evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
Appropriate billing for a total of 49 minutes is 3 units. To allocate those 3 units, determine the 15-minute blocks first18 minutes 97110 = one 15-minute block + 3 remaining minutes13 minutes 97140 = zero 15-minute blocks + 13 remaining minutes10 minutes 97116 = zero 15-minute blocks + 10 remaining minutes8 minutes 97035 = zero 15-minute blocks + 8 remaining minutesCode 97110 shall be billed for at least one unit as it contains one 15-minute block. The additional 2 units billable (for a total of 3 units for the day), must be applied to the services with the greatest remaining minutes. The correct coding is1 unit 97110 + 1 unit 97140 + 1 unit 97116There are not enough total minutes for the day to allow billing for the ultrasound. However, the ultrasound will still be documented in the treatment notes.7 minutes of neuromuscular reeducation (CPT 97112)7 minutes of therapeutic exercise (97110)7 minutes of manual therapy (97140)___________________________________________21 total Timed Code Treatment minutesThe clinician shall select which CPT code to bill since each service was performed for the same amount of time and only one unit is allowed. The correct coding is1 unit 97112OR1 unit 97110OR1 unit 97140For treatment sessions with both timed and untimed services, the units and time documented for any untimed CPT codes should not be included in the counting of units and time for the timed CPT codes for a calendar day. The minutes for the timed codes are reflected in the Timed Code Treatment Minutes, with the units allocated as described above. The untimed minutes are reflected in the Total Treatment Time, which is a combination of the timed code minutes and the untimed code minutes. Per CMS, it is important that the total number of timed treatment minutes support the billing of units on the claim, and that the total treatment time reflects services billed as untimed codes. For example:
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
35 minutes OT evaluation (CPT 97162-untimed code)25 minutes therapeutic exercise (CPT 97110)8 minutes therapeutic activities (CPT 97530)_____________________________________Total Timed Code Treatment minutes = 33 minutesTotal Treatment Time = 68 minutesThe evaluation, being an untimed code, is billable as 1 unit. Do not include the evaluation minutes in the total timed code treatment minutes when determining the appropriate number of units to bill for the timed codes. 33 total minutes of timed codes is billable as 2 units. To allocate the 2 timed code units, break out the 15-minute blocks first25 minutes 97110 = one 15-minute block + 10 remaining minutes8 minutes 97530 = zero 15-minute blocks + 8 remaining minutesSince code 97110 has one 15-minute block, at least 1 unit of 97110 shall be billed. To determine which code shall be billed with the second unit,compare the remaining minutes. Since code 97110 has more remaining minutes, the second timed code unit shall be applied to this code. Correct coding for this session is1 unit 97162 + 2 units 97110The medical record documentation will note that the therapeutic activities wereperformed.40 minutes PT evaluation (CPT97163-untimed)20 minutes unattended electrical stimulation (CPT G0283-untimed)10 minute therapeutic exercise for home exercise program (CPT 97110)Total Timed Code Treatment Minutes = 10 minutesTotal Treatment Time = 70 minutesThe untimed services are billable as 1 unit each. 10 minutes for the timed code is billable as 1 unit. The correct coding for this session is1 unit 97163 + 1 unit G0283 + 1 unit 97110Payment for therapy services is based on the qualified professional/auxiliary personnel's time spent in treating the individual patient. For this reason, in the same time period (such as from 1:00 to 1:15) a clinician cannot bill any of the following pairs of CPT codes for therapy services provided to the same, or to different patients.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
Any two CPT codes for "therapeutic procedures" requiring direct one-on-one patient contact (CPT codes 97110-97762)Any two CPT codes for modalities requiring "constant attendance" and direct one-on-one patient contact (CPT codes 97032-97039)Any two CPT codes requiring either constant attendance or direct one-on-one patient contact - as described in (a) or (b) above - (CPT codes 97032-977622), for example, any CPT code for a therapeutic procedure (e.g., 97116 - gait training) with any attended modality CPT code (e.g., 97035 - ultrasound)Any CPT code for therapeutic procedures requiring direct one-on-one patient contact (CPT codes 97110-97762) with the group therapy CPT code (97150) requiring constant attendance, for example, group therapy (97150) with neuromuscular reeducation (97112)Any CPT code for modalities requiring constant attendance (CPT codes 97032-97039) with the group therapy CPT code (97150) for example, group therapy (97150) with ultrasound (97035)Any untimed evaluation or reevaluation code (CPT codes 97161-97168) with any other timed or untimed CPT codes, including constant attendance modalities (CPT codes 97032-97039), therapeutic procedures (CPT 97110-97762) and group therapy (CPT code 97150)Miscoded services may lead to improper payment, or if medically reviewed, denials of billed charges. Medical records must always support all HCPCS/CPT codes and units billed.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
Miscoded services may lead to improper payment, or if medically reviewed, denials of billed charges. Medical records must always support all HCPCS/CPT codes and units billed.Do not bill for documentation time separately(except for CPT code 96125). This is incorporated in the HCPCS/CPT fee reimbursed for each individual service provided.Do not code higher than what the procedure requires. Coding in this manner may allow the provider to collect inappropriate revenues without incurring additional costs.Do not select the HCPCS/CPT code based on the reimbursement amount associated with a particular HCPCS/CPT. Rather select the HCPCS/CPT based on the code that most accurately describes the service actually provided and/or the intention of the treatment to achieve the desired outcome/goal.Do not unbundle services/procedures. Unbundling refers to the practice of splitting a single payment code into two or more codes. This may lead to inappropriate multiple payments.Do not bill separately for supplies used to provide therapy services, such as electrodes, theraband, theraputty, etc.Therapists, or therapy assistants, working together as a team to treat a patient cannot each bill separately for the same or different service provided at the same time to the same patient. For example, if an OT and PT are co-treating a patient with sitting balance and ADL deficits for 30 minutes, then only 2 units total can be billed to the patient: either 2 units of OT only; 2 units of PT only; or 1 unit of OT and 1 unit of PT.Utilization Guidelines and Maximum Billable Units per Date of ServiceRarely, except during an evaluation, should therapy session length be greater than 30-60 minutes. If longer sessions are required, documentation must support as medically necessary the duration of the session and the amount of interventions performed.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
The following interventions should be reported no more than one unit per code per day per discipline; additional units will be denied:97012, 97016, 97018, 97022, 97024, 97028, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97597, 97598, 97605, 97606, G0281, G0283, G0329.The following timed interventions should be reported no more than 2 (two) units per code per day per discipline; additional units will be denied: 97033, 97034, 97035, 97036.The following interventions should be reported no more than 4 (four) units per code per day per discipline; additional units will be denied:97032, 97110, 97112, 97113, 97116, 97124, 97530,97533, 97535, 97537, 97542, 97760, 97761, 97763, 97129, 97130.Denials due to the limits described in this section of the LCD may be appealed.Documentation Requirements for Unlisted Procedure Codes (97039, 97139, 97799, 29799)97039 - In addition to a detailed service description, information in the medical record submitted to the contractor must specify the type of modality utilized and, if the modality requires the constant attendance of the qualified professional/auxilliary personnel, the time spent by the qualified professional/auxilliary personnel, one-on-one with the beneficiary.97139 - Information in the medical record and on the claim submitted to the contractor must specify the procedure furnished and also meet the other requirements for therapeutic procedures, i.e., the process of effecting change, through the application of clinical skills or services that attempt to improve function.97799 - Information in the medical record submitted to the contractor must specify the service or procedure furnished, provide an adequate description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)
29799 - Information in the medical record submitted to the contractor must specify the service. It should also indicate the nature of the injury being treated and the anticipated outcome of the treatment.Other Comments:For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC to process their claims.In addition to a detailed service description, information in the medical record submitted to the contractor must specify the type of modality utilized and, if the modality requires the constant attendance of the qualified professional/auxiliary personnel, the time spent by the qualified professional/auxiliary personnel, one-on-one with the beneficiary.
Article - Billing and Coding: Ocular Photography - External (A57068)
CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Code of Federal Regulations:42 CFR Section 410.32, indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).Article TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L34393-Ocular Photography - External.General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Article - Billing and Coding: Ocular Photography - External (A57068)
Advance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.
Article - Billing and Coding: Ocular Photography - External (A57068)
The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Office records/progress notes must document the complaint, symptomatology, or reason necessitating the test and must include the examination results/findings.External ocular photographs may be print, slide, video or digital media, and copies must be available for review by Medicare if requested. Photographs must be permanently labeled with the patients name and date, and a notation of which eye is pictured. In addition to the photograph(s), an interpretation and report specific to the photograph(s) must be maintained in the patient's medical record and be available to the contractor upon request.If additional photographs are taken to track changes in the patients condition, written documentation describing changes is required and must be maintained in the patients medical record. An interpretation of the photograph(s) with comparison to prior photographs, if available, must be maintained in the patients medical record and available for review, if requested.The frequency with which external ocular photography should be performed is based on the patient's underlying condition and the usual progression of that condition. This service should not be repeated if there has been no change in the patients conditions.
Article - Billing and Coding: Ocular Photography - External (A57068)
The frequency with which external ocular photography should be performed is based on the patient's underlying condition and the usual progression of that condition. This service should not be repeated if there has been no change in the patients conditions.In some cases, it is expected that this service would be reasonable once yearly. However, in certain conditions, this test may be appropriate more frequently.For claims submitted to the Part B MAC:Claims for external ocular photography services are payable under Medicare Part B in the following places of service.The global service is payable in office (11), home (12), assisted living facility (13), temporary lodging (16), urgent care facility (20), nursing facility for patients not in a Part A stay (32), custodial care facility (33), and independent clinic (49).Modifier TC is reported for the technical component of the service. The technical component is payable in office (11), home (12), assisted living facility (13), temporary lodging (16), urgent care facility (20), nursing facility for patients not in a Part A stay (32), custodial care facility (33), and independent clinic (49), federally qualified health center (50), and rural health clinic (72).The professional component is reported with modifier 26 and is payable in office (11), home (12, assisted living facility (13), temporary lodging (16), urgent care facility (20), inpatient hospital (21), outpatient hospital (22), emergency room (23), skilled nursing facility for patients in a Part A stay (31), nursing facility for patients not in a Part A stay (32), custodial care facility (33), and independent clinic (49).For claims submitted to the Part A MAC:Hospital Inpatient Claims:The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04.The principal diagnosis is the condition established after study to be chiefly responsible for this admission.
Article - Billing and Coding: Ocular Photography - External (A57068)
Hospital Inpatient Claims:The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04.The principal diagnosis is the condition established after study to be chiefly responsible for this admission.The hospital enters ICD-10-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-08,Medicare Program Integrity Manual, Chapter 25, Section 75 for additional instructions.)Hospital Outpatient Claims:The hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67.If no definitive diagnosis is made during the outpatient evaluation, the patients symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the providershould report an ICD-10-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9).The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.
Article - Billing and Coding: Ocular Photography - External (A57068)
For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care for external ocular photography services as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)Other Comments:For claims submitted to the Part A MAC. This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC to process their claims.Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.
Article - Billing and Coding: Ophthalmic Angiography (Fluorescein and Indocyanine Green) (A57069)
CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1862(a) (7) excludes routine physical examination unless otherwise covered by statute.Code of Federal Regulations:42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).CMS Publications:CMS Publication 100-03,Medicare National Coverage Determinations, Chapter 1:80.3 Coverage of photosensitive drugs.Article TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L34175Ophthalmic Angiography (Fluorescein and Indocyanine Green).