evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
 Medicare Summary Notices, Remittance Advice Remark Codes, and Claim Adjustment Reason  Codes   Effective for claims with dates of service on or after February 26, 2010, contractors shall return as unprocessable NaF -18 PET oncologic claims billed with modifier TC or globally (for A/B MACs (A) modifier TC or globally does not apply ) and HCPCS A9580 to inform the initial treatment strategy or subsequent treatment strategy for bone metastasis that do not include ALL of the following:    PI or PS modifier  AND   PET or PET/CT CPT code (78811, 78812, 78813, 78814, 78815, 78816)  AND   Cancer diagnosis code  AND  Q0 modifier -  Investigational clinical service provided in a clinical research study, are present on the  claim.   NOTE: For institutional claims, continue to include ICD -10 diagnosis code Z00.6 and condition code 30 to denote a clinical study.  The contractor shall use the following remittance advice messages and associated codes when returning claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two Group Code: CO CARC: 4 RARC: MA130 MSN: N/A  Effective for claims with dates of service on or after February 26, 2010, contractors shall accept PET oncologic claims billed with modifier 26 and modifier KX to inform the initial treatment strategy or subsequent treatment strategy for bone metastasis that include  the following:   PI or PS modifier  AND   PET or PET/CT CPT code (78811, 78812, 78813, 78814, 78815, 78816)  AND   Cancer diagnosis code  AND  Q0 modifier -  Investigational clinical service provided in a clinical research study, are present on the  claim.   NOTE: If modifier KX is present on the professional component service, Contractors shall process the service as PET NaF -18 rather than PET with FDG.   Contractors shall also return as unprocessable NaF -18 PET oncologic professional component claims (i.e., claims billed with modifiers 26 and KX) to inform the initial treatment strategy or subsequent treatment strategy for bone metastasis billed with HCPCS A9580.
(Medicare Claims Processing Manual)
The contractor shall use the following remittance advice messages and associated codes when returning claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two. Group Code: CO  CARC: 4  RARC: MA130  MSN: N/A  NOTE: Effective for claims with dates of service on or after 12/15/2017, HCPCS code A9580 (NaF -18) is nationally non- covered.   60.19  Local Coverage Determination for PET Using New, Proprietary Radiopharmaceuticals for their FDA -Approved Labeled Indications for Oncologic Imaging Only  (Rev. 3650, Issued: 11- 10-16, Effective: 02 -10-17, Implementation: 02- 10-17)  Effective for dates of service on or after March 7, 2013, local Medicare Administrative Contractors (MACs) may determine coverage within their respective jurisdictions for positron emission tomography (PET) using radiopharmaceuticals for their Food and Drug Administration (FDA) approved labeled indications for oncologic imaging.  When the local MAC determines that a claim is noncovered, the claim is denied:   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: PR (if claim is received with a GA modifier) otherwise CO  CARC: 167  RARC: N/A  MSN: 15.4  70 - Radiation Oncology (Therapeutic Radiology)  (Rev. 1, 10- 01-03)  70.1 - Weekly Radiation Therapy Management (CPT 77419 - 77430)  (Rev. 1, 10- 01-03)
(Medicare Claims Processing Manual)
70.1 - Weekly Radiation Therapy Management (CPT 77419 - 77430)  (Rev. 1, 10- 01-03)  A/B MACs (B) must pay for a physicians weekly treatment management services under code 77427.  Billing entities must indicate on each claim the number of fractions for which payment is sought.  A weekly unit of treatment management is equal to five fractions or treatment sessions.  A week for the purpose of making payments under these codes is comprised of five fractions regardless of the actual time period in which the services are furnished.  I t is not necessary that the radiation therapist personally examine the patient during each fraction for the weekly treatment management code to be payable.  Multiple fractions representing two or more treatment sessions furnished on the same day may be counted as long as there has been a distinct break in therapy sessions, and the fractions are of the character usually furnished on different days.  If, at the final billing of the treatment course, there are three or four fractions beyond a multiple of five, those three or four fractions are paid for as a week.  If there are one or two fractions beyond a multiple of five, payment for these services is considered as having been made through prior payments.  EXAMPLE:  18  fractions  =   4 weekly services  62  fractions  = 12 weekly services  8  fractions  =   2 weekly services  6  fractions  =   1 weekly service   If billings have occurred which indicate that the treatment course has ended (and, therefore, the number of residual fractions has been determined), but treatments resume, adjust A/B MAC (B) payments for the additional services consistent with the above policy.  EXAMPLE:  8 fractions = payment for 2 weeks  2 additional fractions are furnished by the same physician.  No additional Medicare payment is made for the 2 additional fractions. A.  SNF Treatment Management Delivery Services
(Medicare Claims Processing Manual)
A SNF may not bill weekly treatment management services for its outpatients (codes 77419, 77420, 77425, 77430, and 77431).  Instead, the SNF should bill for radiation treatment delivery (codes 77401 -  77404, 77406 -  77409, 77411 -  77414, and 77416).  Also,  SNFs bill for therapeutic radiology port film (code 77417), which was previously a part of the weekly services.  They enter the number of services in the units field.   70.2 - Services Bundled Into Treatment Management Codes  (Rev. 4267, Issued: 03- 27-19, Effective: 01 -01-19, Implementation: 03- 25-19)
(Medicare Claims Processing Manual)
A/B MACs (B) do not make separate payment for services rendered by the radiation oncologists or in conjunction with radiation therapy.   11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin; 6.0 sq. cm or less  11921 6.11 to 20.0 sq. cm  11922 Each additional 20.0 sq. cm  16000 Initial treatment, first- degree burn, when no more than local treatment is required  16010 Dressings and/or debridement, initial or subsequent; under anesthesia, small 16015 Under anesthesia, medium or large, or with major debridement  16020 Without anesthesia, office  or hospital, small  16025 Without anesthesia, medium (e.g., whole face or whole extremity)  16030 Without anesthesia, large (e.g., more than one extremity)  36425 Venipuncture, cut down age 1 or over  53670 Catheterization, urethra; simple  53675 Complicated (may include difficult removal of balloon catheter)  99211 Office or other outpatient visit, established patient; Level I*  99212 Level II*  99213 Level III*  99214 Level IV  99215 Level V  99238 Hospital discharge day management  99281 Emergency department visit, new or established patient; Level I  99282 Level II  99283 Level III  99284 Level IV  99285 Level V  90780 IV Infusion therapy, administered by physician or under direct supervision of physician; up to one hour  90781 Each additional hour, up to 8 hours  90847 Family medical psychotherapy (conjoint psychotherapy) by a physician, with continuing medical diagnostic evaluation, and drug management when indicated  99050 Services requested after office hours in addition to basic service  99052 Services requested between 10:00 PM and 8:00 AM in addition to basic service  99054 Services requested on Sundays and holidays in addition to basic service   99058 Office services provided on an emergency basis  99071 Educational supplies, such as books, tapes, and pamphlets, provided by the physician for the patients education at cost to physician 99090 Analysis of information data stored in computers (e.g., ECG, blood pressures, hematologic data)  99185 Hypothermia;
(Medicare Claims Processing Manual)
provided by the physician for the patients education at cost to physician 99090 Analysis of information data stored in computers (e.g., ECG, blood pressures, hematologic data)  99185 Hypothermia; regional  99371 Telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals; simple or brief (e.g., to report on tests and/or laboratory results, to clarify or alter previous instructions, to integrate new information fro m other health professionals into the medical treatment plan, or to adjust therapy)  99372 Intermediate (e.g., to provide advice to an established patient on a new problem, to initiate therapy that can be handled by telephone, to discuss test results in detail, to coordinate medical management of a new problem in an established patient, to discuss and evaluate new information and details, or to initiate a new plan of care)  99373 Complex or lengthy (e.g., lengthy counseling session with anxious or distraught patient, detailed or prolonged discussion with family members regarding seriously ill patient, lengthy communication necessary to coordinate complex services or several d ifferent health professionals working on different aspects of the total patient care plan)   Anesthesia (whatever code billed)   Care of Infected Skin (whatever code billed)   Checking of Treatment Charts   Verification of Dosage, As Needed (whatever code billed)   Continued Patient Evaluation, Examination,  Written Progress Notes, As Needed (whatever code billed)   Final Physical  Examination (whatever code billed)   Medical Prescription Writing (whatever code billed   Nutritional Counseling (whatever code billed)   Pain Management (whatever code billed)   Review & Revision of Treatment Plan (whatever code billed)   Routine Medical Management of Unrelated Problem (whatever code billed)   Special Care of Ostomy (whatever code billed)   Written Reports, Progress Note (whatever code billed)   Follow -up Examination and Care for 90 Days After Last Treatment (whatever code billed)
(Medicare Claims Processing Manual)
*NOTE: May be billed with Radiation Treatment Delivery, superficial and/or ortho voltage, for the purpose of reporting physician services consisting of radiation therapy planning (including, but not limited to clinical treatment planning, isodose planning, physics consultation), radiation treatment device construction, and radiation treatment management when performed on the same date of service as treatment delivery. Billing with modifier 25 may be necessary if National Correct Coding Initiative (NCCI) edi ts apply.  70.3 - Radiation Treatment Delivery (CPT 77401 - 77417)  (Rev. 1, 10- 01-03)  A/B MACs (B) pay for these TC services on a daily basis  under CPT codes 77401- 77416 for radiation treatment delivery.  They do not use local codes and RVUs in paying for the TC of radiation oncology services.  Multiple treatment sessions on the same day are payable as long as there has been a distinct break in  therapy services, and the individual sessions are of the character usually furnished on different days.  A/B MACs (B) pay for CPT code 77417 (Therapeutic radiology port film(s)) on a weekly (five fractions) basis.  70.4 - Clinical Brachytherapy (CPT Codes 77750 - 77799)  (Rev. 1, 10- 01-03)  A/B MACs (B) must apply the bundled services policy to procedures in this family of codes other than CPT code 77776.  For procedures furnished in settings in which TC payments are made, A/B MACs (B) must pay separately for the expendable source associated with these procedures under CPT code 79900 except in the case of remote after-loading high intensity brachytherapy procedures (CPT codes 77781- 77784).  In the four codes cited, the expendable source is included in the RVUs for the TC of the procedures.   70.5 - Radiation Physics Services (CPT Codes 77300 - 77399)  (Rev. 1, 10- 01-03)
(Medicare Claims Processing Manual)
70.5 - Radiation Physics Services (CPT Codes 77300 - 77399)  (Rev. 1, 10- 01-03)  A/B MACs (B) pay for the PC and TC of CPT codes 77300- 77334 and 77399 on the same basis as they pay for radiologic services generally.  For professional component billings in all settings, A/B MACs (B) presume that the radiologist participated in the provi sion of the service, e.g., reviewed/validated the physicists calculation.  CPT codes 77336 and 77370 are technical services only codes that are payable by A/B MACs (B) in settings in which only technical component is are payable.   80 - Supervision and Interpretation (S&I) Codes and Interventional Radiology (Rev. 1, 10- 01-03)  80.1 - Physician Presence  (Rev. 1, 10- 01-03)  Radiologic supervision and interpretation (S&I) codes are used to describe the personal supervision of the performance of the radiologic portion of a procedure by one or more physicians and the interpretation of the findings.  In order to bill for the supe rvision aspect of the procedure, the physician must be present during its performance.  This kind of personal supervision of the performance of the procedure is a service to an individual beneficiary and differs from the type of general supervision of the radiologic procedures performed in a hospital for which A/B MACs (A) pay the costs as physician services to the hospital.  The interpretation of the procedure may be performed later by another physician.  In situations in which a cardiologist, for example, bills for the supervision (the S) of the S&I code, and a radiologist bills for the interpretation (the I ) of the code, both physicians should use a  -52 modifier indicating a reduced service, e.g., only one of supervision and/or interpretation.  Payment for the fragmented S&I code is no more than if a single physician furnished both aspects of the procedur e.  80.2 - Multiple Procedure Reduction  (Rev. 1, 10- 01-03)
(Medicare Claims Processing Manual)
80.2 - Multiple Procedure Reduction  (Rev. 1, 10- 01-03)  A/B MACs (B) make no multiple procedure reductions in the S&I or primary non-radiologic codes in these types of procedures, or in any procedure codes for which the descriptor and RVUs reflect a multiple service reduction.  For additional procedure codes that do not reflect such a reduction, A/B MACs (B) apply the multiple proce dure reductions.   90 - Services of Portable X -Ray Suppliers  (Rev. 1, 10- 01-03)  Services furnished by portable x- ray suppliers may have as many as four components. A/B MACs (B) must follow the following rules.   90.1 - Professional Component  (Rev. 1, 10- 01-03)  Pay the PC of radiologic services furnished by portable x- ray suppliers on the same basis as other physician fee schedule services.   90.2 - Technical Component  (Rev. 1, 10- 01-03)  Pay the TC of radiology services furnished by portable x- ray suppliers under the fee schedule on the same basis as TC services generally.   90.3 - Transportation Component (HCPCS Codes R0070 - R0076)  (Rev. 3387, Issued: 10- 30-15, Effective: 01 -01-16, Implementation: 01- 01-16)
(Medicare Claims Processing Manual)
90.3 - Transportation Component (HCPCS Codes R0070 - R0076)  (Rev. 3387, Issued: 10- 30-15, Effective: 01 -01-16, Implementation: 01- 01-16)  This component represents the transportation of the equipment to the patient.  Establish local RVUs for the transportation R codes based on Medicare Administrative Contractor (MAC) knowledge of the nature of the service furnished.  The MACs shall allow onl y a single transportation payment for each trip the portable x- ray supplier makes to a particular location.  When more than one patient is x- rayed at the same location, e.g., a nursing home, prorate the single fee schedule transportation payment among all patients (Medicare Parts A and B, and non- Medicare) receiving the portable x- ray services during that trip, regardless of their insurance status.  For example, for portable x- ray services furnished at a Skilled Nursing Facility (SNF), the transportation fe e should be allocated among all patients receiving portable x- ray services at the same location in a single trip irrespective of whether the patient is in a Part A stay, a Part B patient, or not a Medicare beneficiary at all.  If the patient is in a Part A SNF stay, the transpo rtation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B.  For a privately insured patient, it would be the responsibility of that patients insurer.  For a Medicare Part B patient, payment would be made u nder Part B for the share of the transportation fee attributable to that patient.   R0075 must be billed in conjunction with the radiology codes and only when the x- ray equipment used was actually transported to the location where the x -ray was taken.  R0075 would not apply to the x- ray equipment stored in the location where the x- ray was  done (e.g., a nursing home) for use as needed.   Below are the definitions for each modifier that must be reported with R0075.  Only one of these five modifiers shall be reported with R0075.  NOTE : If only one patient is served, R0070 should be reported with no modifier since the descriptor for this code reflects only one patient seen.
(Medicare Claims Processing Manual)
UN -  Two patients served UP - Three patients served  UQ -  Four patients served  UR -  Five Patients served  US - Six or more patients served   Payment for the above modifiers must be consistent with the definition of the modifiers.  Therefore, for R0075 reported with modifiers, - UN, - UP, - UQ, and UR, the total payment for the service shall be divided by 2, 3, 4, and 5 respectively.  For modifier  US, the total payment for the service shall be divided by 6 regardless of the number of patients served.  For example, if 8 patients were served, R0075 would be reported with modifier US and the total payment for this service would be divided by 6.   The units field for R0075 shall always be reported as 1 except in extremely unusual cases.  The number in the units field should be completed in accordance with the provisions of 100- 04, chapter 23, section 10.2 item 24 G which defines the units field as the number of times the patient has received the itemized service during the dates listed in the from/to field.  The units field must never be used to report the number of patients served during a single trip.  Specifically, the units field must reflect t he number of services that the specific beneficiary received, not the number of services received by other beneficiaries.
(Medicare Claims Processing Manual)
As a contractor priced service, MACs must initially determine a payment rate for portable x-ray transportation services that is associated with the cost of providing the service. In order to determine an appropriate cost, the MAC should, at a minimum, cost  out the vehicle, vehicle modifications, gasoline and the staff time involved in only the transportation for a portable x- ray service. A review of the pricing of this service should be done every five years.   Direct costs related to the vehicle carrying the x -ray machine are fully allocable to determining the payment rate. This includes the cost of the vehicle using a recognized depreciation method, the salary and fringe benefits associated with the staff who drive the vehicle, the communication equipment used between the vehicle and the home office, the salary and fringe benefits of the staff who determine the vehicles route (this could be proportional of office staff), repairs and maintenance of the vehicle(s) , insurance for the vehicle(s), operating expenses for the vehicles and any other reasonable costs associated with this service as determined by the MAC.  The MAC will have discretion for allocating indirect costs (those costs that cannot be directly attributed to portable x- ray transportation) between the transportation service and the technical component of the x-ray tests.   Suppliers may send MACs unsolicited cost information. The MACs may use this cost data as a comparison to its contractor priced determination. The data supplied should reflect a years worth (either calendar or corporate fiscal) of information. Each provide r who submits such data is to be informed that the data is subject to verification and will be used to supplement other information that is used to determine Medicares payment rate.
(Medicare Claims Processing Manual)
The MACs are required to update the rate on an annual basis using independently determined measures of the cost of providing the service. A number of readily available measures (e.g., ambulance inflation factor, the Medicare economic index) that are used by the Medicare program to adjust payment rates for other types of services may be appropriate to use to update the rate for years that the MAC does not recalibrate the payment. Each MAC has the flexibility to identify the index it will use to update the ra te. In addition, the MAC can consider locally identified factors that are measured independently of CMS as an adjunct to the annual adjustment.  NOTE: No transportation charge is payable unless the portable x- ray equipment used was actually transported to the location where the x -ray was taken.  For example, MACs do not allow a transportation charge when the x- ray equipment is stored in a nursing home for use as needed.  However, a set -up payment (see 90.4, below) is payable in such situations.  Further, for services furnished on or after January 1, 1997, MACs may not make separate payment under HCPCS code R0076 for the transportation of EKG equipm ent by portable x- ray suppliers or any other entity.  90.4 - Set-Up Component (HCPCS Code Q0092)  (Rev. 1, 10- 01-03)  A/B MACs (B) must pay a set -up component for each radiologic procedure (other than retakes of the same procedure) during both single patient and multiple patient trips under Level II HCPCS code Q0092.  A/B MACs (B) do not make the set -up payment for EKG services furnished by the portable x- ray supplier.   90.5 - Transportation of Equipment Billed by a SNF to a MAC  (Rev. 3230, Issued: 04- 03-15, Effective: 06 -15-15, Implementation: 06- 15-15)  When a SNF bills for portable x- ray equipment transported to a site by van or other vehicle, the SNF should bill for the transportation costs using one of the following HCPCS codes along with the appropriate revenue code: