evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
CERTIFICATION is the physicians/nonphysician practitioners (NPP) approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.    The CLINICIAN is a term used in this manual and in Pub 100- 04, chapter 5, section 10 or section 20, to refer to only a physician, nonphysician practitioner or a therapist (but not to an assistant, aide or any other personnel) providing a service within the ir scope of practice and consistent with state and local law.  Clinicians make clinical judgments and are responsible for all services they are permitted to supervise.  Services that require the skills of a therapist, may be appropriately furnished by clinicians, that is, by or under the supervision of qualified physicians/NPPs when their scope of practice, state and local laws allow it and their personal professional training is judged by Medicare contractors as sufficient to provide to the beneficiary ski lls equivalent to a therapist for that service.    COMPLEXITIES are complicating factors that may influence treatment, e.g., they may influence the type, frequency, intensity and/or duration of treatment.  Complexities may be represented by diagnoses (ICD codes), by patient factors such as age, severity, a cuity, multiple conditions, and motivation, or by the patients social circumstances such as the support of a significant other or the availability of transportation to therapy.    A DATE may be in any form (written, stamped or electronic).  The date may be added to the record in any manner and at any time, as long as the dates are accurate.  If they are different, refer to both the date a service was performed and the date the entry to the record was made.  For example, if a physician certifies a plan and fails to date it, staff may add Received Date in writing or with a stamp.  T he received date is valid for certification/re- certification purposes.  Also, if the physician faxes the referral, certification, or re -certification and forgets to date it, the date that prints out on the fax is valid.  If services provided on one date ar e documented on another date, both dates should be documented.
(Medicare Benefit Policy Manual)
The EPISODE of Outpatient Therapy  For the purposes of therapy policy, an outpatient therapy episode is defined as the period of time, in calendar days, from the first day the patient is under the care of the clinician (e.g., for evaluation or treatment) for the current condition(s) being treated by one therapy discipline (PT, or OT, or SLP) until the last date of service for that discipline in that setting.    During the episode, the beneficiary may be treated for more than one condition; including conditions with an onset after the episode has begun.  For example, a beneficiary receiving PT for a hip fracture who, after the initial treatment session, develops l ow back pain would also be treated under a PT plan of care for rehabilitation of low back pain.  That plan may be modified from the initial plan, or it may be a separate plan specific to the low back pain, but treatment for both conditions concurrently would be considered the same episode of PT treatment.  If that same patient developed a swallowing problem during intubation for the hip surgery, the first day of treatment by the SLP would be a new episode of SLP care.    EVALUATION is a separately payable comprehensive service provided by a clinician, as defined above, that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjectiv e evaluations of patient performance and functional abilities.  Evaluation is warranted e.g., for a new diagnosis or when a condition is treated in a new setting.  These evaluative judgments are essential to development of the plan of care, including goals  and the selection of interventions.    FUNCTIONAL REPORTING, which is required on claims for all outpatient therapy services pursuant to 42CFR410.59, 410.60, and 410.62, uses nonpayable G -codes and related modifiers to convey information about the patients functional status at specified points  during therapy.  (See Pub 100-04, chapter 5, section 10.6)  NOTE : Functional reporting requirements are no longer applicable for claims for dates of service on and after January 1, 2019.  See the NOTE  at the beginning of Section 220.4 for more information about the discontinuation of functional reporting requirements.
(Medicare Benefit Policy Manual)
RE-EVALUATION provides additional objective information not included in other documentation.  Re -evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significan t improvement, or decline, or change in the patient's condition or functional status that was not anticipated in the plan of care.  Although some state regulations and state practice acts require re -evaluation at specific times, for Medicare payment, reevaluations must also meet Medicare coverage guidelines.  The decision to provide a reevaluation shall be made by a clinician.    INTERVAL of certified treatment (certification interval) consists of 90 calendar days or less, based on an individuals needs.  A physician/NPP may certify a plan of care for an interval length that is less than 90 days.  There may be more than one certifi cation interval in an episode of care.  The certification interval is not the same as a Progress Report period.    MAINTENANCE PROGRAM (MP) means a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deter ioration due to a disease or illness.    NONPHYSICIAN PRACTITIONERS (NPP) means physician assistants, clinical nurse specialists, and nurse practitioners, who may, if state and local laws permit it, and when appropriate rules are followed, provide, certify or supervise therapy services.    PHYSICIAN with respect to outpatient rehabilitation therapy services means a doctor of medicine, osteopathy (including an osteopathic practitioner), podiatric medicine, or optometry (for low vision rehabilitation only).  Chiropractors and doctors of dental  surgery or dental medicine are not considered physicians for therapy services and may neither refer patients for rehabilitation therapy services nor establish therapy plans of care.    PATIENT, client, resident, and beneficiary are terms used interchangeably to indicate enrolled recipients of Medicare covered services.
(Medicare Benefit Policy Manual)
PATIENT, client, resident, and beneficiary are terms used interchangeably to indicate enrolled recipients of Medicare covered services.    PROVIDERS of services are defined in 1861(u) of the Act, 42CFR400.202 and 42CFR485 Subpart H as participating hospitals, critical access hospitals (CAH), skilled nursing facilities (SNF), comprehensive outpatient rehabilitation facilities (CORF), home hea lth agencies (HHA), hospices, participating clinics, rehabilitation agencies or outpatient rehabilitation facilities (ORF).  Providers are also defined as public health agencies with agreements only to furnish outpatient therapy services, or community ment al health centers with agreements only to furnish partial hospitalization or intensive outpatient services.  To qualify as providers of services, these providers must meet certain conditions enumerated in the law and enter into an agreement with the Secretary in which they agree not to charge any beneficiary for covered services for which the program will pay and to refund any erroneous collections made.  Note that the word PROVIDER in sections 220 and 230 is not used to mean a person who provides a service, but is used as in the statute to mean a facility or agency such as rehabilitation agency or home health agency.    QUALIFIED PROFESSIONAL means a physical therapist, occupational therapist, speech -language pathologist, physician, nurse practitioner, clinical nurse specialist, or physicians assistant, who is licensed or certified by the state to furnish therapy service s, and who also may appropriately furnish therapy services under Medicare policies.  Qualified professional may also include a physical therapist assistant (PTA) or an occupational therapy assistant (OTA) when furnishing services under the supervision of a  qualified therapist, who is working within the state scope of practice in the state in which the services are furnished.  Assistants are limited in the services they may furnish (see section 230.1 and 230.2) and may not supervise other therapy caregivers.     QUALIFIED PERSONNEL means staff (auxiliary personnel) who have been educated and trained as therapists and qualify to furnish therapy services only under direct supervision incident to a physician or NPP.  See 230.5 of this chapter.  Qualified personnel m ay or may not be licensed as therapists but meet all of the requirements for therapists with the exception of licensure.
(Medicare Benefit Policy Manual)
SIGNATURE means a legible identifier of any type acceptable according to policies in Pub. 100- 08, Medicare Program Integrity Manual, chapter 3, 3.3.2.4 concerning signatures.    SUPERVISION LEVELS for outpatient rehabilitation therapy services are the same as those for diagnostic tests defined in 42CFR410.32.  Depending on the setting, the levels include personal supervision (in the room), direct supervision (in the office suite), and general supervision (physician/NPP is available but not necessarily on the premises).    SUPPLIERS of therapy services include individual practitioners such as physicians, NPPs, physical therapists and occupational therapists who have Medicare provider numbers.  Regulatory references on physical therapists in private practice (PTPPs) and occup ational therapists in private practice (OTPPs) are at 42CFR410.60 (C)(1), 485.701729, and 486.150- 163.    THERAPIST refers only to qualified physical therapists, occupational therapists and speech -language pathologists, as defined in 230.  Qualifications that define therapists are in 230.1, 230.2, and 230.3.  Skills of a therapist are defined by the scope o f practice for therapists in the state).    THERAPY (or outpatient rehabilitation services) includes only outpatient physical therapy (PT), occupational therapy (OT) and speech -language pathology (SLP) services paid using the Medicare Physician Fee Schedule or the same services when provided in hospitals that are exempt from the hospital Outpatient Prospective Payment System and paid on a reasonable cost basis, including critical access hospitals.    Therapy services referred to in this chapter are those skilled services furnished according to the standards and conditions in CMS manuals, (e.g., in this chapter and in Pub. 100- 04, Medicare Claims Processing Manual, chapter 5), within their scope of prac tice by qualified professionals or qualified personnel, as defined in this section, represented by procedures found in the American Medical Associations Current Procedural Terminology (CPT).  A list of CPT (HCPCS) codes is provided in Pub. 100- 04, chapt er 5, 20, and in Local Coverage Determinations developed by contractors.
(Medicare Benefit Policy Manual)
TREATMENT DAY means a single calendar day on which treatment, evaluation and/or reevaluation is provided.  There could be multiple visits, treatment sessions/encounters on a treatment day.    VISITS OR TREATMENT SESSIONS begin at the time the patient enters the treatment area (of a building, office, or clinic) and continue until all services (e.g., activities, procedures, services) have been completed for that session and the patient leaves that area to participate in a non -therapy activity.  It is likely that not all minutes in the visits/treatment sessions are billable (e.g., rest periods).  There may be two treatment sessions in a day, for example, in the morning and afternoon.  When there ar e two visits/ treatment sessions in a day, plans of care indicate treatment amount of twice a day.    B.  References    Paper Manuals.  The following manuals, now outdated, were resources for the Internet Only Manuals:     Part A Medicare Intermediary Manual, (Pub. 13)   Part B Medicare Carrier Manual, (Pub. 14)   Hospital Manual, (Pub. 10)   Outpatient Physical Therapy/CORF Manual, (Pub. 9)    Regulation and Statute.  The information in this section is based in part on the following current references:     42CFR refers to Title 42, Code of Federal Regulation (CFR).   The Act refers to the Social Security Act.    Internet Only Manuals.  Current Policies that concern providers and suppliers of therapy services are located in many places throughout CMS Manuals.  Sites that may be of interest include:     Pub.100- 01 GENERAL INFORMATION, ELIGIBILITY, AND ENTITLEMENT    o Chapter 1 - General Overview    10.1 -  Hospital Insurance (Part A) for Inpatient Hospital, Hospice, Home Health and SNF Services -  A Brief Description  10.2 -  Home Health Services  10.3 -  Supplementary Medical Insurance (Part B) -  A Brief Description  20.2 -  Discrimination Prohibited       Pub. 100- 02, MEDICARE BENEFIT POLICY MANUAL    o Ch 6 -  Hospital Services Covered Under Part B    10 - Medical and Other Health Services Furnished to Inpatients of  Participating Hospitals  20 - Outpatient Hospital Services  20.2 -  Outpatient Defined  20.4.1 -  Diagnostic Services Defined  70 - Outpatient Hospital Psychiatric Services    o Ch 8 -  Coverage of Extended Care (SNF) Services Under Hospital Insurance
(Medicare Benefit Policy Manual)
o Ch 8 -  Coverage of Extended Care (SNF) Services Under Hospital Insurance    30.4. -  Direct Skilled Rehabilitation Services to Patients  40 - Physician Certification and Recertification for Extended Care Services  50.3 -  Physical Therapy, Speech -Language Pathology, and Occupational  Therapy Furnished by the Skilled Nursing Facility or by Others Under  Arrangements with the Facility and Under Its Supervision  70.3 -  Inpatient Physical Therapy, Occupational Therapy, and Speech  Pathology Services    o Ch 12 -  Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage    10 - Comprehensive Outpatient Rehabilitation Facility (CORF) Services Provided by  Medicare  20 - Required and Optional CORF Services  20.1 - Required Services  20.2 - Optional CORF Services  30 - Rules for Provision of Services  30.1 - Rules for Payment of CORF Services  40 - Specific CORF Services  40.1 - Physicians Services  40.2 - Physical Therapy Services  40.3 - Occupational Therapy Services  40.4  Speech Language Pathology Services      Pub. 100- 03 MEDICARE NATIONAL COVERAGE DETERMINATIONS MANUAL    o Part 1    20.10 - Cardiac Rehabilitation Programs  30.1 - Biofeedback Therapy  30.1.1 - Biofeedback Therapy for the Treatment of Urinary Incontinence  50.1  Speech Generating Devices  50.2 - Electronic Speech Aids  50.4 - Tracheostomy Speaking Valve    o Part 2    150.2 - Osteogenic Stimulator  160.7 - Electrical Nerve Stimulators  160.12 - Neuromuscular Electrical Stimulation (NMES)  160.13 - Supplies Used in the Delivery of Transcutaneous Electrical Nerve  Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES)  160.17 - L-Dopa    o Part 3    170.1 - Institutional and Home Care Patient Education Programs  170.2 - Melodic Intonation Therapy  170.3 - Speech Pathology Services for the Treatment of Dysphagia  180  Nutrition    o Part 4    230.8 -  Non -implantable Pelvic Flood Electrical Stimulator  240.7 -  Postural Drainage Procedures and Pulmonary Exercises  270.1 - Electrical Stimulation (ES) and Electromagnetic Therapy for the  Treatment of Wounds  270.4 -  Treatment of Decubitus Ulcers  280.3 - Mobility Assisted Equipment (MAE)  280.4 - Seat Lift  280.13 -  Transcutaneous Electrical Nerve Stimulators (TENS)  290.1 -  Home Health Visits to A Blind Diabetic       Pub. 100- 08 PROGRAM INTEGRITY MANUAL
(Medicare Benefit Policy Manual)
  Pub. 100- 08 PROGRAM INTEGRITY MANUAL    o Chapter 3 -  Verifying Potential Errors and Taking Corrective Actions    3.4.1.1 -  Linking LCD and NCD ID Numbers to Edits    o Chapter 13 -  Local Coverage Determinations     13.5.1 -  Reasonable and Necessary Provisions in LCDs     Specific policies may differ by setting.  Other policies concerning therapy services are found in other manuals.  When a therapy service policy is specific to a setting, it takes precedence over these general outpatient policies.  For special rules on:     CORFs -  See chapter 12 of this manual and also Pub. 100-04, chapter 5;   SNF -  See chapter 8 of this manual and also Pub. 100- 04, chapter 6, for SNF claims/billing;   HHA -  See chapter 7 of this manual, and Pub. 100- 04, chapter 10;   GROUP THERAPY AND STUDENTS -  See Pub. 100- 02, chapter 15, 230;   ARRANGEMENTS -  Pub. 100- 01, chapter 5, 10.3;   COVERAGE is described in the Medicare Program Integrity Manual, Pub. 100- 08, chapter 13, 13.5.1; and   THERAPY CAPS -  See Pub. 100- 04, chapter 5, 10.2, for a complete description of this financial limitation.    C.  General    Therapy services are a covered benefit in 1861(g), 1861(p), and 1861(ll) of the Act.   Therapy services may also be provided incident to the services of a physician/NPP under 1861(s)(2) and 1862(a)(20) of the Act.    Covered therapy services are furnished by providers, by others under arrangements with and under the supervision of providers, or furnished by suppliers (e.g., physicians, NPP, enrolled therapists), who meet the requirements in Medicare manuals for therapy services.    Where a prospective payment system (PPS) applies, therapy services are paid when services conform to the requirements of that PPS.  Reimbursement for therapy provided to Part A inpatients of hospitals or residents of SNFs in covered stays is included in the respective PPS rates.
(Medicare Benefit Policy Manual)
Payment for therapy provided by an HHA under a plan of treatment is included in the home health PPS rate.  Therapy may be billed by an HHA on bill type 34x if there are no home health services billed under a home health plan of care at the same time (e.g.,  the patient is not homebound), and there is a valid therapy plan of treatment.    In addition to the requirements described in this chapter, the services must be furnished in accordance with health and safety requirements set forth in regulations at 42CFR484, and 42CFR485.    When therapy services may be furnished appropriately in a community pool by a clinician in a physical therapist or occupational therapist private practice, physician office, outpatient hospital, or outpatient SNF, the practice/office or provider shall rent  or lease the pool, or a specific portion of the pool.  The use of that part of the pool during specified times shall be restricted to the patients of that practice or provider.  The written agreement to rent or lease the pool shall be available for review  on request.  When part of the pool is rented or leased, the agreement shall describe the part of the pool that is used exclusively by the patients of that practice/office or provider and the times that exclusive use applies.  Other providers, including re habilitation agencies (previously referred to as OPTs and ORFs) and CORFs, are subject to the requirements outlined in the respective State Operations Manual regarding rented or leased community pools.   220.1 - Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech -Language Pathology Services  (Rev.  255, Issued: 01- 25-19, Effective: 01 - 01- 19, Implementation: 02- 26-19)  Reference:  42CFR424.24  Refer to  230.4 for physical therapist/occupational therapist in private practice rules.   Coverage rules for specific services are in Pub. 100- 03, Medicare National Coverage Determinations Manual.   Other payment rules are found in Pub. 100- 04, Medicare Claims Processing Manual, chapter 5 .  Since the outpatient therapy benefit under Part B provides coverage only of therapy services, payment can be made only for those services that constitute therapy.  In cases where there is doubt about whether a service is therapy, the contractors local coverage determination (LCD) shall prevail.
(Medicare Benefit Policy Manual)
In order for a service to be covered, it must have a benefit category in the statute, it must not be excluded and it must be reasonable and necessary.  Therapy services are a benefit under 1861 of the Act.  Consult Pub. 100- 08, chapter 13, 13.5.1 for full descriptions of a reasonable and necessary service.   Outpatient therapy services furnished to a beneficiary by a provider or supplier are payable only when furnished in accordance with certain conditions.  The following conditions apply.   Services are or were required because the individual needed therapy services (see 42CFR424.24(c),220.1.3);    A plan for furnishing such services has been established by a physician/NPP or by the therapist providing such services and is periodically reviewed by a physician/NPP* (see 42CFR424.24(c), 220.1.2 );   Services are or were furnished while the individual is or was under the care of a physician* (see 42CFR424.24(c), 220.1.1);    In certifying an outpatient plan of care for therapy a physician/NPP is certifying that the above three conditions are met (42 CFR 424.24(c)).  Certification is required for coverage and payment of a therapy claim.    Claims submitted for outpatient (and CORF) PT, OT, and SLP services must contain the National Provider (NPI) of the certifying physician identified for a PT, OT, and SLP plan of care.  This requirement is effective for claims with dates of service on or af ter October 1, 2012.  (See Pub. 100- 04, Medicare Claims Processing Manual, chapter 5, section 10.3.)     Claims submitted for outpatient (and CORF) PT, OT, and SLP services must contain the required functional reporting.  (See 42CFR410.59, 60, and 62), Pub. 100-04, Medicare Claims Processing Manual, chapter 5, section 10.6.)  NOTE : The applicable regulatory provisions were removed through the CY 2019 PFS final rule, CMS-1693-F.  Functional reporting requirements are no longer applicable for claims for dates of service on and after January 1, 2019. See the NOTE  at the beginning of Section 220.4 for more information.