evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Code  Description  Z34.00  Encounter for supervision of normal first pregnancy, unspecified trimester  Z34.01  Encounter for supervision of normal first pregnancy, first trimester  Z34.02  Encounter for supervision of normal first pregnancy, second trimester  Z34.03  Encounter for supervision of normal first pregnancy, third trimester  Z34.80  Encounter for supervision of other normal pregnancy, unspecified trimester  Z34.81  Encounter for supervision of other normal pregnancy, first trimester  Z34.82  Encounter for supervision of other normal pregnancy, second trimester  Z34.83  Encounter for supervision of other normal pregnancy, third trimester  Z34.90  Encounter for supervision of normal pregnancy, unspecified, unspecified trimester  Z34.91  Encounter for supervision of normal pregnancy, unspecified, first trimester  Z34.92  Encounter for supervision of normal pregnancy, unspecified, second trimester  Z34.93  Encounter for supervision of normal pregnancy, unspecified, third trimester  O09.90  Supervision of high risk pregnancy, unspecified, unspecified trimester  O09.91  Supervision of high risk pregnancy, unspecified, first trimester  O09.92  Supervision of high risk pregnancy, unspecified, second trimester  O09.93  Supervision of high risk pregnancy, unspecified, third trimester   170.3 - Billing Requirements (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Effective for dates of service November 8, 2011, and later, A/B MACs (A) and (B)  shall recognize HCPCS code G0445 for HIBC.  Medicare shall cover up to two occurrences of G0445 when billed for HIBC to prevent STIs.  A claim that is submitted with HCPCS code G0445 for HIBC shall be submitted with ICD -10-CM diagnosis code Z72.89.  A/B MACs (A) and (B) shall pay for screening for chlamydia, gonorrhea, and syphilis (as indicated by the presence of  ICD -10 is applicable, ICD -10-CM diagnosis code Z11.3;  and/or hepatitis B (as indicated by the presence of ICD -10-CM diagnosis code Z11.59 as follows:
(Medicare Claims Processing Manual)
 One annual occurrence of screening for chlamydia, gonorrhea, and syphilis (i.e., 1 per 12- month period) in women at increased risk who are not  pregnant ,   One annual occurrence of screening for syphilis (i.e., 1 per 12- month period) in men at increased risk,   Up to t wo occurrences per pregnancy of screening for chlamydia and gonorrhea in pregnant women who are at increased risk for STIs and continued increased risk for the second screening,    One occurrence per pregnancy of screening for syphilis in pregnant women,   Up to an additional two occurrences per pregnancy of screening for syphilis in pregnant women if the beneficiary is at continued increased risk for STIs,    One occurrence per pregnancy of screening for hepatitis B in pregnant women, and,    One additional occurrence per pregnancy of screening for hepatitis B in pregnant women who are at continued increased risk for STIs.   170.4 - Types of Bill (TOBs) and Revenue Codes  (Rev. 2476, Issued: 05- 23-12, Effective: 11 -08-11, Implementation: 02- 27-12)  The applicable types of bill (TOBs) for HIBC screening, HCPCS code G0445, are: 13X, 71X, 77X, and 85X.   On institutional claims, TOBs 71X and 77X, use revenue code 052X to ensure coinsurance and deductible are not applied.  Critical access hospitals (CAHs) electing the optional method of payment for outpatient services report this service under revenue codes 096X, 097X, or 098X.  170.4.1 - Payment Method  (Rev. 2476, Issued: 05- 23-12, Effective: 11 -08-11, Implementation: 02- 27-12)  Payment for HIBC is based on the all -inclusive payment rate for rural health clinics (TOBs 71X) and federally qualified health centers (TOB 77X). Hospital outpatient departments (TOB 13X) are paid based on the outpatient prospective payment system and CAHs  (TOB 85X) are paid based on reasonable cost. CAHs electing the optional method of payment for outpatient services are paid based on 115% of the lesser of the Medicare Physician Fee Schedule (MPFS) amount or submitted charge.
(Medicare Claims Processing Manual)
Effective for dates of service on and after November 8, 2011, deductible and coinsurance do not apply to claim lines with G0445.   HCPCS code G0445 may be paid on the same date of service as an annual wellness visit, evaluation and management (E&M) code, or during the global billing period for obstetrical care, but only one G0445 may be paid on any one date of service.  If billed on t he same date of service with an E&M code, the E&M code should have a distinct diagnosis code other than the diagnosis code used to indicate high/increased risk for STIs for the G0445 service.  An E&M code should not be billed when the sole reason for the visit is HIBC to prevent STIs.   For Medicare Part B physician and non- practitioner claims, payment for HIBC to prevent STIs is based on the MPFS amount for G0445.  170.5 - Specialty Codes and Place of Service (POS)  (Rev. 2476, Issued: 05- 23-12, Effective: 11 -08-11, Implementation: 02- 27-12)  Medicare provides coverage for  screening for chlamydia, gonorrhea, syphilis, and/or hepatitis B and HIBC to prevent STIs only when ordered by a primary care practitioner (physician or non- physician) with any of the following specialty codes:    01 - General Practice   08 - Family Practice   11 - Internal Medicine   16 - Obstetrics/Gynecology  37 - Pediatric Medicine   38 - Geriatric Medicine   42 - Certified Nurse Midwife   50 - Nurse Practitioner   89 - Certified Clinical Nurse Specialist  97 - Physician Assistant   Medicare provides coverage for HIBC to prevent STIs only when provided by a primary care practitioner (physician or non- physician) with any of the specialty codes identified above.  Medicare provides coverage for  HIBC to prevent STIs only when the POS billed is 11, 22, 49, or 71.  180 - Alcohol Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse  (Rev. 2433, Issued: 03- 26-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -system changes, 04- 02-12 shared system changes, 07- 02-12 CWF/HICR/MCS MCSDT)
(Medicare Claims Processing Manual)
The United States Preventive Services Task Force (USPSTF) defines alcohol misuse as risky, hazardous, or harmful drinking which places an individual at risk for future problems with alcohol consumption.  In the general adult population, alcohol consumption becomes risky or hazardous when consuming:    Greater than 7 drinks per week or greater than 3drinks per occasion for women and persons greater than 65 years old.    Greater than 14 drinks per week or greater than 4 drinks per occasion for men 65 years old and younger.   180.1 - Policy  (Rev. 2433, Issued: 03- 26-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -system changes, 04- 02-12 shared system changes, 07- 02-12 CWF/HICR/MCS MCSDT)   Claims with dates of service on and after October 14, 2011, the Centers for Medicare & Medicaid Services (CMS) will cover annual alcohol misuse screening (HCPCS code G0442) consisting of 1 screening session, and for those that screen positive, up to 4 brie f, face -to-face behavioral counseling sessions (HCPCS code G0443) per 12 -month period  for Medicare beneficiaries, including pregnant women.  Medicare beneficiaries that may be identified as having a need for behavioral counseling sessions include those:    Who misuse alcohol, but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence (defined as at least three of the following: tolerance, withdrawal symptoms, impaired control, preoccupation with acquisition and/or use, persistent desire or unsuccessful efforts to quit, sustains social, occupational, or recreational disability, use continues despite adverse consequences); and,    Who are competent and alert at the time that counseling is provided; and,   Whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting.   Once a Medicare beneficiary has agreed to behavioral counseling sessions, the counseling sessions are to be completed based on the 5As approach adopted by the United States Preventive Services Task Force (USPSTF.)  The steps to the 5As approach are listed below.   1. Assess:  Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
(Medicare Claims Processing Manual)
1. Assess:  Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.  2. Advise :  Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.   3. Agree:  Collaboratively select appropriate treatment goals and methods based on the patients interest in and willingness to change the behavior.   4. Assist :  Using behavior change techniques (self -help and/or counseling), aid the patient in achieving agreed -upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.   5. Arrange:  Schedule follow -up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.  180.2 - Institutional Billing Requirements  (Rev. 2433, Issued: 03- 26-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -system changes, 04- 02-12 shared system changes, 07- 02-12 CWF/HICR/MCS MCSDT)   For claims with dates of service on and after October 14, 2011, Medicare will allow coverage for annual alcohol misuse screening, 15 minutes, G0442, and brief, face -to-face behavioral counseling for alcohol misuse, 15 minutes, G0443 for:    Rural Health Clinics (RHCs) -  type of bill (TOB) 71X only -  based on the all -inclusive payment rate    Federally Qualified Health Centers (FQHCs) -  TOB 77X  only -  based on the all -inclusive payment rate   Outpatient hospitals -  TOB 13X -  based on Outpatient Prospective Payment System (OPPS)    Critical Access Hospitals (CAHs) -  TOB 85X - based on reasonable cost    CAH Method II -  TOB 85X -  based on 115% of the lesser of the Medicare Physician Fee Schedule (MPFS) amount or actual charge as applicable with revenue codes 096X, 097X, or 098X.
(Medicare Claims Processing Manual)
For RHCs and FQHCs the alcohol screening/counseling is not separately payable with another face -to-face encounter on the same day.  This does not apply to the Initial Preventive Physical Examination (IPPE), unrelated services denoted with modifier 59, and 77X claims containing Diabetes Self Management Training (DSMT) and Medical Nutrition Therapy (MNT)services.  DSMT and MNT apply to FQHCs only.  However, the screening/counseling sessions alone when rendered as a face -to-face visit with a core practitioner do constitute an encounter and is paid based on the all -inclusive payment rate.   Note:  For outpatient hospital settings, as in any other setting, services covered under this NCD must be provided by a primary care provider.   Claims submitted with alcohol misuse screening and behavioral counseling HCPCS codes G0442 and G0443 on a TOB other than 13X, 71X, 77X, and 85X will be denied.   Effective October 14, 2011, deductible and co -insurance should not be applied for line items on claims billed for alcohol misuse screening G0442 and behavioral counseling for alcohol misuse G0443.  180.3 - Professional Billing Requirements  (Rev. 2433, Issued: 03- 26-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -system changes, 04- 02-12 shared system changes, 07- 02-12 CWF/HICR/MCS MCSDT)   For claims with dates of service on and after October 14, 2011, CMS will allow coverage for annual alcohol misuse screening, 15 minutes, G0442, and behavioral counseling for alcohol misuse, 15 minutes, G0443, only when services are submitted by the followi ng provider specialties found on the providers enrollment record:   01 - General Practice  08 - Family Practice  11 - Internal Medicine  16 - Obstetrics/Gynecology 37 - Pediatric Medicine  38 - Geriatric Medicine  42 - Certified Nurse -Midwife  50 - Nurse Practitioner  89 - Certified Clinical Nurse Specialist 97 - Physician Assistant
(Medicare Claims Processing Manual)
Any claims that are not submitted from one of the provider specialty types noted above will be denied.  For claims with dates of service on and after October 14, 2011, CMS will allow coverage for annual alcohol misuse screening, 15 minutes, G0442, and behavioral counseling for alcohol misuse, 15 minutes, G0443, only when submitted with one of the following place of service (POS) codes:   11 - Physicians Office  22 - Outpatient Hospital 49 - Independent Clinic  71 - State or local public health clinic or   Any claims that are not submitted with one of the POS codes noted above will be denied.   The alcohol screening/counseling services are payable with another encounter/visit on the same day.  This does not apply for IPPE.   180.4 - Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Group Codes, and Medicare Summary Notice Messages (Rev. 2433, Issued: 03- 26-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -system changes, 04- 02-12 shared system changes, 07- 02-12 CWF/HICR/MCS MCSDT)   A/B MACs (A) and (B) shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for alcohol misuse screening and alcohol misuse behavi oral counseling sessions:    For RHC and FQHC claims that contain screening for alcohol misuse HCPCS code G0442 and alcohol misuse counseling HCPCS code G0443 with another encounter/visit with the same line item date of service, use group code CO and reason code:   o Claim Adjustment Reason Code (CARC) 97 -  The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.  Note:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present    Denying claims containing HCPCS code G0442 and HCPCS code G0443 submitted on a TOB other than 13X, 71X, 77X, and 85X:
(Medicare Claims Processing Manual)
 Denying claims containing HCPCS code G0442 and HCPCS code G0443 submitted on a TOB other than 13X, 71X, 77X, and 85X:   o Claim Adjustment Reason Code (CARC) 5 -  The procedure code/bill type is inconsistent with the place of service.  Note:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present   o Remittance Advice Remark Code (RARC) M77 -  Missing/incomplete/invalid place of service   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.   Denying claims that contains more than one alcohol misuse behavioral counseling session G0443 on the same date of service:   o Medicare Summary Notice (MSN) 15.6 -  The information provided does not support the need for this many services or items within this period of time.   o Claim Adjustment Reason Code (CARC) 151 -  Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.   o Remittance Advice Remark Code (RARC) M86 -  Service denied because payment already made for same/similar procedure within set time frame.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.   Denying claims that are not submitted from the appropriate provider specialties:   o Medicare Summary Notice (MSN) 21.18 -  This item or service is not covered when performed or ordered by this provider.   o Claim Adjustment Reason Code (CARC) 185 -  The rendering provider is not eligible to perform the service billed. NOTE:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   o Remittance Advice Remark Code (RARC) N95 -  This provider type/provider specialty may not bill this service.
(Medicare Claims Processing Manual)
o Remittance Advice Remark Code (RARC) N95 -  This provider type/provider specialty may not bill this service.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.   Denying claims without the appropriate POS code:   o Medicare Summary Notice (MSN) 21.25 -  This service was denied because Medicare only covers this service in certain settings.   o Claim Adjustment Reason Code (CARC) 58 -  Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.  Note:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present.   o Remittance Advice Remark Code (RARC) N428 - Not covered when performed in this place of service.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.   Denying claims for alcohol misuse screening HCPCS code G0442 more than once in a 12- month period, and denying alcohol misuse counseling sessions HCPCS code G0443 more than four times in the same 12 -month period:   o Medicare Summary Notice (MSN) 20.5 -  These services cannot be paid because your benefits are exhausted at this time.   o Claim Adjustment Reason Code (CARC) 119 -  Benefit maximum for this time period or occurrence has been reached.   o Remittance Advice Remark Code (RARC) N362 - The number of Days or Units of service exceeds our acceptable maximum.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.   Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.
(Medicare Claims Processing Manual)
 Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  180.5 - CWF Requirements  (Rev. 2433, Issued: 03- 26-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -system changes, 04- 02-12 shared system changes, 07- 02-12 CWF/HICR/MCS MCSDT)   When applying frequency, CWF shall count 11 full months following the month of the last alcohol misuse screening visit, G0442, before allowing subsequent payment of another G0442 screening.  Additionally, CWF shall create an edit to allow alcohol misuse br ief behavioral counseling, HCPCS G0443, no more than 4 times in a 12- month period and make this edit overridable.  CWF shall also count four alcohol misuse counseling sessions HCPCS G0443 in the same 12- month period used for G0442 counting from the date the G0442 screening session was billed.  When applying frequency limitations to G0442 screening on the same date of service as G0443 counseling, CWF shall allow both a claim for the professional service and a claim for a facility fee.  CWF shall identify the following institutional claims as facility fee claims for screening services: TOB 13X, TOB 85X when the revenue code is not 096X, 097X, or 098X.  CWF shall identify all other claims as professional service claims for screening services.  NOTE: This does not apply to RHCs and FQHCs.  190 - Screening for Depression in Adults (Effective October 14, 2011)  (Rev. 2431, Issued: 03- 23-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -shared system edits/04 -02-12 shared system edits/07- 02-12 CWF, HICR, MCS MCSDT)   A. Coverage Requirements
(Medicare Claims Processing Manual)
A. Coverage Requirements   Effective October 14, 2011, the Centers for Medicare & Medicaid Services (CMS) will cover annual screening up to 15 minutes for Medicare beneficiaries in primary care settings that have staff -assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow -up.  Various screening tools are available for screening for depression.  CMS does not identify specific depression screening tools.  Rather, the decision to use a specific tool is at the discretion of the clinician in the primary care setting.  Screening for depression is non- covered when performed more than one time in a 12 -month period.  The Medicare coinsurance and Part B deductible are waived for this preventive service.   Additional information on this National Coverage Determination (NCD) for Screening for Depression in Adults can be found in Publication 100- 03, NCD Manual, Section 210.9.  190.1 - A/B MAC (B) Billing Requirements  (Rev. 2431, Issued: 03- 23-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -shared system edits/04 -02-12 shared system edits/07- 02-12 CWF, HICR, MCS MCSDT)   Effective October 14, 2011, A/B MACs (B) shall recognize new HCPCS G0444, annual depression screening, 15 minutes.  190.2 - Frequency  (Rev. 2431, Issued: 03- 23-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -shared system edits/04 -02-12 shared system edits/07- 02-12 CWF, HICR, MCS MCSDT)   A/B MACs (B) shall pay for annual depression screening, G0444, no more than once in a 12- month period.  NOTE:  11 full months must elapse following the month in which the last annual depression screening took place.   190.3 - Place of Service (POS)  (Rev. 2431, Issued: 03- 23-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -shared system edits/04 -02-12 shared system edits/07- 02-12 CWF, HICR, MCS MCSDT)
(Medicare Claims Processing Manual)
A/B MACs (B) shall pay for annual depression screening claims, G0444, only when services are provided at the following places of service (POS):   11 - Office  22 - Outpatient Hospital 49 - Independent Clinic  71 - State or Local Public Health Clinic   190.4 - Common Working File (CWF) Edits  (Rev. 2431, Issued: 03- 23-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -shared system edits/04 -02-12 shared system edits/07- 02-12 CWF, HICR, MCS MCSDT)   CWF shall count 11 full months from the month of the prior annual depression screening, G0444, before allowing subsequent payment.  190.5 - Professional Billing Requirements  (Rev. 2431, Issued: 03- 23-12, Effective: 10 -14-11, Implementation: 12- 27-11 non -shared system edits/04 -02-12 shared system edits/07- 02-12 CWF, HICR, MCS MCSDT)   A/B MACs (B) shall use the following claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare Summary Notice (MSN) messages when denying payment for G0444 when reported more than once in a 12- month period.  o CARC 119 -  Benefit maximum for this time period or occurrence has been reached.   o RARC N362 -  The number of days or units of service exceeds our acceptable maximum.   o MSN 20.5 -  These services cannot be paid because your benefits are exhausted as this time.  Spanish Version -  Estos servicios no pueden ser pagados porque sus beneficios se han agotado.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.