evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
40.9 - Procedures Billed With  Two or More Surgical Modifiers (Rev. 1, 10- 01-03) B3-4829 A/B MACs (B) may receive claims for surgical procedures with more than one surgical modifier.  For example, since the global fee concept applies to all major surgeries, A/B MACs (B) may receive a claim for surgical care only (modifier - 54) for a bilateral surgery (modifier -50).  They may also receive a claim for multiple surgeries requiring the use of an assistant surgeon.  Following is a list of possible combinations of surgical modifiers.  (NOTE:  A/B MACs (B) must price all claims for surgical teams by report.)   Bilateral surgery (-50) and multiple surgery (- 51).   Bilateral surgery (-50) and surgical care only (-54).  Bilateral surgery (-50) and postoperative care only ("55).  Bilateral surgery (-50) and two surgeons (-62).  Bilateral surgery (- 50) and surgical team (- 66).   Bilateral surgery (-50) and assistant surgeon (-80).  Bilateral surgery (-50), two surgeons (-62), and surgical care only (- 54).   Bilateral surgery (- 50), team surgery (-66), and surgical care only (- 54).   Multiple surgery (-51) and surgical care only (-54).  Multiple surgery (-51) and postoperative care only ("55).  Multiple surgery (-51) and two surgeons (-62).  Multiple surgery (- 51) and surgical team (- 66).   Multiple surgery (-51) and assistant surgeon (-80).  Multiple surgery (-51), two surgeons (-62), and surgical care only (- 54).   Multiple surgery (- 51), team surgery (-66), and surgical care only (- 54).   Two surgeons
(Medicare Claims Processing Manual)
and surgical care only (- 54).   Multiple surgery (- 51), team surgery (-66), and surgical care only (- 54).   Two surgeons (-62) and surgical care only (- 54).   Two surgeons (-62) and postoperative care only (55).  Surgical team ( -66) and surgical care only (- 54).   Surgical team ( -66) and postoperative care only (55). Payment is not generally allowed for an assistant surgeon when payment for either two surgeons (modifier -62) or team surgeons (modifier - 66) is appropriate.  If A/B MACs (B) receive a bill for an assistant surgeon following payment for co-surgeons or team surgeons, they pay for the assistant only if a review of the claim verifies medical necessity.  50 - Payment for Anesthesiology  Services  (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17)
(Medicare Claims Processing Manual)
A. General Payment  Rule   The fee schedule amount for physician anesthesia services furnished is, with the exceptions noted, based on allowable base and time units multiplied by an anesthesia conversion factor specific to that locality. The base unit for each anesthesia procedure i s communicated to the A/B MACs by means of the HCPCS file released annually.  CMS releases the conversion factor annually.  The base units and conversion factor are available on the CMS website at: https://www.cms.gov/Center/Provider-Type/Anesthesiologists-Center.html.     B. Payment at Personally Performed  Rate   The A/B MAC must determine the fee schedule payment, recognizing the base unit for the anesthesia code and one time unit per 15 minutes of anesthesia time if:   The physician personally performed the entire anesthesia service alone;    The physician is involved with one anesthesia case with a resident, the physician is a teaching physician as defined in 100;   The physician is involved in the training of physician residents in a single anesthesia case, two concurrent anesthesia cases involving residents or a single anesthesia case involving a resident that is concurrent to another case that meets the requirement s for payment at the medically directed rate. The physician meets the teaching physician criteria in 100.1.4;    The physician is continuously involved in a single case involving a student nurse  anesthetist;   If the physician is  involved with  a single  case with a qualified nonphysician anesthetist (a certified registered nurse anesthetist ( CRNA)  or an anesthesiologists assistant)),  A/B  MACs  may pay the physician service and  the qualified nonphysician anesthetist  service in accordance with the requirements for payment at the medically directed rate;    Or   The physician and the CRNA (or anesthesiologists assistant) are involved in one anesthesia case and the services of each are found to be medically necessary.  Documentation must be submitted by both the CRNA and the physician to support payment of the full fee for each of the two providers. The physician reports the AA  modifier and the CRNA reports the QZ modifier.   C. Payment at the Medically Directed  Rate
(Medicare Claims Processing Manual)
C. Payment at the Medically Directed  Rate   The A/B MAC determines payment at the medically directed rate for the physician on the basis of 50 percent of the allowance for the service performed by the physician alone. Payment will be made at the medically directed rate if the physician medically directs qualified individuals (all of whom could be CRNAs, anesthesiologists assistants, interns, residents, or combinations of these individuals) in two, three, or four concurrent cases and the physician performs the following activities.    Performs a pre -anesthetic examination and  evaluation;    Prescribes the anesthesia plan;    Personally participates in the most demanding procedures in the anesthesia plan, including, if applicable, induction and emergence;    Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified  individual;    Monitors the course of anesthesia administration at frequent  intervals;   Remains physically present and available for immediate diagnosis and treatment of emergencies;  and   Provides indicated post -anesthesia care.   The physician must document in the medical record that he or she performed the pre -anesthetic examination and evaluation.  Physicians must also document that they provided indicated post -anesthesia care, were present during some portion of the anesthesia monitoring, and were present during the most demanding procedu res in the anesthesia plan, including induction and emergence, where  indicated.  NOTE:  C oncurrency refers to to the maximum number of procedures that the physician is medically directing within the context of a single procedure and  whether these other procedures overlap each other. Concurrency is not dependent on each of the cases involving a Medicare patient. For example, if an anesthesiologist medically directs three concurrent procedures, two of which involve non -Medicare patients and the remaining a Medicare patient, this represents three concurrent cases.   The requirements for payment at the medically directed rate also apply to cases involving student nurse anesthetists if the physician medically directs two concurrent cases, with each of the two cases involving a student nurse anesthetist, or the physician directs one case involving a student nurse anesthetist and another involving a qualified individual (for example: CRNA, anesthesiologists assistant, intern or  resident).
(Medicare Claims Processing Manual)
The requirements for payment at the medically directed rate do not apply to a single resident case that is concurrent to another anesthesia case paid at the medically directed rate or to two concurrent anesthesia cases involving residents.   If anesthesiologists are in a group practice, one physician member may provide the pre - anesthesia examination and evaluation while another fulfills the other criteria. Similarly, one physician member of the group may provide post -anesthesia care while ano ther member of the group furnishes the other component parts of the anesthesia  service.  However, the medical record must indicate that the services were furnished by physicians and identify the physicians who furnished them.   A physician who is concurrently furnishing services that meet the requirements for payment at the medically directed rate cannot ordinarily be involved in furnishing additional services to other patients. However, addressing an emergency of short duration in the immediate area, administering an epidural or caudal anesthetic to ease labor pain, periodic (rather than continuous) monitoring of an obstetrical patient, receiving patients entering the operating suite for the next surgery, checking or discharging patients in the recovery room, or handling scheduling matters, do not substantially diminish the scope of control exercised by the physician and do not constitute a separate service for the purpose of determining whether the requirements for payment at the  medically directed rate are met.    However, if the physician leaves the immediate area of the operating suite for other than short durations or devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the surgical patients, the physicians services to the surgical patients would not meet the requirements for payment at the medically directed rate. A/B MACs may not make payment under the fee  schedule.    D. Payment at Medically Supervised  Rate   The A/B MAC may allow only three base units per procedure when the anesthesiologist is involved in furnishing more than four procedures concurrently or is performing other services while directing the concurrent procedures. An additional time unit may be recognized if the physician can document he or she was present at  induction.  E. Billing and Payment for Multiple Anesthesia  Procedures
(Medicare Claims Processing Manual)
E. Billing and Payment for Multiple Anesthesia  Procedures   Physicians bill for the anesthesia services associated with multiple bilateral surgeries by reporting the anesthesia procedure with the highest base unit value with the multiple procedure modifier - 51. They report the total time for all procedures in the l ine item with the highest base unit value.   If the same anesthesia CPT code applies to two or more of the surgical procedures, billers enter the anesthesia code with the - 51 modifier and the number of surgeries to which the modified CPT code  applies.   Payment can be made under the fee schedule for anesthesia services associated with multiple surgical procedures or multiple bilateral procedures. Payment is determined based on the base unit of the anesthesia procedure with the highest base unit value and time units based on the actual anesthesia time of the multiple procedures.  See 40.6-40.7 for billing and claims processing instructions for multiple and bilateral surgeries.   F. Payment for Medical and Surgical Services Furnished in Addition to Anesthesia  Procedure   Payment may be made under the fee schedule for specific medical and surgical services furnished by the anesthesiologist as long as these services are reasonable and medically necessary or provided that other rebundling provisions (see 30 and Chapter 23) do not preclude separate payment. These services may be furnished in conjunction with the anesthesia procedure to the patient or may be furnished as single services, e.g., during the day of or the day before the anesthesia service. These services include the insertion of a Swan Ganz catheter, the insertion of central venous pressure lines, emergency intubation, and critical care visits.   G. Anesthesia Time and Calculation of Anesthesia Time  Units
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G. Anesthesia Time and Calculation of Anesthesia Time  Units   Anesthesia time is defined as the period during which an anesthesia practitioner is present with the patient. It starts when the anesthesia practitioner begins to prepare the patient for anesthesia services in the operating room or an equivalent area and ends when the anesthesia practitioner is no longer furnishing anesthesia services to the patient, that is, when the patient may be placed safely under postoperative care. Anesthesia time is a continuous time period from the start of anesthesia to the end of an anesthesia service. In counting anesthesia time for services furnished, the anesthesia practitioner can add blocks of time around an interruption in anesthesia time as long as the anesthesia practitioner is furnishing continuous anesthesia care within the time periods around the interruption.  Actual anesthesia time in minutes is reported on the claim. For anesthesia services furnished, the A/B MAC computes time units by dividing reported anesthesia time by 15 minutes. Round the time unit to one decimal place. The A/B MAC does not recognize time units for CPT code 01996 (daily hospital management of epidural or subarachnoid continuous drug administration).  For purposes of this section, anesthesia practitioner means:   a physician who performs the anesthesia service alone,   a CRNA who is furnishing services that do not meet the requirements for payment at the medically directed rate,   a qualified nonphysician anesthetist who is furnishing services that meet the requirements for payment at the medically directed rate.   The physician who medically directs the qualified nonphysician anesthetist would ordinarily report the same time as the qualified nonphysician anesthetist reports for the service.  H. Monitored Anesthesia  Care   Monitored anesthesia care involves the intra-operative monitoring by a physician or qualified individual under the medical direction of a physician or of the patients vital physiological signs in anticipation of the need for administration of general anesthesia or of the development of adverse physiological patient reaction to the surgical procedure. It also includes the performance of a pre-anesthetic examination and evaluation, prescription of the anesthesia care required, administration of any necessary oral or parenteral medications (e.g., atropine, demerol, valium) and provision of indicated postoperative anesthesia care.
(Medicare Claims Processing Manual)
The A/B MAC pays for reasonable and medically necessary monitored anesthesia care services on the same basis as other anesthesia services. If the physician personally performs the monitored anesthesia care case, payment is made under the fee schedule using  the payment rules for payment at the personally performed rate.  If the physician medically directs four or fewer concurrent cases and monitored anesthesia care represents one or more of these concurrent  cases, payment is made under the fee schedule using the payment rules for payment at the medically directed rate.  Anesthesiologists use the QS modifier to report monitored anesthesia care cases, in addition to reporting the actual anesthesia time and one of the payment modifiers on the claim.    I. Anesthesia Claims  Modifiers   Physicians report the appropriate modifier to denote whether the service meets the requirements for payment at the personally performed rate, medically directed rate, or medically  supervised rate.  AA -  Anesthesia Services performed personally by the  anesthesiologist   AD -  Medical Supervision by a physician; more than 4 concurrent anesthesia  procedures   G8 - Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical  procedures   G9 - Monitored anesthesia care for patient who has a history of severe cardio-  pulmonary condition  QK -  Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals   QS -  Monitored anesthesia care service   NOTE:  The QS modifier can be used by a physician or a qualified nonphysician anesthetist and is for informational purposes.  Providers must report actual anesthesia time and one of the payment modifiers on the claim.   QY -  Medical direction of one qualified nonphysician anesthetist by an anesthesiologist   GC -  These services have been performed by a resident under the direction of a teaching physician.   NOTE:  The GC modifier is reported by the teaching physician to indicate he/she rendered the service in compliance with the teaching physician requirements in 100 of this chapter.  One of the payment modifiers must be used in conjunction with the GC  modifier.
(Medicare Claims Processing Manual)
The A/B MAC must determine payment for anesthesia in accordance with these instructions. They must be able to determine the uniform base unit that is assigned to the anesthesia code and apply the appropriate reduction where the anesthesia procedure meets t he requirements for payment at the medically directed rate. They must also be able to determine the number of anesthesia time units from actual anesthesia time reported on the claim. The A/B MAC must multiply allowable units by the anesthesia -specific conv ersion factor used to determine fee schedule payment for the payment  area.   J. Moderate Sedation Services Furnished in Conjunction with and in Support of Procedural Services    Anesthesia services range in complexity. The continuum of anesthesia services, from least intense to most intense in complexity is as follows: local or topical anesthesia, moderate (conscious) sedation, regional anesthesia and general anesthesia. Moderate sedation is a drug induced depression of consciousness during which the patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Moderate sedation does not include minimal sedation, deep sedation or monitored anesthesia care.   Practitioners will report the appropriate CPT and/or HCPCS code that describes the moderate sedation services furnished during a patient encounter, which are furnished in conjunction with and in support of a procedural service, consistent with CPT guidance .    Refer to 50 and 140 of this chapter for information regarding reporting of anesthesia services furnished in conjunction with and in support of procedural services.     K.  Anesthesia for Diagnostic or Therapeutic Nerve Blocks and Services Lower in Intensity than Moderate Sedation  If the anesthesiologist or CRNA provides anesthesia for diagnostic or therapeutic nerve blocks or injections and a different provider performs the block or injection, then the anesthesiologist or CRNA may report the anesthesia service using the appropriate  CPT code consistent with CPT guidance.  The service must meet the criteria for monitored anesthesia care as described in this section. If the anesthesiologist or CRNA provides both the anesthesia service and the block or injection, then the anesthesiologi st or CRNA may report the anesthesia service and the injection or block. However, the anesthesia service must meet the requirements for moderate sedation and if a lower level complexity anesthesia service is provided, then the moderate sedation code should not be  reported.
(Medicare Claims Processing Manual)
If the physician performing the medical or surgical procedure also provides a level of anesthesia lower in intensity than moderate sedation, such as a local or topical anesthesia, then the moderate sedation code should not be reported and no separate payme nt should be allowed by the A/B MAC.   60 - Payment for Pathology Services (Rev. 2714, Issued: 05- 24-13, Effective: 07 -01-12 Implementation: 06- 25, 13)   A. Payment for Professional Component (PC) Services   Payment may be made under the physician fee schedule for the professional component of physician laboratory or physician pathology services furnished to hospital inpatients or outpatients by hospital physicians or by independent laboratories, if they quali fy as the re -assignee for the physician service.   B. Payment for Technical Component (TC) Services   1. General Rule  Payment is not made under the physician fee schedule for TC services furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital inpatient and outpatient settings.  Payment is made under the physician fee schedule for TC services furnished in institutional settings where the TC service is not bundled into the facility payment, e.g., an ambulatory surgery center (ASC).  Payment may be made under the physician fee schedule for the TC of physician pathology ser vices furnished by an independent laboratory, or a hospital if it is acting as an independent laboratory, to non- hospital patients.  The physician fee schedule identifies physician laboratory or physician pathology services that have a TC service.   2. TC Services Furnished by Independent Laboratories to Hospital Inpatients and Outpatients    For services furnished on or after July 1, 2012, an independent laboratory may not bill the A/B MAC (B) (and the A/B MAC (B) may not pay) for the TC of a physician pathology service furnished to a hospital inpatient or outpatient.   For services furnished prior to July 1, 2012, payment may be made under the fee schedule, as noted below, for the (TC) of pathology services furnished by an independent laboratory to hospital inpatients or outpatients.
(Medicare Claims Processing Manual)
 For services furnished prior to July 1, 2012, payment may be made under the fee schedule, as noted below, for the (TC) of pathology services furnished by an independent laboratory to hospital inpatients or outpatients.  CMS published a final regulation in 1999 that would no longer allow independent laboratories to bill under the physician fee schedule for the TC of physician pathology services.  The implementation of this regulation was delayed by Section 542 of the Benef its and Improvement and Protection Act of 2000 (BIPA).  Section 542 allows the Medicare A/B MAC (B) to continue to pay for the TC of physician pathology services when an independent laboratory furnishes this service to an inpatient or outpatient of a cover ed hospital.  This provision is applicable to TC services furnished January 1, 2001 through June 30, 2012.  For this provision, a covered hospital is a hospital that had an arrangement with an independent laboratory that was in effect as of July 22, 1999, under which a laboratory furnished the TC of physician pathology services to fee -for-service Medicare benefi ciaries who were hospital inpatients or outpatients, and submitted claims for payment for the TC to a A/B MAC (B).  The TC could have been submitted separately or combined with the professional component and reported as a combined service.   The term, fee- for-service Medicare beneficiary, means an individual who:    Is entitled to benefits under Part A or enrolled under Part B of title XVIII or both; and   Is not enrolled in any of the following:  A Medicare + Choice plan under Part C of such title; a plan offered by an eligible organization under 1876 of the Social Security Act; a program of all -inclusive care for the elderly under 1894; or a social healt h maintenance organization demonstration project established under Section 4108 of the Omnibus Budget Reconciliation Act of 1987.  In implementing Section 542, the A/B MACs (B) should consider as independent laboratories those entities that it has previously recognized as independent laboratories.   An independent laboratory that has acquired another independent laboratory that had an arrangement of July 22, 1999, with a covered hospital, can bill the TC of physician pathology services for that hospitals inpatients and outpatients under the physician fee schedule.