evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Pulmonary Rehabilitation Services (A52770)
CMS National Coverage PolicyN/AArticle TextWe are providing clarification of coverage and documentation requirements for pulmonary rehabilitation services based on Noridian medical review findings. Pulmonary rehabilitation services are covered by Medicare as either: a) Individual component services when medical necessity requirements are met or as; b) Pulmonary Rehabilitation Program services when specific program requirements are met.A. Individual ComponentsThese services must be provided by a qualified clinician, i.e., physician, non-physician practitioner (NPP), respiratory therapist (RT), physical therapist (PT), occupational therapist (OT) or appropriately supervised/qualified therapist assistant (physical therapist assistant (PTA) or occupational therapist assistant (OTA)). Ifallthe Pulmonary Rehabilitation Program requirements listed in Section B below arenotmet, individual pulmonary rehabilitation components are still payable, using the GXXXX or 97XXX codes, when the documentation supports:It is tailored to meet the individual patients specific needs based on a thorough evaluation.It is at a level of complexity that requires a qualified clinician to perform.It is medically reasonable and necessary for the treatment of an individual patients acute/exacerbated pulmonary condition.These services must be billed as follows:Use HCPCS G0237-G0239Services are provided under a physician plan of care by incident-to staff or RT. Note: Incident-to services cannot be provided by a PTA and/or OTA.Inclusive services that are not separately billable include - pulse oximetry, counseling, education, and the 6-minute walk test.Therapy modifiers and revenue codes should not be coded (GP/GO and 42x/43x).Use CPT 97xxx CodesServices are provided under a therapy plan of care by a physician/NPP/incident-to or by PT or OT.Inclusive services that are not separately billable include - pulse oximetry, counseling, education, and the 6-minute walk test.Therapy modifiers and revenue codes should be coded as applicable, GP/GO and 42x/43x).B. Pulmonary Rehabilitation (PR) Programs - effective on or after January 1, 2010
Article - Billing and Coding: Pulmonary Rehabilitation Services (A52770)
B. Pulmonary Rehabilitation (PR) Programs - effective on or after January 1, 2010All requirements of the CMS Internet Only Manual (IOM)Medicare Benefit Policy Manual,Publication 100-02,Chapter 15, Section 231and IOMMedicare Claims Processing Manual,Publication 100-4,Chapter 32, Section 140.4and National Coverage Determination (NCD)Pulmonary Rehabilitation Services 240.8must be fulfilled. Programs must provide a comprehensive, evidence-based multidisciplinary intervention for patients with chronic respiratory impairment.Medicare covers Pulmonary Rehabilitation Program services for:Moderate to very severe COPD (defined as GOLD classification II, III and IV), when referred by the physician treating the chronic respiratory disease.As perthe 2022 Physician Fee Schedule Final Rule (86 FR 65244 dated November 19, 2021), CMS finalized revisions to the conditions of coverage for pulmonary rehabilitation (PR) specified at 42 Code of Federal Register 410.47. These revisions included coverage forconfirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks (effective January 1, 2022).Note: Additional medical indications for coverage for Pulmonary Rehabilitation Program services may be established through an NCD.Medicare will pay for a maximum of 2 one-hour sessions per day, for up to 36 sessions for up to 36 weeks for Pulmonary Rehabilitation Program services when documentation supports thatallof the following program requirements are met:Physician has ordered and prescribed exercise and aerobic exercise combined with other types of exercise (such as conditioning, breathing retraining, step, and strengthening) as determined to be appropriate for individual patients by a physician and is provided at each treatment session.An individualized plan of careplan detailing how components are utilized for each patientis initially established by the physician as well as reviewed and signed by the physician every 30 days.Services must be provided only in the following place of service (POS): 11 (physicians office), 19 (Off-Campus Outpatient Hospital or 22 (On-Campus Outpatient Hospital). All settings must have a physician immediately available and accessible for medical consultations and emergencies at all times when program services are being furnished.Physicians acting as the supervising physician must possess all of the following:
Article - Billing and Coding: Pulmonary Rehabilitation Services (A52770)
Expertise in the management of individuals with respiratory pathophysiology.Cardiopulmonary training in basic life support or advanced cardiac life support.Be licensed to practice medicine in the State in which the PR program is offered.Education or training that is closely and clearly related to the individuals care and treatment which is tailored to the individuals needs and assists in achievement of goals toward independence in activities of daily living, adaptation to limitations and improved quality of life. Education must include information on respiratory problem management and, if appropriate, brief smoking cessation counseling.The education requirement is not met by:Handing out a booklet, "How to Stop Smoking with no additional follow-up."Having the patient take an assessment at the beginning and end of the program.Documenting sporadic and/or vague instruction provided e.g., "discussed self-management techniques."Psychosocial assessment and reassessment must be thorough and occur at periodic intervals. This includes evaluation of an individuals mental and emotional functioning as it relates to the individuals rehabilitation or respiratory condition, an assessment of those aspects of an individuals family and home situation that affects the individuals rehabilitation treatment,and psychosocial evaluation of the individuals response to and rate of progress under the treatment plan.Significant outcomes assessment with clinical measures (initial/ending) must be evident in the medical record. This includes evaluations based on patient-centered outcomes, objective clinical measures of exercise performance and self-reported measures of shortness of breath and behavior.
Article - Billing and Coding: Pulmonary Rehabilitation Services (A52770)
The patient may require an additional 36 sessions for COVID-19 if he/she has already received pulmonary rehabilitation services for COPD initially or vice versa. When billing for these additional sessions for the second approved condition, providersmustappend the KX modifier to the second 36 sessions.Hospitals and practitioners may report a maximum of 2 1-hour sessions per day. In order to report one session ofPRin a day, the duration of treatment must be at least 31 minutes. Two sessions ofPRmay only be reported in the same day if the duration of treatment is at least 91 minutes.Therapy modifiers (GN/GO/GP) and revenue codes (42x/43x) should not be coded.CMS deleted the Pulmonary Rehabilitation Program HCPCS code G0424 effective 12/31/2021. The following CPTcodes replaced G0424 for the Pulmonary Rehabilitation Program effective January 1, 2022, and may only be billed when all the above program requirements are met.94625 - Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; without continuous oximetry monitoring (per session), or94626 - Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; with continuous oximetry monitoring (per session.Public Health Emergency Telehealth ServicesOn March 6, 2020, the Centers for Medicare & Medicaid Services (CMS) broadened access to Medicare telehealth services during the COVID-19 public health emergency (PHE) so beneficiaries can get a wider range of services from their doctors and other clinicians without traveling to a health care facility. These guidelines are effective for dates of service (DOS) on and after March 1, 2020, until the end of the designated PHE.Telehealth services- Visits conducted between a provider and a patient using two-way telecommunication systems with audio and video capabilities.
Article - Billing and Coding: Pulmonary Rehabilitation Services (A52770)
Use of two-way, real-time interactive audio/video telecommunication capability is needed.Bill professional claims for all telehealth services with DOS on and after March 1, 2020, and for the duration of the PHE to Medicare with place of service (POS) equal to what it would have been had the service been furnished in-person (example: POS 11 for office or POS 19 for provider-based outpatient hospital).Bill appropriate covered telehealth service code(s).Modifier 95 should be applied to claim lines for services furnished via telehealth.Only 94625 and 94626 have been added to the list of Covered Telehealth Services foundhere.Due to the Public Health Emergency (PHE) ending on May 11, 2023, this exception is no longer in effect as of May 11, 2023.Sources:Social Security Act (SSA) 1862(a)(1)(A);42 Code of Federal Regulations (CFR), Part 410, Subpart B, Sections 410.17, 410.26, 410.27, 410.47;National Coverage Determination 240.8;IOMMedicare Benefit Policy Manual,Publication 100-02, Chapter 12, Section 40.5 and Chapter 15, Sections 220-230, 230.5, 231;IOMMedicare Claims Processing Manual,Chapter 5, Section 20(C) and Chapter 32, Section 140.4;CMS MLN Matters MM6823-RevisedTransmittal 11426CP, CR 12613 dated May 20, 2022
Article - Billing and Coding: Therapy Driving Evaluations (A52772)
CMS National Coverage PolicyN/AArticle TextMedicare does not reimburse evaluations performed solely to assess a beneficiary's ability to drive a vehicle. In order for a service to be covered, the service must have a benefit category in the statute Title 18 of the Social Security Act (SSA), it must not be excluded, and it must be reasonable and necessary. There is no benefit category for driving evaluations.In addition, both screening (except as specifically exempted by statute) and routine physical examinations are excluded from coverage. 42 United States Code (USC) 1395y (a) describes routine physical checkups as:1. Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptom, complaint, or injury.2. Examinations required by insurance companies, business establishments, government agencies or other third parties.For Medicare purposes, when services provided are related solely to driving, they are not reasonable or necessary for the diagnosis or treatment of an illness or injury and are excluded from coverage under the program by SSA 1862(a)(1).This is a statutory exclusion. The beneficiary is liable for the charges and no Advance Beneficiary Notice of Noncoverage (ABN) is required. However, providers are encouraged to provide a voluntary ABN. Append modifier GX (Notice of Liability Issue, Voluntary under Payer Policy) to any billed line item.Sources: CMS Internet Only Manual (IOM), Medicare Claims Processing Manual, Publication 100-04, Chapter 1 Section 60 Social Security Act (SSA) Sections 1861 and 1862(a)(1) 42CFR 411.15(a)
Article - Billing and Coding: Therapy Evaluation, Re-Evaluation and Formal Testing (A52773)
CMS National Coverage PolicyN/AArticle TextTherapy evaluation and formal testing services involve clinical judgment and decision-making which is not within the scope of practice for therapy assistants. These services can only be provided by qualified clinicians i.e., a physician, non-physician practitioner (NPP), therapist or speech-language pathologist (SLP).Therapy evaluation, re-evaluation, and formal testing codes can only be billed when the medical record supports the completion of a medically necessary comprehensive evaluation or formal test. Documentation must support that the service was based on the patients current clinical status or condition. Medicare does not reimburse for services related solely to workplace skills and activities. Additional evaluative services may be necessary when an episode of care is interrupted by a short-stay inpatient hospitalization or outpatient surgery that could reasonably impact the patients therapy progression. Note that routine continuous assessment of the patient's expected progress in accordance with the plan of care is not separately reimbursable as a re-evaluation or formal testing service.Initial Evaluations- (i.e., CPT  97161-97163, 97165-97167)Providers may simultaneously receive multiple physician referrals for multiple medical conditions for one patient. When this occurs, it is expected that one qualified clinician from each appropriate discipline i.e., physical therapist (PT), and/or occupational therapist (OT), and/or SLP, will complete a thorough initial evaluation that encompasses each of the identified medical conditions. Following completion of the initial evaluation, other staff therapists specializing in specific medical conditions may treat the patient as needed. When medical necessity is supported, an initial evaluation is appropriate for: A new patient who has not received prior therapy services. A patient who has returned for additional therapy after having been discharged from prior therapy services for the same or for a different condition. Time spent evaluating this returning patient should not be coded as a re-evaluation. Prior discharge may have been due to one of the following:Patient no longer significantly benefited from ongoing therapy services or;Patient no longer required therapy services for an extended period of time or;Patient experienced a significant change in medical status that necessitated discharge.
Article - Billing and Coding: Therapy Evaluation, Re-Evaluation and Formal Testing (A52773)
Patient no longer significantly benefited from ongoing therapy services or;Patient no longer required therapy services for an extended period of time or;Patient experienced a significant change in medical status that necessitated discharge. A patient who is currently receiving therapy services and develops a newly diagnosed unrelated condition. Example: A patient is currently receiving treatment following a total knee arthroplasty (TKA). During the therapy episode of care for the TKA, the patient develops an acute rotator cuff injury from an accident at home. The clinician determines that the rotator cuff injury is not related to the TKA. Therefore, it is reasonable for the clinician to provide and code for a new evaluation of the rotator cuff injury since it is a newly identified diagnosis for an unrelated condition.For additional information, see the attachedMedical Necessity of Therapy Servicesarticle in the Related Coverage Documents link below.Re-Evaluations- (i.e., CPT  97164, 97168)Re-evaluations are separately reimbursable when the medical record supports that the patient's clinical status or condition required the additional evaluative service. When medical necessity is supported, a re-evaluation is appropriate and is separately billable for: A patient who is currently receiving therapy services and develops a newly diagnosed related condition e.g., a patient that is currently receiving therapy treatment for TKA. During the episode of care, the patient develops wrist pain. The clinician determines that the wrist pain is due to use of a walker which the patient is using as a result of the TKA. In this scenario, the wrist pain is a condition that is related to the TKA. Therefore, it is reasonable for the clinician to provide a re-evaluation of the patient due to this related condition. A patient who is currently receiving therapy services and demonstrates a significant improvement, decline, or change in condition or functional status which was not anticipated in the plan of care and necessitates additional evaluative services to maximize the patients rehabilitation potential.Note that routine continuous assessment of the patient's expected progress in accordance with the plan of care is not considered to be a medically necessary service and is not separately reimbursable as a re-evaluation. Limited routine assessment (e.g., for progress reporting) is a component of ongoing therapy services and is included in services and procedures.
Article - Billing and Coding: Therapy Evaluation, Re-Evaluation and Formal Testing (A52773)
Formal Testing(i.e., CPT  97750, 95851-95852)Formal testing services are considered inclusive (not separately reimbursable) when they are provided on the same day as an initial evaluation or re-evaluation service. Formal testing services are separately reimbursable when the medical record supports that the patient's clinical status or condition required the additional testing service. Formal testing services should not be billed using therapy service or procedure codes. When medical necessity is supported, a formal test is appropriate and is separately reimbursable when documentation supports the completion of a formal, date signed, distinctly identifiable findings report which includes: Testing and/or measurement results with comparative values for specific standardized grading scales. Providers interpretation of results. Support of how the findings were incorporated into the therapy plan of care, when applicable.Note that routine continuous assessment of the patient's expected progress in accordance with the plan of care is not considered to be a medically necessary service and is not separately reimbursable as a formal test. Limited routine assessment (e.g., for progress reporting) is a component of ongoing therapy services and is included in services and procedures.Sources:Current Procedural Terminology (CPT) Manual CMS Internet Only Manual (IOM),Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Sections 220(A), 220.3.5(A), 230.1 IOM,Medicare Benefit Policy Manual,, Publication 100-02, Chapter 16, Section 150
Article - Billing and Coding: Medical Necessity of Therapy Services (A52775)
CMS National Coverage PolicyN/AArticle TextMedical records must support medical necessity of therapy services provided e.g., Are the services appropriate for the patients condition and do the services require the skills and knowledge of a qualified clinician? For detailed guidance, view the CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 220-230. The requirements in these sections describe a standard of care that is anticipated throughout the therapy plan of care for each discipline. To meet Medicares standard of coverage all of the following requirements must be met.Qualified ClinicianTherapy services must be provided by a qualified clinician i.e., physician, non-physician practitioner (NPP), therapist, or speech-language pathologist (SLP). Treatment services may also be provided by an appropriately supervised physical therapy (PT) or occupational therapy (OT) assistant. Services provided by a therapy aide with or without qualified clinician supervision are not reimbursable in any therapy setting. For additional information, see the attachedBilling and Coding:Therapy Students and Aidesarticle in the Related Local Coverage Documents link below.Skilled Level of CareSkill is a level of expertise acquired through specialized training not attained by the general population. While a patient's medical condition is a valid factor in deciding if skilled therapy services are needed, a patient's diagnosis or prognosis is never the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by non-skilled personnel after sufficient training.To demonstrate that services are at a skilled level of care, the medical record must support that the expertise and knowledge of a qualified clinician was necessary and was provided. Documentation needs to clearly indicate the clinicians unique professional contribution to the therapy services e.g., Why did the patient require professional treatment, education or training? What specialized treatment, education or training did the clinician actually provide? How did the patient benefit from the specialized knowledge applied by the clinician?
Article - Billing and Coding: Medical Necessity of Therapy Services (A52775)
Skilled land and water-based therapy programs require that the patient have direct one-on-one contact with the qualified clinician throughout the procedure. The services of a qualified clinician cannot be billed for supervising a patient that is independently completing an exercise program. Additionally, ongoing repetitive exercises that do not demonstrate the need for continued hands-on involvement and/or teaching by the qualified clinician would not be considered to be at a skilled level of care. Documentation must support that the therapy sessions are at a level of complexity that requires ongoing qualified clinician input.Medical Necessity - RehabilitationServices must be under accepted standards of medical practice and considered to be specific and effective treatment for the patients condition. The amount, frequency, and duration of the services planned and provided must be reasonable. Services must be necessary for treatment of the patients condition: The medical record must clearly describe the patients condition before, during, and after the therapy episode to support that the patient significantly benefited from ongoing therapy services and that the progress was sustainable and of practical value when measured against the patients condition at the start of treatment. Documentation of comparable objective/functional measures plays a key role in demonstrating medical necessity.Example of acceptable and unacceptable comparative measures:Acceptablecomparative measure: At the time of the initial evaluation it was documented that the patient had an objective manual muscle test (MMT) of 3/5 for right knee extension. Documentation in the 10 day progress report supported that the patient had achieved 4/5 for right knee extension which demonstrated significant benefit for the patient.Unacceptablecomparative measure: At the time of the 10 day progress report the documentation supported that the patient had an objective MMT of 4/5 for right biceps flexion. At the time of the 20 day progress report documentation supported that the patient was able to complete 3 sets of 10 repetitions for right biceps flexion during each therapy visit. Since the MMT information is not directly comparable to the therapeutic exercise sets and repetitions this comparison does not clearly demonstrate ongoing significant benefit for the patient and may result in denial.These objective/functional measures must minimally be established for the patients prior level of function (PLOF), status at the initial evaluation, and status at each progress reporting interval. Qualified clinicians must complete the progress reports a minimum of every ten treatment days throughout the episode of care. The progress reporting interval does not match the interval for physician certification of therapy services which may extend up to 90 calendar days.