evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
130.2 - Special Intermediary Billing and Payment Requirements  (Rev. 898, Issued:  03- 31-06; Effective/Implementation Dates:  03 -31-06)  Payment is made to hospitals for the facility costs it incurs under Part B on a reasonable cost basis.  Payment is also made to PPS -exempt hospitals for the facility costs it incurs on a reasonable cost basis.  Deductible and coinsurance apply.   Applicable bill types are 12X, 13X, 83X or 85X.   140 - Cardiac Rehabilitation (CR) Programs, Intensive Cardiac Rehabilitation (ICR) Programs, and Pulmonary Rehabilitation (PR) Programs On or After January 1, 2024 (Rev. 12497; Issued: 02- 08-24; Effective: 01 -01-24; Implementation: 03 -12-24)  Cardiac rehabilitation (CR) means a physician or nonphysician practitioner supervised program that furnishes physician prescribed exercise; cardiac risk factor modification, including education, counseling, and behavioral intervention; psychosocial assessment; and outcomes assessment. Intensive cardiac rehabilitation (ICR) progra m means a physician or nonphysician practitioner supervised program that furnishes CR and has shown, in peer -reviewed published research, that it improves patients cardiovascular disease through specific outcome measurements described in 42 CFR 410.49(c). Nonphysician practitioner means a physician assistant, nurse practitioner, or clinical nurse specialist as those terms are defined in section 1861(aa)(5)(A) of the Social Security Act (the Act).    Effective January 1, 2024, Medicare Part B pays for CR/ICR if specific criteria are met by the Medicare beneficiary, the CR/ICR program itself, the setting in which it is administered, and the physician a dministering the program.   Pulmonary rehabilitation (PR) means a physician or nonphysician practitioner supervised program for chronic obstructive pulmonary disease (COPD) and certain other chronic respiratory diseases designed to optimize physical and social performance and autonomy. Nonphysician practitioner means a physician assistant, nurse practitioner, or clinical nurse specialist as those terms are defined in section 1861(aa)(5)(A) of the Act.
(Medicare Claims Processing Manual)
Effective January 1, 2024, Medicare Part B pays for PR if specific criteria are met by the Medicare beneficiary, the PR program itself, the setting in which it is administered, and the physician administering the program, as outlined below.  140.1  CR Program Services Furnished On or Before December 31, 2009  (Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)   Medicare covers CR exercise programs for patients who meet the following criteria:    Have a documented diagnosis of acute myocardial infarction (MI) within the preceding 12 months; or   Have had coronary bypass surgery; or,   Have stable angina pectoris; or,  Have had heart valve repair/replacement; or,   Have had percutaneous transluminal coronary angioplasty (PTCA) or coronary  stenting; or,  Have had a heart or heart -lung transplant.   Effective for dates of services on or after March 22, 2006, services provided in connection with a CR exercise program may be considered reasonable and necessary for up to 36 sessions. Patients generally receive 2 to 3 sessions per week for 12 to 18 weeks. The contractor has discretion to cover CR beyond 18 weeks. Coverage must not exc eed a total of 72 sessions for 36 weeks.  CR programs shall be performed incident to physicians services in outpatient hospitals, or outpatient settings such as clinics or offices. Follow the policies for services incident to the services of a physician as they apply in each setting. For example, see Pub. 100-02, Chapter 6, 2.4.1, and Pub. 100-02, Chapter 15, 60.1. (Refer to Publication 100-03, 20.10 for further coverage guidelines.)  140.1.1 - Coding Requirements for Cardiac Rehabilitation Services Furnished On or Before Dec. 31, 2009  (Rev. 12497; Issued: 02-08- 24; Effective: 01 -01-24; Implementation: 03-12-24)  The following are the applicable Healthcare Common Procedure Coding System (HCPCS) codes:
(Medicare Claims Processing Manual)
The following are the applicable Healthcare Common Procedure Coding System (HCPCS) codes:   93797 - Physician or other qualified health care professional  services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session); and  93798 - Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session). Note: The above HCPCS descriptors are effective January 1, 2013.   Effective for dates of service on or after January 1, 2008, and before January 1, 2010, providers and practitioners may report more than one unit of CPT code 93797 or 97398 for a date of service if more than one CR session lasting at least 1 hour each is provided on the same day. In order to report more than one session for a given date of service, each session must last a minimum of 60 minutes. For example, if the CR provided on a given day total 1 hour and 50 minutes, then only one session should be billed to report the CR provided on that day.  140.2  Cardiac Rehabilitation Program Services Effective for Dates of Service On or After January 1, 2024  (Rev. 12497; Issued: 02-08- 24; Effective: 01 -01-24; Implementation: 03-12-24)  As specified at 42 CFR 410.49, Medicare Part B covers CR for beneficiaries who have experienced one or more of the following:   An acute MI within the preceding 12 months;  A coronary artery bypass surgery;  Current stable angina pectoris;  Heart valve repair or replacement;   PTCA or coronary stenting;  A heart or heart -lung transplant;  Stable, chronic heart failure defined as patients with left ventricular ejection fraction  of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks, on or after February 18, 2014; or,  Other cardiac conditions as specified through a national coverage determination (NCD).  CR must include all of the following components:
(Medicare Claims Processing Manual)
 Physician prescribed exercise each day CR items and  services are furnished.   Cardiac risk factor modification, including education, counseling, and behavioral  intervention, tailored to the individuals needs.   Psychosocial assessment.  Outcomes assessment.   An individualized treatment plan detailing how components are utilized for each  patient. The individualized treatment plan must be established, reviewed, and signed  by a physician every 30 days.  Medicare Part B pays for CR in a physicians office or a hospital outpatient setting. All settings must have a physician or nonphysician practitioner  immediately available and accessible for medical consultations and emergencies at all times when items and services are being furnished under the program. This provision is satisfied if the physician or nonphysician practitioner meets the requirements for direct supervision for physician office services, at 42 CFR 410.26, and for hospital outpatient services a t 42 CFR 410.27. Note: Nonphysician practitioners are eligible to supervise CR effective January 1, 2024.   As specified at 42 CFR 410.49(f)(1), the number of CR sessions are limited to a maximum of 2 1-hour sessions per day for up to 36 sessions over up to 36 weeks with the option for an additional 36 sessions over an extended period of time if approved by the  Medicare Administrative Contractor (MAC).   140.2.1  Coding Requirements for CR Services Furnished On or After January 1, 2010  (Rev. 12497; Issued: 02- 08-24; Effective: 01 -01-24; Implementation: 03 -12-24)  The following are the applicable Current Procedural Technology (CPT) codes for CR services:   93797 Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitoring (Per Session)   93798 Physician or other qualified care health professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (Per Session)  Note: The above HCPCS descriptors are effective January 1, 2013.
(Medicare Claims Processing Manual)
Effective for dates of service on or after January 1, 2010, hospitals and practitioners may report a maximum of 2 1 -hour sessions per day. In order to report one session of CR  in a day, the duration of treatment must be at least 31 minutes. Two sessions of CR may only be reported in the same day if the duration of treatment is at least 91 minutes. In other words, the first session would account for 60 minutes and the second session would account for at least 31 minutes if two sessions are reported. If seve ral shorter periods of CR are furnished on a given day, the minutes of service during those periods must be added together for reporting in 1-hour session increments.  Example : If the patient receives 20 minutes of CR in the day, no CR session may be reported because less than 31 minutes of services were  furnished.   Example : If a patient receives 20 minutes of CR in the morning and 35 minutes of CR in the afternoon of a single day, the hospital or practitioner would report 1 session of CR under 1 unit of the appropriate CPT code for the total duration of 55 minutes of CR on that day.  Example : If the patient receives 70 minutes of CR in the morning and 25 minutes of CR in the afternoon of a single day, the hospital or practitioner would report two sessions of CR under the appropriate CPT code(s) because the total duration of CR on that day of 95 minutes exceeds 90 minutes.  Example : If the patient receives 70 minutes of CR in the morning and 85 minutes of CR in the afternoon of a single day, the hospital or practitioner would report two sessions of CR under the appropriate CPT code(s) for the total duration of CR of 155 minutes. A m aximum of two sessions per day may be reported, regardless of the total duration of CR.  sessions after 36 (to include completed ICR sessions prior to switch). In these cases, and consistent with the information above, the - KX modifier must be included on the claim should the beneficiary participate in more than 36 CR sessions following the sw itch.
(Medicare Claims Processing Manual)
See Pub. 100- 06, Medicare Financial Management Manual, chapter 6, section 420, and Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, section 232, and Pub. 100- 08, Medicare  Program Integrity Manual, chapter 10, section 10.2.2.5 for detailed information regarding CR and ICR policy and claims processing.  140.2.2  Claims Processing Requirements for Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Services Furnished On or After January 1, 2010 (Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)  NOTE : A beneficiary may switch from an ICR program to a CR program. The beneficiary is limited to a one -time switch, multiple switches are not allowable. Once the beneficiary switches from ICR to CR he or she will be limited to the number of sessions remaining  in the program. For example, a beneficiary who switches from ICR to CR after 12 sessions will have 24 sessions of CR remaining, (i.e., 12 sessions of ICR + 24 sessions of CR = total of 36 sessions). Should a beneficiary experience more than one indica tion simultaneously, he or she may participate in a single series of CR or ICR sessions (i.e., a patient who had a MI within 12 months and currently experiences stable angina is entitled to one series of CR sessions, up to 36 1- hour sessions with contractor discretion for an additional 36 sessions; or one series of ICR sessions, up to 72 1- hour sessions over a period up to 18 weeks). Beneficiaries may not switch from CR to ICR. Upon completion of a CR or ICR program, beneficiaries must experience another in dication in order to be eligible for coverage of more CR or ICR.
(Medicare Claims Processing Manual)
Contractors shall accept the inclusion of the - KX modifier on the claim line(s) as an attestation by the provider of the service that documentation is on file verifying that further treatment beyond 36 sessions of CR up to a total of 72 sessions meets the requirements of the medical policy or, for ICR, that any further sessions beyond 72 sessions within a 126- day period counting from the date of the first session, or for any sessions provided after 126 days from the date of the first session, meet the requi rements of the medical policy. Beneficiaries who switch from ICR to CR may also be eligible for up to 72 combined sessions with contractor discretion for CR sessions after 36 (to include completed ICR sessions prior to switch). In these cases, and consiste nt with the information above, the - KX modifier must be included on the claim should the beneficiary participate in more than 36 CR sessions following the switch.  See Pub. 100- 06, Medicare Financial Management Manual, chapter 6, section 420, and Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, section 232, and Pub. 100- 08, Medicare  Program Integrity Manual, chapter 10, section 10.2.2.5 for detailed information regarding CR and ICR policy and claims processing.  140.2.2.1  Correct Place of Service (POS) Code for CR and ICR Services on Professional Claims  (Rev. 3058, Issued: 08- 29-14, Effective: 02 -18-14, Implementation: 08- 18-14)  Effective for claims with dates of service on and after January 1, 2010, place of service (POS) code 11 shall be used for CR and ICR services provided in a physicians office and POS 22 shall be used for services provided in a hospital outpatient setting.  All other POS codes shall be denied.  Contractors shall adjust their prepayment procedure edits as appropriate.   The following messages shall be used when contractors deny CR and ICR claims for POS:   Claim Adjustment Reason Code (CARC) 171  Payment is denied when performed/billed by this type of provider in this type of facility.  NOTE:   Refer to the 832 Healthcare Policy Identification Segment (loop 2110 Service payment Information REF), if present.
(Medicare Claims Processing Manual)
Remittance Advice Remark Code (RARC) N428 - Service/procedure not covered when performed in this place of service.   Medicare Summary Notice (MSN) 21.25 -  This service was denied because Medicare only covers this service in certain settings.   Group Code PR (Patient Responsibility) -  Where a claim is received with the GA modifier indicating that a signed ABN is on file.  Group Code CO (Contractor Responsibility)  Where a claim is received with the GZ modifier indicating that no signed ABN is on file.  140.2.2.2  Requirements for CR and ICR Services on Institutional Claims  (Rev. 3084, Issued: 10- 03-14, Effective: 05 -06-14, Implementation: 11- 04-14)  Effective for claims with dates of service on and after January 1, 2010, contractors shall pay for CR and ICR services when submitted on Types of Bill (TOBs) 13X and 85X only.  All other TOBs shall be denied.  The following messages shall be used when contractors deny CR and ICR claims for TOBs other than 13X and 85X:   Claim Adjustment Reason Code (CARC) 171  Payment is denied when performed/billed by this type of provider in this type of facility.  NOTE:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   Remittance Advice Remark Code (RARC) N428 - Service/procedure not covered when performed in this place of service.   Medicare Summary Notice (MSN) 21.25 -  This service was denied because Medicare only covers this service in certain settings.   Group Code PR (Patient Responsibility)  Where a claim is received with the GA modifier indicating that a signed ABN is on file.  Group Code CO (Contractor Responsibility)  Where a claim is received with the GZ modifier indicating that no signed ABN is on file.  140.2.2.3  Frequency Edits for CR and ICR Claims  (Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)   Effective for claims with dates of service on or after January 1, 2010, contractors shall deny all CR claims (both professional and institutional claims) that exceed 2 units per date of service for CR and 6 units per date of service for ICR.
(Medicare Claims Processing Manual)
Effective for claims with dates of service on or after January 1, 2010, contractors shall deny all CR claims (both professional and institutional claims) that exceed 2 units per date of service for CR and 6 units per date of service for ICR.   The following messages shall be used when contractors deny CR and ICR claims for exceeding units per date of service:   CARC 119 -  Benefit maximum for this time period or occurrence has been reached.   RARC N362 -  The number of days or units of service exceeds our acceptable maximum.  MSN 20.5 -  These services cannot be paid because your benefits are exhausted at this time.   Spanish Version -  Estos servicios no pueden ser pagados porque sus beneficios se han agotado.   Group Code PR  Where a claim is received with the GA modifier indicating that a signed ABN is on file.   Group Code CO  Where a claim is received with the GZ modifier indicating that no signed ABN is on file.   Contractors shall not research and adjust CR claims (HCPCS 93797 and 93798) paid for more than 2 units on the same date of service processed prior to the implementation of edits. However, contractors may adjust claims brought to their attention.  Contractors shall not research and adjust ICR claims (HCPCS G0422 and G0423) paid for more than 6 units on the same date of service processed prior to the implementation of edits. However, contractors may adjust claims brought to their attention.  140.2.2.4  Edits for CR Services Exceeding 36 Sessions  (Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)  Effective for claims with dates of service on or after January 1, 2010, contractors shall deny all claims with HCPCS 93797 and 93798 (both professional and institutional claims) that exceed 36 CR sessions when a - KX modifier is not included on the claim line.   The following messages shall be used when contractors deny CR claims that exceed 36 sessions, when a - KX modifier is not included on the claim line:  -CARC- ) 119  Benefit maximum for this period or occurrence has been reached.
(Medicare Claims Processing Manual)
The following messages shall be used when contractors deny CR claims that exceed 36 sessions, when a - KX modifier is not included on the claim line:  -CARC- ) 119  Benefit maximum for this period or occurrence has been reached.   RARC N435 -  Exceeds number/frequency approved/allowed within time period without support documentation. MSN 23.17-  Medicare wont cover these services because they are not considered medically necessary.   Spanish Version -  Medicare no cubrir estos servicios porque no son considerados necesarios por razones mdicas.   Group Code PR  Where a claim is received with the GA modifier indicating that a signed ABN is on file.   Group Code CO  Where a claim is received with the GZ modifier indicating that no signed ABN is on file.   Contractors shall not research and adjust CR claims paid for more than 36 sessions processed prior to the implementation of Common Working File (CWF) edits. However, contractors may adjust claims brought to their attention.   140.2.2.5  Edits for ICR Services Exceeding 126 Days and 72 Sessions  (Rev. 1974, Issued: 05- 21-10, Effective: 01 -10-10, Implementation: 10- 04-10)  Effective for claims with dates of service on and after January 1, 2010, CWF shall reject ICR claims (G0422 and G0423)  that exceed 72 sessions or where any billed sessions were provided after126 days from the date of the first session and a KX modifier is  not included on the claim line.   The following messages shall be used when contractors deny ICR claims that exceed 72 sessions or where any billed sessions were received after the 126 days from the date of the first session:   Claim Adjustment Reason Code (CARC) 119 -  Benefit maximum for this time period or occurrence has been reached.   RARC N435 -  Exceeds number/frequency approved/allowed within time period without support documentation.  MSN 20.5 -  These services cannot be paid because your benefits are exhausted at this time.   Spanish Version -  Estos servicios no pueden ser pagados porque sus beneficios se han agotado.
(Medicare Claims Processing Manual)
Spanish Version -  Estos servicios no pueden ser pagados porque sus beneficios se han agotado.   Group Code PR (Patient Responsibility)  Where a claim is received with the GA modifier indicating that a signed ABN is on file.  Group Code CO (Contractor Responsibility)  Where a claim is received with the GZ modifier indicating that no signed ABN is on file.  Contractors shall not research and adjust ICR claims paid for more than 72 sessions or where any billed sessions were received after 126 days from the date of the first session that were processed prior to the implementation of CWF edits.  However, contrac tors may adjust claims brought to their attention.   140.2.2.6  Supplier Specialty Code 31 Requirements for ICR Claims (Rev. 1974, Issued: 05- 21-10, Effective: 01 -10-10, Implementation: 10- 04-10)  Effective for claims with dates of service on and after January 1, 2010, contractors shall pay for ICR services when submitted by providers enrolled as the new supplier specialty code 31 for ICR. ICR services submitted by providers enrolled as other than t he new supplier specialty code 31 for ICR are to be denied using the following messages:   CARC 8: The procedure code is inconsistent with the provider type/specialty (taxonomy).  NOTE:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N95: This provider type may not bill this service.  MSN 21.18  This item or service is not covered when performed or ordered by this provider.  Spanish Version: Este servicio no est cubierto cuando es ordenado o rendido por este proveedor.   Group Code PR (Patient Responsibility)  Where a claim is received with the GA modifier indicating that a signed ABN is on file.  Group Code CO (Contractor Responsibility)  Where a claim is received with the GZ modifier indicating that no signed ABN is on file.  140.3  ICR Program Services Effective for Dates of Service On or After January 1, 2024  (Rev. 12497; Issued: 02-08- 24; Effective: 01 -01-24; Implementation: 03-12-24)