evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
 Telehealth originating site facility fee, billed with HCPCS code Q3014.    190.4 - Conditions of Payment  (Rev. 1, 10- 01-03)  1. Technology  For Medicare payment to occur, interactive audio and video telecommunications must be used, permitting real -time communication between the distant site physician or practitioner and the Medicare beneficiary.  As a condition of payment, the patient must be present and participating in the telehealth visit.   2. Exception to the interactive telecommunications requirement   In the case of Federal telemedicine demonstration programs conducted in Alaska or Hawaii, Medicare payment is permitted for telemedicine when asynchronous store and forward technology in single or multimedia formats is used as a substitute for an interactive telecommunications system.   The originating site and distant site practitioner must be included within the definition of the demonstration program.   3. Store and forward defined   For purposes of this instruction, store and forward means the asynchronous transmission of medical information to be reviewed at a later time by physician or practitioner at the distant site.  A patients medical information may include, but not limited to, video clips, still images, x -rays, MRIs, EKGs and EEGs, laboratory results, audio clips, and text.  The physician or practitioner at the distant site reviews the case without the patient being present.  Store and forward substitutes for an interactive encounter with the patient present; the patient is not present in real -time.   NOTE:  Asynchronous telecommunications system in single media format does not include telephone calls, images transmitted via facsimile machines and text messages without visualization of the patient (electronic mail).  Photographs must be specific to the patients condition and adequate for rendering or confirming a diagnosis and or treatment plan.  Dermatological photographs, e.g., a photograph of a skin lesion, may be considered to meet the requirement of a single media format under this instruction.   4. Telepresenters   A medical professional is not required to present the beneficiary to physician or practitioner at the distant site unless medically necessary.  The decision of medical necessity will be made by the physician or practitioner located at the distant site.   190.5 - Originating Site Facility Fee Payment Methodology  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)   1. Originating site defined
(Medicare Claims Processing Manual)
190.5 - Originating Site Facility Fee Payment Methodology  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)   1. Originating site defined    The term originating site means the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs.  For asynchronous, store and forward telecommunications technologies, an originating site is only a Federal telemedicine demonstration program conducted in Alaska or Hawaii.    2. Facility fee for originating site    The originating site facility fee is a separately billable Part B payment.  The contractor pays it outside of other payment methodologies.  This fee is subject to post payment verification.    For telehealth services furnished from October 1, 2001, through December 31, 2002, the originating site facility fee was the lesser of $20 or the actual charge.  For services furnished on or after January 1 of each subsequent year, the originating site fac ility fee is updated by the Medicare Economic Index.  The updated fee is included in the Medicare Physician Fee Schedule (MPFS) Final Rule, which is published by November 1 prior to the start of the calendar year for which it is effective.  The updated fee for each calendar year is also issued annually in a Recurring Update Notification instruction for January of each year.   3. Payment amount:    The originating site facility fee is a separately billable Part B payment.  The payment amount to the originating site is the lesser of 80 percent of the actual charge or 80 percent of the originating site facility fee, except CAHs.  The beneficiary is res ponsible for any unmet deductible amount and Medicare coinsurance.    The originating site facility fee payment methodology for each type of facility is clarified below.    Hospital outpatient department.  When the originating site is a hospital outpatient department, payment for the originating site facility fee must be made as described above and not under the OPPS. Payment is not based on the OPPS payment methodology.    Hospital inpatient.  For hospital inpatients, payment for the originating site facility fee must be made outside the diagnostic related group (DRG) payment, since this is a Part B benefit, similar to other services paid separately from the DRG payment, (e.g., hemophilia blood clotting factor).
(Medicare Claims Processing Manual)
Critical access hospitals.  When the originating site is a critical access hospital, make payment separately from the cost -based reimbursement methodology.  For CAHs, the payment amount is 80 percent of the originating site facility fee.    Federally qualified health centers (FQHCs) and rural health clinics (RHCs).  The originating site facility fee for telehealth services is not an FQHC or RHC service.  When an FQHC or RHC serves as the originating site, the originating site facility fee mus t be paid separately from the center or clinic all -inclusive rate.    Physicians and practitioners offices.  When the originating site is a physicians or practitioners office, the payment amount, in accordance with the law, is the lesser of 80 percent of the actual charge or 80 percent of the originating site facility fe e, regardless of geographic location.  The A/B MAC (B) shall not apply the geographic practice cost index (GPCI) to the originating site facility fee.  This fee is statutorily set and is not subject to the geographic payment adjustments authorized under the MPFS.    Hospital -based or critical access -hospital based renal dialysis center (or their satellites).  When a hospital- based or critical access hospital -based renal dialysis center (or their satellites) serves as the originating site, the originating site facility  fee is covered in addition to any composite rate or MCP amount.    Skilled nursing facility (SNF).  The originating site facility fee is outside the SNF prospective payment system bundle and, as such, is not subject to SNF consolidated billing.  The originating site facility fee is a separately billable Part B payment.    Community Mental Health Center (CMHC).  The originating site facility fee is not a partial hospitalization or intensive outpatient  service.  The originating site facility fee does not count towards the number of services used to determine payment for partial hospitalization  or intensive outpatient  services.  The originating site facility fee is not bundled in the per diem payment for partial hospitalization or intensive outpatient programs .  The originating site facility fee is a separately billable Part B payment.
(Medicare Claims Processing Manual)
Skilled nursing facilities (SNFs) bill their A/B/MAC (A) for the originating site facility fee.  Telehealth bills originating in SNFs must be submitted on TOB 22X or 23X.  For SNF inpatients in a covered Part A stay, the originating site facility fee must be submitted on a 22X TOB.  All SNFs must use revenue code 078X when billing for the originating site facility fee.  The SNF serving as an originating site must bill for HCPCS code Q3014, telehealth originating site facility fee, on a separate revenue line from any other services provided to the beneficiary.    Community mental health centers (CMHCs) bill their A/B/MAC (A) for the originating site facility fee.  Telehealth bills originating in CMHCs must be submitted on a 76X TOB.  All CMHCs must use revenue code 078X when billing for the originating site facilit y fee.  The CMHC serving as an originating site must bill for HCPCS code Q3014, telehealth originating site facility fee, on a separate revenue line from any other services provided to the beneficiary.  Note that Q3014 does not count towards the number of services used to determine per diem payments for partial hospitalization or intensive outpatient  services.    The beneficiary is responsible for any unmet deductible amount and Medicare coinsurance.   190.6 - Payment Methodology for Physician/Practitioner at the Distant Site (Rev. 3586, Issued: 08- 12-16, Effective:  01 -01-17, Implementation: 01- 03-17)  1. Distant Site Defined   The term distant site means the site where the physician or practitioner, providing the professional service, is located at the time the service is provided via a telecommunications system.   2. Payment Amount (professional fee)
(Medicare Claims Processing Manual)
MSN: 9.4  The only claims from institutional facilities that FIs shall pay for telehealth services at the distant site, except for MNT services, are for physician or practitioner services when the distant site is located in a CAH that has elected Method II, and the physician or practitioner has reassigned his/her benefits to the CAH. The CAH bills its regular FI for the professional services provided at the distant site via a telecommunications syst em, in any of the revenue codes 096x, 097x or 098x. All requirements for billing distant site telehealth services apply.  Claims from hospitals or CAHs for MNT services are submitted to the hospital's or CAH's regular FI. Payment is based on the non-facility amount on the Medicare Physician Fee Schedule for the particular HCPCS codes.
(Medicare Claims Processing Manual)
6. Venom Doses and Catch -Up Billing -  Venom doses are prepared in separate vials and not mixed together -  except in the case of the three vespid mix (white and yellow hornets and yellow jackets).  A dose of code 95146 (the two- venom code) means getting some of two venoms.  Similarly, a dose of code 95147 means getting some of three venoms; a dose of code 95148 means getting some of four venoms; and a dose of 95149 means getting some of five venoms.  Some amount of each of the venoms must be provided.  Questions arise when the administration of these venoms does not remain synchronized because of dosage adjustments due to patient reaction.  For example, a physician prepares ten doses of code 95148 (the four venom code) in two vials -  one containing 10 doses of three vespid mix and another containing 10 doses of wasp venom.  Because of dose adjustment, the three vespid mix doses last longer, i.e., they last for 15 doses.  Consequently, questions aris e regarding the amount of replacement wasp venom antigen that should be prepared and how it should be billed.  Medicare pricing amounts have savings built into the use of the higher venom codes.  Therefore, if a patient is in two venom, three venom, four  venom or five venom therapy, the A/B MAC (B) objective is to pay at the highest venom level possible.  This means that, to the greatest extent possible, code 95146 is to be billed for a patient in two venom therapy, code 95147 is to be billed for a patient in three venom therapy, code 95148 is to be billed for a patient in four venom therapy, and code 95149 is to be billed for a patient in five venom therapy.  Thus, physicians are to be instructed that the venom antigen preparation, after dose adjustment, must be done in a manner that, as soon as possible, synchronizes the preparation back to the highest venom code possible.  In the above example, the physician should prepare and bill for only 5 doses of replacement wasp venom -  billing five doses of code  95145 (the one venom code).  This will permit the physician to get back to preparing the four venoms at one time and therefore billing the doses of the cheaper four venom code.  Use of a code below the venom treatment number for the particular patient s
(Medicare Claims Processing Manual)
one venom code).  This will permit the physician to get back to preparing the four venoms at one time and therefore billing the doses of the cheaper four venom code.  Use of a code below the venom treatment number for the particular patient s hould occur only for the purpose of catching up.
(Medicare Claims Processing Manual)
7. Code 95165 Doses . -  Code 95165 represents preparation of vials of non- venom antigens.  As in the case of venoms, some non- venom antigens cannot be mixed together, i.e., they must be prepared in separate vials.  An example of this is mold and pollen.  Therefore, some patients will be injected at one time from one vial -  containing in one mixture all of the app ropriate antigens - while other patients will be injected at one time from more than one vial.   In establishing the practice expense component for mixing a multidose vial of antigens, we observed that the most common practice was to prepare a 10 cc vial; we also observed that the most common use was to remove aliquots with a volume of 1 cc.  Our PE computations were based on those facts.  Therefore, a physicians removing 10 1cc aliquot doses captures the entire PE component for the service.   This does not mean that the physician must remove 1 cc aliquot doses from a multidose vial.  It means that the practice expenses payable for the preparation of a 10cc vial remain the same irrespective of the size or number of aliquots removed from the vial .  Therefore, a physician may not bill this vial preparation code for more than 10 doses per vial;  paying more than 10 doses per multidose vial would significantly overpay the practice expense component attributable to this service.  (NOTE:  this code doe s not include the injection of antigen(s); injection of antigen(s) is separately billable.)   When a multidose vial contains less than 10cc, physicians should bill Medicare for the number of 1 cc aliquots that may be removed from the vial.  That is, a physician may bill Medicare up to a maximum of 10 doses per multidose vial, but should bill Medica re for fewer than 10 doses per vial when there is less than 10cc in the vial.  If it is medically necessary, physicians may bill Medicare for preparation of more than one multidose vial.  EXAMPLES:   (1) If a 10cc multidose vial is filled to 6cc with antigen, the physician may bill Medicare for 6 doses since six 1cc aliquots may be removed from the vial.   (2) If a 5cc multidose vial is filled completely, the physician may bill Medicare for 5 doses for this vial.
(Medicare Claims Processing Manual)
(2) If a 5cc multidose vial is filled completely, the physician may bill Medicare for 5 doses for this vial.   (3) If a physician removes  cc aliquots from a 10cc multidose vial for a total of 20 doses from one vial, he/she may only bill Medicare for 10 doses.  Billing for more than 10 doses would mean that Medicare is overpaying for the practice expense of making the  vial.   (4) If a physician prepares two 10cc multidose vials, he/she may bill Medicare for 20 doses.  However, he/she may remove aliquots of any amount from those vials.  For example, the physician may remove  aliquots from one vial, and 1cc aliquots from the other vial, but may bill no more than a total of 20 doses.  (5) If a physician prepares a 20cc multidose vial, he/she may bill Medicare for 20 doses, since the practice expense is calculated based on the physicians removing 1cc aliquots from a vial.  If a physician removes 2cc aliquots from this vial, thus getting onl y 10 doses, he/she may nonetheless bill Medicare for 20 doses because the PE for 20 doses reflects the actual practice expense of preparing the vial.  (6) If a physician prepares a 5cc multidose vial, he may bill Medicare for 5 doses, based on the way that the practice expense component is calculated.  However, if the physician removes ten  cc aliquots from the vial, he/she may still bill only 5 doses because the practice expense of preparing the vial is the same, without regard to the number of additional doses that are removed from the vial.
(Medicare Claims Processing Manual)
C. Allergy Shots and Visit Services on the Same Day  At the outset of the physician fee schedule, the question was posed as to whether visits should be billed on the same day as an allergy injection (CPT codes 95115- 95117), since these codes have status indicators of A rather than T.  Visits should not be billed with allergy injection services 95115 or 95117 unless the visit repre sents another separately identifiable service.  This language parallels CPT editorial language that accompanies the allergen immunotherapy codes, which include codes 9515 and 95117.   Prior to January 1, 1995, you appeared to be enforcing this policy through three (3) different means:    Advising physician to use modifier 25 with the visit service;   Denying payment for the visit unless documentation has been provided; and   Paying for both the visit and the allergy shot if both are billed for.   For services rendered on or after January 1, 1995, you are to enforce the requirement that visits not be billed and paid for on the same day as an allergy injection through the following means.  Effective for services rendered on or after that date, the gl obal surgery policies will apply to all codes in the allergen immunotherapy series, including the allergy shot codes 95115 and 95117.  To accomplish this, CMS changed the global surgery indicator for allergen immunotherapy codes from XXX, which meant that the global surgery concept did not apply to those codes, to 000, which means that the global surgery concept applies, but that there are no days in the postoperative global period.    Now that the global surgery policies apply to these services, you are to rely on the use of modifier 25 as the only means through which you can make payment for visit services provided on the same day as allergen immunotherapy services.  In order for a physician to receive payment for a visit service provided on the same day that the physician also provides a service in the allergen immunotherapy series (i.e., any service in the series from 95115 through 95199), the physician is to bill a modifier 25 with t he visit code, indicating that the patients condition required a significant, separately identifiable visit service above and beyond the allergen immunotherapy service provided.
(Medicare Claims Processing Manual)
D. Reasonable Supply of Antigens   See CMS Manual System, Internet Only Manual, Medicare Benefits Policy Manual, CMS Pub. 100- 02 Chapter 15, section 50.4.4, regarding the coverage of antigens, including what constitutes a reasonable supply of antigens.  210 - Outpatient Mental Health Treatment Limitation  (Rev. 2166, Issued: 02- 25-11, Effective: 03 -25-11, Implementation: 03- 25-11)  Regardless of the actual expenses a beneficiary incurs in connection with the treatment of mental, psychoneurotic, and personality disorders while the beneficiary is not an inpatient of a hospital at the time such expenses are incurred, the amount of those  expenses that may be recognized for Part B deductible and payment purposes is limited to 62.5 percent of the Medicare approved amount for those services.  This limitation is called the outpatient mental health treatment limitation (the limitation).  The 6 2.5 percent limitation has been in place since the inception of the Medicare Part B program and it will remain effective at this percentage amount until January 1, 2010.  However, effective January 1, 2010, through January 1, 2014, the limitation will be phased out as follows:    January 1, 2010 -  December 31, 2011, the limitation percentage is 68.75%.  (Medicare pays 55% and the patient pays 45%).    January 1, 2012 -  December 31, 2012, the limitation percentage is 75%.  (Medicare pays 60% and the patient pays 40%).    January 1, 2013 -  December 31, 2013, the limitation percentage is 81.25%.  (Medicare pays 65% and the patient pays 35%).    January 1, 2014 -  onward, the limitation percentage is 100%. (Medicare pays 80% and the patient pays 20%).   For additional details concerning computation of the limitation, please see the examples under section 210.1 E.   210.1 - Application of the Limitation  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    A. Status of Patient
(Medicare Claims Processing Manual)
210.1 - Application of the Limitation  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    A. Status of Patient    The limitation is applicable to expenses incurred in connection with the treatment of an individual who is not an inpatient of a hospital.  Thus, the limitation applies to mental health services furnished to a person in a physicians office, in the patient s home, in a skilled nursing facility, as an outpatient, and so forth.  The term hospital in this context means an institution, which is primarily engaged in providing to inpatients, by or under the supervision of a physician(s):     Diagnostic and therapeutic services for medical diagnosis, treatment and care of injured, disabled, or sick persons;     Rehabilitation services for injured, disabled, or sick persons; or     Psychiatric services for the diagnosis and treatment of mentally ill patients.    B. Disorders Subject to the Limitation    The term mental, psychoneurotic, and personality disorders is defined as the specific psychiatric diagnoses described in the International Classification of Diseases, 9th Revision (ICD -9), under the code range 290-319.    When the treatment services rendered are both for a psychiatric diagnosis as defined in the ICD -9 and one or more nonpsychiatric conditions, separate the expenses for the psychiatric aspects of treatment from the expenses for the nonpsychiatric aspects of treatment.  However, in any case in which the psychiatric treatment component is not readily distinguishable from the nonpsychiatric treatment component, all of the expenses are allocated to whichever component constitutes the primary diagnosis.    1. Diagnosis Clearly Meets Definition -  If the primary diagnosis reported for a particular service is the same as or equivalent to a condition described in the ICD9 under the code range 290- 319 that represents mental, psychoneurotic and personality disorders, the expense for the service is subject to the limitation except as described in subsection D.    2. Diagnosis Does Not Clearly Meet Definition -  When it is not clear whether the primary diagnosis reported meets the definition of mental, psychoneurotic, and personality disorders, it may be necessary to contact the practitioner to clarify the diagnosis.  I n deciding whether contact is necessary in a given case, give consideration to such factors as the type of services rendered, the diagnosis, and the individuals previous utilization history.    C. Services Subject to the Limitation