evekhm/cms_iom_500 huggingface dataset:
Social Security Act §1833
[94]P.L.114-10, 202(b)(1)(B) added subparagraph 1833(g)(5)(E). EffectiveApril 16, 2015.P.L. 115123, 50202(3)(B)inserted text following implemented. Effective February9, 2018.[95]P.L.112-96, 3005(b)(2), added paragraph (6), effective February22, 2012.P.L. 112-240, 603(b)(1), struckout In applying and inserted (A) In applying,effective January 2, 2013.P.L. 113-67, 1103, struck out December 31,2013 and inserted March 31, 2014, effective December26, 2013.P.L. 113-67 1103, struck or 2013, andinserted , 2013 or the first three months of 2014. EffectiveDecember 26, 2013.P.L. 113-93 103(2), struck out March 31, 2014and inserted March 31, 2015*, effective April 1, 2014.P.L. 113-93 103(2)(B), struck , or the firstthree months of 2014, and inserted , 2014 or the firstthree months of 2015. Effective April 1, 2014.P.L. 114-10 202(a)(2)(A), struck out March31, 2015 and inserted December 31, 2017, effectiveApril 16, 2015.P.L. 114-10 202(a)(2)(B), struck 2012, 2013,2014, or the first three months of 2015 and inserted 2012through 2017, effective April 16, 2015.[96]P.L. 112-240, 603(b)(2),added subparagraph (B), effective January 2, 2013.[97]P.L. 115123,50202(4) added paragraph (7). Effective February 9, 2018.
Social Security Act §1833
[98]Thisparagraph was originally designated by P.L. 112-240, 603(c)as subparagraph (g)(5)(D), effective January 2, 2012.P.L. 115123, 50202(3)(A) moved subparagraph1833(g)(5)(D) to paragraph (8). Effective February 9, 2018.[99]P.L. 11296, 3202(1), struck out paragraph (4)and inserted clause (v), subparagraph (B), and paragraph (4),effective February 22, 2012.[100]P.L. 113-93, 216(b)(1)(D), struck andsubject to and inserted and, for tests furnished beforethe date of enactment of section 1834A, subject to. EffectiveApril 1, 2014.[101]P.L. 112-96,3202(3), added clause (v), effective February 22, 2012.[102]P.L. 113-93, 216(b)(1)(E), struckout fee schedules and inserted fee schedules(for tests furnished before January 1, 2017) or under section 1834A(for tests furnished on or after January 1, 2017), subject to subsection(b)(5) of such section, effective April 1, 2014.[103]P.L. 113-93,216(b)(1)(F), struck out in the case and insertedFor tests furnished before January 1, 2017, in the case,effective April 1, 2014.[104]P.L.113-93, 216(b)(1)(G)(i) and P.L. 113-93, 216(b)(1)(G)(ii), struck out and (4) and inserted and (4) andsection 1834A; and struck out under this subsectionand inserted under this part, effective April 1, 2014.
Social Security Act §1833
[105]P.L. 115271, 6082(b),added this paragraph. Effective October 24, 2018.[106]See Vol. II, P.L. 99-509, 9320(k).[107]P.L. 101-239, 6132; 103 Stat. 2222.[108]P.L. 99-509, 9320; 100 Stat. 2013.[109]Probably should be subparagraph.[110]See Vol. II, P.L. 78-410, 332(a).[111]P.L. 103-432, 123(b)(2)(A)(ii); 108 Stat. 4411.[112]See Vol.II, P.L. 115271, 6072, with respect to MEDPAC reportto Congress on payments, adverse incentives and data regarding painmanagement treatment, including opioid prescriptions.[113]P.L. 114-74,603(a)(1)(C) Inserted clause (v). Effective November 2, 2016.[114]P.L. 115141,Div. S, Title XIII, 1301(a)(1)(A), struck The paymentand inserted Subject to subparagraph (G), the payment.Effective March 23, 2018.[115]P.L. 115141, Div. S, Title XIII, 1301(a)(1)(B),inserted subject to subparagraph (H), before inthe case. Effective March 23, 2018.[116]P.L. 115141, Div. S, TitleXIII, 1301(a)(2), added This clause shall not apply for2018. at the end of clause (i).P.L. 11694,Div. N, 107(a), struck 2018 and inserted 2018or 2020. Effective December 20, 2019.
Social Security Act §1833
[117]P.L. 115141,Div. S, Title XIII, 1301(a)(1)(C), added subparagraph (G). EffectiveMarch 23, 2018.[118]P.L. 115141,Div. S, Title XIII, 1301(a)(1)(C), added subparagraph (H). EffectiveMarch 23, 2018.[119]P.L. 115141,Div. S, Title XIII, 1301(a)(1)(C), added subparagraph (I). EffectiveMarch 23, 2018.[120]P.L. 11694,Div. N, 107(a)(2), added subparagraph (J). Effective December20, 2019. P.L. 11694, Div. N. 107(b), authorized implementationby program instruction or otherwise.[121]P.L. 112-78, 308(1)(A),struck out January 1, 2012 and inserted March1, 2012*, effective December 23, 2011.*P.L. 112-96, 3002(a)(1)(A), struck out March 1, 2012and inserted January 1, 2013, effective February 22,2012.[122]P.L. 112-78, 308(1)(B), struck out or 2011and inserted 2011, or the first two months of 2012*,effective December 23, 2011.*P.L. 112-96, 3002(a)(1)(B),struck out or the first two months of 2012 and insertedor 2012, effective February 22, 2012.[123]P.L. 112-78, 308(2)(A), struck out 2009, andbefore January 1, 2012, for which and inserted 2009,and before March 1, 2012*, for which, effective December 23,2011.P.L. 112-96, 3002(a)(2), struck outMarch 1, 2012 and inserted January 1, 2013,effective February 22, 2012.
Social Security Act §1833
[124]P.L. 112-78, 308(2)(B), struckout 2010, and before January 1, 2012, the precedingand inserted 2010, and before March 1, 2012*, the preceding,effective December 23, 2011.P.L. 112-96, 3002(a)(2),struck out March 1, 2012 and inserted January1, 2013, effective February 22, 2012.[125]P.L. 105-33, 4521; 110 Stat. 444.[126]P.L.112-240, 634, added this new subparagraph (D), effective January2, 2013.[127]P.L. 113-93, 218(b)(2), added subparagraph (E). EffectiveApril 1, 2014..[128]P.L.114-255,16002(b)(1), inserted , subject to subparagraph (C),after shall in subparagraph (B), and added new subparagraph(C). 16002(c) applied these changes retroactively as if enactedas part of P.L. 11174, effective November 2, 2015.[129]P.L. 113-93, 218(a)(20(A), added paragraph (20). EffectiveApril 1, 2014.
Social Security Act §1833
[129]P.L. 113-93, 218(a)(20(A), added paragraph (20). EffectiveApril 1, 2014.[130]P.L. 114-74, 603(a)(2) Inserted subparagraph (C).Effective November 2, 2016.[131]P.L.114-255, 16001(a)(1)(A),struck clause (ii) in clause(i), and inserted thesubsequent provisions of this subparagraph; and added new clauses(iii) through (viiI). 16001(b) applied these changes retroactivelyas if enacted as part of P.L. 11174, effective November 2,2015.[132]P.L. 114255, 16002(a)(1)inserted new clause (vi).  16002(c) applied these changes retroactivelyas if enacted as part of P.L. 11174, effective November 2,2015[133]P.L.114-255, 16002(a)(2),inserted Not later than 2 years after the date the Secretaryreceives an attestation under clause (vi) relating to compliance ofa department of a provider with requirements referred to in such clause,the Secretary shall audit the compliance with such requirements withrespect to the department. after the first sentence.  16002(c)applied these changes retroactively as if enacted as part of P.L.11174, effective November 2, 2015.[134]P.L.114-255, 16002(a)(3),added at the end of subclause (III), For purposes of carryingout this subparagraph with respect to clause (vi) (and clause (vii)insofar as it relates to such clause), $2,000,000 shall be availablefrom the Federal Supplementary Medical Insurance Trust Fund undersection 1841, to remain available until expended..  16002(c)applied these changes retroactively as if enacted as part of P.L.11174, effective November 2, 2015.[135]P.L.114-255,16001(a)(2); inserted clause (iv). Effective December 10, 2016.
Social Security Act §1833
[136]P.L. 115271,6082, inserted this paragraph. Effective October 24, 2018.[137]P.L. 114-10, 101(e)(3)(A)Appended sentence referencing subsection (z). Effective April 16,2015.[138]See Vol. II, P.L. 78410,332(a)(1)(A).[139]P.L. 114-10, 101(e)(3)(B) Appended sentence referencingsubsection (z). Effective April 16, 2015.[140]P.L. 114-10, 101(e)(2) Appended subsection (z). EffectiveApril 16, 2015.P.L. 114-10, 514(a); directedadding new subsection (z) to Section 1833 (follows). Effective April16, 2015
Social Security Act §1833
[141]P.L. 114-10, 101(e)(2) Appended subsection (z). EffectiveApril 16, 2015.[142]P.L. 114-10, 514(a); directed adding new subsection, also designatedas (z), to Section 1833. Effective April 16, 2015P.L. 115271, 6083(b) redesignated this subsection (z)as subsection (aa). Effective October 24, 2018.[143]P.L. 115271,6083(b)(2), added new subsection (bb). Effective October 24,2018.[144]21U.S.C. 823(g).END CONTENTPAGE FOOTERFooter menuSSA INTERNET BODY SCRIPTS
Article - Billing and Coding: Endometrial Hyperplasia Treatment (A53043)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, 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.Article TextTreatment of endometrial hyperplasia with the insertion of a hormone-containing intrauterine device (IUD) is an accepted method to manage endometrial hyperplasia for patients with abnormal uterine bleeding and who are unable to tolerate oral megestrol or are at high risk for complications of oral megestrol.Effective for dates of service on and after 02/01/12, Palmetto GBA will reimburse IUD insertion services for patients who meet these criteria.Since IUD insertion services auto-deny, submit the following claim information:CPTcode 58999ICD-10 codes N84.0 or N85.00-N85.02Enter hormone IUD in the comment/narrative field of the CMS-1500 claim form or the equivalent electronic claim field
Article - Billing and Coding: Wound Care and Debridement - Provided by a Therapist, Physician, NPP, or as Incident-to Services (A53046)
CMS National Coverage PolicyN/AArticle TextThis article clarifies wound care and debridement services provided by a therapist, physician, non-physician practitioner (NPP) or as incident-to services.Medical NecessityAll Providers (including therapists) must document the medical necessity for all services provided. If there is no documented evidence (e.g., objective measurements) of ongoing significant benefit, then the medical record documentation must provide other clear evidence of medical necessity for treatments. The medical record must also clearly indicate the complexity of skills required by the treating practitioner/clinician.CodingProper wound care coding requires careful reading of all Current Procedural Terminology (CPT) code descriptors and related CPT Manual instructions. Providers should note that some codes are per session or per wound surface area, not per wound or site.Evaluation and Management (E/M) Coding RequirementsOnlyphysicians and NPPs (Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) can provide and bill E/M and CPT 11000 series codes when the services are appropriate and state licensure allows. These services may not be provided as incident-to services by hospital staff. Services provided by qualified incident-to hospital staff, must meet both the incident-to service delivery requirements and the CPT descriptor requirements for the specific procedure.*Note: For claims with dates of service prior to January 1, 2014: Hospitals maybillany E/M level within the"established patient"category that corresponds to the resources used in the provision of the covered 99211 service in the specific clinic. The charge must be the same for all patients. See the CMS manuals for additional billing instructions. Reference the Noridian article titled"Incident To" Clarification for OPPS and CAH Outpatientattached below for additional information.For claims with dates of service on or after January 1, 2014: Hospitals may only bill HCPCS G0463. The charge must be the same for all patients. See the CMS manuals for additional billing instructions. Reference the Noridian article titled"Incident to" Clarification for OPPS and CAH Outpatientattached below for additional information.Physical Medicine and Rehabilitation (PM&R) Codes (i.e. 97597, 97598, 97602)
Article - Billing and Coding: Wound Care and Debridement - Provided by a Therapist, Physician, NPP, or as Incident-to Services (A53046)
Physical Medicine and Rehabilitation (PM&R) Codes (i.e. 97597, 97598, 97602) A physician, NPP or therapist acting within their scope of practice and licensure may provide debridement services and use the PM&R codes including CPT 97597, 97598 and 97602. These codes must only be billed for services that include medically necessary skilled debridement services. Hospital staff acting within their scope of practice and/or licensure may provide wound care, including debridement services, incident-to the services of a physician/NPP. Staff providing therapy services incident-to the physician treatment plan must meet the qualification guidelines established for auxiliary personnel as described in the IOMMedicare Benefit Policy Manual, Publication 100-02, Chapter 15, Sections 220(A), 230.5.CPT 97597, 97598, 97602 are considered sometimes therapy codes according to the IOMMedicare Claims Processing Manual, Publication 100-04, Chapter 5, Section 20. As such, these treatment codes may be provided without a therapy plan of care by physician/NPPs or as incident-to services. When these sometimes therapy services are provided under a physician's/NPPs treatment plan they should be billed without a therapy modifier. When wound care services are delivered by therapists, there must be a physician certified therapy plan of care based on a thorough evaluation signed by the treating physician or NPP. The services must be billed using the appropriate therapy modifier and deliver within the CMS therapy guidelines found in the IOMMedicare Benefit Policy Manual, Publication 100-02, Chapter 15, Sections 100 and 220-230.Dressing ChangeA dressing change may not be billed as either a debridement or other wound care service under any circumstance (e.g., CPT 97597, 97598, 97602).
Article - Billing and Coding: Wound Care and Debridement - Provided by a Therapist, Physician, NPP, or as Incident-to Services (A53046)
Dressing ChangeA dressing change may not be billed as either a debridement or other wound care service under any circumstance (e.g., CPT 97597, 97598, 97602). Medicare does not separately reimburse for dressing changes or patient/caregiver training in the care of the wound. These services are reimbursed as part of a billable E/M or procedure code that, commonly but not necessarily, occurs on the same date of service as the dressing change. If not included in another service, the costs associated with dressing changes may be reported as not separately payable. All topical applications (e.g. medications, ointments, and dressings) are included in the payment for the procedure codes. It is only appropriate to provide an Advance Beneficiary Notice of Noncoverage (ABN) for services that are anticipated to be denied due to the absence of medical necessity. An ABN for a dressing change is NOT appropriate since the costs of the dressing change are packaged into other procedures billed.Evaluation/Re-assessmentIn general, other than an initial evaluation, the assessment of the wound is an integral part of all wound care service codes and, as such, these assessments are not separately billable.
Article - Billing and Coding: Wound Care and Debridement - Provided by a Therapist, Physician, NPP, or as Incident-to Services (A53046)
Evaluation/Re-assessmentIn general, other than an initial evaluation, the assessment of the wound is an integral part of all wound care service codes and, as such, these assessments are not separately billable. Initial wound assessments that are medically necessary may be reimbursable as a separately identifiable Evaluation and Management (E/M) service or i.e., physical therapy initial evaluation CPT codes 97161-97163.Note that CPT codes 97160-97163 are "always" therapy codes and the therapy modifier must be applied. Re-assessment/re-evaluation of a wound (which may be completed with a dressing change) is generally considered to be a non-covered routine service. An exception would require documentation clearly supporting that there had been a significant improvement, decline, or change in the patients condition or functional status that wasnot anticipated in the plan of careand required further evaluation. The evaluation must be provided by a physician, NPP or therapist or other qualified incident-to hospital staff. Patients may be evaluated by the physician/NPP and the follow-up care may then be provided by qualified hospital incident-to staff working under the physicians plan of care. When a physical therapist provides these incident-to follow-up services and provides an initial therapy evaluation (CPT 97161-97163), the documentation must clearly indicate the medical necessity for these additional evaluative services (as compared to the previously completed physician evaluation of the patients condition) in order to be separately reimbursable. An ABN may be given when medical necessity is not supported for the initial therapy evaluation. However, an ABN may not be given when medical necessity is not supported for a follow-up visit since there is no billable therapy code for a routine re-assessment (i.e. routine wound assessment with/without a dressing change). While a physician/NPP may not bill a new patient E/M with modifier 25 for any global service, the hospital may bill the E/M. See the IOMMedicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 40.3.DebridementSelective Debridement (CPTs 97597 and 97598)- Documentation to support selective debridement should include the following:
Article - Billing and Coding: Wound Care and Debridement - Provided by a Therapist, Physician, NPP, or as Incident-to Services (A53046)
DebridementSelective Debridement (CPTs 97597 and 97598)- Documentation to support selective debridement should include the following: Clear description of instruments used for debridement (i.e. high-pressure waterjet, scissors, scalpel, forceps). Thorough objective assessment of the wound including drainage, color, texture, temperature, vascularity, condition of surrounding tissue, and size of the area to be targeted for debridementNon-Selective Debridement (CPT 97602)- Documentation to support non-selective debridement should include: Type of technique utilized i.e., wet-to-moist, enzymatic, abrasion. Thorough objective assessment of the wound as described in Selective Debridement above.Whirlpool If the patient uses whirlpool for treatment of a wound prior to receiving selective debridement services for the woundduring the same visit, then the whirlpool isnotseparately reimbursable and should not be billed with modifier 59 unless two separate wounds are treated with the different modalities. If the patient uses whirlpool for treatment of a wound prior to receiving non-selective debridement services for the woundduring the same visit, then the whirlpoolisseparately reimbursable and may be billed with modifier 59. Whirlpool can also be completedduring the same visitfor non-wound care related purposes. It is appropriate to separately bill CPT 97022 when the whirlpool is used for other purposes not involving wound care i.e., facilitation of range of motion activitiesUnna Boot ApplicationAll supply items related to the Unna boot are inclusive in the reimbursement for CPT 29580.High Compression Multi-Layered Bandage Systems
Article - Billing and Coding: Wound Care and Debridement - Provided by a Therapist, Physician, NPP, or as Incident-to Services (A53046)
Unna Boot ApplicationAll supply items related to the Unna boot are inclusive in the reimbursement for CPT 29580.High Compression Multi-Layered Bandage SystemsThe application of the high compression bandage systems (i.e., Profore, Dyna-Flex, Surepress, Setopress, and other similar product systems) are used to primarily treat lymphedema and venous or stasis ulcers. Providers should note that the treatment of lymphedema with the application of high compression bandage systems continues to be non-covered by Medicare. However, a brief period of patient and/or caregiver education may be medically necessary and reimbursable. Noridian will cover and separately reimburse for the application training when Medicare coverage requirements are met. Further information may be found in the Noridian article titledBilling and Coding: High Compression Bandage System Clarification.Sources:Current Procedural Terminology Assistant- May 2002 Active Wound Care Management;Current Procedural Terminology Manual;IOMMedicare Benefit Policy ManualPublication 100-02, Chapter 15, Sections 100 and 220-230;IOMMedicare Claims Processing ManualPublication 100-04, Chapter 5, Sections 20 and 100.7 andChapter 12, Sections 30.6 and 40.3;National Corrective Coding Initiatives(NCCI);Change Request9782.
Article - Billing and Coding: Complex Cataract Surgery: Appropriate Use and Documentation (A53047)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claimArticle TextCPTdefines the code 66982 as: "Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage."The billing of CPTcode 66982, is not related to the surgeons perception of the surgical difficulty. The use of this code is governed by the need to employ devices or techniques not generally used in routine cataract surgery.For example, the presence of pseudoexfoliation syndrome, which is known to predispose to weaker lens zonules; and thus, to an increased risk for loss of capsular support for an intraocular lens, wouldnotbe sufficient if the zonular support was adequate and no special tools were employed. Similarly, a particularly dense cataract that required extra time would not qualify.The need for hooks or other devices to address a particularly miotic pupil would qualify, as would pediatric cataract surgery, which may be more difficult intraoperatively because of an anterior capsule that is more difficult to tear, cortex that is more difficult to remove, and the need for a primary posterior capsulotomy or capsulorrhexis.Based on the definition and advice from ophthalmology groups, for clarity, this A/B MAC specifically considers the need for the following to justify the use of this CPTcode 66982: