evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
140.3  - Anesthesia Fee Schedule Payment for Qualified Nonphysician  Anesthetists (Rev. 3883; Issued: 10- 13-17; Effective: 01 -16-18; Implementation: 01 -16-18)   Payment for the services furnished by qualified nonphysician anesthetists are subject to the usual Part B coinsurance and deductible, and are made only on an assignment basis. The assignment agreed to by the qualified nonphysician anesthetist is binding upon any other person or entity presenting a claim or request for payment for the service. Except for deductible and coinsurance amounts, any person who knowingly and willfully presents or causes to be presented to a Medicare beneficiary a bill or request fo r payment for services of a qualified nonphysician anesthetist for which payment may be made on an assignment -related basis is subject to civil monetary penalties.   The fee schedule for anesthesia services furnished by qualified nonphysician anesthetists is the applicable locality -adjusted anesthesia conversion factor multiplied by the sum of allowable base and time units, as defined in 50 of this chapter.   The allowance for an anesthesia service furnished by a qualified nonphysician anesthetist that meets the requirements for payment at the medically directed rate is based on a fixed percentage of the allowance recognized for the anesthesia service personall y performed by the physician alone, as specified in 50 of this chapter.    The anesthesia locality -adjusted conversion factor for anesthesia services furnished by a CRNA that does not meet the requirements for payment at the medically directed rate may not exceed the allowance for a service personally performed by a physician, as  specified in 50 of this chapter.     140.3.1 - Conversion Factors Used for Qualified Nonphysician  Anesthetists  (Rev. 3883; Issued: 10- 13-17; Effective: 01 -16-18; Implementation: 01 -16-18)  The anesthesia locality -adjusted conversion factors are updated by the update factor used to update physicians services under the physician fee schedule. They are generally published in November of the year preceding the year in which they apply.
(Medicare Claims Processing Manual)
140.3.2  - Anesthesia Time and Calculation of Anesthesia Time  Units  (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17) Anesthesia time  means the time  during which a  qualified nonphysician anesthetist is present with the  patient.  It starts when the  qualified nonphysician anesthetist begins to prepare the  patient for  anesthesia services in the operating  room or  an equivalent area and ends when the qualified  nonphysician anesthetist is no longer furnishing anesthesia services to the patient, that is, when the patient may  be placed safely  under postoperative care.  Anesthesia time  is a continuous time period from the  start of  anesthesia to the end of an anesthesia service.  In counting anesthesia time, the  qualified nonphysician anesthetist can add blocks of time  around an interruption in anesthesia time as long as the qualified nonphysician anesthetist is furnishing continuous anesthes ia care within the  time  periods around the interruption.    140.3.3 - Billing  Modifiers (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17)  The following modifiers are used by qualified nonphysician anesthetists when billing for anesthesia services:   QX  Qualified nonphysician anesthetist service: With medical direction by a physician.  QZ  CRNA service: Without medical direction by a physician.   QS  Monitored anesthesia care services   NOTE:  The QS modifier can be used by a physician or a qualified nonphysician anesthetist and is for informational purposes.  Providers must report actual anesthesia time and one of the payment modifiers on the claim.
(Medicare Claims Processing Manual)
140.3.4 - General Billing Instructions  (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17) Claims for reimbursement for qualified nonphysician anesthetist services should be completed in accordance with existing billing instructions for anesthesiologists with the following  additions.  If an employer-physician furnishes concurrent  medical  direction  for a procedure involving CRNAs  and the medical  direction  service is unassigned, the physician should bill on an assigned  basis  on a separate claim  for the qualified  nonphysician anesthetist  service.  If the physician is  participating  or takes  assignment, both services  should be billed on one claim but as separate line items.    All claims  forms  must  have the provider billing  number of the qualified nonphysician anesthetist and/or the employer of the qualified  nonphysician anesthetist  performing  the service in either  block 24.H of the Form  CMS -1500 and/or block 31 as  applicable.  Verify  that the billing  number is valid  before making payment.  Payments should be calculated in accordance with Medicare payment rules in 140.3. The A/B MAC must institute all necessary payment edits to assure that duplicate payments are not made to physicians for qualified nonphysician anesthetist services or to a qualified nonphysician anesthetist directly for bills submitted on their behalf by qualified billers.  A CRNA is identified on the provider file by specialty code 43. An anesthesiologists assistant is identified on the provider file by specialty code  32.  140.4 - Qualified Nonphysician Anesthetist Special Billing and Payment Situations  (Rev. 2716, Issued: 05- 30-13, Effective:01 -01-13, Implementation: 02- 12-13)
(Medicare Claims Processing Manual)
140.4 - Qualified Nonphysician Anesthetist Special Billing and Payment Situations  (Rev. 2716, Issued: 05- 30-13, Effective:01 -01-13, Implementation: 02- 12-13)  140.4.1 - An Anesthesiologist and Qualified Nonphysician Anesthetist Work Together  (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17) A/B MACs will distribute educational releases and use other established means to ensure that anesthesiologists understand the requirements for medical direction of qualified nonphysician anesthetists.  A/B MACs will perform reviews of payments for anesthesiology services to identify situations in which an excessive number of concurrent anesthesiology services may have been performed. They will use peer practice and their experience in developing review criteria. They will also periodically review a sample of claims for medical direction of four or fewer concurrent anesthesia procedures. During this process physicians may be requested to submit documentation of the names of procedures performed and the names of the anesthetists medically  directed.  Physicians who cannot supply the necessary documentation for the sample claims must submit documentation with all subsequent claims before payment will be  made.   140.4.2 - Qualified Nonphysician Anesthetist and an Anesthesiologist in a Single Anesthesia Procedure  (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17) Where a single anesthesia procedure involves both a physician medical direction service and the service of the medically directed qualified nonphysician anesthetist, the payment amount for the service of each is 50 percent of the allowance otherwise recogn ized had the service been furnished by the anesthesiologist alone.  For the single medically directed service, the physician will use the QY modifier  and the qualified nonphysician anesthetist will use the QX modifier.
(Medicare Claims Processing Manual)
In unusual circumstances when it is medically necessary for both the CRNA  and the anesthesiologist to be completely and fully involved during a procedure, full payment for the services of each provider is allowed. The physician would report using the AA modifier and the CRNA  would report using the QZ modifier.  Documentation must be submitted by each provider to support payment of the full  fee.  140.4.3 - Payment for Medical or Surgical Services Furnished by CRNAs (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17) Payment shall be made for reasonable and necessary medical or surgical services furnished by CRNAs if they are legally authorized to perform these services in the State in which the services are furnished. Payment is determined under the physician fee schedule on the basis of the national physician fee schedule conversion factor, the geographic adjustment factor, and the resource -based relative value units for the medical or surgical  service.    140.5 - Payment for Anesthesia Services Furnished by a Teaching CRNA  (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17) Payment can be made under Part B to a teaching CRNA who supervises a single case involving a student nurse anesthetist where the CRNA is continuously present. The CRNA reports the service using the QZ modifier. No payment is made under Part B for the servi ce provided by a student nurse  anesthetist.   The A/B MAC may allow payment, as follows, if a teaching CRNA is involved in cases with two student nurse anesthetists:   Recognize the full base units (assigned to the anesthesia code) where the teaching CRNA is present with the student nurse anesthetist throughout pre and post anesthesia care;  and
(Medicare Claims Processing Manual)
 Recognize the full base units (assigned to the anesthesia code) where the teaching CRNA is present with the student nurse anesthetist throughout pre and post anesthesia care;  and   Recognize the actual time the teaching CRNA is personally present with the student nurse anesthetist.  Anesthesia time may be discontinuous. For example, a teaching CRNA is involved in two concurrent cases with student nurse anesthetists. Case 1 runs from 9:00 a.m. to 11:00 a.m. and case 2 runs from 9:45a.m. to 11:30 a.m. The teaching CRNA is present in case 1 from 9:00 a.m. to 9:30 a.m. and from 10:15 a.m. to 10:30 a.m. From 9:45 a.m. to 10:14 a.m. and from 10:31 a.m. to 11:30 a.m., the CRNA is present in case 2. The CRNA may report 45 minutes of anesthesia time for case 1 (i.e., 3 time units) and 88 minutes (i.e., 5.9 units) of anesthesia time for case  2.  The teaching CRNA must document his/her involvement in cases with student nurse anesthetists. The documentation must be sufficient to support the payment of the fee and available for review upon request.   The teaching CRNA (not under the medical direction of a physician), can be paid for his or her involvement in each of two concurrent cases with student nurse anesthetists; allow payment at the regular fee schedule rate. The teaching CRNA reports the anesthesia service using the QZ  modifier.
(Medicare Claims Processing Manual)
To bill the anesthesia base units, the teaching CRNA must be present with the student nurse anesthetist during pre and post anesthesia care for each of the two cases.  To bill anesthesia time for each case, the teaching CRNA must continue to devote his or her time to the two concurrent cases and not be involved in other activities. The teaching CRNA can decide how to allocate his or her time to optimize patient c are in the two cases based on the complexity of the anesthesia cases, the experience and skills of the student nurse anesthetists, and the patients health status and other factors.  The teaching CRNA must document his or her involvement in the cases with the student nurse anesthetists.   150 - Clinical Social Worker (CSW) Services (Rev. 2656, Issuance: 02-07-13, Effective: 02- 19-13, Implementation: 02-19-13)  See Medicare Benefit Policy Manual, Chapter 15, for coverage requirements.  Assignment of benefits is required.  Payment is at 75 percent of the physician fee schedule.  CSWs are identified on the provider file by specialty code 80 and provider type 56.  Medicare applies the outpatient mental health limitation to all covered therapeutic services furnished by qualified CSWs.  Refer to 210, below, for a discussion of the outpatient mental health limitation.   160 - Independent Psychologist Services  (Rev. 1, 10-01-03) B3-2150, B3-2070.2  See the Medicare Benefit Policy Manual, Chapter 15, for coverage requirements.  There are a number of types of psychologists.  Educational psychologists engage in identifying and treating education-related issues.  In contrast, counseling psychologists provide services that include a broader realm including phobias, familial issues, e tc.  Psychometrists are psychologists who have been trained to administer and interpret tests.  However, clinical psychologists are defined as a provider of diagnostic and therapeutic services.  Because of the differences in services provided, services pro vided by psychologists who do not provide clinical services are subject to different billing guidelines.  One service often provided by nonclinical psychologist is diagnostic testing.  NOTE: Diagnostic psychological testing services performed by persons who meet these requirements are covered as other diagnostic tests.  When, however, the psychologist is not practicing independently, but is on the staff of an institution, agency, or clinic, that entity bills for the diagnostic services.
(Medicare Claims Processing Manual)
Expenses for such testing are not subject to the payment limitation on treatment for mental, psychoneurotic, and personality disorders.  Independent psychologists are not required by law to accept assignment when performing psychological tests.  However, regardless of whether the psychologist accepts assignment, he or she must report on the claim form the name and address of the physician who ordered the test.  160.1 - Payment  (Rev. 1, 10-01-03)  Diagnostic testing services are not subject to the outpatient mental health limitation.  Refer to 210, below, for a discussion of the outpatient mental health limitation. The diagnostic testing services performed by a psychologist (who is not a clinical psychologist) practicing independently of an institution, agency, or physicians office are covered as other diagnostic tests if a physician orders such testing.  Medicare covers this type of testing as an outpatient service if furnished by any psychologist who is licensed or certified to practice psychology in the State or jurisdiction where he or she is furnishing services or, if the jurisdiction does not issue licenses, if provided by any practicing psychologist.  (It is CMS understanding that all States, the District of Columbia, and Puerto Rico license psychologists, but that some trust territories do not.  Examples of psychologists, other than clinical psychologists, whose services are covered under this provision include, but are not limited to, educational psychologists and counseling psychologists.)  To determine whether the diagnostic psychological testing services of a particular independent psychologist are covered under Part B in States which have statutory licensure or certification, A/B MACs (B) must secure from the appropriate State agency a current listing of psychologists holding the required credentials.  In States or territories which lack statutory licensing and certification, A/B MACs (B) must check individual qualifications as claims are submitted.  Possible reference sources are the national directory of membership of the American Psychological Association, which provides data about the educational background of individuals and indicates which members are board-certified, and records and directories of the State or territorial psychologica l association.  If qualification is dependent on a doctoral degree from a currently accredited program, A/B MACs (B) must verify the date of accreditation of the school involved, since such accreditation is not retroactive.  If the reference sources listed  above do not provide enough information (e.g., the psychologist is not a member of the association), A/B MACs (B) must contact the psychologist personally for the required information.  A/B MACs
(Medicare Claims Processing Manual)
the reference sources listed  above do not provide enough information (e.g., the psychologist is not a member of the association), A/B MACs (B) must contact the psychologist personally for the required information.  A/B MACs (B) may wish to maintain a continuing list of psychologists whose qualifications have been verified.
(Medicare Claims Processing Manual)
Medicare excludes expenses for diagnostic testing from the payment limitation on treatment for mental/psychoneurotic/personality disorders.  A/B MACs (B)  must identify the independent psychologists choice whether or not to accept assignment when performing psychological tests.  A/B MACs (B) must accept an independent psychologist claim only if the psychologist reports the name/UPIN of the physician who ordered a test.  A/B MACs (B) pay nonparticipating independent psychologists at 95 percent of the physician fee schedule allowed amount.  A/B MACs (B) pay participating independent psychologists at 100 percent of the physician fee schedule allowed amount.  Independent psychologists are identified on the provider file by specialty code 62 and provider type 35.  170 - Clinical Psychologist Services (Rev. 1, 10-01-03) B3-2150  See Medicare Benefit Policy Manual, Chapter 15, for general coverage requirements.   Direct payment may be made under Part B for professional services.  However, services furnished incident to the professional services of CPs to hospital patients remain bundled.  Therefore, payment must continue to be made to the hospital (by the A/B MAC ( A)) for such incident to services.  170.1 - Payment  (Rev. 2656, Issuance: 02-07-13, Effective: 02- 19-13, Implementation: 02-19-13)  All covered therapeutic services furnished by qualified CPs are subject to the outpatient mental health treatment limitation (the limitation).  Generally, the limitation does not apply to diagnostic services.  Refer to 210 below for a discussion of the outpatient mental health treatment limitation.
(Medicare Claims Processing Manual)
Payment for the services of CPs is made on the basis of a fee schedule or the actual charge, whichever is less, and only on the basis of assignment.  CPs are identified by specialty code 68 and provider type 27.  180 - Care Plan Oversight Services  (Rev. 999, Issued:  07- 14-06; Effective:  01 -01-05; Implementation:  10 -02-06) The Medicare Benefit Policy Manual, Chapter 15, contains requirements for coverage for medical and other health services including those of physicians and non-physician practitioners.  Care plan oversight (CPO) is the physician supervision of a patient receiving complex and/or multidisciplinary care as part of Medicare -covered services provided by a participating home health agency or Medicare approved hospice.  CPO services require complex or multidisciplinary care modalities involving:  Regular physician development and/or revision of care plans;   Review of subsequent reports of patient status;   Review of related laboratory and other studies;   Communication with other health professionals not employed in the same practice who are involved in the patients care;   Integration of new information into the medical treatment plan; and/or   Adjustment of medical therapy.  The CPO services require recurrent physician supervision of a patient involving 30 or more minutes of the physicians time per month.  Services not countable toward the 30 minutes threshold that must be provided in order to bill for CPO include, but are not limited to:   Time associated with discussions with the patient, his or her family or friends to adjust medication or treatment;  Time spent by staff getting or filing charts;   Travel time; and/or   Physicians time spent telephoning prescriptions into the pharmacist unless the telephone conversation involves discussions of pharmaceutical therapies.  Implicit in the concept of CPO is the expectation that the physician has coordinated an aspect of the patients care with the home health agency or hospice during the month for which CPO services were billed.  The physician who bills for CPO must be the sa me physician who signs the plan of care.  Nurse practitioners, physician assistants, and clinical nurse specialists, practicing within the scope of State law, may bill for care plan oversight.  These non- physician practitioners must have been providing ongoing care for the beneficiary through evaluation and management services.  These non -physician practitioners may not bill for CPO if they have been involved only with the delivery of the Medicare -covered
(Medicare Claims Processing Manual)
oversight.  These non- physician practitioners must have been providing ongoing care for the beneficiary through evaluation and management services.  These non -physician practitioners may not bill for CPO if they have been involved only with the delivery of the Medicare -covered home health or hospice service.  A. Home Health CPO  Non-physician practitioners can perform CPO only if the physician signing the plan of care provides regular ongoing care under the same plan of care as does the NPP billing for CPO and either:   The physician and NPP are part of the same group practice; or   If the NPP is a nurse practitioner or clinical nurse specialist, the physician signing the plan of care also has a collaborative agreement with the NPP; or   If the NPP is a physician assistant, the physician signing the plan of care is also the physician who provides general supervision of physician assistant services for the practice.  Billing may be made for care plan oversight services furnished by an NPP when:  The NPP providing the care plan oversight has seen and examined the patient;   The NPP providing care plan oversight is not functioning as a consultant whose participation is limited to a single medical condition rather than multidisciplinary coordination of care; and  The NPP providing care plan oversight integrates his or her care with that of the physician who signed the plan of care. NPPs may not certify the beneficiary for home health care.  B. Hospice CPO  The attending physician or nurse practitioner (who has been designated as the attending physician)  may bill for hospice CPO when they are acting as an attending physician.  An attending physician is one who has been identified by the individual, at the time he/she elects hospice coverage, as having the most significant role in the determination and delivery of their medical care.  They are not employed nor paid by the hospice . The care plan oversight services are billed using Form CMS -1500 or electronic  equivalent.  For additional information on hospice CPO, see Chapter 11, 40.1.3.1 of this manual .