evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
 Comprehensive Outpatient Rehabilitation Facility (POS code 62);    End-Stage Renal Disease Treatment Facility (POS code 65);    State or Local Health Clinic (POS code 71);    Rural Health Clinic (POS code 72);    Independent Laboratory (POS code 81); and    Other Place of Service (POS code 99).   See chapter 26, section 10.5 of this manual for the complete listing of the Place of Service code set, including instructions and special considerations for the application of certain POS codes under Medicare.   Nonfacility rates are applicable to outpatient rehabilitative therapy procedures, including those relating to physical therapy, occupational therapy and speech -language pathology, regardless of whether they are furnished in facility or nonfacility settings .  Nonfacility rates also apply to all comprehensive outpatient rehabilitative facility (CORF) services.  In addition, payment is made at the nonfacility rate for physician services provided to CORF patients and appropriately billed using POS code 62 for C ORF.   20.4.3 - Assistant -at Surgery -Services  (Rev. 2656, Issuance: 02- 07-13, Effective: 02- 19-13, Implementation: 02- 19-13)  For assistant -at-surgery services performed by physicians, the fee schedule amount equals 16 percent of the amount otherwise applicable for the surgical payment.  A/B MACs (B) may not pay assistants -at-surgery for surgical procedures in which a physician is used as an assistant -at-surgery in fewer than five percent of the cases for that procedure nationally.  This is determined through manual reviews.  Procedures billed with the assistant- at-surgery physician modifiers - 80, -81, -82, or the AS modifier for physician assistants, nurse practitioners and clinical nurse specialists, are subject to the assistant- at-surgery policy.  Accordingly, pay claims for  procedures with these modifiers only if the services of an assistant -at-surgery are authorized.
(Medicare Claims Processing Manual)
Medicares policies on billing patients in excess of the Medicare allowed amount apply to assistant -at-surgery services.  Physicians who knowingly and willfully violate this prohibition and bill a beneficiary for an assistant -at-surgery service for these p rocedures may be subject to the penalties contained under 1842(j)(2) of the Social Security Act (the Act.)  Penalties vary based on the frequency and seriousness of the violation.  Go to http://www.ssa.gov/OP_Home/ssact/title18/1800.htm  and select the relevant section.   20.4.4 - Supplies  (Rev. 1, 10- 01-03) B3-15900.2
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20.4.4 - Supplies  (Rev. 1, 10- 01-03) B3-15900.2  A/B MACs (B) make a separate payment for supplies furnished in connection with a procedure only when one of the two following conditions exists:  A. HCPCS code A4300 is billed in conjunction with the appropriate procedure in the Medicare Physician Fee Schedule Data Base (place of service is physicians office).  However, A4550, A4300, and A4263 are no longer separately payable as of 2002.  Supplies ha ve been incorporated into the practice expense RVU for 2002.  Thus, no payment may be made for these supplies for services provided on or after January 1, 2002.  B. The supply is a pharmaceutical or radiopharmaceutical diagnostic imaging agent (including codes A4641 through A4647); pharmacologic stressing agent (code J1245); or therapeutic radionuclide (CPT code 79900).  Other agents may be used which do not have an assigned HCPCS code.  The procedures performed are:   Diagnostic radiologic procedures (including diagnostic nuclear medicine) requiring pharmaceutical or radiopharmaceutical contrast media and/or pharmacologic stressing agent;   Other diagnostic tests requiring a pharmacologic stressing agent;   Clinical brachytherapy procedures (other than remote after -loading high intensity brachytherapy procedures (CPT codes 77781 through 77784) for which the expendable source is included in the TC RVUs); or   Therapeutic nuclear medicine procedures.  Drugs are not supplies, and may be paid incidental to physicians services as described in Chapter 17.  20.4.5 - Allowable Adjustments (Rev. 1, 10- 01-03) B3-15055
(Medicare Claims Processing Manual)
Effective January 1, 2000, the replacement code (CPT 69990) for modifier - 20 - microsurgical techniques requiring the use of operating microscopes may be paid separately only when submitted with CPT codes:  61304 through 61546  61550 through 61711 62010 through 62100  63081 through 63308 63704 through 63710  64831 64834 through 64836 64840 through 64858 64861 through 64871 64885 through 64891 64905 through 64907. 20.4.6 - Payment Due to Unusual Circumstances (Modifiers -22 and  -52) (Rev. 1, 10- 01-03) B3-15028  The fees for services represent the average work effort and practice expenses required to provide a service.  For any given procedure code, there could typically be a range of work effort or practice expense required to provide the service.  Thus, A/B MACs (B) may increase or decrease the payment for a service only under very unusual circumstances based upon review of medical records and other documentation.  20.4.7  Technical Component Payment Reduction for X- Rays and Other Imaging Services  (Rev. 3820, Issued: 11- 21-17, Effective: 01 -01-18, Implementation; 01- 02-18) Several provisions provide for a payment reduction to the technical component (and the technical component of the global fee) for X -rays and imaging services under certain circumstances.  Please see Chapter 13, Section 20.2 of this publication for more information.
(Medicare Claims Processing Manual)
20.5 - No Adjustments in Fee Schedule Amounts  (Rev. 1, 10- 01-03) B3-15054 A/B MACs (B) may not make adjustments in fee schedule amounts provided by CMS for:   Inherent reasonableness;   Comparability;  Multiple visits to nursing homes (i.e., when more than one patient is seen during the same trip);  Refractions -  If A/B MACs (B) receive a claim for a service that also indicates that a refraction was done, A/B MACs (B) do not reduce payment for the service.  The CMS has already made the reduction in the fee for refractions provided to A/B MACs (B);   HCPCS alpha -numeric modifiers AT (acute treatment), ET (emergency treatment), LT (left side of body), RT (right side of body), and SF (second opinion ordered by PRO);   CPT modifiers - 23 (unusual anesthesia), -32 (mandated services), - 47 (anesthesia by surgeon), - 76 (repeat procedure by same physician), and - 90 (reference laboratory); and   A/B MAC (B) -unique local modifiers (HCPCS Level 3 modifiers beginning with the letters w through z).   20.6- Update Factor for Fee Schedule Services  (Rev. 2464, Issued: 05 -04-12, Effective: 10 -01-11-MCS/10 -01-12-VMS, Implementation: 10-03-11-MCS, VMS Analysis and Design /10- 01-12-VMS implementation)   The CMS provides updates to the MPFSDB and other fee schedules annually or as otherwise necessary.  C laims processing A/B MACs (B) must maintain at least five full calendar years of fee schedules and related pricing data (i.e., the current and four prior calendar years) , regardless of the number of updates or pricing periods within those five years.
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20.7 - Comparability of Payment Provision of Delegation of Authority by CMS to Railroad Retirement Board  (Rev. 1, 10- 01-03) B3-15064 The delegation of authority, under which the Railroad Retirement Board (RRB) administers the Supplementary Medical Insurance Benefits Program for qualified railroad retirement beneficiaries, requires that:  The Railroad Retirement Board shall take such action as may be necessary to assure that payments made for services by the A/B MACs (A) it selects will conform as closely as possible to the payment made for comparable services in the same locality by an A/B  MAC (A) acting for CMS.  The purpose of this comparability of payment is to reduce to the extent possible disparities between the payments made by the A/B MAC (B) under the RRB delegation and the payments made by the regular A/B MACs (B) for services or items furnished by the same  physicians, including provider -based physicians, or suppliers.  For all services paid for under the physician fee schedule, A/B MACs (B) under the RRB delegation pay based on the same fee schedule amount used by the A/B MAC (B).  20.8 - Payment for Teleradiology Physician Services Purchased by the Indian Health Service (IHS) Providers and Physicians  (Rev. 1643, Issued: 12- 05-08, Effective: 01 -01-07, Implementation: 03- 09-09)  The IHS providers may choose to purchase or otherwise contract with non- IHS physicians or practitioners for teleradiology interpretations services.  These services may be paid using either contractual reassignment or purchased test methodologies.  See Chapter 19, 120 of this manual for further information.  30 - Correct Coding Policy (Rev. 1, 10- 01-03) B3-15068 The Correct Coding Initiative was developed to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims.  Refer to Chapter 23 for additional information on the initiative. The principles for the correct coding policy are:   The service represents the standard of care in accomplishing the overall procedure;   The service is necessary to successfully accomplish the comprehensive procedure.  Failure to perform the service may compromise the success of the procedure; and   The service does not represent a separately identifiable procedure unrelated to the comprehensive procedure planned.
(Medicare Claims Processing Manual)
For a detailed description of the correct coding policy, refer to http://www.cms.gov/Outreach-and-Education/Medicare -Learning -Network -MLN/MLNProducts/downloads/How -To-Use-NCCI -Tools.pdf .  The CMS as well as many third party payers have adopted the HCPCS/CPT coding system for use by physicians and others to describe services rendered.  The system contains three levels of codes.  Level I contains the American Medical Associations Current Pro cedural Terminology (CPT) numeric codes.  Level II contains alpha -numeric codes primarily for items and services not included in CPT.  Level III contains A/B MAC (B) specific codes that are not included in either Level I or Level II.  For a list of CPT and  HCPCS codes refer to the CMS Web site.
(Medicare Claims Processing Manual)
A.  Upper Gastrointestinal Endoscopy Including Endoscopic Ultrasound (EUS) (Code 43259)   If the person performing the original diagnostic endoscopy has access to the EUS and the clinical situation requires an EUS, the EUS may be done at the same time.  The procedure, diagnostic and EUS, is reported under the same code, CPT 43259.  This code conforms to CPT guidelines for the indented codes.  The service represented by the indented code, in this case code 43259 for EUS, includes the service represented by the unintended code preceding the list of indented codes.  Therefore, when a diagnostic examination of the upper gastrointestinal tract including esophagus, stomach, and either the duodenum or jejunum as appropriate, includes the use of endoscopic ultrasonography, the service is reported by a single code, namely 43259.   Interpretation, whether by a radiologist or endoscopist, is reported under CPT code 76975- 26.  These codes may both be reported on the same day.  B.  Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121)
(Medicare Claims Processing Manual)
References to technicians apply also to other qualified clinical staff.  See Pub. 100- 02, chapter 15, section 80.3.D.   A. Correct Reporting   1. General.  Contact the A/B MAC (B) for guidance if the CPT codebook changes the description of codes mentioned in this section.  Other policies concerning audiological services are found in Pub. 100- 02, chapter 15, section 80.3.  See chapter 26 of this manual for place of service and type of service coding.  Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105- 33), which added section 1834(k)(5) to (the Act), required that all claims for certain audiology services be reported using a uniform coding system.  CMS chose HCPCS (Healthcare Common Procedure  Coding System) as the coding system for the reporting of these services.  This coding requirement is effective for all claims for audiology services submitted on or after April 1, 1998.  The BBA also required payment under a prospective payment system for audiology services.  Effective for claims with dates of service on or after January 1, 1999, the Medicare Physician Fee Schedule (MPFS) became the method of payment for audiology services  furnished in the office setting and for the associated professional services furnished in physicians office and hospital outpatient settings.   2. Use of the NPI.  For audiologists who are enrolled and bill independently for services they render, the audiologists NPI is required on all claims they submit.  For example, in offices and private practice settings, an enrolled audiologist shall use hi s or her own NPI in the rendering loop to bill under the MPFS for the services the audiologist furnished.  If an enrolled audiologist furnishing services to hospital outpatients reassigns his/her benefits to the hospital, the hospital may bill the A/B MAC (B) for the professional services of the audiologist under the MPFS using the NPI of the audiologist.  If an audiologist is employed by a hospital but is not enrolled in Medicare, the only payment for a hospital outpatient audiology service that can be mad e is the payment to the hospital for its facility services under the hospital Outpatient Prospective Payment System (OPPS) or other applicable hospital payment system.  No payment can be made under the MPFS for professional services of an audiologist who i s not enrolled.
(Medicare Claims Processing Manual)
Audiologists must be enrolled and use their NPI on claims for services they render in office settings on or  after October 1, 2008 (for additional information about enrollment, refer to Pub. 100-08, Medicare Program Integrity Manual, chapter 15).  Before October 1, 2008, the services of audiologists who were not yet enrolled in Medicare were billed by a physicia n or group who employed the audiologist.  Audiologists shall use the billing instructions in the Medicare manuals; for example, see this manual, chapter 1, section 30.  See the most recent MPFS for pricing and physician supervision levels for audiology services:  http://www.cms.hhs.gov/PFSlookup/01_Overview.asp#TopOfPage .  The NPI of the supervising physician shall be used to bill audiology services when supervision is appropriate.   The most recent OPPS pricing for audiology services is available in Addendum B at:  http://www.cms.gov/HospitalOutpatientPPS/AU/list.asp#TopOfPage .  B. Billing for Audiology Services   See the CMS Web site at:  www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/PhysicianFeeSched/index.html?  and select Audiology from the column on the left for a listing of all CPT codes for audiology services.  For information concerning codes that are not on the list, and which codes may be billed when furnished by technicians, A/B MACs (B) shall provide gui dance.  The Physician Fee Schedule at http://www.cms.gov/PFSlookup/01_Overview.asp#TopOfPage  allows you to search pricing amounts, various payment policy indicators, RVUs, and GPCIs.   Audiology services may not be billed when the place of service is a comprehensive outpatient rehabilitation facility (CORF) or a rehabilitation agency.   Audiology services may be furnished and billed by audiologists and, when these services are furnished by an audiologist, no physician supervision is required.
(Medicare Claims Processing Manual)
Audiology services may be furnished and billed by audiologists and, when these services are furnished by an audiologist, no physician supervision is required.   The interpretation and report shall be written in the medical record by the audiologist, physician, or NPP who personally furnished any audiology service, or by the physician who supervised the service.  Technicians shall not interpret audiology services, but may record objective test results of those services they may furnish under direct physician supervision.  Payment for the interpretation and report of the services is included in payment for all audiology services, and specifically in the professional component if the audiology service has a professional component/technical component split.   1. Billing under the MPFS for Audiology Services Outside the Facility Setting  The individuals who furnish audiology services in all settings must be qualified to furnish those services.  The qualifications of the individual performing the services must be consistent with the number, type and complexity of the tests, the abilities of  the individual, and the patients ability to interact to produce valid and reliable results.  The physician who supervises and bills for the service is responsible for assuring the qualifications of the technician, if applicable are appropriate to the tes t.  a. Professional Skills.  When a professional personally furnishes an audiology service, that individual must interact with the patient to provide professional skills and be directly involved in decision- making and clinical judgment during the test.   The skills required when professionals furnish audiology services for payment under the MPFS are masters or doctoral level skills that involve clinical judgment or assessment and specialized knowledge and ability including, but not limited to, knowledge of  anatomy and physiology, neurology, psychology, physics, psychometrics, and interpersonal communication.  The interactions of these knowledge bases are required to attain the clinical expertise for audiology tests.  Also required are skills to administer v alid and reliable tests safely, especially when they involve stimulating the auditory nerve and testing complex brain functions.  Diagnostic audiology services also require skills and judgment to administer and modify tests, to make informed interpretations about the causes and implications of the test results in the context of the history and presenting complaints, and to provide both objective results and professional knowledge to the patient and to the ordering physician.   Examples include, but are not limited to:    Comparison or consideration of the anatomical or physiological implications of test results or patient responsiveness to stimuli during the test;    Development and modification of the test battery and test protocols;
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Examples include, but are not limited to:    Comparison or consideration of the anatomical or physiological implications of test results or patient responsiveness to stimuli during the test;    Development and modification of the test battery and test protocols;    Clinical judgment, assessment, evaluation, and decision- making;    Interpretation and reporting observations, in addition to the objective data, that may influence interpretation of the test outcomes;   Tests related to implantation of auditory prosthetic devices, central auditory processing, contralateral masking; and/or    Tests to identify central auditory processing disorders, tinnitus, or nonorganic hearing loss.  Audiology codes may be billed under the MPFS by audiologists, physicians, and NPPs using their own NPI in the rendering loop when those professionals personally furnish the test.  Physicians and NPPs may not bill for these codes when an audiologist has fur nished the service.   b. Technician Skills.  There may be subtests, or parts of a battery of tests, that may be appropriately furnished by an educated and experienced technician using a specific protocol under the direction of a supervising physician.  These services are identified by A/B MAC (B) det ermination as services that do not require professional skills.  They may be furnished by a qualified technician under the direct supervision of a physician, but not under the supervision of an audiologist or an NPP.  The supervising physician is responsible for rendering and documenting all clinical judgment and for the appropriate provision of the service by the technician.   A technician may not perform any part of a service that requires professional skills.  A technician also may not perform a global service.  For example, a technician may not interpret test results or engage in clinical decision -making.  c. Professional Component (PC)/Technical Component (TC) Split Codes .   The PC of a PC/TC split code may be billed by the audiologist, physician, or NPP who personally furnishes the service.  (Note this is also true in the facility setting.)  A physician or NPP may bill for the PC when the physician or NPP furnish the PC and a n (unsupervised) audiologist furnishes and bills for the TC.  The PC may not be billed if a technician furnishes the service.  A physician or NPP may not bill for a PC service furnished by an audiologist.
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 The TC of a PC/TC split code may be billed by the audiologist, physician, or NPP who personally furnishes the service.  Physicians may bill the TC for services furnished by technicians when the technician furnishes the service under the direct supervision of that physician.  Audiologists and NPPs may not bill for the TC of the service when a technician furnishes the service, even if the technician is supervised by the NPP or audiologist.    The global service is billed when both the PC and TC of a service are personally furnished by the same audiologist, physician, or NPP.  The global service may also be billed by a physician, but not an audiologist or NPP, when a technician furnishes the TC of the service under direct physician supervision and that physician furnishes the PC, including the interpretation and report.  d. Tests that are Not Described by Specific CPT Codes .  Tests that have no appropriate CPT code may be reported under CPT code 92700 (Unlisted otorhinolaryngological service or procedure).   e. Tests that are A/B MAC (B) -Priced.   For codes valued by A/B MACs (B), the A/B MAC (B) determines whether and how much, if applicable, to pay for the service.  The A/B MAC (B) sets the requirements for personnel furnishing the tests.  2. Billing for Audiology Services Furnished to Hospital Outpatients.  All codes may be reported for audiology services furnished in the hospital outpatient setting and, in such cases, the code represents the facility service for the diagnostic test.  All audiology services furnished to hospital outpatients must be billed and paid to the hospital under the OPPS or other applicable hospital payment system.  The hospital bills its A/B MAC (A) and is paid for the facility resources required to furnish the services, regardless of whether the service is furnished by a physician, NP P, audiologist, or technician.