evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
30.6.12.8 - Medical Record Documentation  (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  Critical care is a time -based service, and therefore, practitioners must document in the medical record the total time (not necessarily start and stop times) that critical care services are furnished by each reporting practitioner.  Documentation needs to indicate that the services furnished to the patient, including any concurrent care by the practitioners, are medically reasonable and necessary for the diagnosis and/or treatment of illness and/or injury or to improve the functioning of a malformed body me mber.   To support coverage and payment determinations regarding concurrent care, services must be  sufficiently documented to allow a medical reviewer to determine the role each practitioner played in the patients care (that is, the condition or conditions for which the practitioner treated the patient).   When critical care services are reported the same date as another E/M visit, the medical record documentation must support: 1) that the other E/M visit was provided prior to the critical care services at a time when the patient did not require critical care, 2) that the services were medically necessary, and 3) that the services were separate and distinct, with no duplicative elements from the critical care services provided later on that date.   When critical care services are furnished in conjunction with a global procedure, the medical record documentation must support that the critical care was unrelated to the procedure, as discussed above.   To support coverage and payment determinations regarding split (or shared) critical care services, the documentation requirements for all split (or shared) E/M visits apply to critical care visits also (see section 30.6.18).  30.6.13 - Nursing Facility Services  (Rev. 11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)   Definition of Initial and Subsequent Visits
(Medicare Claims Processing Manual)
30.6.13 - Nursing Facility Services  (Rev. 11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)   Definition of Initial and Subsequent Visits   An initial service is one that occurs when the patient has not received any professional services from the physician or other NPP of the same specialty who belongs to the same group practice during the stay. A subsequent service is one that occurs when the patient has received any professional services from the physician or NPP of the same specialty who belongs to the same group practice during the stay.    A. Visits to Perform the Initial Comprehensive Assessment and Annual Assessments  The distinction made between the delegation of physician visits and tasks in a skilled nursing facility (SNF) and in a nursing facility (NF) is based on the Medicare Statute. Section 1819 (b) (6) (A) of the Social Security Act (the Act) governs SNFs while section 1919 (b) (6) (A) of the Act governs NFs. For further information refer to the Medicare Learning Network article SE0418 at:  http://www.cms.gov/Outreach- and-Education/Medicare- Learning- Network -MLN/MLNGenInfo/index.html?redirect=/MLNGenInfo
(Medicare Claims Processing Manual)
The federally mandated visits in a SNF and NF must be performed by the physician except as otherwise permitted (42 CFR 483.40 (c) (4) and (f)).  The principal physician of record must append the modifier  -AI, (Principal Physician of Record), to the initi al nursing facility care code.  This modifier will identify the physician who oversees the patients care from other physicians who may be furnishing specialty care.  All other physicians or qualified NPPs who perform an initial evaluation in the NF or SNF  may bill the initial nursing facility care code.  The initial federally mandated visit is defined in S&C -04-08 (see http://www.cms.gov/site -search/search -results.html?q=S%26C -04-08) as the initial comprehensive visit during which the physician completes a thorough assessment, develops a plan of care, and writes or verifies admitting orders for the nursing facility resident.  For Survey and Certification requirements, a visit must oc cur no later than 30 days after admission.  Further, per the Long Term Care regulations at 42 CFR 483.40 (c) (4) and (e) (2), in a SNF the physician may not delegate a task that the physician must personally perform.  Therefore, as stated in S&C -04-08 the physician may not delegate the initial federally mandated comprehensive visit in a SNF.  The only exception, as to who performs the initial visit, relates to the NF setting.  In the NF setting, a qualified NPP (i.e., a nurse practitioner (NP), physician assistant (PA), or a clinical nurse specialist (CNS)), who is not employed by the facility, may perform the initial visit when the State law permits.  The evaluation and management (E/M) visit shall be within the State scope of practice and licensure requirements where the E/M visit is performed and the requirements for physician collaboration a nd physician supervision shall be met.
(Medicare Claims Processing Manual)
Qualified NPPs, whether employed or not by the SNF, may perform alternating federally mandated physician visits, at the option of the physician, after the initial federally mandated visit by the physician in a SNF.   Qualified NPPs in the NF setting, who are not employed by the NF and who are working in collaboration with a physician, may perform federally mandated physician visits, at the option of the State.   Medicare Part B payment policy does not pay for additional E/M visits that may be required by State law for a facility admission or for other additional visits to satisfy facility or other administrative purposes.  E/M visits, prior to and after the initia l federally mandated physician visit, that are reasonable and medically necessary to meet the medical needs of the individual patient (unrelated to any State requirement or administrative purpose) are payable under Medicare Part B.   C. Visits by Qualified Nonphysician Practitioners   All E/M visits shall be within the State scope of practice and licensure requirements where the visit is performed and all the requirements for physician collaboration and physician supervision shall be met when performed and reported by qualified NPPs.  G eneral physician supervision and employer billing requirements shall be met for PA services in addition to the PA meeting the State scope of practice and licensure requirements where the E/M visit is performed.   Medically Necessary Visits   Qualified NPPs may perform medically necessary E/M visits prior to and after the physicians initial visit in both the SNF and NF. Medically necessary E/M visits for the diagnosis or treatment of an illness or injury or to improve the functioning of a malf ormed body member are payable under the physician fee schedule under Medicare Part B.  A physician or NPP may bill the most appropriate initial nursing facility care code (CPT codes 99304 -99306) or subsequent nursing facility care code (CPT codes 99307- 99310), even if the E/M service is provided prior to the initial federally mandated visit.   SNF Setting --Place of Service Code 31   Following the initial federally mandated visit by the physician, the physician may delegate alternate federally mandated physician visits to a qualified NPP who meets collaboration and physician supervision requirements and is licensed as such by the State  and performing within the scope of practice in that State.
(Medicare Claims Processing Manual)
Following the initial federally mandated visit by the physician, the physician may delegate alternate federally mandated physician visits to a qualified NPP who meets collaboration and physician supervision requirements and is licensed as such by the State  and performing within the scope of practice in that State.   NF Setting --Place of Service Code 32   Per the regulations at 42 CFR 483.40 (f), a qualified NPP, who meets the collaboration and physician supervision requirements, the State scope of practice and licensure requirements, and who is not employed by the NF, may at the option of the State, perfor m the initial federally mandated visit in a NF, and may perform any other federally mandated physician visit in a NF in addition to performing other medically necessary E/M visits.   Questions pertaining to writing orders or certification and recertification issues in the SNF and NF settings shall be addressed to the appropriate State Survey and Certification Agency departments for clarification.   D. Medically Complex Care   Payment is made for E/M visits to patients in a SNF who are receiving services for medically complex care upon discharge from an acute care facility when the visits are reasonable and medically necessary and documented in the medical record.  Physicians an d qualified NPPs shall report initial nursing facility care codes for their first visit with the patient.  The principal physician of record must append the modifier  -AI (Principal Physician of Record), to the initial nursing facility care code when billed to identify the physician who oversees the patients care from other physicians who may be furnishing specialty care.  Follow -up visits shall be billed as subsequent nursing facility care visits.   E. Incident to Services   Where a physician establishes an office in a SNF/NF, the incident to services and requirements are confined to this discrete part of the facility designated as his/her office. Incident to E/M visits, provided in a facility setting, are not payable unde r the Physician Fee Schedule for Medicare Part B.  Thus, visits performed outside the designated office area in the SNF/NF would be subject to the coverage and payment rules applicable to the SNF/NF setting and shall not be reported using the CPT codes f or office or other outpatient visits or use place of service code 11.
(Medicare Claims Processing Manual)
F. Prolonged NF Services   Beginning January 1, 2023, prolonged NF services are reported using Medicare -specific coding (HCPCS code G0317). Prolonged Services can be reported when time is used to select visit level, and the total time for the highest -level visit is exceeded by 15 or more minutes for services that are reasonable and medically necessary. See Prolonged Services section below for detailed reporting instructions on prolonged NF visits. Prolonged services are not reportable in conjunction with codes for NF discharge day management.   G. Multiple Visits   The complexity level of an E/M visit and the CPT code billed must be a covered and medically necessary visit for each patient (refer to 1862 (a)(1)(A) of the Act).  Claims for an unreasonable number of daily E/M visits by the same physician to multiple patients at a facility within a 24- hour period may result in medical review to determine medical necessity for the visits.  The E/M visit (Nursing Facility Services) represents a per day service per patient as defined by the CPT code.  The medical record must be personally documented by the physician or qualified NPP who performed the E/M visit and the documentation shall support the specific level of E/M visit to each individual patient.   H.  Split (or Shared) SNF/NF E/M Visit   SNF E/M visits may be billed as split (or shared) visits if they meet the rules for split (or shared) visit billing, discussed in our other manual sections, except for SNF E/M visits that are required to be performed in their entirety by a physician.  NF visits do not meet the definition of split (or shared) services, and therefore, are not billable as such.  See section 30.6.18 for additional information.   I.  SNF/NF Discharge Day Management Service
(Medicare Claims Processing Manual)
I.  SNF/NF Discharge Day Management Service   Medicare Part B payment policy requires a face- to-face visit with the patient provided by the physician or the qualified NPP to meet the SNF/NF discharge day management service as defined by the CPT code.  The E/M discharge day management visit shall be re ported for the date of the actual visit by the physician or qualified NPP even if the patient is discharged from the facility on a different calendar date.  The CPT codes 99315 -  99316 shall be reported for this visit.  The Discharge Day Management Service  may be reported using CPT code 99315 or 99316, depending on the code requirement, for a patient who has expired, but only if the physician or qualified NPP personally performed the death pronouncement. 30.6.14 - Home or Residence Services (Codes 99341 - 99350)                         (Rev. 11732, Issued: 12 -08-22, Effective: 01 -01-23, Implementation: 01- 03-23)  Physician Visits to Patients Residing in Various Places of Service   Prior to January 1, 2023, the American Medical Associations Current Procedural Terminology (CPT) used new patient codes 99324 -  99328 and established patient codes 99334 -  99337 for Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services, to report evaluation and management (E/M) services to residents residing in a facility whi ch provides room, board, and other personal assistance services, generally on a long- term basis.  These CPT codes were used to report E/M services in facilities assi gned places of service (POS) codes 13 (Assisted Living Facility), 14 (Group Home), 33 (Custodial Care Facility) and 55 (Residential Substance Abuse Treatment Facility).  Assisted living facilities may also be known as adult living facilities.  The CPT code s 99324 -  99337 for Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services are deleted beginning January 1, 2023.
(Medicare Claims Processing Manual)
Beginning January 1, 2023, the CPT is merging the two E/M visit families currently titled Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services and Home Services. The new family will be titled Home or Residence Services.  The codes in this family (CPT codes 99341  99350) will be used to report E/M services furnished to a patient residing in their home, in an assisted living facility, in a group home (that is not licensed as an intermediate care facility for individuals with intellectual disabilities), in a custodial care facility, or in a residential substance abuse treatment facility.  There are no changes to the inclu ded care settings from each respective family, rather the current care settings for each of the current families are being included within the new, merged family.  For services in an intermediate care facility for individuals with intellectual disabilities and services provided in a psychiatric residential treatment center, see Nursing Facility Services in Section 30.6.13.  Physicians and qualified nonphysician practitioners (NPPs) furnishing E/M services to residents in a living arrangement described by one of the POS listed above must use the level of service code in the CPT code range 99341 -  99350 to report the service they provide.   Beginning in 2006, reasonable and medically necessary prolonged services may be reported with the appropriate companion E/M codes when a physician or qualified NPP, provides a prolonged service that is beyond the usual E/M visit service for a Home or Residence Service.  All the requirements for prolonged services at 30.6.15 must be met.  Beginning in 2006, E/M services provided to patients residing in a Skilled Nursing Facility (SNF) or a Nursing Facility (NF) must be reported using the appropriate CPT level of service code within the range identified for Initial Nursing Facility Care (CPT  codes 99304 -  99306) and Subsequent Nursing Facility Care (CPT codes 99307 -  99310).  Use CPT codes 99315 -  99316 for SNF/NF discharge services.  The Home or Residence Services codes should not be used for these places of service.
(Medicare Claims Processing Manual)
HCPCS Code(s)  Total Time Required for Reporting*  99205  60-74 minutes  99205 x 1 and G2212 x 1  89-103 minutes  99205 x 1 and G2212 x 2  104-118 minutes  99215  40-54 minutes  99215 x 1 and G2212 x 1  69-83 minutes  99215 x 1 and G2212 x 2  84-98 minutes  99215 x 1 and G2212 x 3 or more for each additional 15 minutes.  99 or more   *Total time is the sum of all time, including prolonged time, spent by the reporting practitioner on the date of service of the visit.  HCPCS code G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physic ian or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215, 99483 for office or other outpatient evaluation and management services). (Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes)).  Qualifying activities are listed in the CPT Codebooks E/M Service Guidelines (Guidelines for Selecting Level of Service Based on Time). These activities may be counted when time is used to select visit level, when performed and medically reasonable and ne cessary.   30.6.15.3 Prolonged Other E/M Visits  (Rev. 11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)  Beginning January 1, 2023, prolonged Other E/M visit services are reported as discussed in this section. Other E/M visits include inpatient/observation visits, nursing facility visits, home/residence visits, and cognitive impairment assessment and care pla nning. Prolonged Other E/M services may be reported with the highest visit level, for timed visits, when the total visit time spent by the practitioner exceeds a certain time threshold.   Prolonged services are not reported in conjunction with emergency department visits or critical care services.
(Medicare Claims Processing Manual)
Prolonged services are created to provide payment for additional practitioner time that is not already accounted for in the valuation of the primary service. Accordingly, practitioner time spent in qualifying activities can be counted when performed on any date within the surveyed timeframe for the visit, and when the total time (in the physician time file) is exceeded by 15 or more minutes. We show this in the following table.  Primary E/M Service  Prolonged Code*  Time Threshold to Report Prolonged  Count physician/NPP time spent within this time period (surveyed timeframe)  Initial IP/Obs. Visit (99223)  G0316  90 minutes  Date of visit  Subsequent IP/Obs. Visit (99233)   G0316  65 minutes  Date of visit  IP/Obs. Same -Day Admission/Discharge (99236)  G0316  110 minutes  Date of visit to 3 days after  IP/Obs. Discharge Day Management (99238 -9) n/a n/a n/a Emergency Department Visits  n/a n/a n/a Initial NF Visit (99306)  G0317  95 minutes  1 day before visit + date of visit + 3 days after  Subsequent NF Visit (99310)  G0317  85 minutes  1 day before visit + date of visit + 3 days after  NF Discharge Day Management  n/a n/a n/a Home/Residence Visit New Pt (99345)  G0318  140 minutes  3 days before visit + date of visit + 7 days after Home/Residence Visit Estab. Pt (99350)  G0318  110 minutes  3 days before visit + date of visit + 7 days after  Cognitive Assessment and Care Planning (99483)  G2212  100 minutes  3 days before visit + date of visit + 7 days after  Consults  n/a n/a n/a * Time must be used to select visit level. Prolonged service time can be reported when furnished on any date within the primary visits surveyed timeframe and includes time with or without direct patient contact by the physician or NPP. Consistent with CPT s approach, we do not assign a frequency limitation.   Qualifying activities are listed in the CPT Codebooks E/M Service Guidelines (Guidelines for Selecting Level of Service Based on Time). These activities may be counted when time is used to select visit level, when performed and medically reasonable and ne cessary.
(Medicare Claims Processing Manual)
30.6.15.4 - Power Mobility Devices (PMDs) (Code G0372)  (Rev. 748, Issued:  11- 04-05; Effective/Implementation Dates:  10 -25-05)  Section 302(a)(2)(E)(iv) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) sets forth revised conditions for Medicare payment of Power Mobility Devices (PMDs).  This section of the MMA states that payment for motorized or power wheelchairs may not be made unless a physician (as defined in 1861(r)(1) of the Act), a physician assistant, nurse practitioner, or a clinical nurse specialist (as those terms are defined in 1861(aa)(5)) has conducted a face -to-face examination of the beneficiary and written a prescription for the PMD.  Payment for the history and physical examination will be made through the appropriate evaluation and management (E&M) code corresponding to the history and physical examination of the patient.  Due to the MMA requirement that the physician or treating practitioner create a written prescription and a regulatory requirement that the physician or treating practitioner prepare pertinent parts of the medical record for submission to the durable medical equipment supplier, code G0372 (physician service required t o establish and document the need for a power mobility device)  has been established to recognize additional physician services and resources required to establish and document the need for the PMD.   The G code indicates that all of the information necessary to document the PMD prescription is included in the medical record, and the prescription and supporting documentation is delivered to the PMD supplier within 30 days after the face -to-face examination.   Effective October 25, 2005, G0372 will be used to recognize additional physician services and resources required to establish and document the need for the PMD and will be added to the Medicare physician fee schedule.   30.6.17  Physician Management Associated with Superficial Radiation Treatment  (Rev.4339, Issued: 07- 25-19, Effective: 01 -01-19, Implementation: 08- 27-19)
(Medicare Claims Processing Manual)
30.6.17  Physician Management Associated with Superficial Radiation Treatment  (Rev.4339, Issued: 07- 25-19, Effective: 01 -01-19, Implementation: 08- 27-19)   Evaluation and management codes for levels I through III (99211, 99212, and 99213) may be billed with modifier 25 when performed for the purpose of reporting physician work associated with radiation therapy planning, radiation treatment device construction, and radiation treatment management when performed on the same date of service as superficial radiation treatment delivery.   See chapter 13, section 70.2, of this manual for information regarding services bundled into treatment management codes.  30.6.18 - Split (or Shared) Visits  (Rev. 11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)  A. Definition of Split (or Shared) Visit   A split (or shared) visit is an evaluation and management (E/M) visit in the facility setting that is performed in part by both a physician and a nonphysician practitioner (NPP) who are in the same group, in accordance with applicable law and regulations such that the service could be  could be billed by either the physician or NPP if furnished independently by only one of them. Payment is made to the practitioner who performs the substantive portion of the visit.   Facility setting means an institutional setting in which payment for services and supplies furnished incident to a physician or practitioners professional services is prohibited under our regulations.    B. Definition of Substantive Portion   (1) More Than Half of the Total Time   Beginning January 1, 2024, substantive portion means more than half of the total time spent by the physician and NPP performing the split (or shared) visit.