evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
In situations where a CAH has elected payment Method II for CAH outpatients, and the practitioner has reassigned his/her benefits to the CAH, CAHs submit the appropriate HCPCS procedure code for the covered telehealth services with the GT modifier, and A/B/MACs (A) should make payment for telehealth services provided by the physician or practitioner at 80 percent of the MPFS facility amount for the distant site service. In all other cases, except for MNT services as discussed in Section 190.7- A/B MAC (B) E diting of Telehealth Claims, telehealth services provided by the physician or practitioner at the distant site are billed to the A/B/MAC (B).  Physicians and practitioners at the distant site bill their A/B/MAC (B) for covered telehealth services.  Physicians and practitioners offices serving as a telehealth originating site bill their A/B/MAC (B) for the originating site facility fee.   190.6.2 - Exception for Store and Forward (Noninteractive) Telehealth  (Rev. 1, 10- 01-03)  In the case of Federal telemedicine demonstration programs conducted in Alaska or Hawaii, store and forward technologies may be used as a substitute for an interactive telecommunications system. Covered store and forward telehealth services are billed with  the GQ modifier, via asynchronous telecommunications system. By using the GQ modifier, the distant site physician/practitioner certifies that the asynchronous medical file was collected and transmitted to them at their distant site from a Federal te lemedicine demonstration project conducted in Alaska or Hawaii.  190.7 - A/B MAC (B) Editing of Telehealth Claims  (Rev. 3817; Issued; 07- 28-17 Effective; 01 -01-18 Implementation: 01- 02-18)
(Medicare Claims Processing Manual)
Medicare telehealth services (as listed in section 190.3) are billed with POS 02. The contractor shall approve covered telehealth services if the physician or practitioner is licensed under State law to provide the service. Contractors must familiarize the mselves with licensure provisions of States for which they process claims and disallow telehealth services furnished by physicians or practitioners who are not authorized to furnish the applicable telehealth service under State law. For example, if a nurse  practitioner is not licensed to provide individual psychotherapy under State law, he or she would not be permitted to receive payment for individual psychotherapy under Medicare. The contractor shall install edits to ensure that only properly licensed physicians and practitioners are paid for covered telehealth services.  If a contractor receives claims for professional telehealth services coded with the GQ modifier (representing via asynchronous telecommunications system), it shall approve/pay for these services only if the physician or practitioner is affiliated with a Federal telemedicine demonstration conducted in Alaska or Hawaii. The contractor may require the physician or practitioner at the distant site to document his or her participation in a Federal telemedicine demonstration program conducted in Alaska or Haw aii prior to paying for telehealth services provided via asynchronous, store and forward technologies.  Contractors shall deny telehealth services if the physician or practitioner is not eligible to bill for them.  The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.  Group Code: CO  CARC: 185  RARC: N/A  MSN: 21.18  If a service is billed with POS 02 and the procedure code is not designated as a covered telehealth service, the contractor denies the service.  The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.  Group Code: CO  CARC: 96  RARC: N776  MSN: 9.4  The only claims from institutional facilities that FIs shall pay for telehealth services at the distant site, except for MNT services, are for physician or practitioner services when the distant site is located in a
(Medicare Claims Processing Manual)
MSN: 9.4  The only claims from institutional facilities that FIs shall pay for telehealth services at the distant site, except for MNT services, are for physician or practitioner services when the distant site is located in a CAH that has elected Method II, and the physician or practitioner has reassigned his/her benefits to the CAH. The CAH bills its regular FI for the professional services provided at the distant site via a telecommunications system, in any of the revenue codes 096x, 097x or 098x. All requirements for billing distant site telehealth services apply.  Claims from hospitals or CAHs for MNT services are submitted to the hospital's or CAH's regular FI. Payment is based on the non-facility amount on the Medicare Physician Fee Schedule for the particular HCPCS codes.
(Medicare Claims Processing Manual)
200 - Allergy Testing and Immunotherapy  (Rev.  2997, Issued: 07- 25-14, Effective: Upon implementation of ICD -10; 01- 01- 2012 -  ASC X12, Implementation: 08- 25-2014 -  ASC X12; Upon Implementation of ICD- 10)  A. Allergy Testing   The MPFSDB fee amounts for allergy testing services billed under codes 95004- 95078 are established for single tests.  Therefore, the number of tests must be shown on the claim.   EXAMPLE:  If a physician performs 25 percutaneous tests (scratch, puncture, or prick) with allergenic extract, the physician must bill code 95004 and specify 25 units. To compute payment, the Medicare A/B MAC (B) multiplies the payment for one test (i.e., the paymen t listed in the fee schedule) by the quantity listed in the units field.   B. Allergy Immunotherapy  For services rendered on or after January 1, 1995, all antigen/allergy immunotherapy services are paid for under the Medicare physician fee schedule.  Prior to that date, only the antigen injection services, i.e., only codes 95115 and 95117, were paid for under the fee schedule.  Codes representing antigens and their preparation and single codes representing both the antigens and their injection were paid for under the Medicare reasonable charge system.  A legislative change brought all of these services under the fee schedule at the beginning of 1995 and the following policies are effective as of January 1, 1995:   1. CPT codes 95120 through 95134 are not valid for Medicare.  Codes 95120 through 95134 represent complete services, i.e., services that include both the injection service as well as the antigen and its preparation.   2. Separate coding for injection only codes (i.e., codes 95115 and 95117) and/or the codes representing antigens and their preparation (i.e., codes 95144 through 95170) must be used.    If both services are provided both codes are billed.  This includes allergists who provide both services through the use of treatment boards.
(Medicare Claims Processing Manual)
If both services are provided both codes are billed.  This includes allergists who provide both services through the use of treatment boards.   3. If a physician bills both an injection code plus either codes 95165 or 95144, A/B MACs (B) pay the appropriate injection code (i.e., code 95115 or code 95117) plus the code 95165 rate.  When a provider bills for codes 95115 or 95117 plus code 95144, A/B MA Cs (B) change 95144 to 95165 and pay accordingly.  Code 95144 (single dose vials of antigen) should be billed only if the physician providing the antigen is providing it to be injected by some other entity.  Single dose vials, which should be used only as a means of insuring proper dosage amounts for injec tions, are more costly than multiple dose vials (i.e., code 95165) and therefore their payment rate is higher.  Allergists who prepare antigens are assumed to be able to administer proper doses from the l ess costly multiple dose vials.  Thus, regardless of whether they use or bill for single or multiple dose vials at the same time that they are billing for an injection service, they are paid at the multiple dose vial rate.   4. The fee schedule amounts for the antigen codes (95144 through 95170) are for a single dose.  When billing those codes, physicians are to specify the number of doses provided.  When making payment, A/B MACs (B) multiply the fee schedule amount by the number  of doses specified in the units field.
(Medicare Claims Processing Manual)
5. If a patients doses are adjusted, e.g., because of patient reaction, and the antigen provided is actually more or fewer doses than originally anticipated, the physician is to make no change in the number of doses for which he or she bills.  The number of doses anticipated at the time of the antigen preparation is the number of doses to be billed.  This is consistent with the notes on page 30 of the Spring 1994 issue of the American Medical Associations CPT Assistant.  Those notes indicate that the antigen  codes mean that the physician is to identify the number of doses prospectively planned to be provided.  The physician is to identify the number of doses scheduled when the vial is provided.  This means that in cases where the patient actually gets mor e doses than originally anticipated (because dose amounts were decreased during treatment) and in cases where the patient gets fewer doses (because dose amounts were increased), no change is to be made in the billing.  In the first case, A/B MACs (B) are not to pay more because the number of doses provided in the original vial(s) increased.  In the second case, A/B MACs (B) are not to seek recoupment (if A/B MACs (B) have already made payment) because the number of doses is less than originally planned.  This is the case for both venom and nonvenom antigen codes.
(Medicare Claims Processing Manual)
6. Venom Doses and Catch -Up Billing -  Venom doses are prepared in separate vials and not mixed together -  except in the case of the three vespid mix (white and yellow hornets and yellow jackets).  A dose of code 95146 (the two- venom code) means getting some of two venoms.  Similarly, a dose of code 95147 means getting some of three venoms; a dose of code 95148 means getting some of four venoms; and a dose of 95149 means getting some of five venoms.  Some amount of each of the venoms must be provided.  Questions arise when the administration of these venoms does not remain synchronized because of dosage adjustments due to patient reaction.  For example, a physician prepares ten doses of code 95148 (the four venom code) in two vials -  one containing 10 doses of three vespid mix and another containing 10 doses of wasp venom.  Because of dose adjustment, the three vespid mix doses last longer, i.e., they last for 15 doses.  Consequently, questions arise regarding the amount of replacement wasp venom antigen that should be prepared and how it should be billed.  Medicare pricing amounts have savings built into the use of the higher venom codes.  Therefore, if a patient is in two venom, three venom, four venom or five venom therapy, the A/B MAC (B) objective is to pay at the highest venom level possible.  This means that, to the greatest extent possible, code 95146 is to be billed for a patient in two venom therapy, code 95147 is to be billed for a patient in three venom  therapy, code 95148 is to be billed for a patient in four venom therapy, and code 95149 is to be billed for a patient in five venom therapy.  Thus, physicians are to be instructed that the venom antigen preparation, after dose adjustment, must be done in a manner that, as soon as possible, synchronizes the preparation back to the highest venom code possible.  In the above example, the physician should prepare and bill for only 5 doses of replacement wasp venom -  billing five doses of code 95145 (the one venom code).  This will permit the physician to get back to preparing the four venoms at one time and therefore billing the doses of the cheaper four venom code.  Use of a code below the venom treatment number for the particular patient should occur only  for
(Medicare Claims Processing Manual)
This will permit the physician to get back to preparing the four venoms at one time and therefore billing the doses of the cheaper four venom code.  Use of a code below the venom treatment number for the particular patient should occur only  for the purpose of catching up.
(Medicare Claims Processing Manual)
7. Code 95165 Doses . -  Code 95165 represents preparation of vials of non- venom antigens.  As in the case of venoms, some non- venom antigens cannot be mixed together, i.e., they must be prepared in separate vials.  An example of this is mold and pollen.  Therefore, some pati ents will be injected at one time from one vial -  containing in one mixture all of the appropriate antigens -  while other patients will be injected at one time from more than one vial.   In establishing the practice expense component for mixing a multidose  vial of antigens, we observed that the most common practice was to prepare a 10 cc vial; we also observed that the most common use was to remove aliquots with a volume of 1 cc.  Our PE computations were based on those facts.  Therefore, a physicians remo ving 10 1cc aliquot doses captures the entire PE component for the service.   This does not mean that the physician must remove 1 cc aliquot doses from a multidose vial.  It means that the practice expenses payable for the preparation of a 10cc vial remain the same irrespective of the size or number of aliquots removed from the vial .  Therefore, a physician may not bill this vial preparation code for more than 10 doses per vial;  paying more than 10 doses per multidose vial would significantly overpay the practice expense component attributable to this service.  (NOTE:  this code doe s not include the injection of antigen(s); injection of antigen(s) is separately billable.)   When a multidose vial contains less than 10cc, physicians should bill Medicare for the number of 1 cc aliquots that may be removed from the vial.  That is, a physician may bill Medicare up to a maximum of 10 doses per multidose vial, but should bill Medicare for fewer than 10 doses per vial when there is less than 10cc in the vial.  If it is medically necessary, physicians may bill Medicare for preparation of more than one multidose vial.  EXAMPLES:   (1) If a 10cc multidose vial is filled to 6cc with antigen, the physician may bill Medicare for 6 doses since six 1cc aliquots may be removed from the vial.
(Medicare Claims Processing Manual)
(1) If a 10cc multidose vial is filled to 6cc with antigen, the physician may bill Medicare for 6 doses since six 1cc aliquots may be removed from the vial.   (2) If a 5cc multidose vial is filled completely, the physician may bill Medicare for 5 doses for this vial.   (3) If a physician removes  cc aliquots from a 10cc multidose vial for a total of 20 doses from one vial, he/she may only bill Medicare for 10 doses.  Billing for more than 10 doses would mean that Medicare is overpaying for the practice expense of making the  vial.   (4) If a physician prepares two 10cc multidose vials, he/she may bill Medicare for 20 doses.  However, he/she may remove aliquots of any amount from those vials.  For example, the physician may remove  aliquots from one vial, and 1cc aliquots from the other vial, but may bill no more than a total of 20 doses.  (5) If a physician prepares a 20cc multidose vial, he/she may bill Medicare for 20 doses, since the practice expense is calculated based on the physicians removing 1cc aliquots from a vial.  If a physician removes 2cc aliquots from this vial, thus getting onl y 10 doses, he/she may nonetheless bill Medicare for 20 doses because the PE for 20 doses reflects the actual practice expense of preparing the vial.  (6) If a physician prepares a 5cc multidose vial, he may bill Medicare for 5 doses, based on the way that the practice expense component is calculated.  However, if the physician removes ten  cc aliquots from the vial, he/she may still bill only 5 doses because the practice expense of preparing the vial is the same, without regard to the number of additional doses that are removed from the vial.   C. Allergy Shots and Visit Services on the Same Day
(Medicare Claims Processing Manual)
C. Allergy Shots and Visit Services on the Same Day   At the outset of the physician fee schedule, the question was posed as to whether visits should be billed on the same day as an allergy injection (CPT codes 95115- 95117), since these codes have status indicators of A rather than T.  Visits should not be bi lled with allergy injection services 95115 or 95117 unless the visit represents another separately identifiable service.  This language parallels CPT editorial language that accompanies the allergen immunotherapy codes, which include codes 9515 and 95117.   Prior to January 1, 1995, you appeared to be enforcing this policy through three (3) different means:    Advising physician to use modifier 25 with the visit service;   Denying payment for the visit unless documentation has been provided; and   Paying for both the visit and the allergy shot if both are billed for.   For services rendered on or after January 1, 1995, you are to enforce the requirement that visits not be billed and paid for on the same day as an allergy injection through the following means.  Effective for services rendered on or after that date, the gl obal surgery policies will apply to all codes in the allergen immunotherapy series, including the allergy shot codes 95115 and 95117.  To accomplish this, CMS changed the global surgery indicator for allergen immunotherapy codes from XXX, which meant that the global surgery concept did not apply to those codes, to 000, which means that the global surgery concept applies, but that there are no days in the postoperative global period.    Now that the global surgery policies apply to these services, you are to rely on the use of modifier 25 as the only means through which you can make payment for visit services provided on the same day as allergen immunotherapy services.  In order for a physician to receive payment for a visit service provided on the same day that the physician also provides a service in the allergen immunotherapy series (i.e., any service in the series from 95115 through 95199), the physician is to bill a modifier 25 with t he visit code, indicating that the patients condition required a significant, separately identifiable visit service above and beyond the allergen immunotherapy service provided.
(Medicare Claims Processing Manual)
D. Reasonable Supply of Antigens   See CMS Manual System, Internet Only Manual, Medicare Benefits Policy Manual, CMS Pub. 100- 02 Chapter 15, section 50.4.4, regarding the coverage of antigens, including what constitutes a reasonable supply of antigens.  210 - Outpatient Mental Health Treatment Limitation  (Rev. 2166, Issued: 02- 25-11, Effective: 03 -25-11, Implementation: 03- 25-11)  Regardless of the actual expenses a beneficiary incurs in connection with the treatment of mental, psychoneurotic, and personality disorders while the beneficiary is not an inpatient of a hospital at the time such expenses are incurred, the amount of those  expenses that may be recognized for Part B deductible and payment purposes is limited to 62.5 percent of the Medicare approved amount for those services.  This limitation is called the outpatient mental health treatment limitation (the limitation).  The 6 2.5 percent limitation has been in place since the inception of the Medicare Part B program and it will remain effective at this percentage amount until January 1, 2010.  However, effective January 1, 2010, through January 1, 2014, the limitation will be phased out as follows:    January 1, 2010 -  December 31, 2011, the limitation percentage is 68.75%.  (Medicare pays 55% and the patient pays 45%).    January 1, 2012 -  December 31, 2012, the limitation percentage is 75%.  (Medicare pays 60% and the patient pays 40%).    January 1, 2013 -  December 31, 2013, the limitation percentage is 81.25%.  (Medicare pays 65% and the patient pays 35%).    January 1, 2014 -  onward, the limitation percentage is 100%. (Medicare pays 80% and the patient pays 20%).   For additional details concerning computation of the limitation, please see the examples under section 210.1 E.   210.1 - Application of the Limitation  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01 -02-24)    A. Status of Patient
(Medicare Claims Processing Manual)
210.1 - Application of the Limitation  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01 -02-24)    A. Status of Patient    The limitation is applicable to expenses incurred in connection with the treatment of an individual who is not an inpatient of a hospital.  Thus, the limitation applies to mental health services furnished to a person in a physicians office, in the patient s home, in a skilled nursing facility, as an outpatient, and so forth.  The term hospital in this context means an institution, which is primarily engaged in providing to inpatients, by or under the supervision of a physician(s):     Diagnostic and therapeutic services for medical diagnosis, treatment and care of injured, disabled, or sick persons;     Rehabilitation services for injured, disabled, or sick persons; or     Psychiatric services for the diagnosis and treatment of mentally ill patients.    B. Disorders Subject to the Limitation    The term mental, psychoneurotic, and personality disorders is defined as the specific psychiatric diagnoses described in the International Classification of Diseases, 9th Revision (ICD -9), under the code range 290-319.    When the treatment services rendered are both for a psychiatric diagnosis as defined in the ICD -9 and one or more nonpsychiatric conditions, separate the expenses for the psychiatric aspects of treatment from the expenses for the nonpsychiatric aspects of treatment.  However, in any case in which the psychiatric treatment component is not readily distinguishable from the nonpsychiatric treatment component, all of the expenses are allocated to whichever component constitutes the primary diagnosis.    1. Diagnosis Clearly Meets Definition -  If the primary diagnosis reported for a particular service is the same as or equivalent to a condition described in the ICD9 under the code range 290- 319 that represents mental, psychoneurotic and personality disorders, the expense for the service is subject to the limitation except as described in subsection D.    2. Diagnosis Does Not Clearly Meet Definition -  When it is not clear whether the primary diagnosis reported meets the definition of mental, psychoneurotic, and personality disorders, it may be necessary to contact the practitioner to clarify the diagnosis.  I n deciding whether contact is necessary in a given case, give consideration to such factors as the type of services rendered, the diagnosis, and the individuals previous utilization history.    C. Services Subject to the Limitation