evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
CPT/  HCPCS  Code  CPT Consumer Friendly Code Descriptions and PT  Allowed Units  OT  Allowed Units  SLP  Allowed Units  Physician/ NPP Not    Claim Line Outlier/Edit Details  Under Therapy POC  92521  Evaluation of speech fluency  0 0 1 NA 92522  Evaluation of speech sound production  0 0 1 NA 92523  Evaluation of speech sound production with evaluation of language comprehension and expression  0 0 1 NA 92524  Behavioral and qualitative analysis of voice and resonance  0 0 1 NA 92597  Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech  0 0 1 NA 92607  Evaluation of patient with prescription of speech-generating and alternative communication device  0 0 1 NA 92611  Fluoroscopic and video recorded motion evaluation of swallowing function  0 1 1 1 92612  Evaluation and recording of swallowing using an endoscope Evaluation and recording of swallowing using an endoscope  0 1 1 1 92614  Evaluation and recording of voice box sensory function using an endoscope  0 1 1 1 92616  Evaluation and recording of swallowing and voice box sensory function using an endoscope  0 1 1 1 95833  Manual muscle testing of whole body  1 1 0 1 95834  Manual muscle testing of whole body including hands  1 1 0 1 96110  Developmental screening  1 1 1 1   96111  Developmental testing  1 1 1 1 97161  Evaluation of physical therapy, typically 20 minutes  1 0 0 NA 97162  Evaluation of physical therapy, typically 30 minutes  1 0 0 NA 97163  Evaluation of physical therapy, typically 45 minutes   1 0 0 NA 97164  Re-evaluation of physical therapy, typically 20 minutes  1 0 0 NA 97165  Evaluation of occupational therapy, typically 30 minutes  0 1 0 NA 97166  Evaluation of occupational therapy, typically 45 minutes  0 1 0 NA 97167  Evaluation of occupational therapy, typically 60 minutes  0 1 0 NA 97168  Re-evaluation of occupational therapy established plan of care, typically 30 minutes  0 1 0 NA  20.3 -  Determining What Time Counts Towards 15- Minute Timed Codes -  All Claims  (Rev. 1, 10- 01-03)
(Medicare Claims Processing Manual)
20.3 -  Determining What Time Counts Towards 15- Minute Timed Codes -  All Claims  (Rev. 1, 10- 01-03)  Providers report the code for the time actually spent in the delivery of the modality requiring constant attendance and therapy services.  Pre-  and post -delivery services are not to be counted in determining the treatment service time.  In other words, the  time counted as intra -service care begins when the therapist or physician (or an assistant under the supervision of a physician or therapist) is directly working with the patient to deliver treatment services.  The patient should already be in the treat ment area (e.g., on the treatment table or mat or in the gym) and prepared to begin treatment.   The time counted is the time the patient is treated.  For example, if gait training in a patient with a recent stroke requires both a therapist and an assistant , or even two therapists, to manage in the parallel bars, each 15 minutes the patient is being treated can count as only one unit of code 97116.  The time the patient spends not being treated because of the need for toileting or resting should not be bille d.  In addition, the time   spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time.   20.4 -  Coding Guidance for Certain CPT Codes -  All Claims  (Rev. 3475, Issued: 03- 04-16, Effective: 06- 06-16, Implementation: 06 -06-16)  The following provides guidance about the use of codes 96105, 97026, 97150, 97545, 97546, and G0128.    CPT Codes 96105, 97545, and 97546.
(Medicare Claims Processing Manual)
 CPT Codes 96105, 97545, and 97546.  Providers report code 96105, assessment of aphasia with interpretation and report in 1-hour units.  This code represents formal evaluation of aphasia with an instrument such as the Boston Diagnostic Aphasia Examination.  If this formal assessment is performed during treatment, it is typically performed only once during treatment and its medical necessity should be documented.  If the test is repeated during treatment, the medical necessity of the repeat administration of the test must also be documented.  It is common practice for regular assessment of a patients progress in therapy to be documented in the chart, and this may be done using test items taken from the formal examinations.  This is considered to be part of the treatment and should not be billed as 96105 unless a full, formal assessment is completed.   Other timed physical medicine cod es are 97545 and 97546.  The interval for code 97545 is 2 hours and for code 97546, 1 hour.  These are specialized codes to be used in the context of rehabilitating a worker to return to a job.  The expectation is that the entire time period specified in the codes 97545 or 97546 would be the treatment period, since a shorter period of treatment could be coded with another code such as codes 97110, 97112, or 97537.  (Codes 97545 and 97546 were developed for reporting services to persons in the workers compensation program, thus CMS does not expect to see them reported for Medicare patients except under very unusual circumstances.  Further, CMS would not expect to see code 97546 without also seeing code 97545 on the same claim.  Code 97546, when used, is use d in conjunction with 97545.)    CPT Code 97026
(Medicare Claims Processing Manual)
 CPT Code 97026  Effective for services performed on or after October 24, 2006, the Centers for Medicare & Medicaid Services announce a NCD stating the use of infrared and/or near -infrared light and/or heat, including monochromatic infrared energy (MIRE), is non -covered for the treatment, including symptoms such as pain arising from these conditions, of diabetic and/or non- diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues in Me dicare beneficiaries.  Further coverage guidelines can be found in the National Coverage Determination Manual (Pub. 100- 03), section 270.6.  Contractors shall deny claims with CPT 97026 (infrared therapy incident to or as a PT/OT benefit) and HCPCS E0221 or A4639, if the claim contains any of the following diagnosis codes:     ICD- 9-CM  250.60 -  250.63  354.4, 354.5, 354.9  355.1 -  355.4  355.6 -  355.9  356.0, 356.2- 356.4, 356.8- 356.9  357.0 -  357.7  674.10, 674.12, 674.14, 674.20, 674.22, 674.24  707.00 - 707.07, 707.09- 707.15, 707.19  870.0 -  879.9  880.00 -  887.7  890.0 -  897.7  998.31 -  998.32  ICD- 10-CM  See Addendum A Chapter 5, Section 20.4 (at end of this chapter) for the list of ICD 10 -CM diagnosis codes that require denial with the above HCPCD codes.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 50  RARC: N/A  MSN: 21.11  Advanced Beneficiary Notice (ABN):   Physicians, physical therapists, occupational therapists, outpatient r ehabilitation facilities (ORFs), comprehensive outpatient rehabilitation facilities (CORFs), home health
(Medicare Claims Processing Manual)
Physicians, physical therapists, occupational therapists, outpatient r ehabilitation facilities (ORFs), comprehensive outpatient rehabilitation facilities (CORFs), home health   agencies (HHA), and hospital outpatient departments are liable if the service is performed, unless the beneficiary signs an ABN.   Similarly, DME suppliers and HHA are liable for the devices when they are supplied, unless the beneficiary signs an ABN.   20.5 - CORF/OPT Edit for Billing Inappropriate Supplies  (Rev. 319, Issued: 10- 22-04, Effective: 07- 01-01, Implementation: 04- 04-05)  Supplies furnished by CORFs/OPTs are considered part of the practice expense. Under the Medicare Physician Fee Schedule (MPFS) these expenses are already taken into account in the practice expense relative values.  Therefore, CORFs/OPTs should not bill for the supplies they fur nish except for the splint and cast, level II HCPCS Q codes associated with the level I HCPCS in the 29000 series.  The shared system maintainer will return to CORFs/OPTs any claims that they receive that contain a supply revenue code 270 without the splint and cast Level II HCPCS Q codes and the related Level I applicable HCPCS codes in the 29000 series.   The appropriate Level II HCPCS Q codes to be used are Q4001 thru Q4049.  The appropriate Level I HCPCS codes associated with the Level II HCPCS Q  codes are 29000 thru 29085; 29105 thru 29131; and 29305 thru 29515.  30 - Special Claims Processing Rules for Outpatient Rehabilitation Claims - Form CMS -1500 (Rev. 1, 10- 01-03)  Rules for completing a Form CMS -1500 and electronic formats are in Chapter 26.  Instructions in 10.1, 20.1, 20.2, 20.3 and 20.4 above also apply.   30.1 -  Determining Payment Amounts  (Rev. 1, 10- 01-03)  A/B MACs (B)  use the MPFS to determine payment for outpatient rehabilitation services.  Payment rules are the same as those for other services paid on the MPFS.   Assignment is mandatory.
(Medicare Claims Processing Manual)
A/B MACs (B)  use the MPFS to determine payment for outpatient rehabilitation services.  Payment rules are the same as those for other services paid on the MPFS.   Assignment is mandatory.   See chapter 23, for a description of the MPFS.  30.2 -  Applicable A/B MAC (B)  CWF Type of Service Codes  (Rev. 1, 10- 01-03)  The A/B MAC (B) assigns the type of service code before submitting the claim record to CWF.     U = Occupational therapy  W= Physical therapy   40 - Special Claims Processing Rules for Institutional Outpatient Rehabilitation Claims  (Rev. 1921, Issued: 02- 19-10, Effective: 04- 01-10, Implementation: 04- 05-10)  40.1 -  Determining Payment Amounts  Institutional Claims  (Rev. 3367 Issued: 10- 07-15, Effective: 01 -01-16, Implementation: 01- 04-16)  Institutional outpatient rehabilitation claims are paid under the Medicare Physician Fee Schedule (MPFS), except for claims from CAHs and hospitals in Maryland.  Medicare contractors should see 100.2 for details on obtaining the correct fee amounts.  40.2 - Applicable Types of Bill  (Rev. 2736, Issued: 06 -28-13, Effective: 10 -01-12, Implementation: 10- 07-13)  The appropriate types of bill for submitting outpatient rehabili tation services are: 12X, 13X, 22X, 23X, 34X, 74X, 75X, and 85X.   40.3 - Applicable Revenue Codes  (Rev. 2044, Issued: 09- 03-10, Effective: 09- 30-10, Implementation: 09- 30-10)  The appropriate revenue codes for reporting outpatient rehabilitation services are   0420 -  Physical Therapy Services  0430 -  Occupational Therapy Services  0440  Speech -language pathology services   The general classification of revenue codes is all that is needed for billing.  If, however, providers choose to use more specific revenue code classifications, the A/B MAC (A) should accept them.  Reporting of services is not limited to specific revenue c odes; e.g., services other than therapy may be included on the same claim.
(Medicare Claims Processing Manual)
Many therapy services may be provided by both physical and occupational therapists.  Other services may be delivered by either occupational therapists or speech -language pathologis ts.  Therefore, providers report outpatient rehabilitation HCPCS codes in conjunction with the appropriate outpatient rehabilitation revenue code based on the type of therapist who delivered the service, or, if a therapist does not deliver the service, the n on the type of therapy under the plan of care (POC) for which the service is delivered.   40.4 -  Edit Requirements for Revenue Codes  (Rev. 1921, Issued: 02- 19-10, Effective: 04- 01-10, Implementation: 04- 05-10)    Medicare contractors edit to assure the pres ence of a HCPCS code when revenue codes 0420, 0430, 0440, or 0470 are reported.  However, Medicare contractors do not edit the matching of revenue code to certain HCPCS codes or edit to limit provider reporting to only those HCPCS listed in section 20.  40.5 -  Line Item Date of Service Reporting  (Rev. 2044, Issued: 09- 03-10, Effective: 09- 30-10, Implementation: 09- 30-10)  Providers are required to report line item dates of service per revenue code line for outpatient rehabilitation services.  CORFs are also  required to report their full range of CORF services by line item date of service.  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.   Contr actors will return claims that span two or more dates if a line item date of service is not entered for each HCPCS reported.  Line item date of service reporting became effective for claims with dates of service on or after October 1, 1998.   Services that do not require line item date of service reporting may be reported before or after those services that require line item reporting.   40.6 - Non-covered Charge Reporting  (Rev. 1921, Issued: 02- 19-10, Effective: 04- 01-10, Implementation: 04- 05-10)
(Medicare Claims Processing Manual)
40.6 - Non-covered Charge Reporting  (Rev. 1921, Issued: 02- 19-10, Effective: 04- 01-10, Implementation: 04- 05-10)  Institutional outpatient therapy claims may report non- covered charges when appropriate according to the instructions provided in of this manual. Outpatient therapies billed as non-covered charges are not counted toward the financial limitation described above, when that limitation is in effect, unless the charges are subject to review after they are submitted and found to be covered by Medicare.  Modifiers associated with non- covered charges that are presented in Chapter 1, section 60 can be used on claim lines for  therapy services, in addition to the use of modifiers -GN, - GO and - GP.  40.7 - Billing for Biofeedback Training for the Treatment of Urinary Incontinence  (Rev. 2736, Issued: 06 -28-13, Effective: 10 -01-12, Implementation: 10- 07-13)  Medicare covered biofeedback training for the treatment of urinary incontinence may be provided by physical therapists in facility settings. For information regarding the coverage of this service, see the Medicare National Coverage Determinations Manual, Chapter 1, Section 30.1.1. Medicare pays for this service under the Medicare Physician Fee Schedule.   Providers bill this service on one of the types of bill listed in section 40.2 using revenue code 042X and one of the following HCPCS codes:    90901 -  Biofeedback training by any modality      90911 -  Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry   40.8  Rebilling Therapy Services for Hospital Inpatients  (Rev. 2868, Issued: 02- 06-14, Effective: 07 -01-14, Implementation: 0 7-07-14)
(Medicare Claims Processing Manual)
40.8  Rebilling Therapy Services for Hospital Inpatients  (Rev. 2868, Issued: 02- 06-14, Effective: 07 -01-14, Implementation: 0 7-07-14)  If a beneficiary receives therapy services during an inpatient hospital stay which was denied because the stay was not medically necessary, the therapy services may be rebilled under Medicare Part B coverage.  If the therapy would have been reasonable and necessary as hospital outpatient services, and provided the beneficiary has Part B entitlement, the services can be billed using Type of Bill 012x.  All payment and billing requirements for outpatient therapy (including therapy caps, functional r eporting and other instructions in this chapter) apply to these claims.  50 - CWF and PS&R Requirements - A/B MAC (A)  (Rev. 2044, Issued: 09- 03-10, Effective: 09- 30-10, Implementation: 09- 30-10)  The A/B MAC (A)  reports the procedure codes in the financial  data section (field 65a -65j) of the PS&R record.  It includes revenue code, HCPCS, units, and covered charges in the record.  Where more than one HCPCS procedure is applicable to a single revenue code, the provider reports each HCPCS and related charge on a separate line.  The A/B MAC (A)  reports the payment amount before adjustment for beneficiary liability in field 65g Rate and the actual charge in field 65h Covered Charges.  The PS&R system includes outpatient rehabilitation, and CORF services liste d in subsections E and F on a separate report from cost based payments.  See the PS&R guidelines for specific information.  100 - Special Rules for Comprehensive Outpatient Rehabilitation Facilities (CORFs)  (Rev. 1, 10- 01-03)  100.1 -  General  (Rev. 3220, Issued: 03 -16-15, Effective: ICD -10: Upon Implementation of ICD -10, ASC- X12: 01- 01-12, Implementation: 10- 01-14, ICD -10: Upon Implementation of ICD- 10 ASC X12: 09 -16-14)
(Medicare Claims Processing Manual)
The Omnibus Reconciliation Act of 1980 (Public Law 96- 499, Section 933) defines CORFs  (Comprehensive Outpatient Rehabilitation Facilities) as a distinct type of Medicare provider and adds CORF services as a benefit under Medicare Part B.  The Balance Budget Act (P.L.105 -33) requires payment under a prospective system for all CORF services.   See C hapter 1, for the policy on A/B MAC (A)  designations governing CORFs.    See the Medicare Benefit Policy Manual, C hapter 12, for a description of covered CORF services.   Physicians diagnostic and therapeutic services furnished to a CORF patient are n ot considered CORF physicians services.  The physician must bill the area A/B MAC (B) for these services.  If they are covered, the A/B MAC (B) reimburses them via the MPFS.   However, other services are considered CORF services to be billed by the CORF to  the A/B MAC (A), and are also considered included in the fee amount under the MPFS.  These services include such services as administrative services provided by the physician associated with the CORF, examinations for the purpose of establishing and revie wing the plan of care, consultation with and medical supervision of nonphysician staff, team conferences, case reviews, and other facility staff medical and facility administration activities relating to the services described in Medicare Benefit Policy Manual, chapter 12.  Related supplies are also included in the MPFS fee amount.   The CORFs bill Medicare with the ASC X12 837 institutional claim or Form CMS -1450 using HCPCS codes and Revenue Codes.  Usually the zero level revenue code is used.  Payment is based on the HCPCS code and related MPFS amount.  Requirements in 10 -  50 apply to CORF billing.  In addition the following requirements apply.   100.1.1 - Allowable Revenue Codes on CORF 75X Bill Types (Rev. 2736, Issued: 06- 28-13, Effective: 10- 01-12, Implementation: 10- 07-13)  Effective October 1, 2012, the following revenue codes are allowable for reporting CORF services on 75X bill types:   0270  0274  0279  029X  0412  0419  042X  0410  044X  0550  0559  043X  0636  0771  0911  0569  0942
(Medicare Claims Processing Manual)
0270  0274  0279  029X  0412  0419  042X  0410  044X  0550  0559  043X  0636  0771  0911  0569  0942      NOTE:   Billed revenue codes not listed in the above list will be returned to the provider by Medicare systems.  See Chapter 25, Completing and Processing the CMS -1450 Data Set, for revenue code descriptions.  100.2 -  Obtaining Fee Schedule Amounts  (Rev. 1, 10- 01-03)  The CMS furnishes A/B MACs (A) with an annual therapy abstract file and a CORF supplemental file through the Medicare Telecommunications System.  The CMS notifies A/B MACs (A) when new files are availab le.  A/B MACs (A)  are responsible for informing CORFs of new fee schedule amounts.    Payment is calculated at 80 percent of the allowed charge after deductible is met.  The allowed charge is the lower of billed charges or the fee schedule amount.  Unmet deductible is subtracted from the allowed charge, and payment is calculated at 80 percent of the result.   EXAMPLE:   $120 Provider charge;  $100 MPFS amount. Payment is 80 percent of the lower of the actual charge or fee schedule amount, which in this case is $80.00.  ($100.00 (MPFS) X 80 percent.)   The remaining 20 percent or $20 is the patient s coinsurance liability.   These codes are updated as needed by CMS.   If the A/B MAC (A) receives a claim for a Medicare covered CORF service with dates of service on or  after July 1, 2000, that does not appear on its fee schedule abstract file, it has two options for obtaining pricing information:   1. It is provided with a therapy abstract file or CORF supplemental file that contains all therapy services and their related prices.  This supplemental file contains approximately a million records, and may be used as a resource to extract pricing data as needed.  The data in the supplemental file is in the same format as the MPFS abstract file in exhibit 1, but the fields defin ing the fee and outpatient hospital indicators are not populated, instead they are space -filled.
(Medicare Claims Processing Manual)
2. It can contact the local A/B MAC (B)  to obtain the price.  When requesting the pricing data, it advises the A/B MAC (B)  to provide the nonfacility  fee from the MPFS.  The MPFS supplemental file of physician fee schedule services is available for retrieval through CMS Mainframe Telecommunications System.  The A/B MAC (A)  is notified yearly of the file retrieval names and dates by a program memorandum or other communication.  100.3 - Proper Reporting of Nursing Services by CORFs - A/B MAC (A)  (Rev. 1459; Issued:  02- 22-08; Effective:  07- 01-08; Implementation:  07 -07-08)  Nursing services performed in the CORF shall be billed utilizing the following H CPCS code:   G0128  Direct (Face to Face w/ patient) skilled nursing services of a registered nurse provided in a CORF, each 10 minutes beyond the first 5 minutes.  In addition, HCPCS G0128 is billable with revenue codes 0550 and 0559 only.     100.4 - Outpatient Mental Health Treatment Limitation  (Rev. 2736, Issued: 06- 28-13, Effective: 10- 01-12, Implementation: 10- 07-13)  The Outpatient Mental Health Treatment Limitation (the limitation) is not applicable to CORF services because CORFs do not provide service s to treat mental, psychoneurotic and personality disorders that are subject to the limitation in section 1833(c) of the Act.  For dates of service on or after October 1, 2012, HCPCS code G0409 is the only code allowed for social work and psychological ser vices furnished in a CORF.  This service is not subject to the limitation because it is not a psychiatric mental health treatment service.   For additional information on the limitation, see Publication 100- 01, Chapter 3, section 30 and Publication 100- 02, Chapter 12, sections 50- 50.5.  100.5 -  Off-Site CORF Services  (Rev. 3220, Issued: 03- 16-15, Effective: ICD -10: Upon Implementation of ICD -10, ASC- X12: 01- 01-12, Implementation: 10- 01-14, ICD -10: Upon Implementation of ICD- 10 ASC X12: 09 -16-14)