evekhm/cms_iom_500 huggingface dataset:
(Medicare Program Integrity Manual)
R486PI  09/06/2013  Complex Medical Review  Rescinded and replaced by Transmittal 501  10/07/2013  8429  R485PI  08/21/2013  Program Safeguard Contractor (PSC) and Zone Program Integrity Contractor (ZPIC) Provider Notification  01/29/2013  8079  R484PI  08/21/2013  OMB Collection Number  05/21/2012  7750  R477PI  08/02/2013  Tracking Medica re Contractors' Postpayment Reviews  Rescinded and replaced by Transmittal 487  10/03/2013  8362  R465PI  05/17/2013  Use of a Rubber Stamp for Signature  06/18/2013  8219  R464PI  05/17/2013  Reopening Claims with Additional Information or Denied due to Late or No Submission of Requested Information  06/18/2013  8267  R458PI  04/12/2013  EsMD RC Public Announcement  05/13/2013  8208  R455PI  03/15/2013  Progress Notes and Forms  12/10/2012  8033  R453PI  03/13/2013  Progress Notes and Forms  Rescinded and replaced by Transmittal 455  12/10/2012  8033  R447PI  01/18/2013  Medical Review Timeliness Requirements  02/19/2013  8131  R446PI  12/28/2012  Program Safeguard Contractor (PSC) and Zone Program Integrity Contractor (ZPIC) 01/29/2013  8079  Rev #  Issue Date  Subject  Impl Date  CR#  Provider Notification   Rescinded and replaced by Transmittal 485  R442PI  12/07/2012  Update for Amendments, Corrections and Delayed Entries in Medical Documentation  01/08/2013  8105  R438PI  11/09/2012  Progress Notes and Forms  Rescinded and replaced by Transmittal 453  12/10/2012  8033  R426PI  06/15/2012  Process for Handling Electronic Submission of Medical Documentation (esMD)  07/16/2012  7835  R422PI  05/25/2012  Request Records Related to the Claim Being Reviewed  06/26/2012  7837  R418PI  04/20/2012  OMB Collection Number  Rescinded and replaced by Transmittal 484  05/21/2012  7750  R399PI  11/04/2011  Revision of PIM Chapter 3, Section 3.2.1 Setting Priorities and Targeting Reviews
(Medicare Program Integrity Manual)
OMB Collection Number  Rescinded and replaced by Transmittal 484  05/21/2012  7750  R399PI  11/04/2011  Revision of PIM Chapter 3, Section 3.2.1 Setting Priorities and Targeting Reviews  12/05/2011  7622  R398PI  11/04/2011  Revision of PIM Chapter 3, Section 3.7.5, Part B, Corrective Action Reporting on CMS and OIG Identified Vulnerabilities Spreadsheet Submission Instructions  12/05/2011  7479  R396PI  11/02/2011  Medical Review of PWK (paperwork)  04/02/2012  7330  R383PI  08/26/2011  Update to Pub. 100 -08, Medicare Program Integrity Manual -Chapter 3  09/26/2011  7536  R377PI  05/27/2011  Program Integrity Manual Reorganization of Chapters 3 and 8  06/28/2011  6560  R367PI  02/25/2011  Use of Claims History Information in Claim Payment Determination  03/25/2011  7305  R366PI  02/04/2011  Auto Denial of Claim Line(s) Items Submitted with a GZ Modifier  07/05/2011  7228  R360PI  12/10/2010  Corrective Action Reporting  01/12/2011  7241  R343PI  06/18/2010  Medical Review Resolutions in the Absence of a Plan of Care (POC) and the Outcome Assessment Informatio n Set (OASIS)  07/19/2010  6982  R338PI  05/14/2010  Clinical Review Judgment (CRJ)  06/15/2010  6954  R327PI  03/16/2010  Signature Guidelines for Medical Review Purposes  04/16/2010  6698  R303PI  09/25/2009  Local Coverage Determinations (LCD) Exceptions - Rescinded  10/13/2009  6586  R302PI  09/11/2009  Local Coverage Determinations (LCD) Exceptions - Rescinded and replaced by Transmittal 303  10/13/2009  6586 Rev #  Issue Date  Subject  Impl Date  CR#  R282PI  01/08/2009  Zone Program Integrity Contractor (ZPIC) Updates  01/26/2009  6170  R278PI  12/19/2008  Zone Program Integrity Contractor (ZPIC) Updates - Rescinded and replaced by Transmittal 282  01/26/2009  6170  R264PI  08/07/2008  Transition of Responsibility
(Medicare Program Integrity Manual)
6170  R278PI  12/19/2008  Zone Program Integrity Contractor (ZPIC) Updates - Rescinded and replaced by Transmittal 282  01/26/2009  6170  R264PI  08/07/2008  Transition of Responsibility for Medical Review From Quality Improvement Organizations (QIOs)  08/15/2008  5849  R248PI  03/28/2008  Signature Requirements Clarification  04/28/2008  5971  R245PI  02/29/2008  Processing Part B Therapy Claims While the Therapy Cap Exceptions Process is in Effect  03/31/2008  5945  R220PI  08/24/2007  Various Medical Review Clarifications  09/03/2007  5550  R185PI  01/26/2007  Updating Financial Reporting Requirements for Workload and Cost Associated With the Return of Demand Bills  02/26/2007  4378  R184PI  01/26/2007  Revisions for MACs and PSCs  02/26/2007  5399  R181PI  12/29/2006  Outpatient Therapy Cap Exceptions Process for Calendar Year (CY) 2007  01/29/2007  5478  R179PI  12/15/2006  Revised Medical Review Timeliness and Reopening Requirements for Medical Review  01/16/2007  5252  R174PI  11/17/2006  Transition of Medical Review Educational Activities  10/06/2006  5275  R171PI  11/09/2006  Outpatient Therapy Cap Clarifications  12/09/2006  5271  R170PI  11/03/2006  Transition of Medical Review Educational Activities  Replaced by Transmittal 174  10/06/2006  5275  R167PI  10/27/2006  New DMEPOS Certificates of Medical Necessity (CMNs) and DME  Information Forms (DIFS) for Claims Proces sing 10/01/2006  4296  R163PI  09/29/2006  Transition of Medical Review Educational Activities  Replaced by Transmittal 170  10/06/2006  5275  R159PI  09/22/2006  New DMEPOS Certificates of Medical Necessity (CMNs) and DME  Information Forms (DIFS) for Claims Proces sing - Replaced by Transmittal 167  10/02/2006  4296  R149PI  06/30/2006  Notification to Providers, Suppliers, and Beneficiaries of Postpayment Review Results  07/31/2006  5115  Rev #  Issue Date  Subject  Impl Date  CR#
(Medicare Program Integrity Manual)
4296  R149PI  06/30/2006  Notification to Providers, Suppliers, and Beneficiaries of Postpayment Review Results  07/31/2006  5115  Rev #  Issue Date  Subject  Impl Date  CR#  R142PI  03/02/2006  New DMEPOS Certificates of Medical Necessity (CMNs) and DME MAC Information Forms (DIFS) for Claims Processing  Replaced by Transmittal 159  10/02/2006  4296  R140PI  02/15/2006  Therapy Caps Exception Process  03/13/2006  4364  R139PI  02/13/2006  Therapy Caps Exception Process - Replaced by Transmittal 140  03/13/2006  4364  R138PI  02/10/2006  New DMEPOS Certificates of Medical Necessity (CMNs) and DME MAC Information Forms (DIFS) for Claims Processing - Replaced by Transmittal 142  10/03/2006  4296  R135PI  01/06/2006  Changes to the GTL Titles  02/06/2006  4228  R131PI  10/10/2005  Medical Review Matching of Electronic Claims and Additional Documentation in the Medical Review Process  02/10/2006  4052  R125PI  09/30/2005  Medical Review Additional Documentation Requests  12/30/2005  4022  R123PI  09/23/2005  MMA Section 935  10/24/2005  3703  R122PI  09/16/2005  Medical Review Collection Number Requirements  10/17/2005  4091  R120PI  08/25/2005  Correction to Change Request (CR) 3222: Local Medical Review Policy/ Local Coverage Determination Medicare Summary Notice (MSN) Message Revision  N/A 3880  R118PI  08/12/2005  Various Benefit Integrity (BI) Clarifications  09/12/2005  3896  R114PI  06/10/2005  Change in Statistical Sampling Instructions  05/31/2005  3734  R108PI  04/29/2005  Change in Statistical Sampling Instructions  05/31/2005  3734  R100PI  01/21/2005  Review of Documentation During Medical Review  02/22/2005  3644  R098PI  01/21/2005  Psychotherapy Notes  02/22/200 5 3457  R096PI  01/14/2005  Consent Settlements  02/14/2005  3626  R094PI  01/14/2005  Informing Beneficiaries About Which Local Medical Review Policy
(Medicare Program Integrity Manual)
Notes  02/22/200 5 3457  R096PI  01/14/2005  Consent Settlements  02/14/2005  3626  R094PI  01/14/2005  Informing Beneficiaries About Which Local Medical Review Policy (LMRP) and/or Local Coverage Determinatio n (LCD) and/or National Coverage Determination (NCD) is Associated with Their Claim Denial  07/05/2005  3602  R091PI  12/10/2004  Revision of Program Integrity Manual (PIM), Section 3.11.1.4  01/03/2005  3560  R090PI  12/10/2004  Prepayment Re view of Claims for MR 01/10/2005  3569  Rev #  Issue Date  Subject  Impl Date  CR#  Purposes  R087PI  11/05/2004  Informing Beneficiaries About Which Local Medical Review Policy (LMRP) and/or Local Coverage Determination (LCD) and/or National Coverage Determination (NCD) is Associated with Their Claim Denial  04/04/2005  3363  R086PI  11/05/2005  Payment for Emergency Medical Treatment and Labor Act (EMTALA) - Mandated Screening and Stabilization Ser vices  11/22/2004  3437  R85PI  10/22/2004  Informing Beneficiaries About Which Local Medical Review Policy (LMRP) and/or Local Coverage Determination (LCD) and/or National Coverage Determination (NCD) is Associated with Their Claim Denial - Replaced by Transmittal 87  04/04/2005  3363  R084PI  10/22/2004  Payment for Emergency Medical Treatment and Labor Act (EMTALA) - Mandated Screening and Stabilization Services - Replaced by Transmittal 86  11/22/2004  3437  R079PI  07/09/2004  Local Medical Review Policy/ Local Coverage Determination Medicare Summary Notice (MSN) Message Revision; Denial Notices  08/09/2004  3222  R076PI  05/28/2004  Clarification of Complex Medical Review  06/28/2004  3211  R075PI  05/14/2004  Informing Beneficiaries About Which Local Medical Review Policy (LMRP) and/or Local Coverage Determination (LCD) and/or National Coverage Determination (NCD) is Associated with Their Claim Denial  10/04/2004  3089  R072PI  04/16/2004  Automated  Prepayment Review  05/01/2004  3088
(Medicare Program Integrity Manual)
Coverage Determination (LCD) and/or National Coverage Determination (NCD) is Associated with Their Claim Denial  10/04/2004  3089  R072PI  04/16/2004  Automated  Prepayment Review  05/01/2004  3088  R071PI  04/09/2004  Rewrite of Program Integrity Manual (except Chapter 10) to Apply to PSCs  05/10/2004  3030  R070PI  04/09/2004  New Requirements for Self -Administered Drug (SAD) Exclusion List Articles in the Medicare Coverage Database (MCD)  05/10/2004  3136  R066PI  02/20/2004  Progressive Corrective Action Program Memorandum and Updated Instructions on How Contractors Must Identify, Verify, and Correct Billing Errors  04/02/2004  3124  R064PI  01/30/2004  Role Conditions of Participation (COPs) Requirements When Making a Payment 03/02/2004  3042  Rev #  Issue Date  Subject  Impl Date  CR#  Decision  R059PI  11/28/2003  Documentation Specifications for Areas Selected for Prepayment or Postpayment MR  01/05/2004  2937  R054PI  10/31/2003  Denia l Notices  04/05/2004  2936  R053PI  10/31/2003  Prepayment Edits  04/05/2004  2916  R049PI  09/26/2003  Changing the Use of Remittance Advice Code N109 From Mandatory to Contractors Discretion  10/10/2003  2873  R047PI  07/25/2003  CMS Mandated Edits  08/08/2003  2517  R046PI  07/25/2003  Prepayment Edits  08/01/2003  2681  R039PI  03/14/2003  MR Review and Documentation  04/01/2003  2417  R038PI  02/03/2003  When Contractors May Publish Coverage/Coding Articles In Their Bulletins And Web Sites  02/14/2003  2120  R035PI  11/29/2002  Types of Prepayment and Postpayment Review  01/01/2003  2418  R033PI  11/01/2002  FY 2003 Budget Performance Requirements  11/01/2002  2407  R032PI  10/25/2002  Consent Settlements, CMPs Delegated to CMS and Referrals to OIG  10/25/2002  2333  R031PI  10/25/2002  Revised Prepayment Edits  09/01/2002  1793
(Medicare Program Integrity Manual)
10/25/2002  Consent Settlements, CMPs Delegated to CMS and Referrals to OIG  10/25/2002  2333  R031PI  10/25/2002  Revised Prepayment Edits  09/01/2002  1793  R017PIM  12/12/2001  Reorganizes chapter 3, sections 4, 5, and 6 and Removes reference to outdated MCM and MIM overpayment collection instructions and lists the more current CFR citations instead.  04/01/2002  1891  R016PIM  11/28/2001  Adds Various Program Memoranda for BI Requests for Information, O rganizational Requirements, Unsolicited Voluntary Refund Checks, Anti -Kickback Statute Implications  11/28/2001  1732  R013PIM  09/26/2001  Administrative Relief from Medical Review and Benefit Integrity in Disaster Situations  09/26/2001  1879  R003PIM  11/22/2000  Complete Replacement of PIM Revision 1.  NA 1292  R001PIM  06/2000  Initial Release of Manual  NA 931 Back to top of Chapter
Article - Non-Payment for Prefabricated Splints (A52754)
CMS National Coverage PolicyN/AArticle TextNoridian has noted that providers have been advised by some coding sources to report a splint application code for the application of "off the shelf" or pre-packaged splints. While it may be appropriate to bill for the actual splint, Noridian strongly disagrees with the advice to bill separately for the application of these splints. The application of the pre-packaged splint is a packaged service when performed on the same day as an E/M service or other procedure but, in no case, may this type of splint application be separately billed.The CPT codes: 29105, 29125, 29126, 29130, 29131, 97760, 97799 are not appropriate to bill in addition to a splint code that has a "fitting" included in the descriptor. Be aware that a large range of "L" codes do include "fitting" in the descriptor
Article - Billing and Coding: Outpatient Therapy Biofeedback Training (A52755)
CMS National Coverage PolicyN/AArticle TextThe amount of time the therapist, physician, or non-physician practitioner (NPP)spends working with a patient must be accurately documented in the medical record to support the units billed on a claim (for both untimed and time-based code services). Providers should be aware of the provision and billing requirements for each Current Procedural Terminology (CPT) code billed.CPTcode 90901 or 90912 or 90913 should beas appropriatebilled when biofeedback training is provided. Biofeedback training consists of the amount of time that the biofeedback modality is attached to the patient with the feedback results to be used and/or analyzed by the patient and/or clinician. Separate billing for concurrently applied modalities and/or procedures during biofeedback training is not appropriate. For example, a therapist may provide a combination of biofeedback and therapeutic exercises during the same 15 minutes to treat a patient. In these instances, the therapeutic exercises are considered to be a component of the biofeedback training and should not be separately billed. Providers should only bill the appropriate biofeedback training code for these combined services.Example 1Treatment=60 MinutesTreatmentBiofeedback Training= 60 minutesTherapeutic Exercises while on Biofeedback Modality and Electrical stimulationBillBiofeedback Training one (1) unitExample 2Treatment=60 MinutesTreatmentBiofeedback Training= 45 minutesTherapeutic Exercises without Biofeedback Training-15 minutesBillBiofeedback Training= one (1) unitTherapeutic Exercises=one (1) unit
Article - Billing and Coding: Outpatient Therapy Biofeedback Training (A52755)
Example 2Treatment=60 MinutesTreatmentBiofeedback Training= 45 minutesTherapeutic Exercises without Biofeedback Training-15 minutesBillBiofeedback Training= one (1) unitTherapeutic Exercises=one (1) unitTreatment for Urinary IncontinenceMedicare covers biofeedback for the treatment of stress and/or urge incontinence in cognitively intact patients when documentation supports a previously failed trial of pelvic muscle exercise (PME) training. A failed trial is observed when no significant clinical improvement in urinary incontinence is noted after completing four weeks of a physician prescribed plan of PME. Medical record documentation of the failed PME trial must be present to justify coverage for biofeedback.When biofeedback training is provided, the most appropriate biofeedback code (90901 or 90912 or 90913) should be billed. Similarly, separate billing for concurrently applied modalities and/or procedures during biofeedback training is not appropriate. For example, a therapist may provide a combination of neuromuscular electrical stimulation (NMES), biofeedback, and therapeutic exercisesduring the same15 minutes to treat a patient with urinary incontinence. In these instances, the therapeutic exercises and the NMES are considered to be a component of the biofeedback training and should not be billed separately. Providers should only bill the appropriate biofeedback training code for these combined services.Example 1Treatment=60 MinutesTreatmentBiofeedback Training= 60 minutesElectrical Stimulation= 15 minutesTherapeutic Exercises while on Biofeedback Modality and Electrical stimulationBillBiofeedback Training one (1) unitExample 2Treatment=60 MinutesTreatmentBiofeedback Training= 45 minutesElectrical Stimulation while on Biofeedback Modality= 15minutesTherapeutic Exercises without Biofeedback or Electrical Stimulation = 15 minutesBillBiofeedback Training= one (1) unitTherapeutic Exercises= one (1) unitExample 3Treatment=60 MinutesTreatmentBiofeedback Training= 45 minutesElectrical Stimulation while not on Biofeedback Modality= 15minutesTherapeutic Exercises during same 15 minute intervalBillBiofeedback Training= one (1) unitTherapeutic Exercises (or attended Electrical Stimulation)= one (1) unitSources
Article - Billing and Coding: Outpatient Therapy Biofeedback Training (A52755)
Electrical Stimulation while not on Biofeedback Modality= 15minutesTherapeutic Exercises during same 15 minute intervalBillBiofeedback Training= one (1) unitTherapeutic Exercises (or attended Electrical Stimulation)= one (1) unitSourcesCMS Internet Only Manual (IOM) National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Sections 30.1 and 30.1.1CMS IOM National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Section 160.12CMS IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 5, Section 20(B)
Article - Therapy Driving Evaluations (A52759)
CMS National Coverage PolicyN/AArticle TextMedicare does not reimburse evaluations performed solely to assess a beneficiary's ability to drive a vehicle. In order for a service to be covered, the service must have a benefit category in the statute Title 18 of the Social Security Act (SSA), it must not be excluded, and it must be reasonable and necessary. There is no benefit category for driving evaluations.In addition, both screening (except as specifically exempted by statute) and routine physical examinations are excluded from coverage. 42 United States Code (USC) 1395y (a) describes routine physical checkups as:1. Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptom, complaint, or injury.2. Examinations required by insurance companies, business establishments, government agencies or other third parties.For Medicare purposes, when services provided are related solely to driving, they are not reasonable or necessary for the diagnosis or treatment of an illness or injury and are excluded from coverage under the program by SSA 1862(a)(1).This is a statutory exclusion. The beneficiary is liable for the charges and no Advance Beneficiary Notice of Noncoverage (ABN) is required. However, providers are encouraged to provide a voluntary ABN. Append modifier GX (Notice of Liability Issue, Voluntary under Payer Policy) to any billed line item.Sources: CMS Internet Only Manual (IOM), Medicare Claims Processing Manual, Publication 100-04, Chapter 1 Section 60 Social Security Act (SSA) Sections 1861 and 1862(a)(1) 42CFR 411.15(a)
Article - Billing and Coding: Fracture Care (A52767)
CMS National Coverage PolicyN/AArticle TextMany times the initial treating physician does not provide all of the follow-up care after surgery.  View examples of acceptable ways to bill for definitive or restorative treatment of a fracture.Coding and Billing OptionsClaim Coding Example #1When the surgeon does not provide any of the follow-up care for the 90 day global payment period, the surgeon bills the closed treatment of radial shaft fracture as follows:DatePlace of ServiceCPT/ModifierChargeUnits2/15/2014Applicable Code25500 54$$1Second physician bills the follow-up care for the closed treatment of radial shaft fracture as follows:DatePlace of ServiceCPT/ModifierChargeUnits2/15/2014Applicable Code25500 55$$1Documentation in item 19 of 1500 claim form:  2/16/2014- 5/16/2014Claim Coding Example #2When post operative care is provided by both physicians (45 days each), the surgeon bills the closed treatment of radial shaft fracture as follows:DatePlace of ServiceCPT/ModifierChargeUnits2/15/2014Applicable Code25500 54$$12/15/2014Applicable Code25500 55$$1Document in item 19 of 1500 claim form 2/16/14-4/1/2014Second physician bills the closed treatment of radial shaft fracture as follows:DatePlace of ServiceCPT/ModifierChargeUnits2/15/2014Applicable Code25500 55$$1Document in item 19 of 1500 claim form 4/2/2014-5/16/2014If the decision to have surgery was made by the surgeon on the day before or the day of surgery, a modifier 57 needs to be appended to the evaluation and management code used.  Without this modifier, your visit will be denied as included in the global package of the surgery.If a patient visit occurs after surgery which is unrelated to the surgical procedure, a modifier 24 must be appended to the evaluation and management code.To assist physicians and practitioners to select the correct code for the casting, splinting and splinting supplies, the following crosswalk provides guidance on which supply code are applicable for the various types of casts listed by Level I CPT codes.
Article - Billing and Coding: Fracture Care (A52767)
To assist physicians and practitioners to select the correct code for the casting, splinting and splinting supplies, the following crosswalk provides guidance on which supply code are applicable for the various types of casts listed by Level I CPT codes.The splints and cast Q codes are considered Level II codes and to be used when supplies are indicated for cast and splint purposes.  The payment is in addition to the payment made under the physician fee schedule for the procedure for applying the splint or cast.Level ILevel IILevel ILevel II29000Q4001 or Q400229126Q4021 through Q402429010Q4001 or Q400229130Q404929015Q4001 or Q400229131Q405129020Q4001 or Q400229305Q4025 through Q402829025Q4001 or Q400229325Q4025 through Q402829035Q4001 or Q400229345Q4029 through Q403229040Q4001 or Q400229355Q4029 through Q403229044Q4001 or Q400229365Q4033 through Q403629046Q4001 or Q400229405Q4037 through Q40402949Q405029425Q4037 through Q404029055Q4003 or Q400429435Q4037 through Q404029058Q400329440Q405029065Q4005 through Q400829445Q4037 through Q404029075Q4009 through Q401229450Q4035, Q4036, Q403929085Q4013 through Q4016Q404029105Q4017 through Q402029505Q4041 through Q404429125Q4021 through Q402429515Q4045 through Q4048The allowance for application of a cast, splint or strapping includes removal or repair by the same physician or other physician in the same group.  Billing for cast removal or repair (29700-29750) should be employed only for casts applied by another physician group.