evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
2. Exception to rural HPSA and non MSA geographic requirements   Entities participating in a Federal telemedicine demonstration project that were approved by or were receiving funding from the Secretary of Health and Human Services as of December 31, 2000, qualify as originating sites regardless of geographic location.  Such entities are not required to be in a rural HPSA or non-MSA.   3. Originating site defined   The term originating site means the location of an eligible Medicare beneficiary at the time the service being furnished via a telecommunications system occurs.  Originating sites authorized by law are listed below:  The office of a physician or practitioner;  A hospital (inpatient or outpatient);  A critical access hospital (CAH);  A rural health clinic (RHC);  A federally qualified health center (FQHC);  A hospital -based or critical access hospital -based renal dialysis center (including satellites) (effective January 1, 2009);  A skilled nursing facility (SNF) (effective January 1, 2009); and  A community mental health center (CMHC) (effective January 1, 2009).   NOTE:   Independent renal dialysis facilities are not eligible originating sites.   For asynchronous, store and forward telecommunications technologies, an originating site is only a Federal telemedicine demonstration program conducted in Alaska or Hawaii.   190.3 - List of Medicare Telehealth Services  (Rev. 3476, Issued: 03 -11-16, Effective: 01 -01-15, Effective: 04 -11-16)  The use of a telecommunications system may substitute for an in- person encounter for professional consultations, office visits, office psychiatry services, and a limited number of other physician fee schedule (PFS) services.  The various services and corre sponding current procedure terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes are listed on the CMS website at www.cms.gov/Medicare/Medicare-General -Information/Telehealth/
(Medicare Claims Processing Manual)
NOTE:  Beginning January 1, 2010, CMS eliminated the use of all consultation codes, except for inpatient telehealth consultation G -codes.  CMS no longer recognizes office/outpatient or inpatient consultation CPT codes for payment of office/outpatient or inpatient visits.  Instead, physicians and practitioners are instructed to bill a new or established patient office/outpatient visit CPT code or appropriate hospital or nursing facility care code, as appropriate to the particular patient, for all office/outpatient or inpatient visits.   190.3.1 - Telehealth Consultation Services, Emergency Department  or Initial Inpatient versus Inpatient Evaluation and Management (E/M) Visits (Rev. 2354, Issued:  11-18-11 Effective: 01 -01-12, Implementation: 01- 03-12)  A consultation service is an evaluation and management (E/M) service furnished to evaluate and possibly treat a patients problem(s).  It can involve an opinion, advice, recommendation, suggestion, direction, or counsel from a physician or qualified nonphysician practitioner (NPP) at the request of another physician or appropriate source.   Section 1834(m) of the Social Security Act includes professional consultations in the definition of telehealth services. Inpatient or emergency department consultations furnished via telehealth can facilitate the provision of certain services and/or medi cal expertise that might not otherwise be available to a patient located at an originating site.   The use of a telecommunications system may substitute for an in- person encounter for emergency department or initial and follow -up inpatient consultations.  Medicare A/B MACs (B) pay for reasonable and medically necessary inpatient or emergency department telehealth consultation services furnished to beneficiaries in hospitals or SNFs when all of the following criteria for the use of a consultation code are met:   An inpatient or emergency department consultation service is distinguished from other inpatient or emergency department evaluation and management (E/M) visits because it is provided by a physician or qualified nonphysician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specifi c problem is requested by another physician or other appropriate source.  The qualified NPP may perform consultation services within the scope of practice and licensure requirements for NPPs in the State in which he/she practices;
(Medicare Claims Processing Manual)
 A request for an inpatient or emergency department telehealth consultation from an appropriate source and the need for an inpatient or emergency department telehealth consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patients medical record and included in the requesting physician or qualified NPPs plan of care in the patients medical record; and    After the inpatient or emergency department telehealth consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician.   The intent of an inpatient or emergency department telehealth consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professionals knowledge.   Unlike inpatient or emergency department telehealth consultations, the majority of subsequent inpatient hospital, emergency department and nursing facility care services require in -person visits to facilitate the comprehensive, coordinated, and personal care that medically volatile, acutely ill p atients require on an ongoing basis.  Subsequent hospital care services are limited to one telehealth visit every 3 days. Subsequent nursing facility care services are limited to one telehealth visit every 30 days.   190.3.2 - Telehealth Consultation Services, Emergency Department  or Initial Inpatient Defined  (Rev. 3817; Issued; 07- 28-17 Effective; 01 -01-18 Implementation: 01- 02-18)
(Medicare Claims Processing Manual)
190.3.2 - Telehealth Consultation Services, Emergency Department  or Initial Inpatient Defined  (Rev. 3817; Issued; 07- 28-17 Effective; 01 -01-18 Implementation: 01- 02-18)  Emergency department or initial inpatient telehealth consultations are furnished to beneficiaries in hospitals or SNFs via telehealth at the request of the physician of record, the attending physician, or another appropriate source. The physician or practi tioner who furnishes the emergency department or initial inpatient consultation via telehealth cannot be the physician of record or the attending physician, and the emergency department or initial inpatient telehealth consultation would be distinct from the care provided by the physician of record or the attending physician. Counseling and coordination of care with other providers or agencies is included as well, consistent with the nature of the problem(s) and the patients needs. Emergency department or i nitial inpatient telehealth consultations are subject to the criteria for emergency department or initial inpatient telehealth consultation services, as described in section 190.3.1 of this chapter.  Payment for emergency department or initial inpatient telehealth consultations includes all consultation related services furnished before, during, and after communicating with the patient via telehealth. Pre -service activities would include, but would not  be limited to, reviewing patient data (for example, diagnostic and imaging studies, interim labwork) and communicating with other professionals or family members. Intra -service activities must include the three key elements described below for each proced ure code. Post -service activities would include, but would not be limited to, completing medical records or other documentation and communicating results of the consultation and further care plans to other health care professionals. No additional E/M servi ce could be billed for work related to an emergency department or initial inpatient telehealth consultation.  Emergency department or initial inpatient telehealth consultations could be provided at various levels of complexity:   Practitioners taking a problem focused history, conducting a problem focused examination, and engaging in medical decision making that is straightforward, would bill HCPCS code G0425 (Telehealth consultation, emergency department or initial inpatient, ty pically 30 minutes communicating with the patient via telehealth).
(Medicare Claims Processing Manual)
 Practitioners taking a detailed history, conducting a detailed examination, and engaging in medical decision making that is of moderate complexity, would bill HCPCS code G0426 (Telehealth consultation, emergency department or initial inpatient, typically  50 minutes communicating with the patient via telehealth).    Practitioners taking a comprehensive history, conducting a comprehensive examination, and engaging in medical decision making that is of high complexity, would bill HCPCS code G0427 (Telehealth consultation, emergency department or initial inpatient, typ ically 70 minutes or more communicating with the patient via telehealth).   Although emergency department or initial inpatient telehealth consultations are specific to telehealth, these services must be billed with POS 02 to identify the telehealth technology used to provide the service.   190.3.3 - Follow- Up Inpatient Telehealth Consultations Defined  (Rev. 3817; Issued; 07- 28-17 Effective; 01 -01-18 Implementation: 01- 02-18)  Follow -up inpatient telehealth consultations are furnished to beneficiaries in hospitals or SNFs via telehealth to follow up on an initial consultation, or subsequent consultative visits requested by the attending physician. The initial inpatient consultat ion may have been provided in-person or via telehealth.
(Medicare Claims Processing Manual)
Follow -up inpatient telehealth consultations include monitoring progress, recommending management modifications, or advising on a new plan of care in response to changes in the patients status or no changes on the consulted health issue. Counseling and coordination of care with other providers or agencies is included as well, consistent with the nature of the problem(s) and the patients needs.   The physician or practitioner who furnishes the inpatient follow -up consultation via telehealth cannot be the physician of record or the attending physician, and the follow -up inpatient consultation would be distinct from the follow -up care provided by the  physician of record or the attending physician. If a physician consultant has initiated treatment at an initial consultation and participates thereafter in the patients ongoing care management, such care would not be included in the definition of a follow -up inpatient consultation. Follow -up inpatient telehealth consultations are subject to the criteria for inpatient telehealth consultation services, as described in section 190.3.1 of this chapter.  Payment for follow -up inpatient telehealth consultations includes all consultation related services furnished before, during, and after communicating with the patient via telehealth. Pre-service activities would include, but would not be limited to, review ing patient data (for example, diagnostic and imaging studies, interim labwork) and communicating with other professionals or family members. Intra -service activities must include at least two of the three key elements described below for each procedure co de. Post -service activities would include, but would not be limited to, completing medical records or other documentation and communicating results of the consultation and further care plans to other health care professionals. No additional evaluation and management service could be billed for work related to a follow -up inpatient telehealth consultation.  Follow -up inpatient telehealth consultations could be provided at various levels of complexity:   Practitioners taking a problem focused interval history, conducting a problem focused examination, and engaging in medical decision making that is straightforward or of low complexity, would bill a limited service, using HCPCS code G0406 (Follow -up inpat ient telehealth consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth).
(Medicare Claims Processing Manual)
 Practitioners taking an expanded focused interval history, conducting an expanded problem focused examination, and engaging in medical decision making that is of moderate complexity, would bill an intermediate service using HCPCS code G0407(Follow -up inp atient telehealth consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth).    Practitioners taking a detailed interval history, conducting a detailed examination, and engaging in medical decision making that is of high complexity, would bill a complex service, using HCPCS code G0408 (Follow -up inpatient telehealth consultation, co mplex, physicians typically spend 35 minutes or more communicating with the patient via telehealth).   Although follow -up inpatient telehealth consultations are specific to telehealth, these services must be billed with POS 02 to identify the telehealth technology used to provide the service.   190.3.4  Payment for ESRD-Related Services as a Telehealth Service  (Rev. 3476, Issued: 03- 11-16, Effective: 01 -01-15, Effective: 04 -11-16)  The ESRD -related services included in the monthly capitation payment (MCP) with 2 or 3 visits per month and ESRD -related services with 4 or more visits per month may be paid as Medicare telehealth services.  However, at least 1 visit must be furnished face- to-face hands on to examine the vascular access site by a physician, clinical nurse specialist, nurse practitioner, or physician assistant.  An interactive audio and video telecommunications system may be used for providing additional visits required under the 2 -to-3 visit MCP and the 4- or-more visit MCP.  The medical record must indicate that at least one of the visits was furnished face -to-face hands on by a physician, clinical nurse specialist, nurse practitioner, or physician assistant.
(Medicare Claims Processing Manual)
The MCP physician, for example, the physician or practitioner who is responsible for the complete monthly assessment of the patient and establishes the patients plan of care, may use other physicians and practitioners to furnish ESRD -related visits throug h an interactive audio and video telecommunications system.  The non- MCP physician or practitioner must have a relationship with the billing physician or practitioner such as a partner, employees of the same group practice or an employee of the MCP physici an, for example, the non MCP physician or practitioner is either a W -2 employee or 1099 independent contractor.  However, the physician or practitioner who is responsible for the complete monthly assessment and establishes the ESRD beneficiarys plan of care should bill for the MCP in any given month.  Clinical Criteria   The visit, including a clinical examination of the vascular access site, must be conducted face-to-face hands on by a physician, clinical nurse specialist, nurse practitioner or physicians assistant.  For additional visits, the physician or practitioner at the distant site is required, at a minimum, to use an interactive audio and video telecommunications system that allows the physician or practitioner to provide medical management services for a maintenance dialysis beneficiary.  For example, an ESRD -related visit conducted via telecommunications system must permit the physician or practitioner at the distant site to pe rform an assessment of whether the dialysis is working effectively and whether the patient is tolerating the procedure well (physiologically and psychologically).  During this assessment, the physician or practitioner at the distant site must be able to de termine whether alteration in any aspect of the beneficiarys prescription is indicated, due to such changes as the estimate of the patients dry weight.   190.3.5  Payment for Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services  (Rev. 3476, Issued: 03- 11-16, Effective: 01 -01-15, Effective: 04 -11-16)  Subsequent hospital care services are limited to one telehealth visit every 3 days.  The frequency limit of the benefit is not intended to apply to consulting physicians or practitioners, who should continue to report initial or follow -up inpatient telehea lth consultations using the applicable HCPCS G -codes.
(Medicare Claims Processing Manual)
Similarly, subsequent nursing facility care services are limited to one telehealth visit every 30 days.  Furthermore, subsequent nursing facility care services reported for a Federally -mandated periodic visit under 42 CFR 483.40(c) may not be furnished thr ough telehealth.  The frequency limit of the benefit is not intended to apply to consulting physicians or practitioners, who should continue to report initial or follow -up inpatient telehealth consultations using the applicable HCPCS G -codes.   Inpatient telehealth consultations are furnished to beneficiaries in hospitals or skilled nursing facilities via telehealth at the request of the physician of record, the attending physician, or another appropriate source.  The physician or practitioner wh o furnishes the initial inpatient consultation via telehealth cannot be the physician or practitioner of record or the attending physician or practitioner, and the initial inpatient telehealth consultation would be distinct from the care provided by the physician or practitioner of record or the attending physician or practitioner.  Counseling and coordination of care with other providers or agencies is included as well, consistent with the nature of the problem(s) and the patients needs.  Initial and foll ow-up inpatient telehealth consultations are subject to the criteria for inpatient telehealth consultation services, as described in section 190.3 of this chapter.   190.3.6  Payment for Diabetes Self -Management Training (DSMT) as a Telehealth Service  (Rev. 4173, Issued: 11- 30-18, Effective: 01 -01- 19, Implementation: 01- 02-19)  Individual and group DSMT services may be paid as a Medicare telehealth service. Before 03-11-2016, this manual provision required that 1 hour of the 10 hour DSMT benefits initial training must be furnished in -person to allow for effective injection training.  Because injection training is not always clinically indicated, we are revis ing this provision to permit all 10 hours of the initial training and the two (2) hours of annual follow -up training to be furnished via telehealth in those cases when injecti on training is not applicable.
(Medicare Claims Processing Manual)
The in-person injection training , when provided,  may be furnished through either individual or group DSMT services. By reporting place of service (POS) 02 or the GT or GQ modifier with HCPCS code G0108 (Diabetes outpatient self- management training services, individual, per 30 minutes) or G0109 (Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes), the distant site practitioner attests  that the beneficiary has received or will receive 1 hour of in-person DSMT services for purposes of injection training when it is indicated during the year following the initial DSMT service or any calendar years 2 hours of follow -up training .   As specified in 42 CFR 410.141(e) and stated in Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, section 300.2, individual and group  DSMT services may be furnished by a physician, other individual, or entity that furnishes other items or services for which direct Medicare payment may be made and that submits necessary documentation to, and is accredited by a national accreditation organization approved by CMS. However, consistent with the statutory requirements of section 1834(m)(1) of the Act, as provided in 42 CFR 410.78(b)(1) and (b)(2) and stated in section 190.6 of this chapter, Medicare telehealth services, including individual and group DSMT services furnished as a telehealth service, could only be furnished by a physician, PA, NP, CNS, CNM , clinical psychologist, clinical social worker, or registered dietitian or nutrition professional, as applicable.  190.3.7  Payment for Telehealth for Individuals with Acute Stroke  (Rev. 4173, Issued: 11- 30-18, Effective: 01 -01- 19, Implementation: 01- 02-19)
(Medicare Claims Processing Manual)
190.3.7  Payment for Telehealth for Individuals with Acute Stroke  (Rev. 4173, Issued: 11- 30-18, Effective: 01 -01- 19, Implementation: 01- 02-19)  Section 50325 of the Bipartisan Budget Act of 2018 amended section 1834(m) of the Act by adding a new paragraph (6) that provides special rules for telehealth services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatme nt of symptoms of an acute stroke (acute stroke telehealth services), as determined by the Secretary.  Specifically, section 1834(m)(6)(A) of the Act removes the restrictions on the geographic locations and the types of originating sites where acute stroke  telehealth services can be furnished.  Section 1834(m)(6)(B) of the Act specifies that acute stroke telehealth services can be furnished in any hospital, critical access hospital, mobile stroke units (as defined by the Secretary), or any other site determ ined appropriate by the Secretary, in addition to the current eligible telehealth originating sites.  Section 1834(m)(6)(C) of the Act limits payment of an originating site facility fee to acute stroke telehealth services furnished in sites that meet the u sual telehealth restrictions under section 1834(m)(4)(C) of the Act.  These are identified in Section 190.1 of this chapter.   Effective for claims with dates of service on and after January 1, 2019, contractors shall accept new informat  HCPCS modifier G0 (G zero), to be used to identify Telehealth services furnished for  purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke. Modifier G0 is valid for all:    Telehealth distant site codes billed with Place of Service (POS) code 02 or Critical Access Hospitals,   CAH method II (revenue codes 096X, 097X, or 098X); or    Telehealth originating site facility fee, billed with HCPCS code Q3014.    190.4 - Conditions of Payment  (Rev. 1, 10- 01-03)