evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The A/B MAC pays for reasonable and medically necessary monitored anesthesia care services on the same basis as other anesthesia services. If the physician personally performs the monitored anesthesia care case, payment is made under the fee schedule using the payment rules for payment at the personally performed rate.  If the physician medically directs four or fewer concurrent cases and monitored anesthesia care represents one or more of these concurrent  cases, payment is made under the fee schedule using the payment rules for payment at the medically directed rate.  Anesthesiologists use the QS modifier to report monitored anesthesia care cases, in addition to reporti ng the actual anesthesia time and one of the payment modifiers on the claim.    I. Anesthesia Claims  Modifiers   Physicians report the appropriate modifier to denote whether the service meets the requirements for payment at the personally performed rate, medically directed rate, or medically  supervised rate.  AA -  Anesthesia Services performed personally by the  anesthesiologist   AD -  Medical Supervision by a physician; more than 4 concurrent anesthesia  procedures   G8 - Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical  procedures   G9 - Monitored anesthesia care for patient who has a history of severe cardio-  pulmonary condition  QK -  Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals   QS -  Monitored anesthesia care service   NOTE:  The QS modifier can be used by a physician or a qualified nonphysician anesthetist and is for informational purposes.  Providers must report actual anesthesia time and one of the payment modifiers on the claim.   QY -  Medical direction of one qualified nonphysician anesthetist by an anesthesiologist   GC -  These services have been performed by a resident under the direction of a teaching physician.   NOTE:  The GC modifier is reported by the teaching physician to indicate he/she rendered the service in compliance with the teaching physician requirements in 100 of this chapter.  One of the payment modifiers must be used in conjunction with the GC  modifier.
(Medicare Claims Processing Manual)
The A/B MAC must determine payment for anesthesia in accordance with these instructions. They must be able to determine the uniform base unit that is assigned to the anesthesia code and apply the appropriate reduction where the anesthesia procedure meets the requirements f or payment at the medically directed rate. They must also be able to determine the number of anesthesia time units from actual anesthesia time reported on the claim. The A/B MAC must multiply allowable units by the anesthesia -specific conversion factor used to determine fee schedule payment for the payment  area.   J. Moderate Sedation Services Furnished in Conjunction with and in Support of Procedural Services    Anesthesia services range in complexity. The continuum of anesthesia services, from least intense to most intense in complexity is as follows: local or topical anesthesia, moderate (conscious) sedation, regional anesthesia and general anesthesia. Moderate sedation is a drug induced depression of consciousness during which the patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Moderate sedation does not include minimal sedation, deep sedation or monitored anesthesia care.   Practitioners will report the appropriate CPT and/or HCPCS code that describes the moderate sedation services furnished during a patient encounter, which are furnished in conjunction with and in support of a procedural service, consistent with CPT guidance .    Refer to 50 and 140 of this chapter for information regarding reporting of anesthesia services furnished in conjunction with and in support of procedural services.     K.  Anesthesia for Diagnostic or Therapeutic Nerve Blocks and Services Lower in Intensity than Moderate Sedation  If the anesthesiologist or CRNA provides anesthesia for diagnostic or therapeutic nerve blocks or injections and a different provider performs the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using the appropriate  CPT code consistent with CPT guidance.  The service must meet the criteria for monitored anesthesia care as described in this section. If the anesthesiologist or CRNA provides both the anesthesia service and the block or injection, then the anesthesiologi st or CRNA may report the anesthesia service and the injection or block. However, the anesthesia service must meet the requirements for moderate sedation and if a lower level complexity anesthesia service is provided, then the moderate sedation code should not be  reported.
(Medicare Claims Processing Manual)
If the physician performing the medical or surgical procedure also provides a level of anesthesia lower in intensity than moderate sedation, such as a local or topical anesthesia, then the moderate sedation code should not be reported and no separate payme nt should be allowed by the A/B MAC.   60 - Payment for Pathology Services (Rev. 2714, Issued: 05- 24-13, Effective: 07 -01-12 Implementation: 06- 25, 13)   A. Payment for Professional Component (PC) Services   Payment may be made under the physician fee schedule for the professional component of physician laboratory or physician pathology services furnished to hospital inpatients or outpatients by hospital physicians or by independent laboratories, if they quali fy as the re -assignee for the physician service.   B. Payment for Technical Component (TC) Services   1. General Rule  Payment is not made under the physician fee schedule for TC services furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital inpatient and outpatient settings.  Payment is made under the physician fee schedule for TC services furnished in institutional settings where the TC service is not bundled into the facility payment, e.g., an ambulatory surgery center (ASC).  Payment may be made under the physician fee schedule for the TC of physician pathology services furnished by an independent laboratory, or a hospital if it is acting as an independent laboratory, to non- hospital patient s.  The physician fee schedule identifies physician laboratory or physician pathology services that have a TC service.   2. TC Services Furnished by Independent Laboratories to Hospital Inpatients and Outpatients    For services furnished on or after July 1, 2012, an independent laboratory may not bill the A/B MAC (B) (and the A/B MAC (B) may not pay) for the TC of a physician pathology service furnished to a hospital inpatient or outpatient.   For services furnished prior to July 1, 2012, payment may be made under the fee schedule, as noted below, for the (TC) of pathology services furnished by an independent laboratory to hospital inpatients or outpatients.
(Medicare Claims Processing Manual)
Depending upon circumstances and the billing entity, the A/B MACs (B) may pay professional component, technical component or both.  2. Specific Hematology, Cytopathology and Blood Banking Services   Cytopathology services include the examination of cells from fluids, washings, brushings or smears, but generally excluding hematology.  Examining cervical and vaginal smears are the most common service in cytopathology.  Cervical and vaginal smears do not  require interpretation by a physician unless the results are or appear to be abnormal.  In such cases, a physician personally conducts a separate microscopic evaluation to determine the nature of an abnormality.  This microscopic evaluation ordinarily doe s require performance by a physician.  When medically necessary and when furnished by a physician, it is paid under the fee schedule.   For services furnished prior to January 1, 1999, A/B MACs (B)  pay separately under the physician fee schedule for the interpretation of an abnormal pap smear furnished to a hospital inpatient by a physician.  They must pay under the clinical laboratory fe e schedule for pap smears furnished in all other situations.  This policy also applies to screening pap smears requiring a physician interpretation.  For services furnished on or after January 1, 1999, A/B MACs (B)  allow separate payment for a physicians  interpretation of a pap smear to any patient (i.e., hospital or non- hospital) as long as:  (1) the laboratorys screening personnel suspect an abnormality; and (2) the physician reviews and interprets the pap smear.   This policy also applies to screening pap smears requiring a physician interpretation and described in the National Coverage Determination Manual and Chapter 18.  These services are reported under codes P3000 or P3001.  Physician hematology services include microscopic evaluation of bone marrow aspirations and biopsies.  It also includes those limited number of peripheral blood smears which need to be referred to a physician to evaluate the nature of an apparent abnormali ty identified by the technologist. These codes include 85060, 38220, 85097, and 38221.  A/B MACs (B) pay the PC for the interpretation of an abnormal blood smear (code 85060) furnished to a hospital inpatient by a hospital physician or an independent laboratory.
(Medicare Claims Processing Manual)
For other hematology codes, payment may be made for the PC component if the service is furnished to a patient by a hospital physician or independent laboratory.  In addition, payment may be made for these services furnished to patients by an independent la boratory.   Blood banking services of hematologists and pathologists are paid under the physician fee schedule when analyses are performed on donor and/or patient blood to determine compatible donor units for transfusion where cross matching is difficult or where cont amination with transmissible disease of donor is suspected.   The blood banking codes are 86077, 86078, and 86079 and represent professional component only services.   3. Clinical Consultation Services   Clinical consultations are paid under the physician fee schedule only if they:   a. Are requested by the patients attending physician;   b. Relate to a test result that lies outside the clinically significant normal or expected range in view of the condition of the patient;   c. Result in a written narrative report included in the patients medical record; and   d. Require the exercise of medical judgment by the consultant physician.  Clinical consultations are professional component services only, i.e., there is no TC service. The clinical consultation codes are 80500 and 80502.  Routine conversations held between a laboratory director and an attending physician about test orders or results do not qualify as consultations unless all four requirements are met.  Laboratory personnel, including the director, may from time to time cont act attending physicians to report test results or to suggest additional testing or be contacted by attending physicians on similar matters.  These contacts do not constitute clinical consultations.  However, if in the course of such a contact, the attendi ng physician requests a consultation from the pathologist, and if that consultation meets the other criteria and is properly documented, it is paid under the fee schedule.   EXAMPLE:  A pathologist telephones a surgeon about a patients suitability for surgery based on the results of clinical laboratory test results.  During the course of their conversation, the surgeon asks the pathologist whether, based on test results, patient histor y and medical records, the patient is a candidate for surgery.  The surgeons request requires the pathologist to render a medical judgment and provide a consultation.  The pathologist follows up his/her oral advice with a written report and the surgeon notes in the patients medical record that he/she requested a consultation.  This consultation is paid under the fee schedule.
(Medicare Claims Processing Manual)
In any case, if the information could ordinarily be furnished by a nonphysician laboratory specialist, the service of the physician is not a consultation payable under the fee schedule.   See the Program Integrity Manual for guidelines for related data analysis to identify inappropriate patterns of billing for consultations.  4. Clinical Laboratory Interpretation Services   Only clinical laboratory interpretation services, which meet the criteria in subsections C.3.a, c, and d, are billable under the physician fee schedule.  These codes have a PC/TC indicator of 6 on the Medicare Physician Fee Schedule database.  These serv ices are reported under the clinical laboratory code with modifier 26.  These services can be paid under the physician fee schedule if they are furnished to a patient by a hospital pathologist or an independent laboratory.  Note that a hospitals standing order policy can be used as a substitute for the individual request by the patients attending physician.  A/B MACs (B) are not allowed to revise CMSs list to accommodate local medical practice.  The CMS periodically reviews this list and adds or deletes clinical laboratory codes as warranted.   D. Global Billing   Billing globally for services that are split into separate PC and TC services is only possible when the PC and TC are furnished by the same physician or supplier entity.  For example, where the PC and the TC of a diagnostic service are provided in the same  service location, this is reflected as the address entered into Item 32 on CMS Form 1500, which provides the ZIP Code to pay the right locality/GPCI.  In this case, the physician/entity may bill globally.  However, if the PC and the TC are each provided i n different service locations (enrolled practice locations), the PC and the TC must be separately billed.   Merely applying the same place of service (POS) code to the PC and the TC does not permit global billing for any diagnostic procedure.   70 - Payment Conditions for Radiology Services  (Rev. 1, 10- 01-03) B3-15022 See chapter 13, for claims processing instructions for radiology.  80 - Services of Physicians Furnished in Providers or to Patients of Providers  (Rev. 1, 10- 01-03) B3-15014
(Medicare Claims Processing Manual)
This section sets forth special conditions that govern payments for services that physicians furnish in, or to patients of, providers of services including hospitals, SNFs, or Comprehensive Outpatient Rehabilitation Facilities ( CORFs).  If physicians are compensated for their services by a provider or another entity, the compensation they receive must be allocated among the various types of services they furnish.  The A/B MAC (A) pays for services that physicians furnish to the provider.  Physician services to the provider include, but are not limited to, standby surgical services.  Payment for physicians services to individual patients that meet the conditions in subsection A is made under the physicians fee schedule.  However:   Payment for physicians services furnished in teaching settings is subject to the additional conditions in 100;   Payment for physicians services furnished to ESRD patients is subject to additional requirements in Chapter 8, and  The A/B MAC (A) pays for the services of residents, as well as for physicians who are licensed to practice only in the provider setting, as provider services.  (See 100.2)   A. Conditions for Physician Fee Schedule Payment for Physicians Services to Patients in Providers
(Medicare Claims Processing Manual)
1. General  A/B MACs (B) pay for physicians services to patients of providers on a fee schedule basis only if the following requirements are met:   The services are personally furnished for an individual patient by a physician;   The services contribute directly to the diagnosis or treatment or an individual patient;   The services ordinarily require performance by a physician; and  In the case of anesthesiology, radiology, or pathology/laboratory services, certain additional requirements in 50, 60, and 70 are met.  2. Services of Physicians to Patients in Providers  If a physician furnishes services to a patient in a hospital or SNF that do not meet the requirements in 80.A.1, above, but are related to patient care, the services may be covered as provider services and paid by the A/B MAC (A) within the applicable Prospective Payment System (PPS) rate.  3. Effect of Billing Charges for Physician Services to Provider  If services furnished by a physician to a provider may be paid by the A/B MAC (A), neither the provider nor the physician may seek fee schedule payments from the A/B MAC (B), the beneficiary, or another insurer.  A/B MACs (B) must report any situation in w hich this happens to the RO unless it is clearly an isolated case of billing error.  4. Effect of Assumption of Operating Costs  If a physician or an entity enters into an agreement (such as a lease or concession) with a provider under which the physician (or entity) assumes some or all of the operating costs of the provider department:   A/B MACs (B) make fee schedule payments only for physicians services to individual patients;  The physician (or other entity) must make its books and records available to the provider and the A/B MAC (A), as necessary, to verify the nature and extent of the costs of the services furnished by the physician (or other entity); and   The lessees costs associated with producing these services, including overhead, supplies, equipment, and the costs of employing nonphysician personnel are payable by the A/B MAC (A) as provider services.  80.1 - Coverage of Physicians Services Provided in Comprehensive Outpatient Rehabilitation Facility  (Rev. 1, 10- 01-03) B3-2220
(Medicare Claims Processing Manual)
Rehabilitation services furnished by comprehensive outpatient rehabilitation facilities (CORFs) are covered by Medicare Part B.   Under 1832(a)(2)(E), and 1861(cc)(2) (go to http://www.ssa.gov/OP_Home/ssact/title18/1800.htm  and select the applicable title) and related provisions of the Act, a CORF is recognized as a provider of services on the basis of its reasonable costs.  Except for diagnostic and therapeutic services provided by physicians to individual patients, payment  is made to the CORF by A/B MACs (A) (acting in the role of the A/B MAC (B).)  Physicians diagnostic and therapeutic services furnished to a CORF patient are not considered CORF physicians services.  Instead they are services that the physician must bill to the A/B MAC (B).  If covered services, payment is made according to the Medicare Physician Fee Schedule.  When physicians diagnostic and therapeutic services are furnished in a CORF, the claim must be annotated to show the CORF as the place of treatment.  Services considered administrative services provided by the physician associated with the CORF are considered CORF services reimbursable to the CORF by the A/B MACs (A).  Administrative services include consultation with and medical supervision of nonphysi cian staff, establishing and reviewing the plan of treatment, and other medical and facility administration activities.  80.2 - Rural Health Clinic and Federally Qualified Health Center Services  (Rev. 1, 10- 01-03) B3-2260- 2260.3
(Medicare Claims Processing Manual)
a physicians services, and   Visiting nurse  services to the homebound. However, the technical component of diagnostic services may be billed separately by the physician to the A/B MAC (B), if provided.  See Chapter 9, and the Medicare Benefit Policy Manual, Chapter 13, for additional information on the definition of RHC/FQHC services.  Also, an RHC or FQHC may provide other items and services which are covered under Part B, but which are not defined as RHC or FQHC services.  They are listed in the Medicare Benefit Policy Manual, Chapter 13.  Independent RHCs/FQHCs bill the A/B MAC (B) for such services.  Provider -based RHC/FQHC services are billed to the A/B MAC (A) as services of the parent provider.  Independent RHCs/FQHCs must enroll with the A/B MAC (B) in order to bill.  (See the Medicare Program Integrity Manual, Chapter 10, for enrollment instructions). 80.3 - Unusual Travel (CPT Code 99082)  (Rev. 1, 10- 01-03) B3-15026 In general, travel has been incorporated in the MPFSDB individual fees and is thus not separately payable.  A/B MACs (B) must pay separately for unusual travel (CPT code 99082) only when the physician submits documentation to demonstrate that the travel was very unusual. 90 - Physicians Practicing in Special Settings  (Rev. 1, 10- 01-03) 90.1 - Physicians in Federal Hospitals  (Rev. 1, 10- 01-03) B3-2020.5 There are many physicians performing services in hospitals operated by the Federal Government, e.g., military, Veterans Administration, and Public Health Service hospitals.  Normally Medicare does not pay for the services provided by a physician in a Feder al hospital except when the hospital provides services to the public generally as a community institution.  Such a physician working in the scope of his Federal employment may be considered as coming within the statutory definition of physician even though he may not have a license to practice in the State in which he is employed.  90.2 - Physician Billing for End -Stage Renal Disease Services  (Rev. 1, 10- 01-03) See the Medicare Benefit Policy Manual, Chapter 11, for a description of ESRD policy. See chapter 8, for billing
(Medicare Claims Processing Manual)
employed.  90.2 - Physician Billing for End -Stage Renal Disease Services  (Rev. 1, 10- 01-03) See the Medicare Benefit Policy Manual, Chapter 11, for a description of ESRD policy. See chapter 8, for billing requirements for physicians and facilities.  90.2.1 - Inpatient Hospital Visits With Dialysis Patients  (Rev. 1, 10 -01-03) B3-15062- 15062.1 Global billing practices that involve the submission of charges for each day that a patient is hospitalized are allowed.  Therefore, A/B MACs (B) may make payment for inpatient hospital visits that are specified relative to time, place, day, and services d irectly provided to inpatients.  This guideline may, however, differ with respect to daily visit charges for inpatient hospital visits with dialysis inpatients.  When an ESRD patient is hospitalized, the hospitalization may or may not be due to a renal -related condition.  In either case, the patient must continue to be dialyzed.  Chapter 8 provides policy and payment instructions for physicians services furnished to dialysis inpatients.  It also provides instructions for billing physicians renal -related medical services furnished on dialysis days and for dialysis and evaluation a nd management services performed on the same day.