evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
A/B MACs (B) must also inform eligible practitioners about the use of modifier - AQ on claims for 10 -  or 90 - day global surgical procedures that were furnished in HPSAs approved by December 31 of the preceding calendar year, but that are not recognized for automatic payment.  The modifier must be appended to the surgical procedure for the service to be eligible for the 10 percent additional HSIP payment.   B. Method of Payment    Calculate and pay general surgeons an additional 10 percent incentive payment;    Calculate the payment based on the amount actually paid for the service, not the Medicare approved amount;    Combine the HSIP incentive payments, when appropriate, with other incentive payments, including the HPSA physician bonus payment;    Accept and pay the incentive payment for 10 -  and 90 -  day global period surgical procedures furnished by general surgeons (02) and submitted with the modifier -AQ;   Provide a special remittance form that is forwarded with the incentive payment so that physicians and nonphysician  practitioners can identify which type of incentive payment (HPSA, HSIP, and/or PCIP) was paid for which services;    Use the PLB03 adjustment reason code LE;    Add the following message to the incentive checks:  This check is for the HPSA, HSIP and/or PCIP.  See special remittance for details; and    Inform practitioners to contact their A/B MAC (B) with any questions regarding HSIP payments.   C. Changes for A/B MAC (B)  Systems   The Medicare Carrier System, (MCS), Common Working File (CWF,) and National Claims History (NCH) shall be modified to accept a new incentive HPSA/PSA/HSIP/PCIP payment indicator on the claim line.   Once the type of incentive has been identified by the shared systems, the shared system shall transmit the HPSA/PSA/HSIP/PCIP indicator to CWF and modify their systems to set the indicator on the claim line as follows:  1 = HPSA;  2 = PSA;  3 = HPSA and PSA;  4 = HSIP;  5 = HPSA and HSIP;  6 = PCIP;  7 = HPSA and PCIP; and  Space = Not Applicable.
(Medicare Claims Processing Manual)
In accordance with section 102(a)(1) of the PACMBPRA, for outpatient services furnished on or after June 25, 2010, the technical portion of all nondiagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the date of a beneficiarys inpatient admission are deemed related to the admission and thus, must be included on the bill for the inpatient stay. Also, the technical portion of outpatient nondiagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the first, second,  and  the third  calendar days (1 calendar day for a nonsubsec tion (d) hospital) immediately preceding the date of admission are deemed related to the admission and, therefore, must be billed with the inpatient stay, unless the nondiagnostic services are unrelated to the inpatient hospital claim (that is, the preadmission nondiagnostic services are clinically distinct or independent from the reason for the beneficiarys inpatient admission).  In such cases, the unrelated outpatient hospital nondiagnostic services are covered by Medicare Part B, and the hospital or wholly owned or wholly operated physician practice shall include the technical portion of the services in their billing. PACMBPRA did not change the requirement that the technical portion of all diagnostic services provided by the hospital (or entity wholly owned or wholly operated by the hospital) occurring on the date of an inpatient admission, or during the 3 calendar days (or 1 calendar day) immediately preceding the date of an inpatient admission must be billed with the inpatient admission.   Implementation of the 3- day Payment Window Policy in Wholly Owned or Operated Entities
(Medicare Claims Processing Manual)
Implementation of the 3- day Payment Window Policy in Wholly Owned or Operated Entities   Wholly owned or wholly operated entities are subject to the 3- day (or 1- day) payment window policy when they furnish preadmission diagnostic services to a patient, who is later admitted as an inpatient on the same day or within the preceding 3 calendar days (preceding1 calendar day), or when they furnish preadmission nondiagnostic services to a patient, who is later admitted as an inpatient on the same day or within the preceding 3 calendar days (preceding 1 calendar day) for related medical care. Only unre lated nondiagnostic preadmission services are not subject to the payment window policy, where unrelated preadmission nondiagnostic services are clinically distinct or independent from the reason for the beneficiary's inpatient admission and are furnished on the 1st, 2nd, or 3rd calendar day immediately preceding the date of the inpatient admission. (Note: nondiagnostic services furnished by a wholly owned or wholly operated physician practice on the date of a beneficiarys inpatient admission to the hospita l are always deemed to be related to the admission and their technical portion must be included on the bill for the inpatient admission.) When an entity that is wholly owned or wholly operated by a hospital furnishes a service subject to the 3- day window policy, Medicare will pay the professional component of services with payment rates that include a professional and technical split and at the facility rate for services that do not have a professional and technical split. Once the entity has received confi rmation of a beneficiarys inpatient admission from the admitting hospital, they shall, for services furnished during the three -day window,  append a CMS payment modifier to all claim lines for diagnostic services and for those nondiagnostic services that have been identified as related to the inpatient stay.   Physician nondiagnostic services that are unrelated to the hospital admission are not subject to the payment window and shall be billed without the payment modifier.   Definition of Wholly Owned or Wholly Operated Entities
(Medicare Claims Processing Manual)
 The facility rate for codes without a TC/PC split.   Global Surgical Services and the 3 -day Payment Window Policy  We note that the time frames associated with 10 and 90 day global surgical packages could overlap with the 3- day (or 1- day) payment window policy.   The 3- day payment window makes no change in billing surgical services according to global surgical rules, and pre - and post -operative services continue to be included in the payment for the surgery. However, there may be times when the surgery itself is subject to t he three- day window policy, as would occur if the surgery were performed within the three -day window.  For example, a patient could have a minor surgery in a wholly owned or wholly operated physician office and then, due to a complication, be admitted to t he hospital as an inpatient.  In such cases the modifier shall be appended to the appropriate surgical HCPCS/CPT code.
(Medicare Claims Processing Manual)
 Comprehensive care not limited by organ system or  diagnosis.  Residency programs most likely qualifying for this exception include family practice, general internal medicine, geriatric medicine, pediatrics, and obstetrics/gynecology.   Certain GME programs in psychiatry may qualify in special situations such as when the program furnishes comprehensive care for chronically mentally ill patients. These would be centers in which the range of services the residents are trained to furnish, and actually do furnish, include comprehensive medical care as well as psychiatric care. For example, antibiotics are being prescribed as well as psychotropic drugs.   The patient medical record must document the extent of the teaching physicians participation in the review and direction of the services furnished to each beneficiary.  The extent of the teaching physicians participation may be demonstrated by the notes in the medical records made by physicians, residents, or nurses.   100.1.2 - Surgical Procedures  (Rev. 2303, Issued: 09- 14-11, Effective: 06 -01-11, Implementation: 07- 26-11)  In order to bill for surgical, high- risk, or other complex procedures, the teaching physician must be present during all critical and key portions of the procedure and be immediately available to furnish services during the entire procedure.   A. Surgery (Including Endoscopic Operations)   The teaching surgeon is responsible for the preoperative, operative, and postoperative care of the beneficiary.  The teaching physicians presence is not required during the opening and closing of the surgical field unless these activities are considered t o be critical or key portions of the procedure.  The teaching surgeon determines which postoperative visits are considered key or critical and require his or her presence.  If the postoperative period extends beyond the patients discharge and the teaching surgeon is not providing the patients follow -up care, then instructions on billing for less than the global package in 40 apply.  During non- critical or non -key portions of the surgery, if the teaching surgeon is not physically present, he/she must be i mmediately available to return to the procedure, i.e., he/she cannot be performing another procedure.  If circumstances prevent a teaching physician from being immediately available, then he/she must arrange for another qualified surgeon to be immediately available to assist with the procedure, if needed.   1. Single Surgery
(Medicare Claims Processing Manual)
1. Single Surgery   When the teaching surgeon is present for the entire surgery, his or her presence may be demonstrated by notes in the medical records made by the physician, resident, or operating room nurse.  For purposes of this teaching physician policy, there is no required information that the teaching surgeon must enter into the medical records.   2. Two Overlapping Surgeries   In order to bill Medicare for two overlapping surgeries, the teaching surgeon must be present during the critical or key portions of both operations.  Therefore, the critical or key portions may not take place at the same time.  When all of the key portions of the initial procedure have been completed, the teaching surgeon may begin to become involved in a second procedure.  The teaching surgeon must personally document in the medical record that he/she was physically present during the critical or key port ion(s) of both procedures.  When a teaching physician is not present during non- critical or non -key portions of the procedure and is participating in another surgical procedure, he/she must arrange for another qualified surgeon to immediately assist the re sident in the other case should the need arise.  In the case of three concurrent surgical procedures, the role of the teaching surgeon (but not anesthesiologist) in each of the cases is classified as a supervisory service to the hospital rather than a phys ician service to an individual patient and is not payable under the physician fee schedule.  3. Minor Procedures   For procedures that take only a few minutes (five minutes or less) to complete, e.g., simple suture, and involve relatively little decision making once the need for the operation is determined, the teaching surgeon must be present for the entire procedure in order to bill for the procedure.   4. Anesthesia   Medicare pays at the regular fee schedule level if a teaching anesthesiologist is involved in a single procedure with one resident.  The teaching physician must document in the medical records that he/she was present during all critical (or key) portions of the procedure.  The teaching physicians physical presence during only the preoperative or postoperative visits with the beneficiary is not sufficient to receive Medicare payment. If an anesthesiologist is involved in concurrent procedures with more than one resident or with a resident and a nonphysician anesthetist and the service is furnished prior to January 1, 2010, Medicare pays for the anesthesiologists services as medical direction.
(Medicare Claims Processing Manual)
In those cases where the teaching anesthesiologist is involved in two concurrent anesthesia cases with residents on or after January 1, 2004, the teaching anesthesiologist may bill the usual base units and anesthesia time for the amount of time he/she is p resent with the resident.  The teaching anesthesiologist can bill base units if he/she is present with the resident throughout pre and post anesthesia care.  The teaching anesthesiologist should use the AA modifier to report such cases.  The teaching ane sthesiologist must document his/her involvement in cases with residents.  The documentation must be sufficient to support the payment of the fee and available for review upon request.   For anesthesia services furnished on or after January 1, 2010, payment may be made under the Medicare physician fee schedule at the regular fee schedule level if the teaching anesthesiologist is involved in the training of a resident in a single anesthesia  case, two concurrent anesthesia cases involving residents, or a single anesthesia case involving a resident that is concurrent to another case paid under the medical direction rules.  To qualify for payment, the teaching anesthesiologist, or different anesthesiologists in the same anesthesia group, must be present during all critical or key portions of the anesthesia service or procedure involved.  The teaching anesthesiologist (or another  anesthesiologist with whom the teaching physician has entered into an arrangement) must be immediately available to furnish anesthesia services during the entire procedure.  The documentation in the patients medical records must indicate the teaching physicians presence during all critical or key portions of the anesthesia procedure and the immediate availability of another teaching anesthesiologist as necessary.   If different teaching anesthesiologists are present with the resident during the key or critical periods of the resident case, the NPI of the teaching anesthesiologist who started the case must be indicated in the appropriate field on the claim form.   The teaching anesthesiologist should use the AA modifier and the GC certification modifier to report such cases.  See 50 B. and 0 K.  5. Endoscopy Procedures
(Medicare Claims Processing Manual)
The teaching anesthesiologist should use the AA modifier and the GC certification modifier to report such cases.  See 50 B. and 0 K.  5. Endoscopy Procedures   To bill Medicare for endoscopic procedures (excluding endoscopic surgery that follows the surgery policy in subsection A, above), the teaching physician must be present during the entire viewing.  The entire viewing starts at the time of insertion of the endoscope and ends at the time of removal of the endoscope.  Viewing of the entire procedure through a monitor in another room does not meet the teaching physician presence requirement.  6. Interpretation of Diagnostic Radiology and Other Diagnostic Tests   Medicare pays for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by or reviewed with a teaching physician.  If the teaching physicians signature is the only signature on the interpretation, Medicar e assumes that he/she is indicating that he/she personally performed the interpretation.  If a resident prepares and signs the interpretation, the teaching physician must indicate that he/she has personally reviewed the image and the residents interpretat ion and either agrees with it or edits the findings.  Medicare does not pay for an interpretation if the teaching physician only countersigns the residents interpretation.  100.1.3 - Psychiatry  (Rev. 811, Issued: 01- 13-06, Effective: 01 -01-06, Implementation: 02- 13-06)  The general teaching physician policy set forth in 100.1 applies to psychiatric services.  For certain  psychiatric services, the requirement for the presence of the teaching physician during the service may be met by concurrent observation of the service by use of a one -way mirror or video equipment.  Audio- only equipment does not satisfy to the physical pr esence requirement.  In the case of time -based services such as individual medical psychotherapy, see 100.1.4, below.  Further, the teaching physician supervising the resident must be a physician, i.e., the Medicare teaching physician policy does not apply to psychologists who supervise psychiatry residents in approved GME programs.  100.1.4 - Time -Based Codes  (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)
(Medicare Claims Processing Manual)
For procedure codes determined on the basis of time, the teaching physician must be present for the period of time for which the claim is made.  For example, a code that specifically describes a service of from 20 to 30 minutes may be paid only if the teac hing physician is physically present for 20 to 30 minutes.  Do not add time spent by the resident in the absence of the teaching physician to time spent by the resident and teaching physician with the beneficiary or time spent by the teaching physician alone with the beneficiary.  Examples of codes falling into this category include:    Individual medical psychotherapy (HCPCS codes 90804 -  90829);    Critical care services (CPT codes 99291 -99292);    Hospital discharge day management (CPT codes 99238- 99239);   E/M codes in which counseling and/or coordination of care dominates (more than 50 percent) of the encounter, and time is considered the key or controlling factor to qualify for a particular level of E/M service;    Office/outpatient E/M visit codes for which total time is used for the visit level selection.  For purposes of selecting visit level, only count time spent by the teaching physician performing qualifying activities listed by CPT (with or without direct pat ient contact on the date of the encounter), including the time the teaching physician is present when the resident is performing such activities;    Prolonged services (CPT codes 99358- 99359); and   Care plan oversight (HCPCS codes G0181 -  G0182).  100.1.5 - Other Complex or High -Risk Procedures  (Rev. 1, 10- 01-03)  In the case of complex or high- risk procedures for which national Medicare policy,  local policy, or the CPT description indicate that the procedure requires personal (in person) supervision of its performance by a physician, pay for the physician services associated with the procedure only when the teaching physician is present with the resident.  The presence of the resident alone would not establish a basis for fee schedule payment for such services.  These procedures include interventi onal radiologic and cardiologic supervision and interpretation codes, cardiac catheterization, cardiovascular stress tests, and trans -esophageal echocardiography.
(Medicare Claims Processing Manual)
100.1.6 - Miscellaneous  (Rev. 1458, Issued: 02- 22-08, Effective: 03 -24-08, Implementation: 03- 24-08)  In the case of maternity services furnished to women who are eligible for Medicare, apply the physician presence requirement for both types of delivery as A/B MACs (B) would for surgery.  In order to bill for the procedure, the teaching physician must be present for the delivery.  These procedure codes are somewhat different from other surgery codes in that there are separate codes for global obstetrical care (prepartum, delivery, and postpartum) and for deliveries only.  In situations in which the teaching physicians only involvement was at the time of delivery, the teaching physician should bill the delivery only code.  In order to bill for the global procedures, the teaching physician must be present for the minimum indicated number of  visits when such a number is specified in the description of the code.  This policy differs from the policy on general surgical procedures under which the teaching physician is not required to be present for a specified number of visits.  In the case of end stage renal related visits furnished under the monthly capitation payment method (MCP), the physician presence policy as discussed in 100.1 applies.  Patient visits furnished by residents may be counted toward the MCP visits if the teac hing MCP physician is physically present during the visit. The teaching physician may utilize the residents notes, however the teaching physician must document his or her physical presence during the visit(s) furnished by the resident and that he or she r eviewed the residents notes.  The teaching physician could document these criteria as part of an extensive once a month MCP note.   100.1.7 - Assistants at Surgery in Teaching Hospitals  (Rev. 811, Issued: 01- 13-06, Effective: 01 -01-06, Implementation: 02- 13-06)  A. General   A/B MACs (B) do not pay for the services of assistants at surgery furnished in a teaching hospital which has a training program related to the medical specialty required for the surgical procedure and has a qualified resident available to perform the servi ce unless the requirements of one of subsections C, D, or E are met. Each teaching hospital has a different situation concerning numbers of residents, qualifications of residents, duties of residents, and types of surgeries performed.
(Medicare Claims Processing Manual)
Contact those affected by these instructions to learn the circumstances in individual teaching hospitals.  There may be some teaching hospitals in which A/B MACs (B) can apply a presumption about the availability of a qualified resident in a training progr am related to the medical specialty required for the surgical procedures, but there are other teaching hospitals in which there are often no qualified residents available.  This may be due to their involvement in other activities, complexity of the surgery, numbers of residents in the program, or other valid reasons. A/B MACs (B) process assistant at surgery claims for services furnished in teaching hospitals on the basis of the following certification by the assistant, or through the use of modifier - 82 which indicates that a qualified resident surgeon was not available.  This certification is for use only when the basis for payment is the unavailability of qualified residents.   I understand that 1842(b)(7)(D)  of the Act (follow the link and select the applicable title) generally prohibits Medicare physician fee schedule payment for the services of assistants at surgery in teaching hospitals when qualified residents are available to furnish such services. I cer tify that the services for which payment is claimed were medically necessary and that no qualified resident was available to perform the services. I further understand that these services are subject to post -payment review by the A/B MAC (B).  A/B MACs (B) retain the claim and certification for four years and conduct post -payment reviews as necessary.  For example, A/B MACs (B) investigate situations in which it is always certified that there are no qualified residents available, and undertake r ecovery if warranted.   Assistant at surgery claims denied based on these instructions do not qualify for payment under the limitation on liability provision.   B. Definition   An assistant at surgery is a physician who actively assists the physician in charge of a case in performing a surgical procedure.  (Note that a nurse practitioner, physician assistant or clinical nurse specialist who is authorized to provide such services under State law can also serve as an assistant at su rgery).  The conditions for coverage of such services in teaching hospitals are more restrictive than those in other settings because of the availability of residents who are qualified to perform this type of service.  C. Exceptional Circumstances