evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
12/03/2010 Annual Wellness Visit (AWV), Including Personalized Prevention Plan Services (PPPS)  Rescinded and replaced by Transmittal 138 04/04/2011 7079 R132BP 09/03/2010 Revisions and Re- issuance of Audiology Policies 09/30/2010 6447 R131BP  08/20/2010 Expansion of Medicare Telehealth Services for CY 2011  Rescinded and replaced by Transmittal 140 01/03/2011 7049 R129BP 07/23/2010 Revisions and Re- issuance of Audiology Policies - Rescinded and replaced by Transmittal 132 08/11/2010 6447 R127BP 05/28/2010 Revisions and Re- issuance of Audiology Policies - Rescinded and replaced by Transmittal 129 07/28/2010 6447 R126BP 05/21/2010 Cardiac Rehabilitation and Intensive Cardiac Rehabilitation  10042010 6850 Rev #  Issue Date  Subject  Impl Date  CR#  R124BP  05/07/2010 Pulmonary Rehabilitation (PR) Services  10/04/2010 6823 R123BP  04/30/2010 Determining Self -Administration of Drug or Biological 07/30/2010 6950 R120BP  01/29/2010 Revision of Definition of Compendia as Authoritative Source for Use in the Determination of a Medically -Accepted Indication of Drugs/Biologicals Used Off- Label in Anti- Cancer Chemotherapeutic Regimens  03/01/2010 6806 R118BP 12/18/2009 Expansion of Telelhealth Services for CY 2010 01/04/2010 6705 R117BP 12/18/2009 Coverage of Kidney Disease Patient Education Services  04/05/2010 6557 R116BP 12/11/2009 January 2010 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/04/2010 6751 R109BP 08/07/2009 Diabetes Self -Management Training (DSMT) Certified Diabetic Educator  09/08/2009 6510 R108BP 07/31/2009 New Reporting Requirements for the Quarterly Opt Out Report in Contractor Reporting of Operational Workload Data (CROWD)  01/04/2010 6562 R106BP
(Medicare Benefit Policy Manual)
07/31/2009 New Reporting Requirements for the Quarterly Opt Out Report in Contractor Reporting of Operational Workload Data (CROWD)  01/04/2010 6562 R106BP 04/24/2009 Speech -Language Pathology Practice Payment Policy  07/06/2009 6381 R105BP  04/24/2009 List of Medicare Telehealth Services  05/26/2009 6458 R104BP 03/13/2009 April 2009 Update to the ASC Payment System; Summary of Payment Policy Changes/Manual Revisions 04/06/2009 6424 Rev #  Issue Date  Subject  Impl Date  CR#  R99BP  12/24/2008 Expansion of Medicare Telehealth Services  01/05/2009 6130 R97BP  11/14/2008 Adding Certain Entities as Originating Sites for Payment of Telehealth Services -Section 149 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)  01/05/2009 6215 R96BP 10/24/2008 Compendia as Authoritative Sources for Use in the Determination of a Medically Accepted Indication of Drugs and Biologicals Used Off-Label in an Anti-Cancer Chemotherapeutic Regimen  11/25/2008 6191 R94BP 08/29/2008 Physician Signature Requirements for Diagnostic Tests 09/30/2008 6100 R93BP 07/25/2008 Screening DNA Stool Test for Colorectal Cancer  08/25/2008 6145 R92BP 06/27/2008 Private Contracting/Opting Out of Medicare  09/29/2008 6081 R91BP 06/20/2008 Self-Administered Drug Exclusion Lists  07/21/2008 5988 R88BP  05/07/2008 Therapy Personnel Qualifications and Policies Effective January 1, 2008 06/09/2008 5921 R87BP 05/02/2008 Incident to Policy Update - Rescinded  06/02/2008 5288 R86BP 04/18/2008 Payments for Medicare Part B Services Furnished by Certain Indian Health Service (IHS) Hospitals and Clinics  05/19/2008 5807 R85BP
(Medicare Benefit Policy Manual)
04/18/2008 Payments for Medicare Part B Services Furnished by Certain Indian Health Service (IHS) Hospitals and Clinics  05/19/2008 5807 R85BP 02/29/2008 Psychological and Neuropsychological Tests 12/28/2006 5204 Rev #  Issue Date  Subject  Impl Date  CR#  R84BP  02/29/2008 Update to Audiology Policies 04/07/2008 5717 R81BP  02/07/2008 Process for Amending the List of Compendia for Determination of Medically -Accepted Indications for Off-Label Uses of Drugs and Biologicals in an Anti- Cancer Chemotherapeutic Regimen  03/07/2008 5870 R80BP 01/11/2008 Requirements for Ordering and Following Orders for Diagnostic Tests  Replaced by Transmittal 80  11/19/2007 5743 R79BP 10/19/2007 Requirements for Ordering and Following Orders for Diagnostic Tests  Replaced by Transmittal 80  11/19/2007 5743 R78BP 09/21/2007 Unlabeled Use for Anti- Cancer Drugs  Medical Literature Used to Determine Medically Accepted Indications for Drugs and Biologicals Used in Anti- Cancer Treatment  10/22/2007 5729 R77BP 08/29/2007 Testing and Implementation of 2008 Ambulatory Surgical Center (ASC) Payment System Changes 01/07/2008 5680 R76BP 07/20/2007 Testing and Implementation of 2008 Ambulatory Surgical Center (ASC) Payment System Changes  Replaced by Transmittal 77  01/07/2008 5680 R75BP 08/17/2007 Nurse Practitioner (NP) Services and Clinical Nurse Specialist (CNS) Services  11/19/2007 5639 R74BP 06/29/2007 Medicare Telehealth Services  01/07/2008 5628 R72BP  05/25/2007 Guidelines for Payment of Diabetes Self-Management Training (DSMT) 07/02/2007 5433 Rev #  Issue Date  Subject  Impl Date  CR#  R71BP  05/25/2007 Clarification of Manual Instruction Regarding the Scope of Portable X-Ray Benefit  07/02/2007 5536 R70BP
(Medicare Benefit Policy Manual)
05/11/2007 Bone Mass Measurements (BMMs)  07/02/2007 5521 R64BP  01/19/2007 Guidelines for Payment of Diabetes Self-Management Training (DSMT)  Replaced by Transmittal 72 07/02/2007 5433 R63BP 12/29/2006 Outpatient Therapy Cap Exceptions Process for Calendar Year (CY) 2007 01/29/2007 5478 R62BP 12/22/2006 Private Contracting -Definition of Physician/Practitioner  04/02/2007 5426 R60BP  11/09/2006 Outpatient Therapy Cap Clarification  01/02/2007 5271 R55BP 09/29/2006 Psychological and Neuropsychological Tests  Rescinded and Replaced by Transmittal 85  12/28/2006 5204 R53BP 07/07/2006 Medicare Telehealth Services Update 08/07/2006 5122 R52BP 06/30/2006 Therapy Caps Exception Process 03/13/2006 4364 R51BP  06/23/2006 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests; Clinical Psychologist Services 09/21/2006 4400 R48BP 03/24/2006 Expansion of Glaucoma Screening Services  04/03/2006 4365 R47BP 02/15/2006 Therapy Caps Exception Process 03/13/2006 4364 R46BP  02/13/2006 Therapy Caps Exception Process - Rescinded and replaced by Transmittal 47  03/13/2006 4364 Rev #  Issue Date  Subject  Impl Date  CR#  R43BP  12/23/2005 List of Medicare Telehealth Services  04/03/2006 4204 R37BP  08/12/2005 Conforming Changes for Change Request 3648 to Pub. 100-02 09/12/2005 3912 R36BP 06/24/2005 Pub. 100-02, Chapter 15, Sections 220 and 230 Therapy Services 06/06/2005 3648 R34BP 05/06/2005 Pub. 100-02, Chapter 15, Sections 220 and 230 Therapy Services 06/06/2005 3648 R31BP 04/01/2005 List of Medicare Telehealth Services  05/02/2005 3747 R30BP
(Medicare Benefit Policy Manual)
04/01/2005 List of Medicare Telehealth Services  05/02/2005 3747 R30BP 02/18/2005 Policy for Repair and Replacement of Durable Medical Equipment (DME)  N/A 3693 R24BP 10/29/2004 Revision of Section 300.5.1, Chapter 15 of the Medicare Benefit Policy Manual to include 22x TOB as an applicable TOB for Diabetes Self-Management Training  01/03/2005 3531 R23BP 10/08/2004 Revised Requirements for Chiropractic Billing of Active/Corrective Treatment and Maintenance Therapy. Full Replacement of CR 3063 10/04/2004 3449 R20BP 09/17/2004 Providing Information for Incident to Services.  Full Replacement of CR CR 3242. - Rescinded  04/01/2005 3460 R18BP 09/03/2004 Revised Requirements for Chiropractic Billing of Active/Corrective Treatment and Maintenance Therapy.  Full Replacement of CR 3063 10/04/2004 3449 R17BP 06/18/2004 Providing Information for Incident to Services. - Replaced by Transmittal 20 -CR 3460. 10/04/2004 3242 Rev #  Issue Date  Subject  Impl Date  CR#  R13BP  05/28/2004 Diabetes Self Management Training Services  06/28/2004 3185 R12BP  05/28/2004 Chiropractors Services  10/04/2004 3063 R09BP  04/23/2004 Arrangements for Physical, Occupational, and Speech Language Pathology Services (PT, OT, SLP)  05/24/2004 3134 R06BP 01/23/2004 Intravenous Immune Globulin 04/05/2004 3059 R05BP  01/09/2004 Coverage of Outpatient Physical Therapy, Occupational Therapy and Speech -Language Pathology Services Under Medical Insurance  03/15/2004 2859 & 2779 R04BP 01/02/2004 Dentists, podiatrists, and optometrists are added to the definition/list of physicians who may opt out of Medicare 02/02/2004 3016 R03BP 12/19/2003 Coverage of iFOBT 01/05/2004 2996 R01BP  10/01/2003 Introduction to the Benefit Policy Manual  N/A N/A Back to top of chapter
Article - Billing and Coding: Therapy Students and Aides (A52776)
CMS National Coverage PolicyN/AArticle TextCoverage and documentation requirements for the provision of services by/or in the presence of a therapy student or therapy aide in both inpatient and outpatient therapy settings.Inpatient: Inpatient Skilled Nursing Facility (SNF)Outpatient: Therapist In Private Practice (TPP), Physician, Non-Physician Practitioner (NPP), long-term care facility, hospital-based outpatient therapy clinic, outpatient rehabilitation facility (ORF), comprehensive outpatient rehabilitation facility (CORF)Medicare coverage requirements state that rehabilitation services must be provided and/or supervised by a qualified clinician i.e., physician, non-physician practitioner (NPP), qualified physical therapist (PT), occupational therapist (OT), speech-language pathologist (SLP), or appropriately supervised/qualified therapy assistant.Inpatient SNF SettingTherapy AidesTherapy aides cannot provide skilled services. However, the time that a therapy aide spends on set-up preceding skilled therapy may be coded on the Minimum Data Set (MDS) (e.g., set up the treatment area for wound therapy) and should be coded under the appropriate mode for the skilled therapy (individual, concurrent, or group) in O0400. The therapy aide must be under direct supervision of the therapist or assistant.Therapy StudentsTherapy students are not required to be in line-of-sight of the supervising therapist/assistant. The determination of whether or not a student is ready to treat patients without line-of-sight supervision is left to the discretion of the supervising therapist/assistant. Time may be coded on the MDS when the therapist provides skilled services and direction to a student who is participating in the provision of therapy. All state and professional practice guidelines for student supervision must be followed.Individual therapy is for treatment of one patient at a time. When a therapy student is involved the minutes may be coded when only one patient is being treated by the therapy student and the supervising therapist/assistant. The supervising therapist/assistant cannot be treating or supervising another individual and he/she must be available to immediately assist the student as needed.Concurrent therapy is for treatment of two residents who are performing different activities at the same time and are both in line-of sight of the treating therapist/assistant. When a therapy student is involved the minutes may be coded when one of the following occurs:
Article - Billing and Coding: Therapy Students and Aides (A52776)
Student is treating one patient and the supervising therapist/assistant is treating another patient and both patients are in line of sight of the therapist/assistant or student; orStudent is treating two patients both of whom are in line-of-sight of the student and the therapist/assistant is not treating any patients and is not supervising other individuals; orStudent is not treating any patients and the supervising therapist/assistant is treating two patients at the same time both of whom are in line-of-sight.Group therapy is for treatment of four patients who are performing the same or similar activities and are supervised by a therapist/assistant who is not supervising any other individuals. When a therapy student is involved with group therapy the minutes may be coded when one of the following occurs:Student is providing group treatment and the supervising therapist/assistant is not treating any patient and is not supervising other individuals (students or patients); orSupervising therapist/assistant is providing group treatment and the student is not treating any patient.Outpatient Therapy SettingTherapy AidesTherapy aides cannot provide skilled services. Also, unskilled service minutes provided by the therapy aide cannot be counted and are not reimbursable even when provided under direct supervision by the qualified therapist or assistant e.g.The patient arrived at the clinic and worked in the gym with the therapy aide for 15 minutes, then the qualified therapist provided direct patient treatment for 20 minutes, then the patient worked for another 15 minutes in the gym with the therapy aide. Total of 20 individual minutes of service were provided by the qualified clinician and are billable for the session.The patient arrived at the clinic and received direct patient treatment with the qualified therapist for 10 minutes, then the patient worked in the gym with a qualified therapy assistant for 15 minutes, then the patient received direct patient treatment with the qualified therapist for an additional 15 minutes. Total of 40 individual minutes of service were provided by qualified clinicians and are billable for the session.Therapy StudentsServices provided by therapy students are not reimbursable even if provided under direct supervision of the therapist/assistant. However, when a student is in the room, the time that a qualified clinician spends with the patient is reimbursable when the medical record supports:
Article - Billing and Coding: Therapy Students and Aides (A52776)
The qualified clinician is present and in the room for the entire session. The student may participate in the delivery of services only when the qualified clinician is directing the service, making the skilled judgment, and is responsible for the assessment and treatment.The qualified clinician is not engaged in treating another patient or doing other tasks at the same time and is present in the room guiding the student in service delivery when the therapy student is participating in the provision of services.The qualified clinician is responsible for the services and signs all documentation. A student may also sign but payment is for the clinician's service and not for the student's services.When a therapy student is involved the skilled minutes of the qualified clinician may be counted and coded when all requirements listed above are met. For additional information, see the attached article"Medical Necessity of Therapy Services"in the Related Local Coverage Documents link below.SourcesCMS, Resident Assessment Instrument Manual (RAI) Version 3.0, Section OCMS Medicare Learning Network, Medicare Outpatient Therapy BillingInternet Only Manual (IOM),Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Sections 220(A), 230.230.6
Article - Self-Administered Drug Exclusion List: (SAD List) (A52800)
CMS National Coverage PolicyN/AArticle TextThe Medicare program provides limited benefits for outpatient prescription drugs. The program covers drugs that are furnished "incident to" a physician's service provided the drugs are not usually self-administered by the patients who take them. On May 15, 2002, the Centers for Medicare and Medicaid Services (CMS) issued Program Memorandum AB-02-072/Change Request 2200 which contains guidelines to be used by contractors to determine whether a drug or biological is usually self-administered and excluded from payment. For the purposes of applying this exclusion, the term "usually" means more than 50 percent of the time for all Medicare beneficiaries who use the drug. Therefore, if a drug is self-administered by more than 50 percent of Medicare beneficiaries, the drug is excluded from coverage.Please note: some drugs may be listed more than once, using a different code, on the CPT/HCPCS coding table.The following guidelines are to be used for the process of determining whether a drug is usually self-administered:Evidentiary CriteriaOnly evidence of the following types will be considered: peer reviewed medical literature, standards of medical practice, evidence based practice guidelines, FDA approved labeling information and package inserts.PresumptionsBecause reliable statistical information on the extent of self-administration by the patient may not always be available, the following considerations will be used:Absent evidence to the contrary, drugs delivered intravenously should be presumed to be not usually self-administered by the patient.Absent evidence to the contrary, drugs delivered by intramuscular injection should be presumed to be not usually self-administered by the patient.Absent evidence to the contrary, drugs delivered by subcutaneous injection should be presumed to be usually self-administered by the patient.Absent evidence to the contrary, oral drugs, suppositories, topical medications and inhaled medications are considered to be usually self-administered by the patient.Additional consideration will be given to whether the condition being treated by the drug is acute or chronic and the frequency of administration.Basis for Non-Coverage
Article - Self-Administered Drug Exclusion List: (SAD List) (A52800)
Additional consideration will be given to whether the condition being treated by the drug is acute or chronic and the frequency of administration.Basis for Non-CoverageApparent on its FaceFor certain injectable drugs, it will be apparent due to the nature of the condition(s) for which they are administered or the usual course of treatment for those conditions, they are, or are not, usually self-administered. For example, an injectable drug used to treat migraine headaches is usually self-administered. On the other hand, an injectable drug, administered at the same time as chemotherapy, used to treat anemia secondary to chemotherapy is not usually self-administered.The list of drugs identified below have been determined, following the above guidelines, to be usually self-administered by the patients who use them and are excluded from payment. Publication on this list begins a 45-day notice period whereby existing medical review and payment procedures will remain in effect. After the 45-day notice period ends, payment will be denied. The list will be reviewed periodically and updated as further determinations are made. Therefore, the absence of any particular drug on the exclusion list does not mean, at some later date, the drug might be deemed excluded based on the guidelines listed above.Presumption: Long-Term Non-Acute AdministrationIn accordance with CMS instructions, if the condition being treated is for a short term acute basis (e.g. less than two weeks), the drug for this indication is considered "not usually self-administered." If the condition being treated is for a longer term (more than two weeks), the drug for this indication is considered "usually self-administered by the patient."Acceptable Evidentiary Criteria Available- Peer reviewed medical literature,- Standards of medical practice,- Evidence-based practice guidelines,- FDA approved label, and- Package inserts
Article - Self-Administered Drug Exclusion List: (SAD List) (A52800)
Acceptable Evidentiary Criteria Available- Peer reviewed medical literature,- Standards of medical practice,- Evidence-based practice guidelines,- FDA approved label, and- Package insertsRoute of Administration ModifierThe use of the JA and JB modifiers is required for drugs which have one HCPCS Level II (J or Q) code but multiple routes of administration. Drugs that fall under this category will be marked with an asterisk (*) and must be billed with the JA modifier for the intravenous infusion of the drug or billed with the JB modifier for the subcutaneous injection form of administration. Subcutaneously administered drugs listed on the Usually Self-Administered list will be denied as a benefit exclusion. Claims for drugs marked with an asterisk (*) billed without either a JA or JB modifier will also be denied.CPT/HCPCS ModifiersGroup 1 Paragraph:Claim denials may occur when the appropriate modifier is not applied to a J code/medication, which has more than one route of administration.Group 1 Codes:JAIntravenous administrationJBSubcutaneous administration
Article - Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians – Medical Policy Article (A52825)
CMS National Coverage PolicyN/AArticle TextAbstract:"Incident to" a physician's professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness.(CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60.1) The "incident to" provision may also apply to coverage for psychological services furnished "incident to" the professional services of certain non-physician practitioners including clinical psychologists, nurse practitioners, and clinical nurse specialists (CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60.2). Section 1862(a)(1)(A) of the Social Security Act governs payment for the provision of medical care to Medicare beneficiaries.The training requirements and state licensure or authorization of individuals who perform psychological services are intended to ensure an adequate level of expertise in the cognitive skills required for the performance of diagnostic and therapeutic psychological services. Therefore, only the types of individuals listed later in this policy are considered qualified to perform medically necessary psychological services addressed in this policy. Delegation of diagnostic and therapeutic psychological services to personnel not performing within the scope of practice as authorized by state law, under the "incident to" provision, would bypass the safeguards afforded by professional credentialing and state licensure requirements. Such delegated services under the "incident to" provision would be inappropriate, unreasonable, and medically unnecessary, and therefore not covered by Medicare.Coverage of services and supplies "incident to" the professional services of a physician in private practice is limited to situations in which there is general physician supervision of auxiliary personnel.(CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60.1B. To be considered an employee (auxiliary personnel) for purposes of this section, the nonphysician performing an "incident to" service is defined asany individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician or legal entity that employs or contracts with the physician.(CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60.1B).Indications and Limitations:
Article - Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians – Medical Policy Article (A52825)
Indications and Limitations:For psychology services rendered under the "incident to" provision, the billing provider must first evaluate the patient personally and then initiate the course of treatment. The appropriately trained therapists may then render psychological services to the patient under the billing provider's general supervision.While a variety of psychiatric/psychotherapeutic techniques are recognized for coverage, the services must be performed by persons authorized by Medicare and licensed by their state to render these services.Only the types of practitioners listed below, when they are performing within their scope of clinical practice as authorized under state law, are qualified to perform the indicated diagnostic and/or therapeutic psychological services under the "incident to" provision.