evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
1. If an occupational therapist and an occupational therapy assistant visit the patient together to provide therapy and the therapist is there to supervise the assistant, one visit is counted.  2. If a nurse visits the patient in the morning to dress a wound and later must return to replace a catheter, two visits are counted.  3. If the therapist visits the patient for treatment in the morning and the patient is later visited by the assistant for additional treatment,  two visits are counted.   4. If an individual is taken to a hospital to receive outpatient therapy that could not be furnished in their own home (e.g., hydrotherapy) and, while at the hospital receives speech -language pathology services and other services, two or more visits would be charged.  5. Many home health agencies provide home health aide services on an hourly basis (ranging from 1 to 8 hours a day).  However, in order to allocate visits properly against a patient's maximum allowable visits, home health aide services are to be counted in terms of visits.  Thus, regardless of the number of continuous hours a home health aide spends in a patient's home on any given day, one "visit" is counted for each such day.  If, in a rare situation, a home health aide visits a patient for an hour or two in the morning, and again for an hour or two in the afternoon, two visits are counted.  C.  Evaluation Visits  The HHAs are required by regulations to have written policies concerning the acceptance of patients by the agency.  These include consideration of the physical facilities available in the patient's place of residence, the homebound status, and the attitude s of family members for the purpose of evaluating the feasibility of meeting the patient's medical needs in the home health setting.  When personnel of the agency make such an initial evaluation visit, the cost of the visit is considered an administrative cost of the agency and is not chargeable as a visit since at this point the patient has not been accepted for care.  If, however, during the course of this initial evaluation visit, the patient is determined suitable for home health care by the agency, and is also furnished the first skilled service as ordered under the physician or allowed practitioner's plan of care, the visit would become the first billable visit in the 30 -day period.
(Medicare Benefit Policy Manual)
The Medicare contractor will cover an observation and evaluation (or reevaluation) visit made by a nurse (see 40.1.2.1 for a further discussion of skilled nursing observation and evaluation visits) or other appropriate personnel, ordered by the physician or allowed practitioner for the purpose of evaluating the patient's condition and continuing need for skilled services,  as a skilled visit.   A supervisory visit made by a nurse or other appropriate personnel (as required by the conditions of participation) to evaluate the specific personal care needs of the patient or to review the manner in which the personal care needs of the patient are bein g met by the aide is an administrative function, not a skilled visit.   80 - Specific Exclusions From Coverage as Home Health Services  (Rev. 1, 10-01-03) A3-3125, HHA-230.A  In addition to the general exclusions from coverage under health insurance listed in the Medicare Benefit Policy Manual, Chapter 16, "General Exclusions from Coverage," the following are also excluded from coverage as home health services:   80.1 - Drugs and Biologicals (Rev. 1, 10-01-03) A3-3125.A, HHA-230.A  Drugs and biologicals are excluded from payment under the Medicare home health benefit.   A drug is any chemical compound that may be used on or administered to humans or animals as an aid in the diagnosis, treatment, prevention of disease or other condition, for the relief of pain or suffering, or to control or improve any physiological pathologic condition.  A biological is any medicinal preparation made from living organisms and their products including, but not limited to, serums, vaccines, antigens, and antitoxins.  The one drug exception is the osteoporosis drug, which is part of the home health benefit, and home health agencies may provide services such as vaccines outside the home health benefit.   80.2 - Transportation  (Rev. 1, 10- 01-03) A3-3125.B, HHA -230.B   The transportation of a patient, whether to receive covered care or for other purposes, is excluded from home health coverage.  Costs of transportation of equipment, materials, supplies, or staff may be allowable as administrative costs, but no separate pa yment is made.
(Medicare Benefit Policy Manual)
80.3 - Services That Would Not Be Covered as Inpatient Services  (Rev. 1, 10- 01-03) A3-3125C, HHA -230.C   Services that would not be covered if furnished as inpatient hospital services are excluded from home health coverage.  80.4 - Housekeeping Services  (Rev. 1, 10- 01-03) A3-3125D, HHA -230D   Services for which the sole purpose is to enable the patient to continue residing in their home (e.g., cooking, shopping, Meals on Wheels, cleaning, laundry) are excluded from home health coverage.   80.5 - Services Covered Under the End Stage Renal Disease (ESRD) Program  (Rev.  208, Issued: 04- 22-15, Effective: 01 -01-15, Implementation: 05- 11-15)  Renal dialysis services that are covered and paid for under the ESRD PPS, which include any item or service furnished to an ESRD beneficiary that is directly related to that individual's dialysis, are excluded from coverage under the Medicare home health benefit.  However, to the extent that other requirement s for coverage are met, an item or service that is not directly related to a patient's dialysis would be covered (e.g., a skilled nursing visit to furnish wound care for an abandoned shunt site).  Within these restrictions, beneficiaries may simultaneously  receive items and services under the ESRD PPS through their ESRD facility at home at the same time as receiving items and services under the home health benefit that are not related to ESRD.  80.6 - Prosthetic Devices  (Rev. 1, 10- 01-03) A3-3125F, HHA -230F   Prosthetic items are excluded from home health coverage.  However, catheters, catheter supplies, ostomy bags, and supplies related to ostomy care are not considered prosthetic devices if furnished under a home health plan of care and are not subject to this exclusion from coverage but are bundled while a patient is under a HH plan of care.  80.7 - Medical Social Services Furnished to Family Members (Rev. 1, 10-01-03) A3-3125G, HHA-230G
(Medicare Benefit Policy Manual)
Except as provided in 50.3, medical social services furnished solely to members of the patient's family and that are not incidental to covered medical social services being furnished to the patient are not covered.  80.8 - Respiratory Care Services  (Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)   If a respiratory therapist is used to furnish overall training or consultative advice to HHA staff and incidentally furnishes respiratory therapy services to patients in their homes, the costs of the respiratory therapist's services are allowable only as administrative costs to the HHA.  Visits by a respiratory therapist to a patient's home are not separately billable during a HH period of care when a HH plan of care is in effect.  However, respiratory therapy services furnished as part of a plan of care ot her than a home health plan of care by a licensed nurse or physical therapist and that constitute skilled care may be covered and separately billed as skilled visits when the beneficiary is not in a home health period of care.  Note that Medicare billing does not recognize respiratory therapy as a separate discipline, but rather sees the services in accordance with the revenue code used on the claims (i.e. 042x).  80.9 - Dietary and Nutrition Personnel  (Rev. 1, 10-01-03) A3-3125.I, HHA-230.I  If dieticians or nutritionists are used to furnish overall training or consultative advice to HHA staff and incidentally furnish dietetic or nutritional services to patients in their homes, the costs of these professional services are allowable only as administrative costs.  Visits by a dietician or nutritionist to a patient's home are not separately billable.   80.10 - Telecommunications Technology  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)
(Medicare Benefit Policy Manual)
80.10 - Telecommunications Technology  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)   Telecommunications technology (other than audio-only telephone calls) can include: remote patient monitoring, defined as the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient or caregiver or both to the home health agency; teletypewriter (TTY) technology; and 2- way audio-video telecommunications technology that allows for real- time interaction between the patient and clinician.  Telecommunications technology can be ordered as part of a home health plan of care but such services cannot be reported as a visit without the provision of another skilled service.  If telecommunications technologies are used by the home health agency, the costs of any equipment, set-up, and service related to the technology are allowable only as administrative costs. Visits to a beneficiary's home for the sole purpose of supplying, connecting, or training the patient on the technology, without the provision of a skilled service, are not separ ately billable.  However, HHAs may include the costs of telecommunications technology as an allowable administrative cost (that is, operating expense), if the technology is used by the HHA to augment the care planning process.  90 - Medical and Other Health Services Furnished by Home Health Agencies  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)   Payment may be made by Medicare contractors to a home health agency which furnishes either directly or under arrangements with others the following "medical and other health services" to beneficiaries with Part B coverage in accordance with Part B billing and payment rules other than when a home health plan of care is in effect .  1.  Surgical dressings (for a patient who is not under a home health plan of care), and splints, casts, and other devices used for reduction of fractures and dislocations;  2.  Prosthetic (Except for items excluded from the term "orthotics and prosthetics" in accordance with 1834(h)(4)(C) of the Act for patients who are under a home health plan of care);
(Medicare Benefit Policy Manual)
of the Act for patients who are under a home health plan of care);  3.  Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes and adjustments to these items when ordered by a physician or allowed practitioner.  (See Pub 100-02, Medicare Benefit Policy Manual, Chapter 15);  4.  Outpatient physical therapy, outpatient occupational therapy, and outpatient speech -language pathology services (for a patient not under a home health plan of care).  (See Pub 100-02, Medicare Benefit Policy Manual, Chapter 15); and  5.  Rental and purchase of durable medical equipment.  (See Pub 100- 02, Medicare Benefit Policy Manual, Chapter 15.)  If a beneficiary meets all of the criteria for coverage of home health services and the HHA is providing home health care under the Hospital Insurance Program (Part A), any DME provided and billed to the Medicare contractor by the HHA to that patient must also be provided under Part A.  Where the patient meets the criteria for coverage of home health services and the HHA is providing the hom e health care under the Supplementary Medical Insurance Program (Part B) because the patient is not eligible for Part A, the DME provided by the HHA may, at the beneficiary's option, be furnished under the Part B home health benefit or as a medical and other health service.  Irrespective of how the DME is furnished, the beneficiary is responsible for a 20 percent coinsurance.   6. Ambulance service. (See Pub 100- 02, Medicare Benefit Policy Manual, Chapter 10, Ambulance Services)
(Medicare Benefit Policy Manual)
6. Ambulance service. (See Pub 100- 02, Medicare Benefit Policy Manual, Chapter 10, Ambulance Services)   7. Hepatitis B Vaccine.  Hepatitis B vaccine and its administration are covered under Part B for patients who are at high or intermediate risk of contracting hepatitis B.  High risk groups currently identified include:  end -stage renal disease (ESRD) patie nts, hemophiliacs who receive factor VIII or IX concentrates, clients of institutions for the mentally retarded, persons who live in the same household as a hepatitis B virus carrier, homosexual men, illicit injectable drug users.  Intermediate risk groups  currently identified include staff in institutions for the mentally retarded, workers in health care professions who have frequent contact with blood or blood- derived body fluids during routine work.  Persons in the above listed groups would not be considered at high or intermediate risk of contracting hepatitis B, however, if there is laboratory evidence positive for antibodies to hepatitis B.  ESRD patients are routinely tested for hepatitis B antibodies as part of their continuing monitoring and therapy.  The vaccine may be administered, upon the order of a doctor of medicine or osteopathy, by home health agencies.   8. Hemophilia clotting factors.  Blood clotting factors for hemophilia patients competent to use such factors to control bleeding without medical or other supervision and items related to the administration of such factors are covered under Part B.   9. Pneumococcal and influenza vaccines.  See Pub 100- 02, Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 50.4.2 Immunizations.   10. Splints, casts.  See Pub 100- 02, Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services.   11. Antigens. See Pub 100- 02, Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services.   100 - Physician or Allowed Practitioner Certification for Medical and Other Health Services Furnished by Home Health Agency (HHA)     (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)
(Medicare Benefit Policy Manual)
A physician or allowed practitioner must certify that the medical and other health services covered by medical insurance, which were provided by (or under arrangements made by) the HHA, were medically required.  This certification needs to be made only once where the patient may require over a period of time the furnishing of the same item or service related to one diagnosis.  There is no requirement that the certification be entered on any specific form or handled in any specific way as long as the approac h adopted by the HHA permits the Medicare contractor to determine that the certification requirement is, in fact, met.  A written physician or allowed practitioner's order designating the services required would also be an acceptable certification.   110 - Use of Telehealth in Delivery of Home Health Services  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)   Section 1895(e) governs the home health prospective payment system (PPS) and provides that telehealth services are outside the scope of the Medicare home health benefit and home health PPS.  This provision does not provide coverage or payment for Medicare home health services provided via a telecommunications system.  The law does not permit the substitution or use of a telecommunications system to provide any covered home health services paid under the home health PPS, or any covered home health service paid outside of the home health PPS.  As stated in 42 CFR 409.48(c), a visit is an episode of personal contact with the beneficiary by staff of the home health agency (HHA), or others under arrangements with the HHA for the purposes of providing a covered service. The provision clarifies that there is nothing to preclude an HHA from adopting telemedicine or other technologies that they believe promote efficiencies, but there is no separate reimbursement for those technologies under the Medicare home health benefit. However, Medicare does recognize services furnished via telecommunications technology (see section 80.10) as an allowed administrative cost on Medicare cost reports if telecommunications technology is used by the HHA to augment the care planning process, and the technology is indicated on the plan of care.
(Medicare Benefit Policy Manual)
This provision does not waive the current statutory requirement for a physician or allowed practitioner certification of a home health plan of care under current 1814(a)(2)(C)  or 1835(a)(2)(A) of the Act.              Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12425BP  12/21/2023 Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92 - Additional Publication Update 01/02/2024  13496  R12382BP  11/28/2023 Separate Payment for Disposable Negative Pressure Wound Therapy Devices on Home Health Prospective Payment System Claims    01/02/2024  13244  R12291BP  10/05/2023 Separate Payment for Disposable Negative Pressure Wound Therapy Devices on Home Health Prospective Payment System Claims   No Longer Sensitive - Rescinded and Replaced by Transmittal 12382 01/02/2024  13244
(Medicare Benefit Policy Manual)
07/20/2023 Separate Payment for Disposable Negative Pressure Wound Therapy Devices on Home Health Prospective Payment System Claims  SENSITIVE/CONTROVERSIAL DO NOT POST - Rescinded and Replaced by Transmittal 12291 01/02/2024  13244  R11447BP  06/06/2022 Update to Chapter 7, Home Health Services, of the Medicare Benefit Policy Manual (Pub 100-02) 05/26/2022  12615  R11386BP  04/27/2022 Update to Chapter 7, Home Health Services, of the Medicare Benefit Policy Manual (Pub 100-02) - Rescinded and replaced by Transmittal 11447 05/26/2022  12615  R11296BP  03/25/2022 Update to Chapter 7, Home Health Services, of the Medicare Benefit Policy Manual (Pub 100-02)   Rescinded and replaced by Transmittal 11386 05/26/2022  12615  R10738BP  05/07/2021 Home Health Manual Update to Implement Calendar Year 2021 Request for Anticipated Payment Policies and Corrections to Certification and Recertification for Home Health Beneficiaries  08/09/2021  12218  R10438BP  11/06/2020 Home Health Manual Update to Incorporate Allowed Practitioners into Home Health Policy  01/11/2121  12023  R265BP  01/10/2020 Manual Updates Related to Calendar Year (CY) 2020 Home Health Payment Policy Changes, Maintenance Therapy, and Remote Patient Monitoring  02/11/2020  11577  R258BP  03/22/2019 Manual Updates Related to Home Health Certification and Recertification Policy Changes 04/22/2019  11104  R233BP  02/24/2017 Clarification of Payment Policy Changes for Negative Pressure Wound Therapy (NPWT) Using a Disposable Device and the Outlier Payment Methodology for Home Health Services  03/27/2017  9898 R208BP  04/22/2015 Manual Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Home Health Services  05/11/2015  9119 R207BP  04/10/2015 Manual Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Home Health Services  Rescinded and replaced by Transmittal 208  05/11/2015  9119 R179BP  01/14/2014 Manual Updates to Clarify Skilled
(Medicare Benefit Policy Manual)
Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Home Health Services  Rescinded and replaced by Transmittal 208  05/11/2015  9119 R179BP  01/14/2014 Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius 01/07/2014  8458 R176BP  12/13/2013 Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius  Rescinded and replaced by Transmittal 179 01/07/2014  8458 R172BP  10/18/2013 Home Health - Clarification to Benefit Policy Manual Language on Confined to the Home Definition  11/19/2013  8444 R144BP  05/06/2011 Home Health Therapy Services  05/05/2011  7374 R142BP  04/15/2011 Home Health Therapy Services  Rescinded and replaced by Transmittal 144 05/05/2011  7374 R139BP  02/16/2011 Clarifications for Home Health Face -to Face Encounter Provisions 03/10/2011  7329 R37BP  08/12/2005 Conforming Changes for Change Request 3648 to Pub. 100-02 09/12/2005  3912 R26BP  11/05/2004 Inclusion of Forteo as a Covered Osteoporosis Drug and Clarification of Manual Instructions Regarding Osteoporosis Drugs 04/04/2004  3524 R1BP  10/01/2003 Introduction to the Benefit Policy Manual N/A N/A Back to top of Chapter
(Medicare Claims Processing Manual)
Medicare Claims Processing Manual  Chapter 4 - Part B Hospital  (Including Inpatient Hospital Part B and OPPS)  Table of Contents  (Rev. 12552; Issued : 03-21-24)    Transmittals for Chapter 4   10 - Hospital Outpatient Prospective Payment System (OPPS)  10.1 -  Background  10.1.1 -  Payment Status Indicators  10.2 -  APC Payment Groups  10.2.1 -  Composite APCs  10.2.2 -  Cardiac Resynchronization Therapy  10.2.3 -  Comprehensive APCs   10.2.4. -  Reporting for Certain Outpatient Department Services (That Are Similar to Therapy Services) (Non -Therapy Outpatient Department Services) and Are Adjunctive to Comprehensive APC Procedures  10.3 -  Calculation of APC Payment Rates  10.4 -  Packaging  10.4.1 -  Combinations of Packaged Services of Different Types That are Furnished on the Same Claim  10.5 -  Discounting 10.6 -  Payment Adjustments  10.6.1 -  Payment Adjustment for  Rural  Sole Community Hospitals  10.6.2 -  Payment Adjustment for Failure to Meet the Hospital Outpatient Quality Reporting Requirements  10.6.2.1 -  Hospitals to which the Payment Reduction Applies  10.6.2.2 -  Services to which the Payment Reduction Applies  10.6.2.3 -  Contractor Responsibilities  10.6.2.4 -  Application of the Payment Reduction Factor in Calculation of the Reduced Payment and Reduced Copayment  10.6.3 -  Payment Adjustment for Certain Cancer Hospitals  10.6.3.1 -  Payment Adjustment for Certain Cancer Hospitals for CY 2012 and CY 2013 10.6.3.2 -  Payment Adjustment for Certain Cancer Hospitals for CY 2014  10.6.3.3 -  Payment Adjustment for Certain Cancer Hospitals Beginning CY 2015 10.6.3.4 -  Payment Adjustment for Certain Cancer Hospitals   Beginning CY 2016 10.6.3.5 -  Payment Adjustment for Certain Cancer Hospitals Beginning CY 2017 10.6.3.6 -  Payment Adjustment for Certain Cancer Hospitals Beginning CY 2018        10.6.3.7 -  Payment Adjustment for Certain Cancer Hospitals         Beginning CY 2019        10.6.3.8 -  Payment Adjustment for Certain Cancer Hospitals         Beginning CY 2020   10.6.4 -  Payment Adjustment for Rural Emergency Hospitals