evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
See Pub. 100- 02,Medicare Benefit Policy Manual, chapter 15, section 280.5, for detailed policy regarding the AWV, including definitions of:  (1) detection of cognitive impairment, (2) eligible beneficiary, (3) establishment of, or an update to, an individuals medical/family history, (4&5) first and subsequent AWVs providing PPPS, (6) health professional, and, (7) review of an individuals functional ability/level of safety.   140.1 - Healthcare Common Procedure Coding System (HCPCS) Coding for the AWV  (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  The HCPCS codes listed below were developed for the AWV benefit effective January 1, 2011, for individuals whose initial enrollment is on or after January 1, 2011.   G0438 -  Annual wellness visit; includes a personalized prevention plan of service (PPPS); first visit   G0439 -  Annual wellness visit; includes a personalized prevention plan of service (PPPS); subsequent visit   140.2 - A/B MAC (B) Billing Requirements  (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  Effective for dates of service on and after January 1, 2011, A/B MACs (B) shall recognize HCPCS codes G0438 and G0439 shown above in section 140.1 for billing AWVs.  The type of service (TOS) for each of the new codes is 1.  AWV services are paid under the  Medicare Physician Fee Schedule (MPFS).   For further instructions regarding practitioner reporting of HCPCS codes G0438 and G0439 under different clinical scenarios, see chapter 12, sections 30.6.1.1 and 100.1.1 of this manual.  140.3 - A/B MAC (A) Billing Requirements (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)
(Medicare Claims Processing Manual)
The A/B MAC (A) will pay for AWV services only when submitted on one of the following types of bill (TOBs): 12X, 13X, 22X, 23X, 71X, 77X, and 85X.  Type of facility and setting determines the basis of payment:    For services performed on a 12X TOB and 13X TOB, hospital inpatient Part B and hospital outpatient, payment shall be made under the MPFS.    For services performed in a skilled nursing facility, TOB 22X and TOB 23X, make payment based on the MPFS.    For services performed on a 71X TOB, rural health clinic (RHC) or 77X TOB, Federally Qualified Health Center (FQHC), payment is made based on an all -inclusive rate and the AWV does not qualify for separate payment with another encounter.    For services performed on an 85X TOB, Critical Access Hospital (CAH), pay based on reasonable cost.   For services performed on an 85X TOB, CAH Method II, payment is based on the MPFS.   For inpatient or outpatient services in hospitals in Maryland, make payment according to the Health Services Cost Review Commission.   Only CAHs paid under the optional method are paid for professional services for the AWV (in addition to the facility payment) when those charges are reported under revenue codes 096X, 097X, or 098X.   140.4 - Rural Health Clinic (RHC)/Federally Qualified Health Center (FQHC) Special Billing Instructions  (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  Beginning with dates of service on or after January 1, 2011, if an AWV 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 77X, respectively, and must include HCPCS code G0438 or G0439.  De ductible and coinsurance do not apply.  140.5 - Coinsurance and Deductible  (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04 -04-11)
(Medicare Claims Processing Manual)
140.5 - Coinsurance and Deductible  (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04 -04-11)  Sections 4103 and 4104 of the Affordable Care Act provide for a waiver of Medicare coinsurance/copayment and Part B deductible requirements for the AWV effective for services furnished on or after January 1, 2011.  140.6 - Common Working File (CWF) Edits  (Rev. 2575, Issued: 10- 26-12, Effective: 04 -01-13, Implementation: 04- 01-13)  Effective for claims with dates of service on and after January 1, 2011, CWF shall reject:    AWV claims for G0438 when a previous (first) AWV, HCPCS code G0438, is paid in history regardless of when it occurred.    AWV claims when a previous AWV, G0438 or G0439, is paid in history within the previous 12 months.   Beginning January 1, 2011, AWV claims when a previous IPPE, HCPCS code G0402, is paid in history within the previous 12 months.    AWV claims (G0438 and G0439) billed for a date of service within 12 months after the effective date of a beneficiarys first Medicare Part B coverage period.   The following change shall be effective for claims processed on or after April 1, 2013. Typically, when a preventive service is posted to a beneficiarys utilization history, separate entries are posted for a professional service (the professional claim for the delivery of the service itself) and a technical service (the institutional claims for a facility fee).  However, in the case of AWV services, since there is no separate payment for a facility fee, the AWV claim will be posted as the professional service only, regardless of whether it is paid on a professional claim or an institutional claim.   140.7 - Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claims Adjustment Reason Codes (CARCs), and Advance Beneficiary Notices (ABNs)  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)
(Medicare Claims Processing Manual)
Messages for A/B MACs (A) and (B):   When paying claims for an AWV, A/B MACs (A) and (B) shall use the following Medicare Summary Notices (MSNs):   MSN:  18.25: -  Your Annual Wellness Visit has been approved.  You will qualify for another Annual Wellness Visit 12 months after the date of this visit.   Spanish Version Su Visita Anual de Bienestar ha sido aprobada. Usted tendr derecho a otra Visita Anual de Bienestar 12 meses despus de la fecha de esta visita.  When denying claims for a first AWV, HCPCS G0438, when a first AWV, HCPCS G0438, is already paid in history, A/B MACs (A) and (B) shall use the following messages:   MSN 20.12: -  This service was denied because Medicare only covers this service once a lifetime.   Spanish Version:  Este servicio fue negado porque Medicare slo cubre este servicio una vez en la vida.   CARC 149: Lifetime benefit maximum has been reached for this service/benefit category.   RARC N117:   This service is paid only once in a patient's lifetime .  Group Code -  PR  When denying claims for a subsequent AWV, HCPCS G0439, because a previous AWV, HCPCS G0438 or G0439, is paid in history within the past 12 months, A/B MACs (A) and (B) shall use the following messages:  MSN 18.26:  This service was denied because it occurred too soon after your last covered Annual Wellness Visit.  Medicare only covers one Annual Wellness Visit within a 12 month period.   Spanish Version:  Este servicio fue negado porque ocurri antes del perodo de 12 meses de su ltima Visita Anual de Bienestar.  Medicare slo paga por una Visita Anual de Bienestar dentro de un perodo de 12 meses.   CARC 119:  Benefit maximum for this time period or occurrence has been reached.   RARC N130 Consult plan benefit documents/guidelines for information about restrictions for this service.
(Medicare Claims Processing Manual)
CARC 119:  Benefit maximum for this time period or occurrence has been reached.   RARC N130 Consult plan benefit documents/guidelines for information about restrictions for this service.   Group Code -  PR  When denying claims for an AWV, HCPCS G0438 or G0439, because an IPPE, HCPCS G0402, is paid in history with the past 12 months, A/B MACs (A) and (B) shall use the following messages:   (New) MSN  18.27:  This service was denied because it occurred too soon after your Initial Preventive Physical Exam.   Spanish Version:  Este servicio fue negado porque ocurri demasiado pronto despus de su examen fsico preventivo inicial.   CARC 119:  Benefit maximum for this time period or occurrence has been reached.   RARC N130:  Consult plan benefit documents/guidelines for information about restrictions for this service.   Group Code -  PR  When denying claims for an AWV, HCPCS G0438 or G0439, because the services were rendered within the first 12 months after the effective date of a beneficiarys first Medicare Part B coverage period, A/B MACs (A) and (B) shall use the following messages:   (New)  MSN  18.24:  This service was denied.  Medicare doesnt cover an Annual Wellness Visit within the first 12 months of your Medicare Part B coverage.  Medicare does cover a one -time initial preventive physical exam (Welcome to Medicare physical exam) within the fir st 12 months of your Medicare Part B coverage.   Spanish Version:  Este servicio fue negado.  Medicare no cubre la Visita Anual de Bienestar durante los primeros 12 meses de su inscripcin a la Parte B de Medicare.  Medicare cubre un examen fsico preventivo ("Bienvenido a Medicare") durante los primeros 12 meses de su inscripcin a la Parte B de Medicare.  CARC 26:  Expenses incurred prior to coverage   RARC N130: Consult plan benefit documents/guidelines for information about restrictions for this service.   Group Code -  PR
(Medicare Claims Processing Manual)
RARC N130: Consult plan benefit documents/guidelines for information about restrictions for this service.   Group Code -  PR  140.8  Advance Care Planning (ACP) as an Optional Element of an Annual Wellness Visit (AWV)  (Rev.  10456, Issued: 11- 13-20, Effective: 04 -01-21, Implementation: 04- 05-21)  For services furnished on or after January 1, 2016, Advance Care Planning (ACP) is treated as a preventive service when furnished with an AWV.  The Medicare coinsurance and Part B deductible are waived for ACP when furnished as an optional element of an AWV.  The codes for the optional ACP services furnished as part of an AWV are 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; first 30 minutes, face -to-face with the patient, family member(s) and/or surrogate;) and an add- on code 99498 (each additional 30 minutes (List separately in addition to code for primary procedure)).  When ACP services are provided as a part of an AWV, practitioners would report CPT code 99497 (and add- on CPT code 99498 when applicable) for the ACP services in addition to either of the AWV codes (G0438 or G0439).  Note: ACP services are payable in hospice (Types of Bill 081x or 082x) when not part of the AWV when the services are performed by attending physicians that are employed by, or under arrangement with, the hospice.   150 - Counseling to Prevent Tobacco Use  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)
(Medicare Claims Processing Manual)
150 - Counseling to Prevent Tobacco Use  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Effective September 30, 2016, HCPCS codes G0436 and G0437 are no longer valid. The services previously represented by G0436 and G0437 should be billed under existing CPT codes 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater  than 3 minutes up to 10 minutes) or 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater 10 minutes) respectively. See Chapter 32 section 12 for coverage and billing requirements for smoking cessation services.   Note: For claims effective 10/1/16. CPT Codes 99406 or 99407 used for processing NCD210.4.1   NOTE: Instructions in sections 150 thru 150.4 are no longer valid.  Effective for claims with dates of service on and after August 25, 2010, the Centers for Medicare & Medicaid Services (CMS) will cover counseling to prevent tobacco use services for outpatient and hospitalized Medicare beneficiaries:    Who use tobacco, regardless of whether they have signs or symptoms of tobacco-  related  disease;    Who are competent and alert at the time that counseling is provided;  and,   Whose counseling is furnished by a qualified physician or other Medicare -recognized  practitioner.   These individuals who do not have signs or symptoms of tobacco- related disease will be covered under Medicare Part B when the above conditions of coverage are met, subject to certain frequency and other limitations.   Conditions of Medicare Part A and Medicare Part B coverage for counseling to prevent tobacco use are located in the Medicare National Coverage Determinations (NCD) Manual, Publication 100- 3, chapter1, section 210.4.1.   NOTE: Effective 9/30/15, NCD210.4 has been deleted from Pub. 100- 03 NCD Manual.  See NCD210.4.1 for remaining NCD re: Counseling to Prevent Tobacco Use.   150.1 - Healthcare Common Procedure Coding System (HCPCS) and Diagnosis Coding  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)
(Medicare Claims Processing Manual)
150.1 - Healthcare Common Procedure Coding System (HCPCS) and Diagnosis Coding  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)    Effective September 30, 2016, HCPCS codes G0436 and G0437 are no longer valid. The services previously represented by G0436 and G0437 should be billed under existing CPT codes 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater  than 3 minutes up to 10 minutes) or 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater 10 minutes) respectively. See Chapter 32 section 12 for coverage and billing requirements for smoking cessation services.   The CMS has created two new CPT codes for billing for tobacco cessation counseling services to prevent tobacco use for those individuals who use tobacco but do not have signs or symptoms of tobacco- related disease.   The two CPT codes 99406 or 99407 that currently are used for smoking and tobacco- use cessation counseling for symptomatic individuals.   NOTE: The above G codes will not be active in A/B MAC (A), (B), and (HHH) systems until January 1, 2011. Therefore, A/B MACs (A), (B), and (HHH) shall advise non-  outpatient perspective payment system (OPPS) providers to use unlisted code 99199 to bill for counseling to prevent tobacco use a nd tobacco-related disease services during the interim period of August 25, 2010, through December 31, 2010.   On January 3, 2011, A/B MAC (A), (B), and (HHH) systems will accept the new G codes for services performed on or after August 25, 2010.  Two new C codes have been created for facilities paid under OPPS when billing for counseling to prevent tobacco use and tobacco- related disease services during the interim period of August 25, 2010, through December 31, 2010:   C9801 -  Smoking and tobacco cessation counseling visit for the asymptomatic patient, intermediate, greater than 3 minutes, up to 10 minutes   Short descriptor: Tobacco- use counsel 3- 10 min
(Medicare Claims Processing Manual)
C9801 -  Smoking and tobacco cessation counseling visit for the asymptomatic patient, intermediate, greater than 3 minutes, up to 10 minutes   Short descriptor: Tobacco- use counsel 3- 10 min   C9802 -  Smoking and tobacco cessation counseling visit for the asymptomatic patient, intensive, greater than 10 minutes   Short descriptor: Tobacco- use counsel >10min  Claims for smoking and tobacco use cessation counseling services 99406 or 99407  shall be submitted with the applicable diagnosis codes:   ICD- 10-CM
(Medicare Claims Processing Manual)
ICD- 10-CM      ICD-10 CM Code  Code Description  F17.210  Nicotine dependence, cigarettes, uncomplicated  F17.211  Nicotine dependence, cigarettes, in remission  F17.213  Nicotine dependence, cigarettes, with withdrawal  F17.218  Nicotine dependence, cigarettes, with other nicotine -induced disorders  F17.219  Nicotine dependence, cigarettes, with unspecified nicotine -induced disorders  F17.220  Nicotine dependence, chewing tobacco, uncomplicated  F17.221  Nicotine dependence, chewing tobacco, in remission  F17.223  Nicotine dependence, chewing tobacco, with withdrawal  F17.228  Nicotine dependence, chewing tobacco, with other nicotine -induced disorders  F17.229  Nicotine dependence, chewing tobacco, with unspecified nicotine -induced disorders  F17.290  Nicotine dependence, other tobacco product, uncomplicated  F17.291  Nicotine dependence, other tobacco product, in remission  F17.293  Nicotine dependence, other tobacco product, with withdrawal  F17.298  Nicotine dependence, other tobacco product, with other nicotine -induced disorders  F17.299  Nicotine dependence, other tobacco product, with unspecified nicotine -induced disorders  T65.211A  Toxic effect of chewing tobacco, accidental (unintentional), initial encounter  T65.212A  Toxic effect of chewing tobacco, intentional self -harm, initial encounter  T65.213A  Toxic effect of chewing tobacco, assault, initial encounter  T65.214A  Toxic effect of chewing tobacco, undetermined, initial encounter  T65.221A  Toxic effect of tobacco cigarettes, accidental (unintentional), initial encounter  T65.222A  Toxic effect of tobacco cigarettes, intentional self -harm, initial encounter  T65.223A  Toxic effect of tobacco cigarettes, assault, initial encounter  T65.224A  Toxic effect of tobacco cigarettes, undetermined, initial encounter  T65.291A  Toxic effect of other tobacco and nicotine, accidental (unintentional), initial encounter  T65.292A  Toxic effect of other tobacco and nicotine, intentional self -harm, initial encounter  T65.293A  Toxic effect of other tobacco and nicotine, assault, initial encounter  T65.294A  Toxic effect of other tobacco and nicotine, undetermined, initial encounter  Z87.891  Personal history of nicotine dependence
(Medicare Claims Processing Manual)
A/B MAC (A), (B), and (HHH) shall allow payment for a medically necessary E/M service on the same day as the smoking and tobacco -use cessation counseling service   when it is clinically appropriate. Physicians and qualified non- physician practitioners shall use an appropriate HCPCS code to report an E/M service with modifier - 25 to indicate that the E/M service is a separately identifiable service from 99406 or 99407.  150.2 - A/B MACs (B) Billing Requirements  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  A/B MACs (B) shall pay for counseling to prevent tobacco use services billed with code G0436 or G0437 for dates of service on or after January 1, 2011. A/B MACs (B) shall pay for counseling services billed with code 99199 for dates of service performed on or after August 25, 2010 through December 31, 2010. The type of service (TOS) for each of the new codes is 1.  A/B MACs (B) pay for counseling services billed based on the Medicare Physician Fee Schedule (MPFS). Deductible and coinsurance apply for services performed on August 25, 2010, through December 31, 2010. For claims with dates of service on and after Januar y 1, 2011, coinsurance and deductible do not apply on G0436 and G0437.  Physicians or qualified non- physician practitioners shall bill the A/B MACs (B) for counseling to prevent tobacco use services on Form CMS -1500 or an approved electronic format.   NOTE: The above G codes will not be active in MACs systems until January 1, 2011. Therefore, MACs shall advise providers to use unlisted code 99199 to bill for counseling to prevent tobacco use services during the interim period of August 25, 2010, through Dece mber 31, 2010.
(Medicare Claims Processing Manual)
NOTE: Effective September 30, 2016, HCPCS codes G0436 and G0437 are no longer valid. The services previously represented by G0436 and G0437 should be billed under existing CPT codes 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) or 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater 10 minutes) respectively.   150.2.1 - A/B MAC (A) and (HHH) Billing Requirements  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  The A/B MACs (A) and (HHH) shall pay for counseling to prevent tobacco use services with codes G0436 and G0437 for dates of service on or after January 1, 2011. A/B MACs (A) and (HHH) shall pay for counseling services billed with code 99199 for dates of service performed on or after August 25, 2010, through December 31, 2010. For facilities paid under OPPS, A/B MAC s (A) shall pay for counseling services billed with codes C9801 and C9802 for dates of service performed on or after August 25, 2010, through December 31, 2010.  Claims for counseling to prevent tobacco use services should be submitted on Form CMS -1450 or its electronic equivalent.   The applicable bill types are 12X, 13X, 22X, 23X, 34X, 71X, 77X, and 85X. Payment for outpatient services is as  follows:
(Medicare Claims Processing Manual)
The applicable bill types are 12X, 13X, 22X, 23X, 34X, 71X, 77X, and 85X. Payment for outpatient services is as  follows:   Type of Facility  Method of Payment  Rural Health Centers (RHCs) TOB 71X/Federally Qualified Health Centers (FQHCs)TOB  77X All-inclusive rate (AIR) for the encounter  Hospitals TOBs 12X and 13X  OPPS for hospitals subject to OPPS MPFS for  hospitals not subject to OPPS  Indian Health Services (IHS)  Hospitals TOB 13X  AIR for the encounter  Skilled Nursing Facilities  (SNFs) TOBs 22X and 23X  Medicare Physician Fee Schedule (MPFS)  Home Health Agencies  (HHAs) TOB 34X  MPFS  Critical Access Hospitals (CAHs) TOB 85X  Method I: Technical services are paid at 101% of reasonable cost. Method II: technical services are paid at 101% of reasonable cost, and Professional services are paid at 115% of the MPFS Data Base  IHS CAHs TOB 85X  Based on specific rate  Maryland Hospitals  Payment is based according to the Health Services Cost Review Commission (HSCRC). That is 94% of submitted charges subject to any unmet deductible, coinsurance, and non- covered charges policies.   Deductible and coinsurance apply for services performed on August 25, 2010, through December 31, 2010. For claims with dates of service on and after January 1, 2011, coinsurance and deductible do not apply for G0436 and G0437.  Effective September 30, 2016, HCPCS codes G0436 and G0437 are no longer valid. The services previously represented by G0436 and G0437 should be billed under existing CPT codes 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater  than 3 minutes up to 10 minutes) or 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater 10 minutes) respectively
(Medicare Claims Processing Manual)
NOTE: Section 4104 of ACA provided for a waiver of Medicare coinsurance and Part B deductible for this service effective on or after 1/1/11. Copayment/coinsurance waived; Deductible waived for HCPCS G0436 & G0437 through 9/30/16, for CPT codes 99406 & 99407 effe ctive 10/1/16.  150.3 - Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claims Adjustment Reason Codes (CARCs), and Group Codes  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  When denying claims for counseling to prevent tobacco use services submitted without ICD -10-CM is applicable, one of the following diagnosis codes: