evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Qualifying general surgeons are identified on a claim for a 10 - or 90 - day global surgical procedure based on the primary specialty of the rendering physician, identified by his or her National Provider Identifier (NPI), of 02 - general surgery.  If the claim is submitted by a physician group practice, the rendering physicians NPI must be included on the line-item for the qualifying surgical procedure in order for a determination to be made regarding whether or not the procedure is eligible for payment under the HSIP.  Eligible surgical procedures are those procedures for which a 10 - or 90 - day global period is used for payment under the PFS.  The specific HCPCS procedure codes eligible for the HSIP are identified in column U (global period) of the Physician Fee Schedule Relative Value Update (RVU) file located at:  http://www.cms.gov/Medicare/Medicare -Fee-for-Service -Payment/PhysicianFeeSched/PFS -Relative -Value- Files.html, with a global period designation of 10 - or 90 - days.   90.4.11.5 - Claims Processing and Payment  (Rev. 2040, Issued: 08- 27-10, Effective: 01-01-11 and 04-04-11, Implementation: 01-03-11 for the claim identification of the incentive and 04 -04-11 for full implementation)   A. General Overview   The HPSA physician bonus program guidelines are contained in Pub. 100-04, Chapter 12, 90.4.  Refer to that section for payment and claims processing guidance for the HPSA physician bonus program that was established in 2005.  The following guidelines pertain only to the additional 10 percent incentive payment for 10 - or 90 - day global surgical procedures furnished by 02 - general surgeons in HPSAs from January 1, 2011 through December 31, 2015.  A/B MACs (B) shall identify eligible surgical procedures with a 10 - or 90 - day global period rendered in an eligible primary care HPSA zip code area based on the HPSA physician bonus ZIP code file for the appropriate date of service.  The HPSAs eligible for automatic payment may be found on the CMS Web site at: http://www.cms.gov/HPSAPSAPhysicianBonuses/01_overview.asp.
(Medicare Claims Processing Manual)
A/B MACs (B) must also inform eligible practitioners about the use of modifier - AQ on claims for 10 - or 90 - day global surgical procedures that were furnished in HPSAs approved by December 31 of the preceding calendar year, but that are not recognized for automatic payment.  The modifier must be appended to the surgical procedure for the service to be eligible for the 10 percent additional HSIP payment.  B. Method of Payment    Calculate and pay general surgeons an additional 10 percent incentive payment;    Calculate the payment based on the amount actually paid for the service, not the Medicare approved amount;    Combine the HSIP incentive payments, when appropriate, with other incentive payments, including the HPSA physician bonus payment;    Accept and pay the incentive payment for 10 -  and 90 -  day global period surgical procedures furnished by general surgeons (02) and submitted with the modifier -AQ;   Provide a special remittance form that is forwarded with the incentive payment so that physicians and nonphysician  practitioners can identify which type of incentive payment (HPSA, HSIP, and/or PCIP) was paid for which services;    Use the PLB03 adjustment reason code LE;    Add the following message to the incentive checks:  This check is for the HPSA, HSIP and/or PCIP.  See special remittance for details; and    Inform practitioners to contact their A/B MAC (B) with any questions regarding HSIP payments.   C. Changes for A/B MAC (B)  Systems   The Medicare Carrier System, (MCS), Common Working File (CWF,) and National Claims History (NCH) shall be modified to accept a new incentive HPSA/PSA/HSIP/PCIP payment indicator on the claim line.   Once the type of incentive has been identified by the shared systems, the shared system shall transmit the HPSA/PSA/HSIP/PCIP indicator to CWF and 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)
The MCS shall send the HIGLAS 810 invoice for incentive payment invoices, including the new HSIP payment.  The A/B MAC (B) shall also combine the practitioners HPSA physician bonus, Physician Scarcity (PSA) bonus (if it should become available at a later date), HSIP payment, and/or PCIP payment invoice per practitioner.  The A/B MAC (B) shall receive the HIGLAS 835 payment file from HIGLAS showing a single incentive payment per practitioner.   90.5 - Billing and Payment in a Physician Scarcity Area (PSA)  (Rev. 1434; Issued:  02- 05-08; Effective:  01 -01-08; Implementation:  01 -07-08)  Section 413a of the MMA requires that a 5 percent bonus payment be established for physicians in designated physician scarcity areas for dates of service January 1, 2005, through December 31, 2007.  T he Medicare, Medicaid, and State Childrens Health Insurance Program (SCHIP) Extension Act of 2007 amended 1833(u)(1) of the Social Security Act and has extended payment of that bonus through June 30, 2008.  Physician scarcity designations will be based on the lowest primary care and specialty care ratios of Medicare beneficiaries to active physicians in every county.  In addition, based on rural census tracts of metropolitan statistical areas identified through the latest modification of the Goldsmith Modification (i.e., Rural -Urban Commuting Area Codes), addi tional physician scarcity areas will be identified based on the lowest primary care and specialty care ratios of Medicare beneficiaries to active physicians in each identified rural census area.   90.5.1 - Provider Education  (Rev. 280, Issued 08- 13-04, Effective/Implementation: October 1, 2004 for the analysis and design phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for the coding, testing, and implementation phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for all phases for the VIPS Maintainers and A/B MACs (B))
(Medicare Claims Processing Manual)
Upon publication of the final rule of the 2005 Medicare Physician Fee Schedule, CMS will post on its Web site zip codes that are eligible for automatic payment of the physician scarcity bonus payment.  90.5.2 - Identifying Physician Scarcity Area Locations  (Rev. 1434; Issued:  02- 05-08; Effective:  01 -01-08; Implementation:  01 -07-08)  The CMS shall provide to the standard systems and A/B MACs (B)  file of zip codes for the automated payment of the primary care and specialty physician scarcity bonus.  The file will be effective for claims with dates of service on or after January 1, 2005, through December 31, 2007.  A/B MACs (B)  and shared systems will be notified by e -mail of the name of the file and when it will be available for downloading.  The Medicare, Medicaid, and State Childrens Health Insurance Program (SCHIP) Extension Act of 2007 amended 1833(u)(1) of the Social Security Act and has extended payment of the Physician Scarcity Area bonus through June 30, 2008, using the same file used for prior years.   90.5.3 - Claims Coding Requirements (Rev. 280, Issued 08- 13-04, Effective/Implementation: October 1, 2004 for the analysis and design phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for the coding, testing, and implementation phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for all phases for the VIPS Maintainers and A/B MACs (B))
(Medicare Claims Processing Manual)
Medicare will automatically pay the physician scarcity bonus on a quarterly basis  for services provided in ZIP  code areas that fully fall within a county designated as a PSA, partially fall within a county designated as a PSA area and are considered to be dominant for that county based on a determination by the United States Postal Service (USPS), or fall within a  rural census tract of a metropolitan statistical area identified through the latest modification of the Goldsmith Modification that is determined  to be a PSA.  In some cases, a service may be provided in a county that is considered to be a PSA, but the ZIP  code is not considered to be dominant for that area.  The bonus payment cannot automatically be made.  In order to receive the bonus for those areas, physicians must include the following modifier on the claim:
(Medicare Claims Processing Manual)
AR - Physician providing service in a Physician Scarcity Area.  In order to be considered for the bonus payment, the name, address, and ZIP  code of where the service was rendered must be included on all electronic and paper claims submissions.  90.5.4 - Payment  (Rev. 280, Issued 08- 13-04, Effective/Implementation: October 1, 2004 for the analysis and design phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for the coding, testing, and implementation phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for all phases for the VIPS Maintainers and A/B MACs (B))  Section 413a of the MMA adds subsection (u)(6) to Section 1833 of the Social Security Act.  For the payment of the physician scarcity bonus, this section defines physicians as doctors of medicine or osteopathy described per Section 1861(r)(1).  Therefore, dentists, chiropractors, podiatrists, and optometrists are not eligible for the physician scarcity bonus as either primary care or specialty physicians  Only the provider specialty designations of General Practice - 01, Family Practice - 08, Internal Medicine -  11, and Obstetrics/Gynecology -  16, will be paid the bonus for the zip codes designated as primary care PSAs.  All other physician provider specialties  will be eligible for the specialty physician scarcity bonus for the zip codes designated as specialty PSAs.  The bonus is to be paid based on date of service.  Accommodations must be made in payment systems to maintain an active file for a current period as well as an active file for a previous period so that the bonus can be paid based on date of service.  Also, the A/B MACs (B)  and standard systems maintainers shall program systems to be able to maintain files for the periods prior to the two active periods as an archive for reference purposes.  90.5.5 - Services Eligible for the Physician Scarcity Bonus  (Rev. 280, Issued 08- 13-04, Effective/Implementation: October 1, 2004 for the analysis and design phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for the coding, testing, and implementation phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for all phases for the
(Medicare Claims Processing Manual)
MCS Maintainer and A/B MACs (B)  January 1, 2005 for the coding, testing, and implementation phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for all phases for the VIPS Maintainers and A/B MACs (B))
(Medicare Claims Processing Manual)
Eligible physician services for the physician scarcity bonus are identified in the same manner that they are currently identified for the HPSA bonus payment per Pub. 100- 4, Chapter 12, 90.4.5A and B.  A quarterly 5 percent bonus payment is made to the physician based on the amount actually paid, not the Medicare approved amount of the service.  90.5.5.1 - Remittance Messages (Rev. 280, Issued 08- 13-04, Effective/Implementation: October 1, 2004 for the analysis and design phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for the coding, testing, and implementation phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for all phases for the VIPS Maintainers and A/B MACs (B)) See 90.4.6 for applicable remittance messages when submitted services are not eligible for a HPSA and/or physician scarcity bonus payment. 90.5.6 - Post-payment Review (Rev. 280, Issued 08- 13-04, Effective/Implementation: October 1, 2004 for the analysis and design phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for the coding, testing, and implementation phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for all phases for the VIPS Maintainers and A/B MACs (B))
(Medicare Claims Processing Manual)
On a post -pay basis, services submitted with the AR modifier will be subject to validation. 90.5.7 - Administrative and Judicial Review  (Rev. 280, Issued 08- 13-04, Effective/Implementation: October 1, 2004 for the analysis and design phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for the coding, testing, and implementation phases for the MCS Maintainer and A/B MACs (B)  January 1, 2005 for all phases for the VIPS Maintainers and A/B MACs (B))  Per Section 413(a) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, there shall be no administrative or judicial review respecting:   The identification of a county or area;   The assignment of a specialty of any physician;   The assignment of a physician to a county; or   The assignment of a postal ZIP code to a county or other area.   90.6 - The Indian Health Service (IHS) Provider Payment to Non -IHS Physicians for Teleradiology Interpretations  (Rev. 1643, Issued: 12- 05-08, Effective: 01 -01-07, Implementation: 03- 09-09)  The IHS providers may choose to purchase or otherwise contract with non- IHS physicians or practitioners for teleradiology interpretations services.  These services may be paid using either contractual reassignment or purchased test methodologies.  See Chap ter 19, Section 120 of this Manual for further information.  90.7 - Bundling of Payments for Services Provided in Wholly Owned and Wholly Operated Entities (including Physician Practices and Clinics): 3- Day Payment Window  (Rev. 2373, Issued: 12- 21-11, Effective: 01 -01-12, Implementation: 01- 03-12)
(Medicare Claims Processing Manual)
In accordance with section 102(a)(1) of the PACMBPRA, for outpatient services furnished on or after June 25, 2010, the technical portion of all nondiagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the date of a beneficiarys inpatient admission are deemed related to the admission and thus, must be included on the bill for the inpatient stay. Also, the technical portion of outpatient nondiagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the first, second,  and  the third  calendar days (1 calendar day for a nonsubsec tion (d) hospital) immediately preceding the date of admission are deemed related to the admission and, therefore, must be billed with the inpatient stay, unless the nondiagnostic services are unrelated to the inpatient hospital claim (that is, the preadmission nondiagnostic services are clinically distinct or independent from the reason for the beneficiarys inpatient admission).  In such cases, the unrelated outpatient hospital nondiagnostic services are covered by Medicare Part B, and the hospital or wholly owned or wholly operated physician practice shall include the technical portion of the services in their billing. PACMBPRA did not change the requirement that the technical portion of all diagnostic services provided by the hospital (or entity wholly owned or wholly operated by the hospital) occurring on the date of an inpatient admission, or during the 3 calendar days (or 1 calendar day) immediately preceding the date of an inpatient admission must be billed with the inpatient admission.   Implementation of the 3 -day Payment Window Policy in Wholly Owned or Operated Entities
(Medicare Claims Processing Manual)
Implementation of the 3 -day Payment Window Policy in Wholly Owned or Operated Entities   Wholly owned or wholly operated entities are subject to the 3- day (or 1- day) payment window policy when they furnish preadmission diagnostic services to a patient, who is later admitted as an inpatient on the same day or within the preceding 3 calendar days (preceding1 calendar day), or when they furnish preadmission nondiagnostic services to a patient, who is later admitted as an inpatient on the same day or within the preceding 3 calendar days (preceding 1 calendar day) for related medical care. Only unre lated nondiagnostic preadmission services are not subject to the payment window policy, where unrelated preadmission nondiagnostic services are clinically distinct or independent from the reason for the beneficiary's inpatient admission and are furnished on the 1st, 2nd, or 3rd calendar day immediately preceding the date of the inpatient admission. (Note: nondiagnostic services furnished by a wholly owned or wholly operated physician practice on the date of a beneficiarys inpatient admission to the hospita l are always deemed to be related to the admission and their technical portion must be included on the bill for the inpatient admission.) When an entity that is wholly owned or wholly operated by a hospital furnishes a service subject to the 3- day window policy, Medicare will pay the professional component of services with payment rates that include a professional and technical split and at the facility rate for services that do not have a professional and technical split. Once the entity has received confi rmation of a beneficiarys inpatient admission from the admitting hospital, they shall, for services furnished during the three -day window,  append a CMS payment modifier to all claim lines for diagnostic services and for those nondiagnostic services that have been identified as related to the inpatient stay.   Physician nondiagnostic services that are unrelated to the hospital admission are not subject to the payment window and shall be billed without the payment modifier.   Definition of Wholly Owned or Wholly Operated Entities
(Medicare Claims Processing Manual)
Definition of Wholly Owned or Wholly Operated Entities   Wholly owned or wholly operated entities are defined in 42 CFR 412.2; "An entity is wholly owned by the hospital if the hospital is the sole owner of the entity. And, an entity is wholly operated by a hospital if the hospital has exclusive responsibilit y for conducting and overseeing the entitys routine operations, regardless of whether the hospital also has policymaking authority over the entity."   90.7.1 - Payment Methodology: 3 -Day Payment Window in Wholly Owned or Wholly Operated Entities (including Physician Practices and Clinics)  (Rev. 2373, Issued: 12- 21-11, Effective: 01 -01-12, Implementation: 01- 03-12)  CMS has established HCPCS payment modifier PD (Diagnostic or related nondiagnostic item or service provided in a wholly owned or operated physician office to a patient who is admitted as an inpatient within 3 days), and requires that the modifier be appended to the physician preadmission diagnostic and admission- related nondiagnostic services, reported with HCPCS/CPT codes, which are subject to the 3- day payment window polic y. The wholly owned or wholly operated physicians office will need to manage their billing processes to ensure that they bill for their physician services appropriately when a related inpatient admission has occurred.  The hospital is responsible for noti fying the practice of an inpatient admissions for a patient who received services in a wholly owned or wholly operated physician office within the 3- day (or, when appropriate,1- day) payment window prior to the inpatient stay.  The modifier is effective for  claims with dates of service on or after January  1, 2012. Wholly owned or wholly operated per their readiness to do so. Entities have the discretion to apply these policies for claims with dates of service on and after January 1, 2012, but shall comply wi th these polices no later than July 1. 2012.  When the modifier is present on claims for service CMS shall pay   only the Professional Component (PC) for CPT/HCPCS codes with a Technical Component (TC)/PC split that are provided in the 3- day (or, in the case of non -IPPS hospitals, 1- day) payment window, and    The facility rate for codes without a TC/PC split.
(Medicare Claims Processing Manual)
 The facility rate for codes without a TC/PC split.   Global Surgical Services and the 3 -day Payment Window Policy  We note that the time frames associated with 10 and 90 day global surgical packages could overlap with the 3- day (or 1- day) payment window policy.   The 3- day payment window makes no change in billing surgical services according to global surgical rules, and pre - and post -operative services continue to be include d in the payment for the surgery. However, there may be times when the surgery itself is subject to the three -day window policy, as would occur if the surgery were performed within the three -day window.  For example, a patient could have a minor surgery in a wholly owned or wholly operated physician office and then, due to a complication, be admitted to the hospital as an inpatient.  In such cases the modifier shall be appended to the appropriate surgical HCPCS/CPT code.
(Medicare Claims Processing Manual)
100 - Teaching Physician Services  (Rev. 811, Issued: 01- 13-06, Effective: 01 -01-06, Implementation: 02- 13-06) Definitions  For purposes of this section, the following definitions apply. Resident -  An individual who participates in an approved graduate medical education (GME) program or a physician who is not in an approved GME program but who is authorized to practice only in a hospital setting.  The term includes interns and fellows in GME program s recognized as approved for purposes of direct GME payments made by the FI.  Receiving a staff or faculty appointment or participating in a fellowship does not by itself alter the status of "resident".  Additionally, this status remains unaffected    regardless of whether a hospital includes the physician in its full time equivalency count of residents.  Student  - An individual who participates in an accredited educational program (e.g., a medical school) that is not an approved GME program. A student is never considered to be an intern or a resident.  Medicare does not pay for any service furnished by a student.  See 100.1.1B for a discussion concerning E/M service documentation performed by students. Teaching Physician -  A physician (other than another resident) who involves residents in the care of his or her patients. Direct Medical and Surgical Services -  Services to individual beneficiaries that are either personally furnished by a physician or furnished by a resident under the supervision of a physician in a teaching hospital making the reasonable cost election for physician services furnished in teaching hospitals.  All payments for such services are made by the A/B MAC (A) for the hospital.  Teaching Hospital -  A hospital engaged in an approved GME residency program in medicine, osteopathy, dentistry, or podiatry. Teaching Setting -  Any provider, hospital -based provider, or nonprovider setting in which Medicare payment for the services of residents is made by the A/B MAC (A) under the direct graduate medical education payment methodology or freestanding SNF or HHA in which such payme nts are made on a reasonable cost basis.  Critical or Key Portion  - That part (or parts) of a service that the teaching physician determines is (are) a critical or key portion(s).  For purposes of this section, these terms are interchangeable.  Documentation  - Notes recorded in the patient's medical records by a resident, and/or teaching physician or others as outlined in the specific situations