evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
In addition, for the planning services, hospitals must report the specific CPT code  that accurately describes the service provided.  The planning services may include but are not limited to CPT code 77290, 77295, 77300, 77334, or  77370.  CPT  Code  Long Descriptor  77290 Therapeutic radiology simulation- aided field setting; complex  77295 Therapeutic radiology simulation- aided field setting; 3-dimensional  77300 Basic radiation dosimetry calculation, central axis depth dose  calculation, tdf, nsd, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non- ionizing radiation surface and depth dose, as  required during course of treatment, only when prescribed by the  treating physician  77334 Treatment devices, design and construction; complex (irregular  blocks, special shields, compensators, wedges, molds or  casts)  77370 Special medical radiation physics  consultation   Effective for cranial single session stereotactic radiosurgery procedures (CPT code 77371 or 77372) furnished on or after January 1, 2016, costs  for certain adjunctive services (e.g., planning and preparation) are not factored into the  APC payment rate for APC 5627 (Level 7 Radiation Therapy).  Rather, the ten planning and preparation codes, will be paid according to their assigned status indicator when furnished 30 days prior or 30 days post SRS treatment  delivery. A list of the excluded planning and preparation CPT codes is provided in the CY 2018 OPPS/ASC final rule with comment period.   200.4 - Billing for Amniotic Membrane  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  Hospitals should report HCPCS code V2790 (Amniotic membrane for surgical reconstruction, per procedure) to report amniotic membrane tissue when the tissue is used.  A specific procedure code associated with use of amniotic membrane tissue is CPT code 65780 (Ocular surface reconstruction; amniotic membrane transplantation).  Payment for the amniotic membrane tissue is packaged into payment for CPT code 65780 or other procedures with which the amniotic membrane is used.
(Medicare Claims Processing Manual)
200.5 - Reserved  (Rev. 1882, Issued:  12 -21-09; Effective Date:  01 -01-10; Implementation Date:  01-04-10)  200.6 - Billing and Payment for Alcohol and/or Substance Abuse Assessment and Intervention Services  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  For CY 2008, the CPT Editorial Panel has created two new Category I CPT codes for reporting alcohol and/or substance abuse screening and intervention services.  They are CPT code 99408 ( Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes); and CPT code 99409 ( Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minut es).  However, screening services are not covered by Medicare without specific statutory authority, such as has been provided for mammography, diabetes, and colorectal cancer screening.  Therefore, beginning January 1, 2008, the OPPS recognizes two parallel G -codes (HCPCS codes G0396 and G0397) to allow for appropriate reporting and payment of alcohol and substance abuse structured assessment and intervention services that are not provided as screening services, but that are performed in the context of the diagnosis or treatment of illness or injury.  Contractors shall make payment under the OPPS for HCPCS code G0396 (Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST) and brief intervention, 15 to 30 minutes) and HCPCS code G0397, (Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST) and intervention greater than 30 minutes), only when reasonable and necessary (i.e., when the service is provided to evaluate patients with signs/symptoms of illness or injury) as per section  1862(a)(1)(A) of the Act.
(Medicare Claims Processing Manual)
HCPCS codes G0396 and G0397 are to be used for structured alcohol and/or substance (other than tobacco) abuse assessment and intervention services that are distinct from other clinic and emergency department visit services performed during the same encount er.  Hospital resources expended performing services described by HCPCS codes G0396 and G0397 may not be counted as resources for determining the level of a visit service and vice versa (i.e., hospitals may not double count the same facility resources in order to reach a higher level clinic or emergency department visit).  However, alcohol and/or substance structured assessment or intervention services lasting less than 15 minutes should not be reported using these HCPCS codes, but the hospital resources expended should be included in determining the level of the visit service reported.  200.7 - Billing for Cardiac Echocardiography Services (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  200.7.1 - Cardiac Echocardiography Without Contrast  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  Hospitals are instructed to bill for echocardiograms without contrast in accordance with the CPT code descriptors and guidelines associated with the applicable Level I CPT code(s) (93303- 93350).   200.7.2 - Cardiac Echocardiography With Contrast  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  Hospitals are instructed to bill for echocardiograms with contrast using the applicable HCPCS code(s) included in Table 200.7.2 below.  Hospitals should also report the appropriate units of the HCPCS codes for the contrast agents used in the performance of  the echocardiograms.  Table 200.7.2 -  HCPCS Codes For Echocardiograms With Contrast
(Medicare Claims Processing Manual)
HCPCS  Long Descriptor  C8921 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; complete  C8922 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; follow -up or limited study C8923 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real -time with image documentation (2D), includes M -mode recording, when performed, complete, without spectral or color Doppler echocardiography C8924 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real -time with image documentation (2D), includes M -mode recording, when performed, follow -up or limited study  HCPCS  Long Descriptor  C8925 Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, real time with image documentation (2D) (with or without M -mode recording); including probe placement, image acquisition, interpretation and report   C8926 Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report  C8927 Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with contrast, for monitoring purposes, including probe placement, real time 2- dimensional image acquisition and interpretation leading to ongoing (continuous) assessment  of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis  C8928 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real -time with image documentation (2D), includes M -mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report  C8929 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real -time with image documentation (2D), includes M -mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler e chocardiography C8930 Transthoracic echocardiography, with contrast, or without contrast followed by with
(Medicare Claims Processing Manual)
-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler e chocardiography C8930 Transthoracic echocardiography, with contrast, or without contrast followed by with contrast, real -time with image documentation (2D), includes M -mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision
(Medicare Claims Processing Manual)
200.8 - Billing for Nuclear Medicine Procedures  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  Beginning January 1, 2008, the I/OCE began editing for the presence of a radiolabeled product when a separately payable nuclear medicine procedure is present on a claim.  Hospitals should include radiolabeled product HCPCS codes on the same claim as a nuclear medicine procedure beginning on January 1, 2008.  Hospitals are required to submit the HCPCS code for the radiolabeled product on the same claim as the HCPCS code for the nuclear medicine procedure.  Hospitals are also instructed to submit the claim so that the services on the claim each reflect the date the particular service was provided.  Therefore, if the nuclear medicine procedure is provided on a different date of service from the radiolabeled product, the claim will contain more than one date of service.  More information regarding these edits is available on the OPPS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/ .  Hospitals are instructed to use HCPCS code C9898 (Radiolabeled product provided during a hospital inpatient stay) on outpatient claims for nuclear medicine procedures to indicate that a radiolabeled product that provides the radioactivity necessary for the  reported diagnostic nuclear medicine procedure was provided during a hospital inpatient stay.  This HCPCS code is assigned status indicator N because no separate payment is made for the code under the OPPS.  The effective date of the code is January 1, 2008, the date the nuclear medicine procedure- to-radiolabeled product edits were initially implemented.  Because the Medicare claims processing system requires that there be a charge for each HCPCS code reported on the claim, hospitals should always report  a token charge of less than $1.01 for HCPCS code C9898.  The date of service reported on the claim for HCPCS code C9898 should be the same as the date of service for the nuclear medicine procedure HCPCS code, which should always accompany the reporting of HCPCS code C9898.  HCPCS code C9898 should never be reported on a claim without a diagnostic nuclear medicine procedure that is subject to the nuclear medicine procedure -to-radiolabeled product edits.
(Medicare Claims Processing Manual)
More information regarding these edits is available on the OPPS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS   Future updates to this section will be communicated in a Recurring Update Notification.   200.9 - Billing for Sometimes Therapy Services that May be Paid as Non-Therapy Services for Hospital Outpatients  (Rev. 3156, Issued: 12 -22-14, Effective: 01 -01-15, Implementation: 01- 05-15)  Section 1834(k) of the Act, as added by Section 4541 of the BBA, allows payment at 80 percent of the lesser of the actual charge for the services or the applicable fee schedule amount for all outpatient therapy services; that is, physical therapy services, speech -language pathology services, and occupational therapy services.  As provided under Section 1834(k)(5) of the Act, a therapy code list was created based on a uniform coding system (that is, the HCPCS) to identify and track these outpatient therapy s ervices paid under the Medicare Physician Fee Schedule (MPFS).   The list of therapy codes, along with their respective designation, can be found on the CMS Website, specifically at http://www.cms.hhs.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage .  Two of the designations that are used for therapy services are: always therapy and sometimes therapy.  An always therapy service must be performed by a qualified therapist under a certified therapy plan of care, and a sometimes therapy service m ay be performed by physician or a non- physician practitioner outside of a certified therapy plan of care.   Under the OPPS, separate payment is provided for certain services designated as sometimes therapy services if these services are furnished to hospital outpatients as a non-therapy service, that is, without a certified therapy plan of care. Specifically, to be paid under the OPPS for a non- therapy service, hospitals SHOULD NOT append the therapy modifier GP (physical therapy), GO (occupational therapy), or GN (speech language pathology), or report a therapy revenue code 042x, 043x, or 044x in association with the sometimes therapy codes listed in the table below.
(Medicare Claims Processing Manual)
To receive payment under the MPFS, when sometimes therapy services are performed by a qualified therapist under a certified therapy plan of care, providers should append the appropriate therapy modifier GP, GO, or GN, and report the charges under an appropriate therapy revenue code, specifically 042x, 043x, or 044x. This instruction does not apply to claims for sometimes therapy codes furnished as non- therapy services in the hospital outpatient department and paid under the OPPS.   Effective January 1, 2015, two HCPCS codes designated as Sometimes Therapy services, G0456 (Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a mechanically -powered device, not durable medical equipment, including provision of cartridge and dressing(s), topic al application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area less than or equal to 50 square centimeters) and G0457 (Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a me chanically -powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area greater than 50 square centim eters) would be terminated and replaced with two new CPT codes 97607 (Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non- durable medical equipment including provision of exudate management collection syste m, topical application(s), wound assessment, and instructions for ongoing care, per session;  total wounds(s) surface area less than or equal to 50 square centimeters) and 97608 (Negative pressure wound therapy, (eg, vacuum assisted drainage collection), ut ilizing disposable, non- durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session;  total wounds(s) surface area greater than 50 square cen timeters).
(Medicare Claims Processing Manual)
The list of HCPCS codes designated as sometimes therapy services that may be paid as non-therapy services when furnished to hospital outpatients is displayed in the table below.  Services Designated as Sometimes Therapy that May be Paid as Non -Therapy Services for Hospital Outpatients  HCPCS Code  Long Descriptor  92520  Laryngeal function studies (i.e., aerodynamic testing and acoustic testing)  97597  Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (eg., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, pe r session; total wound(s) surface area less than or equal to 20 square centimeters  97598  Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assess ment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area greater than 20 square centimeters  97602  Removal of devitalized tissue from wound(s), non -selective debridement, without anesthesia (e.g., wet -to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session  97605  Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters  97606  Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters  97607  Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable,
(Medicare Claims Processing Manual)
assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters  97607  Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non- durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session;  total wounds(s) surface area less than or equal to 50 square centimeters  97608  Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non- durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session;  total wounds(s) surface area greater than 50 square centimeters  97610  Low frequency, non -contact, non -thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care, per day
(Medicare Claims Processing Manual)
200.10 - Billing for Cost Based Payment for Certified Registered Nurse Anesthetists (CRNA) Services Furnished by Outpatient Prospective Payment System (OPPS) Hospitals (Rev. 3065, Issued: 09- 12-14, Effective: 04 -01-03, Implementation: 12- 15-14)  Payment of outpatient services of CRNAs furnished by small rural hospitals subject to OPPS that qualify for cost based payment under 42 CFR 412.113(c) are made through biweekly interim payments that are calculated based on retrospective adjustments from a settled cost report.   In order for interim payments to be made to these hospitals based on submitted claims, a number of changes were required in the reporting and acceptance of revenue code 0964 Anesthetists (CRNA).  Those changes are as follows:   (1) Hospitals that qualify for cost based CRNA services must report these services under revenue code 0964;   (2) Shared System Maintainer is required to accept revenue code 0964 on type of bill 013X for these hospitals; and   (3) Reporting and acceptance of revenue code 0964 from other OPPS hospitals (without a CRNA pass -through exemption) may not be allowed.   NOTE:   Value code 05 Professional Component Included In Charges and Also Billed Separately to A/B MACs (B), should not be reported with revenue code 0964.  The Integrated Outpatient Code Editor (IOCE) will assign a service indicator of F to revenue code 0964. This allows for cost -based payment for revenue code 0964.  The facility is paid a cost- based interim payment (charges multiplied by the hospitals outpatient interim rate) for the revenue code 0964 charge on the claim, and assume when calculating the interim payment that coinsurance is billed (by the hospital to the beneficiary) in the amount of 20 percent of the submitted charges.  In addition, an adjustment to the hospitals biweekly interim payment amount for cost paid services should exclude any amounts attributable to outpatient hospital CRNA services from all  future biweekly interim payments.  Hospitals shall not bill Healthcare Common Procedure Coding System (HCPCS) when billing for CRNA services.  Beneficiaries are billed for coinsurance for cost based CRNA services billed under revenue code 0964.  Coinsurance is based on 20 percent of the submitted covered charges.  The Part B deductible is applicable.
(Medicare Claims Processing Manual)
200.11  Billing Advance Care Planning (ACP) as an Optional Element of an Annual Wellness Visit (AWV)   (Rev. 3739, Issued: 03- 17-17, Effective: 01 -01-16, Implementation: 06- 19-17)   Effective January 1, 2016 payment for the service described by CPT code 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face -to-face with the patient, family member(s), and/or surrogate) is conditionally packaged under the OPPS and is consequently assigned to a conditionally packaged payment status indicator of Q1. When this service is furnished with another s ervice paid under the OPPS, payment is packaged; when it is the only service furnished, payment is made separately. CPT code 99498 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)) is an add- on code and therefore payment for the service described by this  code is unconditionally packaged (assigned status indicator N) in the OPPS in accordance with 42 CFR 419.2(b)(18).   In addition, for services furnished on or after January 1, 2016, Advance Care Planning (ACP) is treated as a preventive service when furnished with an AWV. The Medicare coinsurance and Part B deductible are waived for ACP when furnished as an optional elem ent of an AWV.