practitione rs (other than physician assistants (PA) bill the Medicare A/B MAC (B) directly for the professional services furnished to hospital outpatient partial hospitalization patients.  The hospital can also serve as a billing agent for these professionals by bill ing the A/B MAC (B) on their behalf under their billing number for their professional services.  The professional services of a PA can be billed to the A/B MAC (B) only by the PA's employer.  The employer of a PA may be such entities or individuals as a physician, medical group, professional corporation, hospital, SNF, or nursing facility.  For example, if a physician is the employer of the PA and the PA renders services in the hospital, the physician and not the hospital would be responsible for billing the A/B MAC (B) on Form CMS -1500 for the services of the PA.  The following direct professional services are unbundled and not paid as partial hospitalization services.     Physician services that meet the criteria of 42 CFR 415.102, for payment on a fee schedule basis;     Physician assistant (PA) services as defined in 1861(s)(2)(K)(i) of the Act;     Nurse practitioner and clinical nurse specialist services, as defined in  1861(s)(2)(K)(ii) of the Act; and     Clinical psychologist services as defined in 1861(ii) of the Act.    The services of other practitioners (including clinical social workers, marriage and family therapists, mental health counselors, and occupational therapists), are bundled when furnished to hospital patients, including partial hospitalization patients.  The hospital must bill the contractor for such nonphysician practitioner services as partial hospitalization services.  Make payment for the services to the hospital.    C. Outpatient Mental Health Treatment Limitation
(Medicare Claims Processing Manual)
C. Outpatient Mental Health Treatment Limitation     The outpatient mental health treatment limitation may apply to services to treat mental, psychoneurotic, and personality disorders when furnished by physicians, clinical psychologists, NPs, CNSs, and PAs to partial hospitalization patients.  However, the outpatient mental health treatment limitation does not  apply to such mental health treatment services billed to the A/B MAC (A) by a CMHC or hospital outpatient department as partial hospitalization services.    D. Reporting of Service Units     Hospitals report the number of times the service or procedure, as defined by the HCPCS code, was performed. CAHs report the number of times the revenue code visit was performed.    NOTE : Service units are not required to be reported for drugs and biologicals (Revenue Code 0250).    E. Line Item Date of Service Reporting     Hospitals other than CAHs are required to report line item dates of service per revenue code line for partial hospitalization claims.  This means each service (revenue code) provided must be repeated on a separate line item along with the specific date the  service was provided for every occurrence.  Line item dates of service are reported in FL 45 Service Date (MMDDYY).  See 260.5 for a detailed explanation.    F. Payment    Starting in CY 2024 and subsequent years, the payment structure for partial hospitalization services provided in hospital outpatient departments and CMHCs has been set to four (4) separate APCs: Community Mental Health Center PHP APCs 5853 (Level 1 Partial Hospitalization Program (up to 3 services)) and 5854 (Level 2 Partial Hospitalization Program (4 or more services)) and Hospital -based PHP APCs 5863 (Level 1 Partial Hospitalization Program (up to 3 services)) and 5864 (Level 2 Partial Hospitalization Pro gram (4 or more services)).   The following chart displays the CMHC and hospital -based PHP APCs:    Hospital -Based and Community Mental Health Center PHP APCs    CY 2024  APC  Group Title  5853  Paral Hospitalizaon (3 or fewer services per day) for CMHCs   5854  Paral Hospitalizaon (4 or more services per day) for CMHCs  5863  Paral Hospitalizaon (3 or fewer services per day) for hospital -based PHPs  5864  Paral Hospitalizaon (4 or more services per day) for hospital -based PHPs
(Medicare Claims Processing Manual)
Apply Part B deductible, if any, and coinsurance.    G. Data for CWF and PS&R     Include revenue codes, HCPCS/CPT codes, units, and covered charges in the financial data section (fields 65a -  65j), as appropriate.  Report the billed charges in field 65h, "Charges," of the CWF record.    Include in the financial data portion of the PS&R UNIBILL, revenue codes, HCPCS/CPT codes, units, and charges, as appropriate.    Future updates will be issued in a Recurring Update Notification.   260.1.1 - Bill Review for Partial Hospitalization Services Provided in Community Mental Health Centers (CMHC)  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01 -02-24)    A. General    Medicare Part B coverage for partial hospitalization services provided by CMHCs is available effective for services provided on or after October 1, 1991.    B. Special Requirements    Section  1866(e)(2) (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm)  of the Act recognizes CMHCs as providers of services but only for furnishing partial hospitalization or intensive outpatient services.  Applicable provider ranges are 1400- 1499, 4600- 4799, and 4900- 4999.    C. Billing Requirements    The CMHCs bill for partial hospitalization services under bill type 76X.  CMHCs are required to report condition code 41 in FLs 18- 28 to indicate the claim is for partial hospitalization program services. The A/B MACs (A) follow bill review instructions in chapter 25 of this manual, except for those listed below.    The acceptable revenue codes are as follows:    Revenue  Code  Descripon  0250  Drugs and Biologicals  043X  Occupaonal Therapy  0900  Behavioral Health Treatments/Services  0904  Acvity Therapy  0910  Psychiatric/Psychological Services (Dates of Service prior to  October 16, 2003)  0914  Individual Therapy  0915  Group Therapy  0916  Family Therapy  0918  Behavioral Health/Tesng  0942  Educaon/Training    The CMHCs are also required to report appropriate HCPCS codes as follows: