evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
4. Partial Hospitalization Services Not Directly Provided by a Physician or a Practitioner -  The limitation does not apply to partial hospitalization services that are not directly provided by a physician, clinical psychologist, nurse practitioner, clinical n urse specialist , or a physician assistant.  Partial hospitalization services are billed by hospital outpatient departments and community mental health centers (CMHCs) to A/B MACs (A).  However, services furnished by physicians, clinical psychologists, nurs e practitioners, clinical nurse specialists, and physician assistants to partial hospitalization patients are billed separately from the partial hospitalization program of services.   Accordingly, these professionals mental health services to partial hospitalization patients are paid under the physician fee schedule by A/B MACs (B) and may be subject to the limitation. (See chapter 4, section 260.1C).  5. Intensive Outpatient Services Not Directly Provided by a Physician or a Practitioner -  The limitation does not apply to intensive outpatient services that are not directly provided by a physician, clinical psychologist, nurse practitioner, clinical nurse s pecialist, or a physician assistant.  Intensive outpatient services are billed by hospital outpatient departments, community mental health centers (CMHCs), RHCs, FQHCs, and OTPs to A/B MACs (A).  However, services furnished by physicians, clinical psychologists, nurse practitioners, clinical nurse specialists, and physician assistants to intensive outpatient patients are billed separately from the intensive outpatient program of services.   Accordingly, these professional s mental health services to intensi ve outpatient patients are paid under the physician fee schedule by A/B MACs (B) and may be subject to the limitation. (See chapter 4, section 261.1C).   E. Computation of Limitation    A/B MACs (B) determine the Medicare approved payment amount for services subject to the limitation.  They:     Multiply the approved amount by the limitation percentage amount;      Subtract any unsatisfied deductible; and,      Multiply the remainder by 0.8 to obtain the amount of Medicare payment. The beneficiary is responsible for the difference between the amount paid by Medicare and the full Medicare approved amount.
(Medicare Claims Processing Manual)
 Multiply the remainder by 0.8 to obtain the amount of Medicare payment. The beneficiary is responsible for the difference between the amount paid by Medicare and the full Medicare approved amount.    The following examples illustrate the application of the limitation in various circumstances as it is gradually reduced under section 102 of the Medicare Improvements for Patients and Providers Act (MIPPA).  Please note that although the calendar year 2009 Part B deductible of $135 is used under these examples, the actual deductible amount for calendar year 2010 and future years is unknown and will be subject to change.    Example #1:   In 2010, a clinical psychologist submits a claim for $200 for outpatient treatment of a patients mental disorder.  The Medicare -approved amount is $180.  Since clinical psychologists must accept assignment, the patient is not liable for the $20 in exces s charges.  The patient previously satisfied the $135 annual Part B deductible.  The limitation reduces the amount of incurred expenses to 68  percent of the approved amount.  Medicare pays 80 percent of the remaining incurred expenses.  The Medicare paym ent and patient liability are computed as follows:    1. Actual charges..$200.00  2. Medicare- approved amount   ..$180.00  3. Medicare incurred expenses (0.6875 x line 2) .....$123.75  4. Unmet deductible..$0.00  5. Remainder after subtracting deductible (line 3 minus line 4) ..$123.75  6. Medicare payment (0.80 x line 5).$99.00  7. Patient liability (line 2 minus line 6).$81.00
(Medicare Claims Processing Manual)
Example  #2:   In 2012, a clinical social worker submits a claim for $135 for outpatient treatment of a patients mental disorder.  The Medicare -approved amount is $120.  Since clinical social workers must accept assignment, the patient is not liable for the $15 in exc ess charges.  The limitation reduces the amount of incurred expenses to 75 percent of the approved amount.  The patient previously satisfied $70 of the $135 annual Part B deductible, leaving $65 unmet.  The Medicare payment and patient liability are computed as follows:    1. Actual charges..$135.00  2. Medicare- approved am........$120.00  3. Medicare incurred expenses (0.75 x line...$90.00  4. Unmet deductible...$65.00  5. Remainder after subtracting deductible (line 3 minus line   6. Medicare payment (0.80 x line ...$20.00  7. Patient liability (line 2 minus line 6)..........$100.00    Example #3:   In calendar year 2013, a physician who does not accept assignment submits a claim for $780 for services in connection with the treatment of a mental disorder that did not require inpatient hospitalization.  The Medicare -approved amount is $750.  Because the physician does not accept assignment, the patient is liable for the $30 in excess charges.  The patient has not satisfied any of the $135 Part B annual deductible.  The Medicare payment and patient liability are computed as follows:
(Medicare Claims Processing Manual)
1. Actual charges. .$780.00  2. Medicare- approved amount..$750.00  3. Medicare incurred expenses (0.8125 x line 2....$609.38  4. Unmet deductible ..$135.00  5. Remainder after subtracting deductible (line 3 minus line  4 6.  4)...$474.38 7. Medicare payment (0.80 x line 5)  ..$379.50  8. Patient liability (line 1 minus line 6)    $400.50    Example #4:   A patients Part B expenses during calendar year 2014 are for a physicians services in connection with the treatment of a mental disorder that initially required inpatient hospitalization, with subsequent physician services furnished on an outpatient ba sis.  The patient has not satisfied any of the $135 Part B deductible.  The physician accepts assignment and submits a claim for $780.  The Medicare -approved amount is $750.  Since the limitation will be completely phased out as of January 1, 2014, the ent ire $750 Medicare -approved amount is recognized as the total incurred expenses because such expenses are no longer reduced.  Also, there is no longer any distinction between mental health services the patient receives as an inpatient or outpatient.  The Me dicare payment and patient liability are computed as follows:
(Medicare Claims Processing Manual)
1. Actual charges..$780.00  2. Medicare- approved amount ..$750.00  3. Medicare incurred expenses (1.00 x line     ..$750.00  4. Unmet deductible    ..$135.00  5. Remainder after subtracting deductible (line 3 minus line 4) ..$615.00  6. Medicare payment (0.80 x line 5).$492.00 7.  Beneficiary liability (line 2 minus line 6).$258.00   220 - Chiropractic Services  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  A.   Verification of Chiropractor's Qualifications   Establish a reference file of chiropractors eligible for payment as physicians under the criteria in Pub. 100- 02, Benefits Policy Manual, Chapter 15, Sections 30.5 & 240A.  Pay only chiropractors on file.  Information needed to establish such files is furnished by the RO.  The RO is notified by the appropriate State agency which chiropractors are licensed and whether each meets the national uniform standards.  B.   Durable Medical Equipment Regional Carriers Processing Claims When a Chiropractor is the Supplier   Effective July 1, 1999, except for restrictions to chiropractor services as stipulated in 1861(s)(2)(A) of the Social Security Act, chiropractors (specialty 35) can bill for durable medical equipment, prosthetics, orthotics and supplies if, as the supplier, they have a valid supplier number assigned by the National Supplier Clearinghouse.  In order to process claims, the Common Working File has been changed to allow specialty 35 to bill for services furnished as a supplier.   C.   Documentation
(Medicare Claims Processing Manual)
C.   Documentation   The following information must be recorded by the chiropractor and kept on file.  The date of the initial treatment or date of exacerbation of the existing condition must be entered in Item 14 of Form CMS -1500.  This serves as affirmation by the chiropract or that all documentation required as listed below and in Pub. 100- 02, Benefits Policy Manual, Chapter 15, Section 240.1.2 is being maintained on file by the chiropractor.   1. Specification of the precise spinal location and level of subluxation (see Pub. 100- 02, Benefits Policy Manual, Chapter 15, Section 240.1.4) giving rise to the diagnosis and symptoms.   2. Effective for claims with dates of service on and after January 1, 2000, the x-ray is no longer required .  However, the x- ray may  still be used to demonstrate subluxation for claims processing purposes.  Effective for claims with dates of service on or after October 1, 2000, when the x- ray is used to demonstrate subluxation, the date of the x -ray must be entered in Item 19 of Form C MS-1500 and the date must be within the parameters specified in Pub. 100- 02, Benefits Policy Manual, Chapter 15, Section 240.1.2.  For claims with dates of service prior to January 1, 2000, and for claims with dates of service on or after October 1, 2000, for which an x- ray is still used to show subluxation, the following instructions on documentation apply:   An x -ray film (including the date of the film) is available for your review demonstrating the existence of a subluxation at the specified level of the spine.  If the beneficiary refuses to have the x -ray, the chiropractor must submit one of the appropriate  HCPCS codes for chiropractic manipulation in addition to modifier GX (service not covered by Medicare), and the claim will be denied as a technical denial.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.   Group Code: PR  CARC: 96  RARC: M111  MSN: 3.1
(Medicare Claims Processing Manual)
Group Code: PR  CARC: 96  RARC: M111  MSN: 3.1  NOTE:  The refusal of the beneficiary to have an x -ray taken will no longer need to be coded for claims with dates of service on or after January 1, 2000.   D.   Claims Processing   Edits and suggested MSN and RA messages.   1. Do not pay for manual manipulation of the spine in treating conditions other than those indicated in Pub. 100- 02, Benefits Policy Manual, Chapter 15, Section 240.1.3.  The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.   Group Code: CO  CARC: 50  RARC: N/A  MSN: 15.4  1. Deny claims for treatment of any condition not reasonably related to a subluxation involving vertebrae at the spinal level specified.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  The CARC below is not included in the CAQH CORE Business Scenarios.  Group Code: CO  CARC: B22  RARC: N/A  MSN: 15.4  2. Edit to verify that the date of the initial visit or the date of exacerbation of the existing condition is entered.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 2.   Group Code: CO  CARC: 16  RARC: MA122  MSN: 9.2  E.   X -ray Review  Effective for claims with dates of service on and after January 1, 2000, the x -ray is no longer required.  However, effective for claims with dates of service on or after October 1, 2000, should the chiropractor choose to use the x- ray to show subluxation, the x -ray review process is still required as outlined below minus the requirement in the last sentence of number 2. For claims with dates of service prior to January 1, 2000, all aspects of the following instructions still apply.   1. Carriers should conduct post -payment reviews of x -rays on a sample basis.  Prepayment review should be undertaken in all questionable cases.
(Medicare Claims Processing Manual)
1. Carriers should conduct post -payment reviews of x -rays on a sample basis.  Prepayment review should be undertaken in all questionable cases.  2. It is the responsibility of the treating chiropractor to make the documenting x-ray(s) available to the carrier's review staff.  If x -rays are not made available, or suggest a pattern in failing to demonstrate subluxation for any reason, including unacceptable technical quality, the carrier should conduct prepayment review of x-rays in 100 percent of the subsequent claims for treatments by the practitioner involved until satisfied that the deficiency will no longer occur.  Where there is no x-ray documentation of subluxation on prepayment review, the claims, of course, should be denied.  (The  last sentence of this paragraph only refers to claims with dates of service prior to January 1, 2000.)   3. The x -ray film(s) must have been taken at a time reasonably proximate to the initiation of the course of treatment and must demonstrate a subluxation at the level of the spine specified by the treating chiropractor on the claim.  (See Pub. 100-02, Benef its Policy Manual, Chapter 15, Section 240.1.2.)   4. An x -ray obtained by the chiropractor for his own diagnostic purposes before commencing treatment should suffice for claims documentation purposes. However, when subluxation was for treatment purposes diagnosed by some other means and x -rays are taken t o satisfy Medicare's documentation requirement, carriers should ask chiropractors to hone in on the site of the subluxation in producing x- rays.  Such a practice would not only minimize the exposure of the patient but also should result in a film more clea rly portraying the subluxation.  5. An x -ray will be considered of acceptable technical quality if any individual trained in the reading of x- rays could recognize a subluxation if present.   6. When claims have been denied because the x -ray(s) initially offered failed to document the existence of a subluxation requiring treatment, no review of these decisions should be undertaken on the basis of x -ray(s) subsequently taken.  Permitting such re views could be an inducement to excessive exposure of patients to radiation in cases where the decision to treat was made despite x -rays that did not show a subluxation.
(Medicare Claims Processing Manual)
230 - Primary Care Incentive Payment Program (PCIP)  (Rev. 2152, Issued: 02- 11-11, Effective: 07 -01-11, Implementation: 07- 05-11)  Section 5501(a) of the Affordable Care Act revises section 1833 of the Social Security Act (the Act) by adding a new paragraph, (x), Incentive Payments for Primary Care Services.  Section 1833(x) of the Act states that in the case of primary care services furnished on or after January 1, 2011, and before January 1, 2016, there shall be a 10 percent incentive payment for such services under Part B when furnished by a primary care practitioner.   Information regarding Primary Care Incentive Payment Program (PCIP) payments made to critical access hospitals (CAHs) paid under the optional method can be found in Pub. 100-04, Chapter 4, 250.12 of this manual.  230.1 - Definition of Primary Care Practitioners and Primary Care Services  (Rev. 2152, Issued: 02- 11-11, Effective: 07 -01-11, Implementation: 07- 05-11)  Primary care practitioner is defined as:   1. A physician who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine for whom primary care services accounted for at least 60 percent of the allowed charges under the PFS (excluding hospital i npatient care and emergency department visits) for the practitioner in a prior period as determined appropriate by the Secretary; or   2. A nurse practitioner, clinical nurse specialist, or physician assistant for whom primary care services accounted for at least 60 percent of the allowed charges under the PFS (excluding hospital inpatient care and emergency department visits) for the practitioner in a prior period as determined appropriate by the Secretary.   Primary care services are defined as HCPCS Codes:   1. 99201 through 99215 for new and established patient office or outpatient evaluation and management (E/M) visits;   2. 99304 through 99340 for initial, subsequent, discharge, and other nursing facility E/M services; new and established patient domiciliary, rest home or custodial care E/M services; and domiciliary, rest home or home care plan oversight services; and  3. 99341 through 99350 for new and established patient home E/M visits.   Practitioner Identification
(Medicare Claims Processing Manual)
3. 99341 through 99350 for new and established patient home E/M visits.   Practitioner Identification   Primary care practitioners will be identified using the National Provider Identifier (NPI) number of the rendering practitioner on claims.  If the claim is submitted by a practitioners group practice, the rendering practitioners NPI must be included on t he line-item for the primary care service and reflect an eligible HCPCS as identified.  In order to be eligible for the PCIP, physician assistants, clinical nurse specialists, and nurse practitioners must be billing for their services under their own NPI a nd not furnishing services incident to physicians services.  Regardless of the specialty area in which they may be practicing, the specific nonphysician practitioners are eligible for the PCIP based on their profession and historical percentage of allowed charges as primary care services that equals or exceeds the 60 percent threshold.   The claims data  used for the primary care percentage calculations depend on the potential primary care practitioners date of enrollment in Medicare.  We will use Medicare claims data 2 years prior to the PCIP payment year to determine PCIP eligibility fo r those potential primary care practitioners who were enrolled in Medicare in that year.  For example, for CY 2011, we will use Medicare claims data from CY 2009 for practitioners who were already enrolled in Medicare in CY 2009. We will use claims data fr om the year immediately preceding the PCIP payment year in order to determine PCIP eligibility for potential primary care practitioners who newly enroll in Medicare in the year immediately preceding the PCIP payment year.  For example, for CY 2011, we will use the available Medicare claims data from CY 2010 only for potential primary care practitioners who newly enrolled in Medicare in CY 2010.  Eligible practitioners for PCIP payments in a given calendar year who were enrolled in Medicare 2 years earlier will be listed by eligible NPI in the Primary Care Incentive Payment Program Eligibility File, available after January 31 of the PCIP payment ye ar on their A/B MAC (B)s website.  Eligible practitioners for PCIP payments in a given calendar year who were newly enrolled in Medicare in the year immediate preceding the PCIP payment year will be identified in the PCIP Payment  for New Providers Enroll ed in Medicare File, available after October 1 of the PCIP payment year.  Practitioners should contact their A/B MAC (B) with any questions regarding their eligibility for the PCIP.
(Medicare Claims Processing Manual)
230.2 - Coordination with Other Payments (Rev. 2152, Issued: 02- 11-11, Effective: 07 -01-11, Implementation: 07- 05-11)  Section 5501(a)(3) of the Affordable Care Act authorizes payment under the PCIP as an additional payment amount for specified primary care services without regard to any additional payment for the service under Section 1833(m) of the Act.  Therefore, an eligible primary care physic ian furnishing a primary care service in a health professional shortage area (HPSA) may receive both a HPSA physician bonus payment (as described in the Medicare Claims Processing Manual, Pub. 100- 04, Chapter 12, 90.4) under the HPSA physician bonus progr am and a PCIP incentive payment under the new program beginning in CY 2011.  230.3 - Claims Processing and Payment  (Rev. 2152, Issued: 02- 11-11, Effective: 07 -01-11, Implementation: 07- 05-11)  A. General Overview   Incentive payments will be made on a quarterly basis and shall be equal to 10 percent of the amount paid for such services under the Medicare Physician Fee Schedule (PFS) for those services furnished during the incentive payment year. PCIP payments for new ly enrolled practitioners will be delayed due to the lag in their eligibility determination.  Newly enrolled primary care practitioners will receive a single cumulative PCIP payment, retroactive for primary care services furnished from the beginning of the  PCIP payment year, following the fourth quarter of the PCIP payment year after the primary care practitioner is deemed eligible.  Quarterly payments will be made for subsequent incentive payments.   For information on PCIP payments to CAHs paid under the optional method, see the Medicare Claims Processing Manual, Pub. 100- 04, Chapter 4, 250.12.   On an annual basis A/B MACs (B) shall receive a Primary Care Incentive Payment Program Eligibility File and PCIP Payment for New Providers Enrolled in Medicare File that they shall post to their websites.  The files will list the NPIs of all practitioners who are eligible to receive PCIP payments for the PCIP payment year.   B. Method of Payment    Calculate and pay qualifying primary care practitioners an additional 10 percent incentive payment.    Calculate the payment based on the amount actually paid for the services, not the Medicare approved amount.
(Medicare Claims Processing Manual)
B. Method of Payment    Calculate and pay qualifying primary care practitioners an additional 10 percent incentive payment.    Calculate the payment based on the amount actually paid for the services, not the Medicare approved amount.    Combine the PCIP incentive payments, when appropriate, with other incentive payments, including the HPSA physician bonus payment, and the HPSA Surgical Incentive Payment Program (HSIP) payment;    Provide a special remittance form that is forwarded with the incentive payment so that physicians and practitioners can identify which type of incentive payment (HPSA physician and/or PCIP) was paid for which services.    Practitioners should contact their A/B MAC (B) with any questions regarding PCIP payments.   C. Changes for Contractor Systems   The Medicare Carrier System, (MCS), Common Working File (CWF) and the National Claims History (NCH) shall be modified to accept a new PCIP indicator on the claim line.  Once the type of incentive payment has been identified by the shared systems, the shared system shall modify their systems to set the indicator on the claim line as follows:   1 = HPSA;  2 = PSA;  3 = HPSA and PSA;  4 = HSIP;  5 = HPSA and HSIP;  6 = PCIP;  7 = HPSA and PCIP; and  Space = Not Applicable.
(Medicare Claims Processing Manual)
1 = HPSA;  2 = PSA;  3 = HPSA and PSA;  4 = HSIP;  5 = HPSA and HSIP;  6 = PCIP;  7 = HPSA and PCIP; and  Space = Not Applicable.   The MCS shall send the HIGLAS 810 invoice for incentive payment invoices, including the new PCIP payment.  The A/B MAC (B) shall also combine the providers HPSA physician bonus, physician scarcity (PSA) bonus (if it should become available at a later date), HSIP payment and/or PCIP payment invoice per provider.  The A/B MAC (B) shall receive the HIGLAS 835 payment file from HIGLAS showing a single incentive payment per provider.  Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12423CP  12/20/2023  Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92  01/02/2024  13222  R12370CP  11/21/2023  Implement Edits to Prevent Payment of Complexity Add- On Code G2211 When Associated Office/Outpatient Evaluation and Management Visit (Codes 99202-99205, 99211- 99215) is Reported With Modifier 25 NO LONGER SENSITIVE  01/02/2024  13272