evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Outpatient Physical Therapy (A53065)
Self-Care/Home Management Training (CPTcode 97535)When instructing the patient in a self-management program, use the code that best describes the focus of the self-management activity. For example, if the instruction given is for exercises to be done at home to improve range of motion (ROM) or strength, use 97110; if instructing the patient in balance or coordination activities at home, use 97112; if instructing the patient's spouse or caregiver how to assist the patient up/down steps using an assistive device to get into and out of the home, use 97116; if teaching the patient aquatic exercises to use as an independent program in the community pool, use 97113.Hot/Cold Packs (CPTcode 97010)The payment for hot or cold packs is bundled into the payment for other covered services and is not reimbursable. Ice massage should be reported usingCPTcode 97010.Direct 1-on-1 ContactRegardless of the procedure or modality being performed, if the patient is not receiving direct 1-on-1 contact but is being supervised by the therapist, the group therapy code should be used.Orthotic Management and Training and Prosthetic Training (CPTcode 97760)For entities subject to the related LCD, assessment of the patient regarding the orthotic, measurement and/or fitting, supplies to fabricate or modify the orthotic, and time associated with making the orthotic should not be reported with CPTcode 97760, unless the entities are certain that duplicate payments will not be made to Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) suppliers using the "L" code.Community/Work Reintegration (CPTcode 97537)Should be utilized when a patient is trained in the use of assistive technology to assist with mobility, seating systems, and environmental control systems for use in the community.
Social Security Act §1861
html  PUBLIC "-//W3C//DTD HTML 4.01//EN"SSA INTERNET HEAD SCRIPTSSocial Security Act 1861BANNERSkip to main contentSocial SecuritySearchMenuEspaolSign inSITE NAVIGATION#include virtual="/framework/includes/english/navigation.shtml"PAGE TITLECompilation of the Social Security LawsCONTENTThere is a more recent version of this section in the official Social Security ActStatute Compilation.
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Part EMiscellaneous ProvisionsDEFINITIONS OF SERVICES, INSTITUTIONS, ETC.[495]Sec.1861.[42 U.S.C. 1395x]For purposesof this titleSpell of Illness(a)The term spell of illness withrespect to any individual means a period of consecutive days(1)beginning withthe first day (not included in a previous spell of illness) (A) onwhich such individual is furnished inpatient hospital services, inpatientcritical access hospital services or extended care services, and (B)which occurs in a month for which he is entitled to benefits underpart A, and(2)ending with theclose of the first period of 60 consecutive days thereafter on eachof which he is neither an inpatient of a hospital or critical accesshospital nor an inpatient of a facility described in section 1819(a)(1) or subsection(y)(1).Inpatient Hospital Services(b)The term inpatient hospital services means the following items and services furnished to an inpatientof a hospital and (except as provided in paragraph (3)) by the hospital(1)bed and board;(2)such nursing servicesand other related services, such use of hospital facilities, and suchmedical social services as are ordinarily furnished by the hospitalfor the care and treatment of inpatients, and such drugs, biologicals,supplies, appliances, and equipment, for use in the hospital, as areordinarily furnished by such hospital for the care and treatment ofinpatients; and(3)such other diagnosticor therapeutic items or services, furnished by the hospital or byothers under arrangements with them made by the hospital, as are ordinarilyfurnished to inpatients either by such hospital or by others undersuch arrangements;excluding, however(4)medical or surgicalservices provided by a physician, resident, or intern, services describedby subsection (s)(2)(K), certified nurse-midwife services, qualifiedpsychologist services, and services of a certified registered nurseanesthetist; and(5)the services ofa private-duty nurse or other private-duty attendant.Paragraph (4) shall not apply to services provided in a hospitalby
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(5)the services ofa private-duty nurse or other private-duty attendant.Paragraph (4) shall not apply to services provided in a hospitalby(6)an intern or aresident-in-training under a teaching program approved by the Councilon Medical Education of the American Medical Association or, in thecase of an osteopathic hospital, approved by the Committee on Hospitalsof the Bureau of Professional Education of the American OsteopathicAssociation, or, in the case of services in a hospital or osteopathichospital by an intern or resident-in-training in the field of dentistry,approved by the Council on Dental Education of the American DentalAssociation, or in the case of services in a hospital or osteopathichospital by an intern or resident-in-training in the field of podiatry,approved by the Council on Podiatric Medical Education of the AmericanPodiatric Medical Association; or(7)a physician wherethe hospital has a teaching program approved as specified in paragraph(6), if (A) the hospital elects to receive any payment due under thistitle for reasonable costs of such services, and (B) all physiciansin such hospital agree not to bill charges for professional servicesrendered in such hospital to individuals covered under the insuranceprogram established by this title.Inpatient Psychiatric Hospital Services(c)The term inpatient psychiatric hospitalservices means inpatient hospital services furnished to aninpatient of a psychiatric hospital.Supplier(d)The term supplier means, unlessthe context otherwise requires, a physician or other practitioner,a facility, or other entity (other than a provider of services) thatfurnishes items or services under this title.Hospital(e)The term hospital (except forpurposes of sections 1814(d), 1814(f), and 1835(b), subsection (a)(2) of this section, paragraph (7)of this subsection, and subsection (i) of this section) means an institutionwhich(1)is primarily engagedin providing, by or under the supervision of physicians, to inpatients(A) diagnostic services and therapeutic services for medical diagnosis,treatment, and care of injured, disabled, or sick persons, or (B)rehabilitation services for the rehabilitation of injured, disabled,or sick persons;(2)maintains clinicalrecords on all patients;
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(2)maintains clinicalrecords on all patients;(3)has bylaws ineffect with respect to its staff of physicians;(4)has a requirementthat every patient with respect to whom payment may be made underthis title must be under the care of a physician except that a patientreceiving qualified psychologist services (as defined in subsection(ii)) may be under the care of a clinical psychologist with respectto such services to the extent permitted under State law;(5)provides 24-hournursing service rendered or supervised by a registered professionalnurse, and has a licensed practical nurse or registered professionalnurse on duty at all times; except that until January 1, 1979, theSecretary is authorized to waive the requirement of this paragraphfor any one-year period with respect to any institution, insofar assuch requirement relates to the provision of twenty-four-hour nursingservice rendered or supervised by a registered professional nurse(except that in any event a registered professional nurse must bepresent on the premises to render or supervise the nursing serviceprovided, during at least the regular daytime shift), where immediatelypreceding such one-year period he finds that(A)such institutionis located in a rural area and the supply of hospital services insuch area is not sufficient to meet the needs of individuals residingtherein,(B)the failureof such institution to qualify as a hospital would seriously reducethe availability of such services to such individuals, and(C)such institutionhas made and continues to make a good faith effort to comply withthis paragraph, but such compliance is impeded by the lack of qualifiednursing personnel in such area;(6)(A)has in effecta hospital utilization review plan which meets the requirements ofsubsection (k) and(B)has in placea discharge planning process that meets the requirements of subsection(ee);(7)in the case ofan institution in any State in which State or applicable local lawprovides for the licensing of hospitals, (A) is licensed pursuantto such law or (B) is approved, by the agency of such State or localityresponsible for licensing hospitals, as meeting the standards establishedfor such licensing;(8)has in effectan overall plan and budget that meets the requirements of subsection(z); and(9)meets such otherrequirements as the Secretary finds necessary in the interest of thehealth and safety of individuals who are furnished services in theinstitution.
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For purposes of subsection (a)(2), such term includes any institutionwhich meets the requirements of paragraph (1) of this subsection.For purposes of sections 1814(d) and 1835(b) (including determinationof whether an individual received inpatient hospital services or diagnosticservices for purposes of such sections), section 1814(f)(2), and subsection (i) ofthis section, such term includes any institution which (i) meets therequirements of paragraphs (5) and (7) of this subsection, (ii) isnot primarily engaged in providing the services described in section 1861(j)(1)(A) and(iii) is primarily engaged in providing, by or under the supervisionof individuals referred to in paragraph (1) of section 1861(r), to inpatientsdiagnostic services and therapeutic services for medical diagnosis,treatment, and care of injured, disabled, or sick persons, or rehabilitationservices for the rehabilitation of injured, disabled, or sick persons.For purposes of section 1814(f)(1), such term includes an institution which (i) isa hospital for purposes of sections 1814(d), 1814(f)(2), and 1835(b) and (ii) is accredited by theJoint Commission on Accreditation of Hospitals, or is accredited byor approved by a program of the country in which such institutionis located if the Secretary finds the accreditation or comparableapproval standards of such program to be essentially equivalent tothose of the Joint Commission on Accreditation of Hospitals. Notwithstandingthe preceding provisions of this subsection, such term shall not,except for purposes of subsection (a)(2), include any institutionwhich is primarily for the care and treatment of mental diseases unlessit is a psychiatric hospital (as defined in subsection (f)). The term hospital also includes a religious nonmedical health careinstitution (as defined in subsection (ss)(1)), with respect to itemsand services ordinarily furnished by such institution to inpatients,and payment may be made with respect to services provided by or insuch an institution only to such extent and under such conditions,limitations, and requirements (in addition to or in lieu of the conditions,limitations, and requirements otherwise applicable) as may be providedin regulations consistent with section 1821. For provisions deeming certain requirementsof this subsection to be met in the case of accredited institutions,see section
Social Security Act §1861
addition to or in lieu of the conditions,limitations, and requirements otherwise applicable) as may be providedin regulations consistent with section 1821. For provisions deeming certain requirementsof this subsection to be met in the case of accredited institutions,see section 1865. The term hospital also includes a facility of fiftybeds or less which is located in an area determined by the Secretaryto meet the definition relating to a rural area described in subparagraph(A) of paragraph (5) of this subsection and which meets the otherrequirements of this subsection, except that
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(A)with respectto the requirements for nursing services applicable after December31, 1978, such requirements shall provide for temporary waiver ofthe requirements, for such period as the Secretary deems appropriate,where (i) the facilitys failure to fully comply with the requirementsis attributable to a temporary shortage of qualified nursing personnelin the area in which the facility is located, (ii) a registered professionalnurse is present on the premises to render or supervise the nursingservice provided during at least the regular daytime shift, and (iii)the Secretary determines that the employment of such nursing personnelas are available to the facility during such temporary period willnot adversely affect the health and safety of patients;(B)with respectto the health and safety requirements promulgated under paragraph(9), such requirements shall be applied by the Secretary to a facilityherein defined in such manner as to assure that personnel requirementstake into account the availability of technical personnel and theeducational opportunities for technical personnel in the area in whichsuch facility is located, and the scope of services rendered by suchfacility; and the Secretary, by regulations, shall provide for thecontinued participation of such a facility where such personnel requirementsare not fully met, for such period as the Secretary determines that(i) the facility is making good faith efforts to fully comply withthe personnel requirements, (ii) the employment by the facility ofsuch personnel as are available to the facility will not adverselyaffect the health and safety of patients, and (iii) if the Secretaryhas determined that because of the facilitys waiver under thissubparagraph the facility should limit its scope of services in ordernot to adversely affect the health and safety of the facilityspatients, the facility is so limiting the scope of services it provides;and
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(C)with respectto the fire and safety requirements promulgated under paragraph (9),the Secretary (i) may waive, for such period as he deems appropriate,specific provisions of such requirements which if rigidly appliedwould result in unreasonable hardship for such a facility and which,if not applied, would not jeopardize the health and safety of patients,and (ii) may accept a facilitys compliance with all applicableState codes relating to fire and safety in lieu of compliance withthe fire and safety requirements promulgated under paragraph (9),if he determines that such State has in effect fire and safety codes,imposed by State law, which adequately protect patients.The term hospital does not include, unless thecontext otherwise requires, a critical access hospital (as definedin section 1861(mm)(1)).Psychiatric Hospital(f)The term psychiatric hospital means an institution which(1)is primarily engagedin providing, by or under the supervision of a physician, psychiatricservices for the diagnosis and treatment of mentally ill persons;(2)satisfies therequirements of paragraphs (3) through (9) of subsection (e);(3)maintains clinicalrecords on all patients and maintains such records as the Secretaryfinds to be necessary to determine the degree and intensity of thetreatment provided to individuals entitled to hospital insurance benefitsunder part A; and(4)meets such staffingrequirements as the Secretary finds necessary for the institutionto carry out an active program of treatment for individuals who arefurnished services in the institution.In the case of an institution which satisfies paragraphs (1)and (2) of the preceding sentence and which contains a distinct partwhich also satisfies paragraphs (3) and (4) of such sentence, suchdistinct part shall be considered to be a psychiatric hospital.Outpatient Occupational Therapy Services(g)The term outpatient occupational therapyservices has the meaning given the term outpatientphysical therapy services in subsection (p), except that occupational shall be substituted for physical each place it appears therein.Extended Care Services(h)The term extended care services means the following items and services furnished to an inpatientof a skilled nursing facility and (except as provided in paragraphs(3), (6), and (7)) by such skilled nursing facility
Social Security Act §1861
(1)nursing care providedby or under the supervision of a registered professional nurse;(2)bed and boardin connection with the furnishing of such nursing care;(3)physical or occupationaltherapy or speech-language pathology services furnished by the skillednursing facility or by others under arrangements with them made bythe facility;(4)medical socialservices;(5)such drugs, biologicals,supplies, appliances, and equipment, furnished for use in the skillednursing facility, as are ordinarily furnished by such facility forthe care and treatment of inpatients;(6)medical servicesprovided by an intern or resident-in-training of a hospital with whichthe facility has in effect a transfer agreement (meeting the requirementsof subsection (l)), under a teaching program of such hospital approvedas provided in the last sentence of subsection (b), and other diagnosticor therapeutic services provided by a hospital with which the facilityhas such an agreement in effect; and(7)such other servicesnecessary to the health of the patients as are generally providedby skilled nursing facilities, or by others under arrangements withthem made by the facility; able).excluding, however, any item or service if it would not be includedunder subsection (b) if furnished to an inpatient of a hospital.Post-Hospital Extended Care Services(i)The term post-hospital extended careservices means extended care services furnished an individualafter transfer from a hospital in which he was an inpatient for notless than 3 consecutive days before his discharge from the hospitalin connection with such transfer. For purposes of the preceding sentence,items and services shall be deemed to have been furnished to an individualafter transfer from a hospital, and he shall be deemed to have beenan inpatient in the hospital immediately before transfer therefrom,if he is admitted to the skilled nursing facility (A) within 30 daysafter discharge from such hospital, or (B) within such time as itwould be medically appropriate to begin an active course of treatment,in the case of an individual whose condition is such that skillednursing facility care would not be medically appropriate within 30days after discharge from a hospital; and an individual shall be deemednot to have been discharged from a skilled nursing facility if, within30 days after discharge therefrom, he is admitted to such facilityor any other skilled nursing facility.Skilled Nursing Facility
Social Security Act §1861
Skilled Nursing Facility(j)The term skilled nursing facility has the meaning given such term in section 1819(a).Utilization Review(k)A utilization review plan of a hospital orskilled nursing facility shall be considered sufficient if it is applicableto services furnished by the institution to individuals entitled toinsurance benefits under this title and if it provides(1)for the review,on a sample or other basis, of admissions to the institution, theduration of stays therein, and the professional services (includingdrugs and biologicals) furnished, (A) with respect to the medicalnecessity of the services, and (B) for the purpose of promoting themost efficient use of available health facilities and services;(2)for such reviewto be made by either (A) a staff committee of the institution composedof two or more physicians (of which at least two must be physiciansdescribed in subsection (r)(1) of this section), with or without participation of other professional personnel, or (B) a group outsidethe institution which is similarly composed and (i) which is establishedby the local medical society and some or all of the hospitals andskilled nursing facilities in the locality, or (ii) if (and for aslong as) there has not been established such a group which servessuch institution, which is established in such other manner as maybe approved by the Secretary;(3)for such review,in each case of inpatient hospital services or extended care servicesfurnished to such an individual during a continuous period of extendedduration, as of such days of such period (which may differ for differentclasses of cases) as may be specified in regulations, with such reviewto be made as promptly as possible, after each day so specified, andin no event later than one week following such day; and(4)for prompt notificationto the institution, the individual, and his attending physician ofany finding (made after opportunity for consultation to such attendingphysician) by the physician members of such committee or group thatany further stay in the institution is not medically necessary.
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The review committee must be composed as provided in clause(B) of paragraph (2) rather than as provided in clause (A) of suchparagraph in the case of any hospital or skilled nursing facilitywhere, because of the small size of the institution, or (in the caseof a skilled nursing facility) because of lack of an organized medicalstaff, or for such other reason or reasons as may be included in regulations,it is impracticable for the institution to have a properly functioningstaff committee for the purposes of this subsection. If the Secretarydetermines that the utilization review procedures established pursuantto title XIX are superior in their effectiveness to the proceduresrequired under this section, he may, to the extent that he deems itappropriate, require for purposes of this title that the proceduresestablished pursuant to title XIX be utilized instead of the proceduresrequired by this section.Agreements for Transfer Between Skilled Nursing Facilitiesand Hospitals(l)A hospital and a skilled nursing facility shallbe considered to have a transfer agreement in effect if, by reasonof a written agreement between them or (in case the two institutionsare under common control) by reason of a written undertaking by theperson or body which controls them, there is reasonable assurancethat(1)transfer of patientswill be effected between the hospital and the skilled nursing facilitywhenever such transfer is medically appropriate as determined by theattending physician; and(2)there will beinterchange of medical and other information necessary or useful inthe care and treatment of individuals transferred between the institutions,or in determining whether such individuals can be adequately caredfor otherwise than in either of such institutions.