evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The HCPCS codes listed below were developed for the IPPE benefit effective January 1, 2005, for individuals whose initial enrollment is on or after January 1, 2005.  G0344:   Initial preventive physical examination; face -to-face visit, services limited to new beneficiary during the first 6 months of Medicare enrollment   Short Descriptor:  Initial Preventive Exam   G0366:   Electrocardiogram, routine ECG with 12 leads; performed as a component of the initial preventive examination with interpretation and report   Short Descriptor :  EKG for initial prevent exam  G0367:  tracing only, without interpretation and report, performed as a component of the initial preventive examination   Short Descriptor:  EKG tracing for initial prev   G0368:  interpretation and report only, performed as a component of the initial preventive examination  Short Descriptor:   EKG interpret & report preve   The following new HCPCS codes were developed for the IPPE benefit effective January 1, 2009, and replaced codes G0344, G0366, G0367, and G0368 shown above beginning with dates of service on or after January 1, 2009:   G0402:  Initial preventive physical examination; face -to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment   Short Descriptor:  Initial Preventive exam   G0403:  Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report   Short Descriptor:  EKG for initial prevent exam  G0404:  Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination   Short Descriptor:  EKG tracing for initial prev   G0405:  Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination  Short Descriptor:  EKG interpret & report preve   80.2 - A/B MAC) (B) Billing Requirements  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)
(Medicare Claims Processing Manual)
80.2 - A/B MAC) (B) Billing Requirements  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  Effective for dates of service on and after January 1, 2005, through December 31, 2008, A/B MACs (B)  shall recognize the HCPCS codes G0344, G0366, G0367, and G0368 shown above in 80.1 for an IPPE.  The type of service (TOS) for each of these codes is as follows:   G0344: TOS = 1 G0366: TOS = 5 G0367: TOS = 5 G0368: TOS = 5  A/B MACs (B)  shall pay physicians or qualified nonphysician practitioners for only one IPPE performed not later than 6 months after the date the individuals first coverage begins under Medicare Part B, but only if that coverage period begins on or after January 1, 2005.  Effective for dates of service on and after January 1, 2009, A/B MACs (B)  shall recognize the HCPCS codes G0402, G0403, G0404, and G0405 shown above in 80.1 for an IPPE.  The TOS for each of these codes is as follows:
(Medicare Claims Processing Manual)
G0402:  TOS = 1 G0403:  TOS = 5 G0404:  TOS = 5 G0405:  TOS = 5  Under the MIPPA of 2008, A/B MACs (B)  shall pay physicians or qualified nonphysician practitioners for only one IPPE performed not later than 12 months after the date the individuals first coverage begins under Medicare Part B only if that coverage period begins on or after January 1, 2009.  A/B MACs (B)  shall allow payment for a medically necessary Evaluation and Management (E/M) service at the same visit as the IPPE when it is clinically appropriate.  Physicians and qualified nonphysician practitioners shall use CPT codes 99201- 99215 to report an E/M wi th CPT modifier 25 to indicate that the E/M is a significant, separately identifiable service from the IPPE code reported (G0344 or G0402, whichever applies based on the date the IPPE is performed).  Refer to chapter 12, 30.6.1.1, of this manual for the physician/practitioner billing correct coding and payment policy regarding E/M services.   If the EKG performed as a component of the IPPE is not performed by the primary physician or qualified NPP during the IPPE visit, another physician or entity may perform and/or interpret the EKG.  The referring physician or qualified NPP needs to make sure  that the performing physician or entity bills the appropriate G code for the screening EKG, and not  a CPT code in the 93000 series.  Both the IPPE and the EKG should be billed in order for the beneficiary to receive the complete IPPE service.  Effective f or dates of service on and after January 1, 2009, the screening EKG is optional and is no longer a mandated service of an IPPE if  performed as a result of a referral from an IPPE.   Should the same physician or NPP need to perform an additional medically necessary EKG in the 93000 series on the same day as the IPPE, report the appropriate EKG CPT code(s) with modifier 59, indicating that the EKG is a distinct procedural service.
(Medicare Claims Processing Manual)
Physicians or qualified nonphysician practitioners shall bill the A/B MACs (B)  the appropriate HCPCS codes for IPPE.  The HCPCS codes for an IPPE and screening EKG are paid under the Medicare Physician Fee Schedule (MPFS).  See 1.3 of this chapter for waiver of cost sharing requirements of coinsurance, copayment and deductible for furnished preventive services available in Medicare.   80.3 - A/B MAC (A) Billing Requirements  (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  A/B MACs (A)  will pay for IPPE or EKG only when the services are submitted on one of the following TOBs: 12X, 13X, 22X, 71X, 73X and 85X.   Type of facility and setting determines the basis of payment:    For the IPPE or the screening EKG tracing only performed on a 12X and 13X TOB, hospital inpatient Part B and hospital outpatient, for hospitals subject to the outpatient prospective payment system (OPPS), under the OPPS.  Hospitals not subject to OPPS shal l be paid under current methodologies.    For services performed on an 85X TOB, Critical Access Hospitals (CAHs), pay on reasonable cost.   For services performed in a skilled nursing facility, TOB 22x, make payment for the technical component of the EKG based on the MPFS.    For inpatient or outpatient services in hospitals in Maryland, make payment according to the Health Services Cost Review Commission.    For services performed on a 12X TOB, Indian Health Services (IHS) hospitals, payment is made based on an all -inclusive ancillary per diem rate.    For services performed on a 13X TOB, IHS hospitals, payment is made based on the all -inclusive rate (AIR).    For services performed on an 85X TOB, IHS CAHs, payment is made based on an all -inclusive facility specific per visit rate.
(Medicare Claims Processing Manual)
 For services performed on an 85X TOB, IHS CAHs, payment is made based on an all -inclusive facility specific per visit rate.   All CAHs are paid for the technical or facility component of the IPPE itself.  They are also paid for the technical component of the EKG, the tracing only, if the EKG is performed.  Only CAHs paid under the optional method are paid for the professional component of the IPPE itself (in addition to the facility payment) for charges under revenue code 0960.  If the EKG is performed, CAHs paid under the optional method may also be paid for the interpretation of the EKG (in addition to the payment for the tracing) when billed under revenue codes 0985 or 0986.  80.3.1 - Rural Health Clinic (RHC)/Federally Qualified Health Center (FQHC) Special Billing Instructions  (Rev. 3669, Issued: 12- 02-16, Effective: 01 -01-17, Implementation: 01- 03-17)  There are Initial Preventive Physical Examination ( IPPE)  instructions that are unique to Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).  Refer to chapter 9, section 70.6 of this manual for a description of these instructions.  80.3.2 - Indian Health Services (IHS) Hospitals Special Billing Instructions  (Rev. 1615, Issued: 10- 17-08, Effective: 01 -01-09, Implementation: 01- 05-09)
(Medicare Claims Processing Manual)
For the period January 1, 2005 through December 31, 2008, the designated A/B MAC (A) pays IHS hospitals when G0344 is submitted; this includes the IPPE whether or not the screening EKG is performed at the same time.  The designated A/B MAC (A) will also pa y IHS hospitals for the screening EKG if HCPCS code G0367 is present.  For the professional component of the EKG, the designated A/B MAC (B) shall pay the billing physician or other practitioner the established amount.  Effective January 1, 2009 the following new HCPCS codes have been developed for the IPPE benefit and replace the codes in the paragraph above:  G0402 for the IPPE itself, and G0404 for the technical component (tracing only) of the EKG.  80.3.3 - Outpatient Prospective Payment System (OPPS) Hospital Billing (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  Hospitals subject to OPPS (TOBs 12X and 13X) must use modifier - 25 when billing the IPPE G0344 along with the technical component of the EKG, G0367, on the same claim.  The same is true when billing IPPE code G0402 along with the technical component of the screening EKG, code G0404.  This is due to an OPPS Outpatient Code Editor (OCE) which contains an edit that requires a modifier - 25 on any evaluation and management (E/M) HCPCS code if there is also a status S or T HCPCS procedure code on the claim.   80.4 - Coinsurance and Deductible  (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  The Medicare deductible and coinsurance apply for the IPPE provided before January 1, 2009.   The Medicare deductible is waived effective for the IPPE provided on or after January 1, 2009.  Coinsurance continues to apply for the IPPE provided on or after January 1, 2009.
(Medicare Claims Processing Manual)
The Medicare deductible is waived effective for the IPPE provided on or after January 1, 2009.  Coinsurance continues to apply for the IPPE provided on or after January 1, 2009.   As a result of the Affordable Care Act, effective for the IPPE provided on or after January 1, 2011, the Medicare deductible and coinsurance (for HCPCS code G0402 only) are waived.  80.5 - Medicare Summary Notices (MSNs)  (Rev. 1615, Issued: 10- 17-08, Effective: 01 -01-09, Implementation: 01- 05-09)  When denying additional claims for G0344, G0366, G0367 and G0368, A/B MACs (A) and (B) shall use MSN 18.22 -  This service was denied because Medicare only covers the one- time initial preventive physical exam with an electrocardiogram within the first 6 mon ths that you have Part B coverage, and only if that coverage begins on or after January 1, 2005.   The Spanish version is :  18.22 -  Este servicio fue denegado porque Medicare solamente cubre un examen fisico preventivo con un electrocardiograma dentro de los primeros 6 meses que usted tenga cobertura de la Parte B, y slo si  esta cobertura comienza en o despus del 1 de enero de 2005.  When denying additional claims for G0402 (or claims with dates of service beyond the 12 month period) A/B MACs (A) and (B) shall use MSN 20.91 -  This service was denied.  Medicare covers a one- time initial preventive physical exam (Welcome to Medicare physical exam) if you get it within the first 12 months of the effective date of your Medicare Part B coverage.   The Spanish version is:  Este servicio fue negado.  Medicare cubre un examen fsico de Bienvenido a Medicare ofrecido una sola vez si se obtiene dentro de los primeros 12 meses de la fecha efectiva de su inscripcin a la Parte B de Medicare.
(Medicare Claims Processing Manual)
When denying additional claims for screening EKG codes G0403, G0404 and G0405, A/B MACs (A) and (B) shall use MSN 20.12 -  This service was denied because Medicare only covers this service once a lifetime.   The Spanish version is:  Este servicio fue negado porque Medicare slo cubre este servicio una vez en la vida.   80.6 - Remittance Advice Remark Codes (Rev. 1615, Issued: 10- 17-08, Effective: 01 -01-09, Implementation: 01- 05-09)  A/B MACs (A) and (B) shall use the appropriate claim Remittance Advice Remark code, such as N117 (This service is paid only once in a patients lifetime) when denying additional claims for an IPPE and/or a screening EKG.   80.7 - Claims Adjustment Reason Codes  (Rev. 1615, Issued: 10- 17-08, Effective: 01 -01-09, Implementation: 01- 05-09)  A/B MACs (A) and (B) shall use the appropriate Claim Adjustment Reason code, such as 149 (Lifetime benefit maximum has been reached for this service/benefit category) when denying additional claims for an IPPE and/or a screening EKG.   80.8 - Advanced Beneficiary Notice (ABN) as Applied to the IPPE  (Rev. 1615, Issued: 10- 17-08, Effective: 01 -01-09, Implementation: 01- 05-09)
(Medicare Claims Processing Manual)
80.8 - Advanced Beneficiary Notice (ABN) as Applied to the IPPE  (Rev. 1615, Issued: 10- 17-08, Effective: 01 -01-09, Implementation: 01- 05-09)  If a second IPPE is billed for the same beneficiary, it would be denied based on Section 1861(s)(2) of the Act, since the IPPE is a one- time benefit, and an ABN would not be required in order to hold the beneficiary liable for the cost of the second IPPE.  However, an ABN should be issued for all IPPEs conducted after the beneficiarys statutory 6- month period has lapsed since based on Section 1862(a)(1)(K), Medicare is statutorily prohibited from paying for an IPPE outside the initial 6- month period under the MMA of 2003.  Effective for  dates of service on or after January 1, 2009, an ABN should be issued for all IPPEs conducted after the beneficiarys statutory 12 -month period has lapsed since based on Section 1862(a)(1)(K), Medicare is statutorily prohibited from paying for an IPPE out side the initial 12 -month period under the MIPPA of 2008.  90 - Diabetes Screening  (Rev. 457, Issued: 01- 28-05, Effective: 04 -01-05, Implementation: 04- 04-05)  90.1 - HCPCS Coding for Diabetes Screening  (Rev. 457, Issued: 01- 28-05, Effective: 04 -01-05, Implementation: 04- 04-05)  The following HCPCS codes are to be billed for diabetes screening:   82947 -  Glucose, quantitative, blood (except reagent strip)  82950 -  post -glucose dose (includes glucose)  82951 -  tolerance test (GTT), three specimens (includes glucose)   90.2 - A/B MAC (B) Billing Requirements  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  Effective for dates of service January 1, 2005 and later, A/B MAC (B) shall recognize the above HCPCS codes for diabetes screening.
(Medicare Claims Processing Manual)
Effective for dates of service January 1, 2005 and later, A/B MAC (B) shall recognize the above HCPCS codes for diabetes screening.   A/B MACs (B) shall pay for diabetes screening once every 12 months for a beneficiary that is not pre -diabetic.  A/B MACs (B) shall pay for diabetes screening at a frequency of once every 6 months for a beneficiary that meets the definition of pre -diabetes.   A claim that is submitted for diabetes screening by a physician or supplier for a beneficiary that does not meet the definition of pre -diabetes shall be submitted in the following manner:   The line item shall contain 82947, 82950 or 82951 with a  diagnosis code of V77.1 (if ICD -9-CM is applicable) or (if ICD -10-CM is applicable) diagnosis code Z13.1, encounter for screening for diabetes mellitis reported in the header.   90.2.1 - Modifier Requirements for Pre -diabetes  (Rev. 3329, Issued: 08 -14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  A claim that is submitted for diabetes screening and the beneficiary meets the definition of pre -diabetes shall be submitted in the following manner:   The line item shall contain 82497, 82950 or 82951 with an ICD -9-CM diagnosis code of V77.1 reported (if ICD-9-CM is applicable) or, if ICD -10-CM is applicable, a diagnosis code of Z13.1in the header.  In addition, modifier TS (follow -up service) shall be reported on the line item.   90.3 - A/B MAC (A) Billing Requirements  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  Effective for dates of service January 1, 2005 and later, A/B MACs (A) shall recognize the above HCPCS codes for diabetes screening.
(Medicare Claims Processing Manual)
Effective for dates of service January 1, 2005 and later, A/B MACs (A) shall recognize the above HCPCS codes for diabetes screening.   A/B MACs (A)  shall pay for diabetes screening once every 12 months for a beneficiary that is not pre -diabetic.  A/B MACs (A) shall pay for diabetes screening at a frequency of once every 6 months for a beneficiary that meets the definition of pre -diabetes.   A claim that is submitted for diabetes screening by a physician or supplier for a beneficiary that does not meet the definition of pre -diabetes shall be submitted in the following manner:   The line item shall contain 82947, 82950 or 82951 with an ICD -9-CM diagnosis code of V77.1 or, if ICD -10-CM is applicable, a diagnosis code of Z13 .1.  90.3.1 - Modifier Requirements for Pre -diabetes  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  A claim that is submitted for diabetes screening and the beneficiary meets the definition of pre -diabetes shall be submitted in the following manner:   The line item shall contain 82497, 82950 or 82951 with a diagnosis code of V77.1 (if ICD -9-CM is applicable) or, if, ICD -10-CM is applicable, diagnosis code Z13.1.  In addition, modifier TS (follow -up service) - shall be reported on the line item.  90.4 - Diagnosis Code Reporting  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  A claim that is submitted for diabetes screening shall include the diagnosis code V77.1 (if ICD -9-CM is applicable) or (if ICD -10-CM is applicable) diagnosis code Z13.1.   90.5 - Medicare Summary Notices (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)
(Medicare Claims Processing Manual)
90.5 - Medicare Summary Notices (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  When denying claims for diabetes screening based upon a CWF reject for 82947, 82950 or 82951 reported with ICD -9-CM diagnosis code V77.1 or ICD -10-CM diagnosis code Z13.1, A/B MACs (A) and (B) shall use MSN 18.4, This service is being denied because it has not been 6 months since your last examination of this kind.  (See chapter 30 section 40.3.6.4(c) for additional information on ABNs.)   90.6 - Remittance Advice Remark Codes (Rev. 457, Issued: 01- 28-05, Effective: 04 -01-05, Implementation: 04- 04-05)  A/B MACs (A) and (B) shall use the appropriate remittance advice notice that appropriately explains the denial of payment.   90.7 - Claims Adjustment Reason Codes  (Rev. 457, Issued: 01- 28-05, Effective: 04 -01-05, Implementation: 04- 04-05)  A/B MACs (A) and (B) shall use the appropriate claims adjustment reason code such as 119 Benefit maximum for this time period or occurrence has been reached.   100 - Cardiovascular Disease Screening  (Rev. 408, Issued: 12- 17-04, Effective: 01 -01-05, Implementation: 01 -03-05)  100.1 - HCPCS Coding for Cardiovascular Disease Screening  (Rev. 408, Issued: 12- 17-04, Effective: 01 -01-05, Implementation: 01- 03-05)  The following HCPCS codes are to be billed for Cardiovascular Disease Screening:   80061 -  Lipid Panel  82465 -  Cholesterol, serum or whole blood, total  83718 -  Lipoprotein, direct measurement, high density cholesterol  84478 -  Triglycerides   100.2 - A/B MAC (B) Billing Requirements  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)
(Medicare Claims Processing Manual)
100.2 - A/B MAC (B) Billing Requirements  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  Effective for dates of service, January 1, 2005, and later, A/B MACs (B) shall recognize the above HCPCS codes for Cardiovascular Disease Screening.   A/B MACs (B) shall pay for Cardiovascular Disease Screening once every 60 months.  A claim that is submitted for Cardiovascular Disease Screening shall be submitted in the following manner:   The line item shall contain 80061, 82465, 83718 or 84478 with one of the following diagnoses:   If ICD -9-CM is applicable  V81.0 -  Special screening for ischemic heart disease,  V81.1 -  Special screening for hypertension or  V81.2 -  Special screening for other and unspecified cardiovascular conditions   If ICD -10-CM is applicable  Z13.6 -  encounter for screening for cardiovascular disease   The appropriate diagnosis codes are reported in the header and pointed to the line item.  100.3 - A/B MAC (A) Billing Requirements (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  Effective for dates of service, January 1, 2005, and later, A/B MACs (A)  shall recognize the above HCPCS codes for Cardiovascular Disease Screening.   A/B MACs (A) shall pay for Cardiovascular Disease Screening once every 60 months.  A claim that is submitted for Cardiovascular Disease Screening shall be submitted in the following manner:   The line item shall contain 80061, 82465, 83718 or 84478 with one of the following diagnosis codes reported in the header:   If ICD -9-CM is applicable  V81.0 -  Special screening for ischemic heart disease,  V81.1 -  Special screening for hypertension or  V81.2 -  Special screening for other and unspecified cardiovascular conditions   If ICD -10-CM is applicable  Z13.6 -  encounter for screening for cardiovascular disease   100.4 - Diagnosis Code Reporting  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)
(Medicare Claims Processing Manual)
100.4 - Diagnosis Code Reporting  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  A claim that is submitted for Cardiovascular Disease Screening shall be submitted with one or more of the following diagnosis codes in the header and pointed to the line item:   If ICD -9-CM is applicable  V81.0 -  Special screening for ischemic heart disease,  V81.1 -  Special screening for hypertension, or  V81.2 -  Special screening for other and unspecified cardiovascular conditions   If ICD -10-CM is applicable  Z13.6 -  encounter for screening for cardiovascular disease   100.5 - Medicare Summary Notice  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  When denying claims for cardiovascular screening based upon a CWF reject for 80061, 82465, 83718, or 84478 billed with one or more the of the following diagnosis codes , A/B MACs (A) and (B) shall use MSN 16.54 Medicare does not pay for this many services or supplies.  ICD- 9-CM V81.0, V81.1 or V81.2,   ICD- 10-CM Z13.6  100.6 - Remittance Advice Remark Codes  (Rev. 408, Issued: 12- 17-04, Effective: 01 -01-05, Implementation: 01- 03-05)  A/B MACs (A) and (B) shall use the appropriate remittance advice notice that appropriately explains the denial of payment.   100.7 - Claim Adjustment Reason Code  (Rev. 408, Issued: 12- 17-04, Effective: 01 -01-05, Implementation: 01- 03-05)  A/B MACs (A) and (B) shall use claims adjustment reason code 119 Benefit maximum for this time period has been reached.   110 - Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)  (Rev. 3096, Issued: 10- 17-14, Effective: 01 -27-14, Implementation: 11- 18-14)