evekhm/cms_iom_500 huggingface dataset:
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6. Preparation of chemotherapy agent(s).  Payment for the above is included in the payment for the chemotherapy administration service.  If a significant separately identifiable evaluation and management service is performed, the appropriate E & M code should be reported utilizing modifier 25 in addition to the chemotherapy code.  For an evaluation and management service provided on the sam e day, a different diagnosis is not required.  E. Coding Rules for Chemotherapy Administration and Nonchemotherapy Injections and Infusion Services  Instruct physicians to follow the CPT coding instructions to report chemotherapy administration and nonchemotherapy injections and infusion services with the exception listed in subsection C for CPT code 90772.  The physician should be aware of the followi ng specific rules.  When administering multiple infusions, injections or combinations, the physician should report only one initial service code unless protocol requires that two separate IV sites must be used.  The initial code is the code that best describes the key or pr imary reason for the encounter and should always be reported irrespective of the order in which the infusions or injections occur.  If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code should be reported.  For example, the first IV push given subsequent to an initial one -hour infusion is reported using a subsequent IV push code.  If more than one initial service code is billed per day, the A/B MAC (B) shall deny the second initial service code unless the patient has to come back for a separately identifiable service on the same day or has two IV lines per protocol.  For these separately identifiable services, instruct the physician to report with modifier 59.  The CPT includes a code for a concurrent infusion in addition to an intravenous infusion for therapy, prophylaxis or diagnosis.  Allow only one concurrent infusion per patient per encounter.  Do not allow payment for the concurrent infusion billed with modifier 59 unless it is provided during a second encounter on the same day with the patient and is documented in the medical record.  For chemotherapy administration and therapeutic, prophylactic and diagnostic injections and infusions, an intravenous or intra -arterial push is defined as:   1.) an injection in which the healthcare professional is continuously present to administer the substance/drug and observe the patient; or
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prophylactic and diagnostic injections and infusions, an intravenous or intra -arterial push is defined as:   1.) an injection in which the healthcare professional is continuously present to administer the substance/drug and observe the patient; or 2.) an infusion of 15 minutes or less. The physician may report the infusion code for each additional hour only if the infusion interval is greater than 30 minutes beyond the 1 hour increment.  For example if the patient receives an infusion of  a single drug that lasts 1 hour and 45 minutes,  the physician would report the initial code up to 1 hour and the add- on code for the additional 45 minutes. Several chemotherapy administration and nonchemotherapy injection and infusion service codes have the following parenthetical descriptor included as a part of the CPT code, List separately in addition to code for primary procedure.  Each of these codes has a physician fee schedule indicator of ZZZ meaning this service is allowed if billed with another chemotherapy administration or nonchemotherapy injection and infusion service code.  Do not interpret this parenthetical descriptor to mean that the add- on code can be billed only if it is listed with another drug administration primary code.  For example, code 90761 will be ordinarily billed with code 90760.  However, there may be instanc es when only the add- on code, 90761, is billed because an initial code from another section in the drug administration codes, instead of 90760, is billed as the primary code. Pay for code 96523, Irrigation of implanted venous access device for drug delivery systems, if it is the only service provided that day.  If there is a visit or other chemotherapy administration or nonchemotherapy injection or infusion service provided o n the same day, payment for 96523 is included in the payment for the other service.  F. Chemotherapy Administration (or Nonchemotherapy Injection and Infusion) and Evaluation and Management Services Furnished on the Same Day  For services furnished on or after January 1, 2004, do not allow payment for CPT code 99211, with or without modifier 25, if it is billed with a nonchemotherapy drug infusion code or a chemotherapy administration code.  Apply this policy to code 99211 when it is billed with
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for CPT code 99211, with or without modifier 25, if it is billed with a nonchemotherapy drug infusion code or a chemotherapy administration code.  Apply this policy to code 99211 when it is billed with a diagnostic or therapeutic injection code on or after January 1, 2005.  Physicians providing a chemotherapy  administration service or a nonchemotherapy drug infusion service and evaluation and management services, other than CPT code 99211, on the same day must bill in accordance with 30.6.6 using modifier 25.  The A/B MACs (B) pay for evaluation and management services provided on the same day as the chemotherapy  administration services or a nonchemotherapy injection or infusion service if the evaluation and management service meets the requirements of section 30.6.6  even though the underlying codes do not have global periods.  If a chemotherapy service and a significant separately identifiable evaluation and management service are provided on the same day, a different diagnosis is not required.  In 2005, the Medicare physician fee schedule status database indicators for therapeutic and diagnostic injections were changed from T to A.  Thus, beginning in 2005, the policy on evaluation and management services, other than 99211, that is applicable to a chemotherapy or a nonchemotherapy injection or infusion service applies equally to these codes.  30.6 - Evaluation and Management Service Codes - General (Codes 9920 2 - 99499)  (Rev.  11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)
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30.6.1 - Selection of Level of Evaluation and Management Service  (Rev .11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)  A.  General Rules   Advise physicians to generally use CPT codes (level 1 of HCPCS) to code physician services, including evaluation and management (E/M) services.  Medicare has created Medicare- specific codes that must be used to report prolonged E/M services and E/M visit c omplexity add- on services.   Medicare will pay for E/M services for specific, non -physician practitioners (i.e., nurse practitioner (NP), clinical nurse specialist (CNS), and certified nurse midwife (CNM)), whose Medicare benefit permits them to bill these services.  A physician assis tant (PA) may also provide a physician service; however, the physician collaboration and general supervision rules as well as all billing rules apply to all the above non -physician practitioners.  The service provided must be medically necessary, and the s ervice must be within the scope of practice for a non- physician practitioner in the State in which he/she practices. Do not pay for CPT evaluation and management codes billed by physical therapists in independent practice or by occupational therapists in i ndependent practice.   The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.   B.  Selection of Level of Evaluation and Management Service   As of January 1, 2023, for most E/M visit families, practitioners will select visit level based on the level of medical decision making (MDM) or the amount of time spent by the physician or non-physician practitioner. For some types of visits (such as emer gency department visits and critical care), in accordance with their CPT codes, practitioners do not have this choice and will use only MDM or only time to bill. The CPT E/M Guidelines for MDM apply. For all E/M visits, history and physical exam must be pe rformed in accordance with code descriptors, but history and exam no longer impact visit level selection. When practitioner time is used to select visit level, the full time must be completed; the general CPT rule regarding the midpoint for certain timed s ervices does not apply.
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Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of an E/M visit code.  It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service  is warranted.  The volume of documentation should not be the primary influence upon which a specific level of service is billed.  Documentation should support the level of service reported.     Any physician or non- physician practitioner (NPP) authorized to bill Medicare services will be paid by the Medicare Administrative Contractor (MAC) at the appropriate physician fee schedule amount based on the rendering national provider identifier (NPI) number.  "Incident to" Medicare Part B payment policy is applicable for office visits when the requirements for "incident to" are met (refer to sections 60.1, 60.2, and 60.3, chapter 15 in IOM 100-02).  SPLIT/SHARED E/M SERVICE   See section 30.6.18 for rules regarding billing of E/M visits that are split (or shared).   30.6.1.1 - Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV)  (Rev. 3096, Issued: 10- 17-14, Effective: 01 -27-14, Implementation: 11- 18-14)  A. Definitions   1. Initial Preventive Physical Examination (IPPE)   The initial preventive physical examination (IPPE), or Welcome to Medicare Preventive Visit is a preventive visit authorized by sections 1861(s)(2)(w) and 1861(ww) of the Social Security Act (and implementing regulations at 42 CFR 410.16, 411.15(a)(1), a nd 411.15(k)(11)).   As described in the implementing regulations, the IPPE includes the following:   (1) review of the individuals medical and social history with attention to modifiable risk factors for disease detection,   (2) review of the individuals potential (risk factors) for depression or other mood disorders,   (3) review of the individuals functional ability and level of safety,   (4) an examination to include measurement of the individuals height, weight, body mass index, blood pressure, a visual acuity screen, and other factors as deemed appropriate, based on the beneficiarys medical and social history,
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(5) end-of-life planning, upon agreement of the individual,   (6) education, counseling, and referral, as deemed appropriate, based on the results of the review and evaluation services described in the previous 5 elements, and   (7) education, counseling, and referral including a brief written plan (e.g., a checklist or alternative) provided to the individual for obtaining the appropriate screening and other preventive services, which are separately covered under Medicare Part B ( that is, pneumococcal, influenza and hepatitis B vaccines and their administration, screening mammography, screening pap smear and screening pelvic examinations, prostate cancer screening tests, colorectal cancer screening tests, diabetes outpatient self-management training services, bone mass measurements, glaucoma screening, medical nutrition therapy for individuals with diabetes or renal disease, cardiovascular screening blood tests, diabetes screening tests, screening ultrasound for abdominal aortic ane urysms, an electrocardiogram, and additional preventive services covered under Medicare Part B through the Medicare national coverage determinations process).   2. Annual Wellness Visit (AWV)   Effective January 1, 2011, Sections 1861(s)(2)(FF) and 1861(hhh) of the Social Security Act and implementing regulations at 42 CFR 410.15, authorize an AWV providing personalized prevention plan services (PPPS).  The AWV is a preventive visit available to eligible beneficiaries, and identified by HCPCS codes G0438 (Annual wellness visit, including PPPS, first visit) and G0439 (Annual wellness visit, including PPPS, subsequent visit).  Information, including definitions of relevant terms and coverage require ments for the AWV are included in Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15, section 280.5.   The first AWV providing PPPS (HCPCS G0438) is a one time allowed Medicare benefit and includes the following elements furnished to an eligible beneficiary by a health professional:    Review (and administration if needed) of a health risk assessment,    Establishment of the individuals medical/family history,    Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual,
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Review (and administration if needed) of a health risk assessment,    Establishment of the individuals medical/family history,    Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual,   Measurement of the individuals height, weight, body mass index (or waist circumference, if appropriate), blood pressure (BP), and other routine measurements as deemed appropriate, based on the individuals medical and family history,    Detection of any cognitive impairment that the individual may have,    Review of an individuals potential risk factors for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national professional medical organizations,    Review of the individuals functional ability and level of safety, based on direct observation of the individual, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available sc reening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations,    Establishment of a written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and Advisory Committee of Immunizations Practices (ACIP), and the individuals health risk assessment, health status, screening history, and age -appropriate preventive services covered by Medicare,    Establishment of a list of risk factors and conditions of which primary, secondary, or tertiary interventions are recommended or underway for the individual, including any mental health conditions or any such risk factors or conditions that have been ident ified through an IPPE, and a list of treatment options and their associated risks and benefits,    Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self -management or community- based lifestyl e interventions to reduce health risks and promote self -management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition, and,   Any other element(s) determined appropriate by the Secretary through the national coverage determinations process.
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 Any other element(s) determined appropriate by the Secretary through the national coverage determinations process.   Subsequent AWVs providing PPPS (HCPCS G0439) include the following key elements furnished to an eligible beneficiary by a health professional:    Review (and administration, if needed) of an updated health risk assessment,   Update of the individuals medical/family history,    Update to the list of current providers and suppliers that are regularly involved in providing medical care to the individual as that list was developed for the first AWV providing PPPS, or the previous subsequent AWV providing PPPS,    Measurement of an individuals weight (or waist circumference), blood pressure, and other routine measurements as deemed appropriate, based on the individuals medical and family history,   Detection of any cognitive impairment that the individual may have,    Update to the individuals written screening schedule as developed at the first AWV providing PPPS,    Update to the individuals list of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or are underway for the individual, as that list was developed at the first AWV providing PPPS, or the previous subsequent AWV providing PPPS,    Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs, and,    Any other element determined appropriate by the Secretary through the national coverage determinations process.   See chapter 18 of this manual for additional information regarding preventive services that are separately covered under Medicare Part B.   B. Who May Perform an IPPE or AWV   The A/B MAC (B) pays the appropriate physician fee schedule amount based on the rendering National Provider Identification (NPI) number.   The IPPE may be performed by:    a doctor of medicine or osteopathy as defined in Section 1861(r) (1) of the Social Security Act, or    a qualified nonphysician practitioner (nurse practitioner, physician assistant or clinical nurse specialist).   The AWV may be performed by a health professional, which is defined as:    a doctor of medicine or osteopathy as defined in Section 1861(r)(1) of the Social Security Act,    a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the Social Security Act), or
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a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the Social Security Act), or    a medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner) or a team of such medical professionals, working under the direct supervision of a physician (doctor of medicine or osteopathy).   C. Eligibility   1. IPPE   Medicare pays for one IPPE per beneficiary per lifetime for beneficiaries within the first 12 months of the effective date of the beneficiarys first Part B coverage period.   2. AWV   Medicare pays for an AWV for a beneficiary who is no longer within 12 months after the effective date of his/her first Medicare Part B coverage period, and who has not received either an IPPE or an AWV providing PPPS within the past 12 months.  Medicare pa ys for only one first AWV (HCPCS G0438), per beneficiary per lifetime.  All subsequent AWVs must be billed using HCPCS G0439.  D. Deductible and Coinsurance   1. IPPE   The Medicare deductible and coinsurance apply for the IPPE provided before January 1, 2009.   The Medicare deductible is waived effective for the IPPE provided on or after January 1, 2009.  However, the applicable coinsurance continues to apply for the IPPE provided on or after January 1, 2009.   As a result of the Affordable Care Act (ACA), effective for the IPPE provided on or after January 1, 2011, the Medicare deductible and coinsurance (for HCPCS code G0402 only) are waived.   2. AWV   As a result of the ACA, effective January 1, 2011, the Medicare deductible and coinsurance for the AWV (HCPCS G0438 and G0439) are waived.  E. The EKG Component of the IPPE   The once -in-a-lifetime screening EKG may be performed, as appropriate, with a referral from an IPPE.   F. HCPCS Codes Used to Bill the IPPE or AWV  1. HCPCS Codes Used to Bill the IPPE
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F. HCPCS Codes Used to Bill the IPPE or AWV  1. HCPCS Codes Used to Bill the IPPE   For IPPE and EKG services provided prior to January 1, 2009, the physician or qualified NPP shall bill HCPCS code G0344 for the IPPE performed face -to-face, and HCPCS code G0366 for performing a screening EKG that includes both the interpretation and repor t.  If the primary physician or qualified NPP performs only the IPPE, he/she shall bill HCPCS code G0344 only.  The physician or entity that performs the screening EKG that includes both the interpretation and report shall bill HCPCS code G0366.  The physi cian or entity that performs the screening EKG tracing only (without interpretation and report) shall bill HCPCS code G0367.  The physician or entity that performs the interpretation and report only (without the EKG tracing) shall bill HCPCS code G0368. Me dicare will pay for a screening EKG only as part of the IPPE.  HCPCS codes G0344, G0366, G0367 and G0368 will not be billable codes effective on or after January 1, 2009.   Effective for a beneficiary who has the IPPE on or after January 1, 2009, and within his/her 12-month enrollment period of Medicare Part B, the IPPE and screening EKG services are billable with the appropriate HCPCS G code(s).  The physician or qualified NPP shall bill HCPCS code G0402 for the IPPE performed face -to-face with the patient.   The physician or entity shall bill HCPCS code G0403 for performing the complete screening EKG that includes the tracing, interpretation and report.  The physician or entity that performs the screening EKG tracing only (without interpretation and report) shall bill HCPCS code G0404.  The physician or entity that performs the screening EKG interpretation and report only, (without the EKG tracing) shall bill HCPCS code G0405.  2. HCPCS Codes Used to Bill the AWV
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For the first AWV provided on or after January 1, 2011, the health professional shall bill HCPCS G0438 (Annual wellness visit, including PPPS, first visit).  This is a once per beneficiary per lifetime allowable Medicare Part B benefit.   All subsequent AWVs shall be billed with HCPCS G0439 (Annual Wellness Visit, including PPPS, subsequent visit). In the event that a beneficiary selects a new health professional to complete a subsequent AWV, the new health professional will continue to bil l the subsequent AWV with HCPCS G0439.   NOTE:  For an IPPE or AWV performed during the global period of surgery, refer to chapter 12, 30.6.6 of this chapter for reporting instructions.  G. Documentation for the IPPE or AWV   Practitioners eligible to furnish an IPPE or an AWV are required to use the 1995 and 1997 E/M documentation guidelines to document the medical record with the appropriate clinical information. (http://xmarks.com/site/www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp).  All referrals and a written medical plan must be included in this documentation.   H. Reporting a Medically Necessary E/M Service Furnished During the Same Encounter as an IPPE or AWV   When the physician or qualified NPP, or for AWV the health professional, provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or an AWV, CPT codes 99201 -  99215 may be reported depending on the clinical appropriateness of the circumstances. CPT Modifier - 25 shall be appended to the medically necessary E/M service identifying this service as a significant, separately identifiable service from the IPPE or AWV code reported (HCPCS code G0344 or G0402, whicheve r applies based on the date the IPPE is performed, or HCPCS code G0438 or G0439 whichever AWV code applies).