evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
110 - Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)  (Rev. 3096, Issued: 10- 17-14, Effective: 01 -27-14, Implementation: 11- 18-14)  Section 1861(s)(2)(AA) and 1861(bbb) of the Social Security Act and implementing regulations at 42 CFR 410.19 authorize coverage under Medicare Part B for a one -time ultrasound screening for abdominal aortic aneurysm (AAA), effective January 1, 2007.   110.1 - Definitions  (Rev. 3096, Issued: 10- 17-14, Effective: 01 -27-14, Implementation: 11- 18-14)  The term ultrasound screening for abdominal aortic aneurysm means the following services furnished to an asymptomatic individual for the early detection of an abdominal aortic aneurysm:   1. a procedure using sound waves (or such other procedures using alternative technologies, of commensurate accuracy and cost, as specified by the Secretary of Health and Human Services, through the national coverage determination process) provided for the ear ly detection of abdominal aortic aneurysms; and   2. includes a physician's interpretation of the results of the procedure.   110.2 - Coverage  (Rev. 3096, Issued: 10- 17-14, Effective: 01 -27-14, Implementation: 11- 18-14)  Payment may be made for a one- time ultrasound screening for AAA for beneficiaries who meet the following criteria:   (i) receives a referral for such an ultrasound screening from the beneficiarys attending physician, physician assistant, nurse practitioner or clinical nurse specialist;   (ii) receives such ultrasound screening from a provider or supplier who is authorized to provide covered ultrasound diagnostic services;   (iii) has not been previously furnished such an ultrasound screening under the Medicare Program; and   (vi) is included in at least one of the following risk categories --   (I) has a family history of abdominal aortic aneurysm;   (II) is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; or
(Medicare Claims Processing Manual)
(I) has a family history of abdominal aortic aneurysm;   (II) is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; or   (III) is a beneficiary who manifests other risk factors in a beneficiary category recommended for screening by the United States Preventive Services Task Force regarding AAA, as specified by the Secretary of Health and Human Services, through the national coverage determination process.   110.3 - Payment  (Rev. 1113, Issued: 11- 17-06, Effective: 01 -01-07, Implementation: 01- 02-07)  If the screening is provided in a physician office, the service is billed to the A/B MAC (B) using the HCPCS code identified in section 110.3.2 below.  Payment is under the Medicare Physicians Fee Schedule (MPFS).  A/B MACs (A) shall pay for the AAA screening only when the services are performed in a hospital, including a critical access hospital (CAH), Indian Health Service (IHS) Facility, Skilled Nursing Facility (SNF), Rural Health Clinic (RHC), or Federally Qualified Health Center (FQHC) and submitted on one of the following types of bills (TOBs): 12X, 13X, 22X, 23X, 71X, 73X, 85X.  The following describes the payment methodology for AAA Screening:
(Medicare Claims Processing Manual)
The following describes the payment methodology for AAA Screening:   Facility  Type of Bill  Payment  Hospitals subject to OPPS  12X, 13X  OPPS  Method I and Method II Critical Access Hospitals (CAHs)  12X and 85X  101% of reasonable cost  IHS providers  13X, revenue code 051X  OMB -approved outpatient per visit all inclusive rate (AIR)  IHS providers  12X, revenue code 024X  All-inclusive inpatient ancillary per diem rate  IHS CAHs  85X, revenue code 051X  101% of the all -inclusive facility specific per visit rate Facility  Type of Bill  Payment  IHS CAHs  12X, revenue code 024X  101% of the all -inclusive facility specific per diem rate SNFs **  22X, 23X  Non-facility rate on the MPFS  RHCs*  71X, revenue code 052X  All-inclusive encounter rate  FQHCs*  73X, revenue code 052X  All-inclusive encounter rate  Maryland Hospitals under jurisdiction of the Health Services Cost Review Commission (HSCRC)  12X, 13X  94% of provider submitted charges or according to the terms of the Maryland Waiver   * If the screening is provided in an RHC or FQHC, the professional portion of the service is billed to the A/B MAC (A) using TOBs 71X and 73X, respectively, and the appropriate site of service revenue code in the 052X revenue code series.   If the screening is provided in an independent RHC or freestanding FQHC, the technical component of the service can be billed by the practitioner to the A/B MAC (B) under the practitioners ID following instructions for submitting practitioner claims to th e Medicare A/B MAC (B).   If the screening is provided in a provider -based RHC/FQHC, the technical component of the service can be billed by the base provider to the A/B MAC (A) under the base providers ID, following instructions for submitting claims to the A/B MAC (A) from the b ase provider.
(Medicare Claims Processing Manual)
** The SNF consolidated billing provision allows separate part B payment for screening services for beneficiaries that are in skilled Part A SNF stays, however, the SNF must submit these services on a 22X bill type.  Screening services provided by other pr ovider types must be reimbursed by the SNF.   110.3.1 - Deductible and Coinsurance  (Rev. 3669, Issued: 12- 02-16, Effective: 01 -01-17, Implementation: 01- 03-17)  The Part B deductible and coinsurance for screening AAA is waived.   110.3.2 - HCPCS Code  (Rev. 3669, Issued: 12- 02-16, Effective: 01 -01-17, Implementation: 01- 03-17)  Effective for services furnished on or after January 1, 2007 through December 31, 2016, the following code and modifiers are used for AAA screening services:   G0389: Ultrasound, B -scan and or real time with image documentation; for abdominal aortic aneurysm (AAA) screening   Short Descriptor:   Ultrasound exam AAA screen   Modifiers:   TC, 26   Effective for services furnished on or after January 1, 2017, the following code and modifiers, are used for AAA screening services:   76706: Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA).  (For screening ultrasound or duplex ultrasound of the abdominal aorta other than screening, see 76770, 76775, 93978, 93979.)   Short Descriptor:   Us abdl aorta screen AAA   Modifiers:   TC, 26   110.3.3 - Advance Beneficiary Notice  (Rev. 3669, Issued: 12- 02-16, Effective: 01 -01-17, Implementation: 01- 03-17)  A/B MACs (A) and (B) will deny an AAA screening service billed more than once in a beneficiarys lifetime.
(Medicare Claims Processing Manual)
A/B MACs (A) and (B) will deny an AAA screening service billed more than once in a beneficiarys lifetime.   If a second AAA ultrasound screening is billed for the same beneficiary or if any of the other statutory criteria for coverage listed in section 1861(s)(2)(AA) of the Social Security Act are not met, the service would be denied as a statutory (technical) d enial under section 1861(s)(2)(AA), not a medical necessity denial.  If a provider cannot determine whether or not the beneficiary has previously had an AAA screening, but all of the other statutory requirements for coverage have been met, the provider should issue the ABN -G.  Likewise, if all of the statutory requirements for coverage have been met, but a question of medical necessity still exists, the provider should issue the ABN -G.  110.3.4 - RHCs/FQHCs Special Billing Instructions  (Rev. 3669, Issued: 12- 02-16, Effective: 01 -01-17, Implementation: 01- 03-17)  Detailed billing instructions for ultrasound screening for AAA screenings provided in RHCs and FQHCs can be found in chapter 9, section 70.3 of this manual.  120 - Diabetes Self -Management Training (DSMT) Services (Rev. 1255, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, section 300 for information on coverage requirements, certified providers and enrollment.  120.1 - Coding and Payment of DSMT Services  (Rev. 1255, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  The following HCPCS codes are used to report DSMT:    G0108 -  Diabetes outpatient self -management training services, individual, per 30 minutes.   G0109 -  Diabetes outpatient self -management training services, group session (2 or more), per 30 minutes.   The type of service for these codes is 1.
(Medicare Claims Processing Manual)
 G0109 -  Diabetes outpatient self -management training services, group session (2 or more), per 30 minutes.   The type of service for these codes is 1.   Payment to physicians and providers for outpatient DSMT is made as follows:   Type of Facility Payment Method  Type of Bill  Physician (billed to the A/B MAC (B))  MPFS  NA Hospitals subject to OPPS  MPFS  12X, 13X  Method I and Method II Critical Access Hospitals (CAHs) (technical services)  101% of reasonable cost  12X and 85X  Indian Health Service (IHS) providers billing hospital outpatient Part B  OMB -approved outpatient per visit all inclusive rate (AIR)  13X IHS providers billing inpatient Part B  All-inclusive inpatient ancillary per diem rate  12X IHS CAHs billing outpatient Part B  101% of the all -inclusive facility specific per visit rate  85X IHS CAHs billing inpatient Part B  101% of the all -inclusive facility specific per diem rate  12X FQHCs*  All-inclusive encounter rate with other qualified services. Separate visit payment available with HCPCS.  73X Skilled Nursing Facilities **  MPFS non- facility rate  22X, 23X  Maryland Hospitals under jurisdiction of the Health Services Cost Review Commission (HSCRC)  94% of provider submitted charges in accordance with the terms of the Maryland Waiver  12X, 13X  Home Health Agencies (can be billed only if the service is provided outside of the treatment plan)  MPFS non- facility rate  34X  * Effective January 1, 2006, payment for DSMT provided in an FQHC that meets all of the requirements as above, may be made in addition to one other visit the beneficiary had during the same day, if this qualifying visit is billed on TOB 73X, with HCPCS G0108 or G0109, and revenue codes 0520, 0521, 0522, 0524, 0525, 0527, 0528, or 0900.  ** The SNF consolidated billing provision allows separate part B payment for training services for beneficiaries that are in skilled Part A SNF stays, however, the SNF must submit these services on a 22 bill type.  Training services provided by other provi der types must be reimbursed by X the SNF.
(Medicare Claims Processing Manual)
NOTE:  An ESRD facility is a reasonable site for this service, however, because it is required to provide dietician and nutritional services as part of the care covered in the composite rate, ESRD facilities are not allowed to bill for it separately and do not re ceive separate reimbursement.  Likewise, an RHC is a reasonable site for this service, however it must be provided in an RHC with other qualifying services and paid at the all -inclusive encounter rate.   Deductible and co -insurance apply.   120.2 - Bill Processing Requirements (Rev. 1255, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  See Pub. 100- 04, chapter 25 for instructions for A/B MACs (A) and (HHH).  See Pub. 100- 04, chapter 26 for instructions for A/B MACs (B).  Billing is to the "certified providers" regular A/B MAC (A), (B), or (HHH), i.e., there are no specialty contractors for this service.  (See Pub 100- 02, chapter 15, section 300.2 for the definition of certified provider in this instance.)   120.2.1 - Special Processing Instructions for Billing Frequency Requirements  (Rev. 1255, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  The frequency editing for DSMT is performed in CWF as follows:   A - Initial Training   The initial year for DSMT is the '12' month period following the initial date.  When a claim contains a DSMT HCPCS code and the associated units cause the total time for the DSMT initial year to exceed '10' hours, a CWF error will set.   See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, section 300 for information on coverage for initial training.  B - Follow -Up Training
(Medicare Claims Processing Manual)
See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, section 300 for information on coverage for initial training.  B - Follow -Up Training   Follow -up training for subsequent years are based on a 12 month calendar year after the initial year.  However, if the beneficiary exhausts 10 hours in the initial year then the beneficiary would be eligible for follow -up training in the next calendar year.  When a claim contains a DSMT HCPCS code and the associated units cause the total time for any follow -up year to exceed 2 hours, a CWF error will set.  See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, section 300 for information on coverage for follow -up training.   C - Examples   Example # 1 -- Beneficiary Exhausts 10 hours in the Initial Year (12 continuous months)   Bene receives first service: April, 2006 Bene completes initial 10 hours DSMT training:  April, 2007 Bene is eligible for follow -up training: May 2007 (13th month begins the subsequent year)  Bene completes follow -up training: December, 2007 Bene is eligible for next year follow -up training:  January, 2008   Example # 2 Beneficiary Exhausts 10 hours Within the Initial Calendar Year   Bene receives first service: April 2006  Bene completes initial 10 hours of DSMT training, December 2006  Bene is eligible for follow -up training: January, 2007 Bene completes follow -up training:  July 2007 Bene is eligible for next year follow -up training: January 2008   120.2.2 - Advance Beneficiary Notice (ABN) Requirements  (Rev. 1255, Issued:  05- 25-07; Effective:  07 -01-07; Implementation:  07 -02-07)  The beneficiary is liable for services denied over the limited number of hours with referrals for DSMT.  An ABN should be issued in these situations.  In absence of evidence of a valid ABN, the provider will be held liable.   An ABN should not be issued for Medicare -covered services such as those provided by hospital dietitians or nutrition professionals who are qualified to render the service in their State but who have not obtained Medicare Provider Numbers.
(Medicare Claims Processing Manual)
An ABN should not be issued for Medicare -covered services such as those provided by hospital dietitians or nutrition professionals who are qualified to render the service in their State but who have not obtained Medicare Provider Numbers.   120.2.3 - RHCs/FQHCs Special Billing Instructions  (Rev. 3669, Issued: 12- 02-16, Effective: 01 -01-17, Implementation: 01- 03-17)  Detailed billing instructions for DSMT services provided in RHCs and FQHCs can be found in chapter 9, section 70.5 of this manual.  120.3 - Duplicate Edits  (Rev. 1846; Issued: 11- 06-09; Effective Date:  04 -01-10; Implementation Date:  04- 05-10)  There are CWF edits applicable to DSMT. Refer to chapter 4, section 300.6 of this manual for a description of these instructions.  130 - Human Immunodeficiency Virus (HIV) Screening Tests  (Rev.  3835, Issued: 08- 16-17, Effective: 04 -13-15, Implementation: 10- 02-17)   130.1 - Healthcare Common Procedure Coding System (HCPCS) for HIV Screening Tests  (Rev.  3835, Issued: 08- 16-17, Effective: 04 -13-15, Implementation: 10- 02-17)   Effective for claims with dates of service on and after December 8, 2009, implemented with the April 5, 2010, IOCE, the following HCPCS codes are to be billed for human immunodeficiency virus (HIV) screening:    G0432-  Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV -1 and/or HIV-2, screening,    G0433 -  Infectious agent antibody detection by enzyme -linked immunosorbent assay (ELISA) technique, HIV -1 and/or HIV -2, screening, and,    G0435 -  Infectious agent antibody detection by rapid antibody test, HIV -1 and/or HIV -2, screening.  In addition to the above codes,  effective for claims with dates of service on or after April 13, 2015, the following HCPCS/CPT code may also be billed for HIV screening:    G0475 -   HIV antigen/antibody, combination assay, screening  80081 -   Obstetric panel
(Medicare Claims Processing Manual)
 G0475 -   HIV antigen/antibody, combination assay, screening  80081 -   Obstetric panel   130.2 - Billing Requirements (Rev.  3835, Issued: 08- 16-17, Effective: 04 -13-15, Implementation: 10- 02-17) Medicare Administrative Contractors (MACs) shall recognize the above HCPCS codes for HIV screening in accordance with Publication 100- 03, Medicare National Coverage Determinations Manual, section 210.7.  Effective for claims with dates of service on and after December 8, 2009, MACs shall pay for voluntary HIV screening as follows :   A maximum of once annually for beneficiaries at increased risk for HIV infection (11 full months must elapse following the month the previous test was performed in order for the subsequent test to be covered), and,    A maximum of three times per term of pregnancy for pregnant Medicare beneficiaries beginning with the date of the first test when ordered by the womans clinician.   Claims that are submitted for HIV screening shall be submitted in the following manner:   For beneficiaries reporting increased risk factors, claims shall contain HCPCS code G0432, G0433, or G0435 with diagnosis code V73.89 (Special screening for other specified viral disease) as primary, and V69.8 (Other problems related to lifestyle), as seco ndary.   For beneficiaries not reporting increased risk factors, claims shall contain HCPCS code G0432, G0433, or G0435 with diagnosis code V73.89 only.  For pregnant Medicare beneficiaries, claims shall contain HCPCS code G0432, G0433, or G0435 with diagnosis code V73.89 as primary, and one of the following ICD -9 diagnosis codes: V22.0 (Supervision of normal first pregnancy), V22.1 (Supervision of other normal pregnancy), or V23.9 (Supervision of unspecified high- risk pregnancy), as secondary.   Effective for claims with dates of service on or after April 13, 2015, MACs shall also pay for voluntary, HIV screening as follows  (replacing ICD -9 with ICD -10 beginning October 1, 2015):
(Medicare Claims Processing Manual)
Effective for claims with dates of service on or after April 13, 2015, MACs shall also pay for voluntary, HIV screening as follows  (replacing ICD -9 with ICD -10 beginning October 1, 2015):   For pregnant Medicare beneficiaries , claims shall contain HCPCS code G0432, G0433, G0435, G0475 or CPT-80081 with primary ICD -9/ICD -10 diagnosis code V73.89/Z11.4, along with one of the following ICD -9/ICD -10 diagnosis codes as secondary listed below, and allow no more than 3 HIV screening tests during each term of pregnancy beginning with the date of the 1st test:   ICD-9:  V22.0 Supervision of normal first pregnancy  ICD-10:  Z34.00 Encounter for supervision of normal first pregnancy, unspecified trimester  Z34.01 Encounter for supervision of normal first pregnancy, first trimester  Z34.02 Encounter for supervision of normal first pregnancy, second trimester  Z34.03 Encounter for supervision of normal first pregnancy, third trimester  ICD-9:  V22.1 Supervision of other normal pregnancy  ICD-10:  Z34.80 Encounter for supervision of other normal pregnancy, unspecified trimester  Z34.81 Encounter for supervision of other normal pregnancy, first trimester  Z34.82 Encounter for supervision of other normal pregnancy, second trimester  Z34.83 Encounter for supervision of other normal pregnancy, third trimester  Z34.90 Encounter for supervision of normal pregnancy, unspecified, unspecified trimester  Z34.91 Encounter for supervision of normal pregnancy, unspecified, first trimester  Z34.92 Encounter for supervision of normal pregnancy, unspecified, second trimester  Z34.93 Encounter for supervision of normal pregnancy, unspecified, third trimester  ICD-9:  V23.9 Supervision of unspecified high- risk pregnancy ICD-10:  O09.90 Supervision of high risk pregnancy, unspecified, unspecified trimester  O09.91 Supervision of high risk pregnancy, unspecified, first trimester  O09.92 Supervision of high risk pregnancy, unspecified, second trimester  O09.93 Supervision of high risk pregnancy, unspecified, third trimester
(Medicare Claims Processing Manual)
For non- pregnant Medicare beneficiaries , claims shall contain HCPCS code G0432, G0433, G0435, or G0475 for beneficiaries between 15 and 65 years of age one time per annum with ICD -9/ICD -10 diagnosis code V73.89/Z11.4 as primary regardless of risk factors.  If primary ICD -9/ICD -10 diagnosis code  V73.89/Z11.4 is not present and the beneficiary is between 15 and 65 years of age, or the service is billed more than one time per annum, the detail line shall be denied.   For non- pregnant Medicare beneficiaries , claims shall contain HCPCS code G0432, G0433, G0435, or G0475 for beneficiaries less than 15 and greater than 65 years of age one time per annum with ICD -9/ICD -10 diagnosis code V73.89/ Z11.4 as primary, and one of the following secondary ICD -9/ICD -10 di agnosis codes:   V69.8 (Other problems related to lifestyle)/Z72.89 (Other problems related to lifestyle)  Z72.51 (High risk heterosexual behavior)  Z72.52 (High risk homosexual behavior)  Z72.53 (High risk bisexual behavior)   If ICD -9/ICD -10 diagnosis code V73.89/Z11.4 is not present as primary and one of the ICD -9/ICD -10 secondary codes listed above is not present and the beneficiary is less than 15 or greater than 65 years of age, or the service is billed more than one time p er annum, the detail line shall be denied.   130.3 - Payment Method  (Rev. 3835, Issued: 08- 16-17, Effective: 04 -13-15, Implementation: 10- 02-17)
(Medicare Claims Processing Manual)
130.3 - Payment Method  (Rev. 3835, Issued: 08- 16-17, Effective: 04 -13-15, Implementation: 10- 02-17)   Payment for HIV screening, HCPCS codes G0432, G0433, G0435, is under the Medicare Clinical Laboratory Fee Schedule (CLFS) for Types of Bill (TOB) 12X, 13X, 14X, 22X, and 23X beginning January 1, 2011.  For TOB 85X payment is based on reasonable cost.  Deductible and coins urance do not apply.  Between December 8, 2009, and April 4, 2010, these services can be billed with unlisted procedure code 87999.  Between April 5, 2010, and January 1, 2011, HCPCS codes G0432, G0433, and G0435 will be contractor priced.   Payment for HIV screening, HCPCS code G0475, for institutional claims will be under the Medicare CLFS for TOB 12X, 13X, 14X, 22X, and 23X for claims on or after January 1, 2017.  For TOB 85X payment is based on reasonable cost.  Effective for claims with date of service from April 13, 2015 through December 31, 2016, HCPCS code G0475 will be contractor priced.  Beginning with date of service January 1, 2017 and after, HCPCS code G0475 will be priced and paid according to the CLFS.  HCPCS code G0475 will be included in the January 2017 CLFS, January 1, 2016 IOCE, the January 2016 OPPS and January 1, 2016 MPFSD.  HCPCS code G0475 will be effective retroactive to April 13, 2015 in the IOCE & OPPS.   A/B MACs (B) shall only accept claims submitted with a G0475, G0432, G0433, or G0435 with a Place of Service (POS) Code equal to 81 Independent Lab, and 11, Office.   Deductible and coinsurance do not apply.