evekhm/cms_iom_500 huggingface dataset:
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II. BUSINESS REQUIREMENTS TABLE  "Shall" denotes a mandatory requirement, and "should" denotes an optional requirement.    Number  Requirement  Responsibility     A/B MAC DME  MAC Shared -System Maintainers  Other  A B HHH FISS MCS VMS CWF 8863.1  Shared System Maintainers and individual contractors shall accept and process claims containing lines reporting HCPCS codes with the new modifiers, XE, XP, XS and XU.    X X   X    IOCE  8863.2  Shared System Maintainers and individual contractors shall apply or bypass edits to lines containing a -  X{EPSU}  modifier in the same manner as the edits would apply to a line containing a - 59 modifier.  Any edit that currently evaluat es modifiers, such as a multiple procedure edit, should react to a - X{EPSU}  in the same manner that it does to a -59.    X X   X X  X IOCE  8863.3  Shared System Maintainers and individual contractors shall recognize each of the -  X{EPSU}  modifiers as a separate modifier.  The system shall allow multiple lines to be reported with the -59 and different - X X   X X    Number  Requirement  Responsibility     A/B MAC DME  MAC Shared -System Maintainers  Other  A B HHH FISS MCS VMS CWF X{EPSU}  modifiers.  However, the system shall aggregate lines with any of the -  X{EPSU}  modifiers with lines containing - 59 modifiers whenever it aggreg ates lines containing the -59 modifier.   8863.4  Shared System Maintainers and individual contractors shall retain the -  X{EPSU}  modifiers in systems records and claims histories as valid and active modifiers.   X X         III. PROVIDER ED UCATION TABLE   Number  Requirement  Responsibility     A/B MAC  DME
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III. PROVIDER ED UCATION TABLE   Number  Requirement  Responsibility     A/B MAC  DME  MAC CEDI  A B HHH 8863.5  MLN Article: A provider education article related to this instruction will be available at http://www.cms.gov/Outreach -and-Education/Medicare- Learning -Network -MLN/MLNMattersArticles/ shortly after the CR is released.  You will receive notification of the article release via the established "MLN Matters" listserv.  Contractors shall post this article, or a direct link to this article, on their Web sites and include information about it in a listserv message within one week of the availability of the provider education article.  In addition, the provider education article shall be included in the contractors next regularly scheduled bulletin.  Contractors are free to supplement MLN Matters articles with localized information that would benefit their provider community in billing and administering the Medicare program correctly.  X X     IV. SUPPORTING INFORMATION Section A:  Recommendations and supporting informatio n associated with listed requirements: N/A  "Should" denotes a recommendation.  X-Ref  Requirement  Number  Recommendations or other supporting information:   Section B:  All other recommendations and supporting information: N/A   V. CONTACTS   Pre-Implementation Contact(s): Valeria Allen, 410 -786-7443 or valeria.allen@cms.hhs.gov   Post-Implementation Contact(s): Contact your Contracting Officers Representative (COR) or Contractor Manager, as applicable.   VI. FUNDING   Section A: For Medicare Administrative C ontractors (MACs):  The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract.  CMS does not construe this as a change to the MAC Statement of Work.  The contractor is not obligated to inc ur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer.  If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor sha ll withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e -mail, and request formal directions regarding continued performance requirements.  ATTACHMENTS: 0
(MM10176)
MLN Matters  MM10176       Related CR  10176     Page 1 of 5    MLN Matters Number: MM10176 Revised  Related CR Release Date: December 21 , 2017  Related CR Transmittal Number: R3 936CP   Updated Editing of Always Therapy Services - MCS  Related Change Request (CR) Number: 10176 Effective Date: January 1, 2018 Implementation Date: January 2, 2018This article was revised on December 21 , 2017, to reflect an updated CR10176 . The CR was revised to delete HCPCS code 97532 from the list of therapy codes in the attachment to the CR.  That code is also removed from the list of those codes in this article. Also, i n the article, the CR release da te, transmittal, number and link to the transmittal changed. All other information is unchanged.   PROVIDER TYPE AFFECTED   This MLN Matters Article is intended for therapists, physicians, and certain other practitioners billing Medicare Administrative Contr actors (MACs) for therapy services provided to Medicare beneficiaries.   PROVIDER ACTION NEEDED  CR 10176 implements revised editing of Part B Always Therapy services to require the appropriate therapy modifier in order for the service to be accurately applied to the therapy cap. CR10176 contains no new policy. Instead, the guidelines presented in the CR improve the enforcement of longstanding, existing instructions. Make sure your billing staffs are aware of these revisions.  BACKGROUND   Services furnis hed under the Outpatient Therapy (OPT) services benefit  including Speech -Language Pathology (SLP), Occupational Therapy (OT), and Physical Therapy (PT)  are subject to the financial limitations, known as therapy caps, originally required under Section 4541 of the Balanced Budget Act (1997).   There are two such caps. One cap is for PT and SLP services combined and another cap is for OT services. In order to accrue incurred expenses to the correct therapy cap; the use of one of the three therapy modifiers  (GN, GO, or GP) is required on a certain set of Healthcare Common Procedure Coding System (HCPCS) codes in order to identify when each OPT service is furnished under an SLP, OT, or PT plan of care, respectively.    MLN Matters  MM10176       Related CR  10176     Page 2 of 5
(MM10176)
MLN Matters  MM10176       Related CR  10176     Page 2 of 5   Medicare recognizes the services furnishe d under the OPT services benefit as either always or sometimes therapy and publishes this list as an Annual Update on the Therapy Services Billing page at https://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html .   On professional claims, each code designated as always therapy:    Must always be furnished under an SLP, OT, or PT plan of care, regardless of who furnishes them; and, as such,  Must always be accompanied by one of the GN, GO, or GP therapy modifiers.   In addition, several always therapy codes have been identified as discipline -specific   requiring the GN modifier for six codes, the GO modifier for four codes, and the GP modifier for four codes, as illustrated in Tables 1-3.  Table 1: Codes Requiring the GN Therapy Modifier  Code  CPT Short Descriptor  Therapy Modifier Required  92521  Evaluation of speech fluency  GN 92522  Evaluate speech production  GN 92523  Speech sound lang comprehend  GN 92524  Behavral quality analys voice  GN 92597  Oral speech device eval  GN 92607  Ex for speech device rx 1hr  GN  Table 2: Codes Requiring the  GO Therapy Modifier  Code  CPT Short Descriptor  Therapy Modifier Required  97165  Ot eval low complex 30 min  GO 97166  Ot eval mod complex 45 min  GO 97167  Ot eval high complex 60 min  GO 97168  Ot re -eval est plan care  GO     MLN Matters  MM10176       Related CR  10176     Page 3 of 5   Table 3: Codes Requiring the  GP Therapy Modifier  Code  CPT Short Descriptor  Therapy Modifier Required  97161  Pt eval low complex 20 min  GP 97162  Pt eval mod complex 30 min  GP 97163  Pt eval high complex 45 min  GP 97164  Pt re -eval est plan care  GP
(MM10176)
The following Always Therapy  HCPCS codes require a GN, GO, or GP modifier, as appropriate. Descriptors for these codes are included as an attachment to CR 10176.  92507 92508 92526 92608 92609 96125 97012 97016 97018 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97530 97533 97535 97537 97542  97750 97755 97760 97761 97762 97799 G0281 G0283 G0329 In addition to Therapists in Private Practice (TPPs)  including physical therapists, occupational therapists, and speech-language pathologists  professional claims for OPT services may be furnished by physicians and certain Non-Physician Practitioners (NPPs)  specifically, physician assistants, nurse practitioners, and certified nurse specialists.   All OPT services furnished by TPPs are always considered therapy services, regardless of whether they are designated as always therapy or sometimes therapy. As such, the appropriate therapy modifier must be included on the claim. However, it may be clinically appropriate for physicians and NPPs to furnish OPT services that have been designated sometimes therapy codes outside a therapy plan of care - in these cases, therapy modifiers are not required and claims may be processed without them.
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During analyses of Medicare claims da ta for OPT services, the Centers for Medicare & Medicaid Services (CMS) found that these always therapy codes and modifiers are not always used in a correct and consistent manner. CMS found OPT professional claims for always therapy codes without the required modifiers. Also, CMS found claims that reported more than one therapy modifier for the same therapy service; for example, both a GP and GO modifier, when only one modifier was allowed. These claims represent non-compliant billing by TPPs, physicians, and NPPs, and hamper CMS ability to properly track the therapy caps and analyze claims data for purposes of Medicare program improvements. The requirements in CR10176 will create new edits for Medicare professional claims processing systems to return c laims when always therapy codes and the associated therapy modifiers are improperly reported.    MLN Matters  MM10176       Related CR  10176     Page 4 of 5   Providers should expect the following:  MACs will return/reject claims which contain an always therapy procedure code, but do not also contain the appropriate discipline-specific therapy modifier of GN, GO, or GP.   MACs will also return/reject claims if any service line on the claim contains more than one occurrence of a GN, GO, or GP therapy modifier.   MACs who are returning/rejecting such claims will use Group Code CO and Claim Adjustment Reason Code (CARC) 4 on the related remittance advice.   ADDITIONAL INFORMATION  The official instruction, CR 10176, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3 936CP.pdf .  If you have any questions, please contact your MAC at their toll-free number. That number is available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS -Compliance-Programs/Review-Contractor-Directory-In teractive-Map/ .  DOCUMENT HISTORY
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DOCUMENT HISTORY  Date of Change  Description  December 21, 2017  The article was revised to reflect an updated CR. The CR was revised to remove  HCPCS code 97532 from the list of always therapy codes in the attachment to the CR. That code is also removed from the list of those codes in this article. Also, in the article, the CR release date, transmittal, number and link to the transmittal changed.  All other information is unchanged.  September 15, 2017  The article was revised to reflect an updated CR. In the article, the CR release date, transmittal, number and link to the transmittal changed. All other information is unchanged.  July 31, 2017  Initial article released.     Disclaimer : This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2016 American Medical Association. All rights reserved.  Copyright  2017, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA   MLN Matters  MM10176       Related CR  10176     Page 5 of 5
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Copyright  2017, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA   MLN Matters  MM10176       Related CR  10176     Page 5 of 5  copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials , please contact the AHA at 312-893- 6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB -04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. T o license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816 or Laryssa Marshall at (312 ) 893-6814. You may also contact us at ub04@healthforum.com    The American Hospital Association (the AHA) has not reviewed, and is not responsible for, the completeness or accuracy of a ny information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.
Article - Billing and Coding: Wound and Ulcer Care (A58567)
CMS National Coverage PolicyN/AArticle TextRefer to Local Coverage Determination (LCD) L38904, Wound and Ulcer Care, for reasonable and necessary requirements.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.Coding GuidelinesClaims must be submitted with an ICD-10-CM code that represents the reason the procedure was done. The ICD-10-CM code must be billed to the highest level of specificity for that code set. The ICD-10-CM code must be linked to the appropriate procedure code.When the only service provided is the non-surgical cleansing of the ulcer site with or without the applications of a surgical dressing, the provider should bill this service with the appropriate evaluation and management (E/M) code and not bill a debridement code(s).The debridement codes listed below are appropriate for treatment of skin ulcers, circumscribed dermal infections, conditions affecting contiguous deeper structures, and debridement of ground-in dirt such as from road abrasions.Active Wound Care Management  CPT codes 97597, 97598, 97602, 97605, 97606, 97607, and 97608
Article - Billing and Coding: Wound and Ulcer Care (A58567)
Currently, code 97602 is a status B (bundled) code for physicians services; therefore, separate payment is not allowed for this service.A therapist acting within their scope of practice and licensure performing active wound care management services must add the appropriate therapy modifier to the CPT code billed. In addition, the therapy Revenue Code must be submitted for that service when performed in a Part A outpatient facility setting. If a non-therapist performs the service, no therapy modifiers are used, and a non-therapy Revenue Code must be submitted for the service if performed in a Part A outpatient facility setting. Please see MM10176 for more information.For debridement codes 97597, 97598, or 97602:Debridement should be coded with either selective or non-selective CPT codes (97597, 97598, or 97602) unless the medical record supports a surgical debridement has been performed.Dressings applied to the wound are part of the services for CPT codes 97597, 97598 and 97602 and they may not be billed separately.It is not appropriate to report CPT code 97602 in addition to CPT code 97597 and/or 97598 for wound care performed on the same wound on the same date of service.Code(s) 97597, 97598 and 97602 should not be reported in conjunction with code(s) 11042-11047 for the same wound. The wound depth debrided determines the appropriate code.For example, when only biofilm on the surface of a muscular ulceration is debrided, then codes 97597-97598 would be appropriate. If muscle substance was debrided, then the 11043-11046 series would be appropriate, depending on the area.
Article - Billing and Coding: Wound and Ulcer Care (A58567)
Codes 97602, 97605, 97606, 97607 and 97608 include the application of and the removal of any protective or bulk dressings. However, if only a dressing change is performed without any active wound procedure as described by these debridement codes, these debridement codes should not be reported.CPT 97597 and 97598 may be used for the medically reasonable and necessary debridement with utilization consistent with this LCD and within scope of practice of the performing provider.Generally, whirlpool is a component of CPT codes 97597/97598 and should not be reported separately during the same encounter. Only when there is a separately identifiable service being treated by the therapist, and the documentation supports this treatment, would the service be considered for payment utilizing modifier -59 or a more specific modifier as appropriate (e.g., LT, RT, -XS, etc.).Surgical Debridement  CPT codes 11000-11012, and 11042-11047
Article - Billing and Coding: Wound and Ulcer Care (A58567)
Dressings applied to the wound are part of the service for CPT codes 11000-11012 and 11042-11047 and may not be billed separately.Medicare does not separately reimburse for dressing changes or patient/caregiver training in the care of the wound. It is only appropriate to provide an Advance Beneficiary Notice of Non-coverage (ABN) for services that are anticipated to be denied due to the absence of medical necessity. Based on this information, an ABN for a dressing change is not appropriate since the costs of the dressing change are packaged into other procedures billed.Debridement of Necrotizing Soft Tissue Infections (CPT codes 11004-11006, and 11008) are inpatient only procedure codes.CPT codes 11042-11047 do not refer solely to ulcer size, but also to levels of actual tissue debridement levels (based on tissue type, e.g., partial skin, full thickness skin, subcutaneous tissue, etc.) of independent (noncontiguous) skin and other deeper tissue structures.When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of wounds that are the same depth, but do not combine wounds from different depths. This A/B MAC allows payment for an aggregate total of one independent tissue debridement on a given day of service. Any number greater than the aggregate total of four for one or both feet per date of service will result in a denial which may be appealed with documentation justifying the additional services. Once debridement is properly done repeat debridement is not expected for several days afterward.CPT codes 11042, 11043, 11044, 11045, 11046, and 11047 are used to report surgical removal (debridement) of devitalized tissue from wounds.Use appropriate modifiers when more than one wound is debrided on the same day.Per CMS Change Request (CR) 8863, CMS will continue to recognize the -59 modifier, a modifier used to define a Distinct Procedural Service, but notes that Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available. Please see CMS CR 8863 for more information.
Article - Billing and Coding: Wound and Ulcer Care (A58567)
The use of CPT codes 11042-11047 is not appropriate for the following services: washing bacterial or fungal debris from feet, paring or cutting of corns or calluses, incision and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, or destruction of warts. Report these procedures, when they represent covered reasonable and necessary services using the CPT/HCPCS code that most closely describes the service supplied.The CPT code selected should reflect the level of debrided tissue (e.g., skin, subcutaneous tissue, muscle and/or bone), not the extent, depth, or grade of the ulcer or wound.For example, CPT code 11042 defined as debridement, subcutaneous tissue should be used if only necrotic subcutaneous tissue is debrided, even though the ulcer or wound might extend to the bone. In addition, if only fibrin is removed, this code would not be billed.Debridement of tissue in the surgical field of another musculoskeletal procedure is not separately reportable. However, debridement of tissue at the site of an open fracture or dislocation may be reported separately with CPT codes 11010-11012.For example, debridement of muscle and/or bone (CPT codes 11043-11044, 11046-11047) associated with excision of a tumor of bone is not separately reportable. Similarly, debridement of tissue (e.g., CPT codes 11042, 11045, 11720-11721, 97597, 97598) superficial to, but in the surgical field, of a musculoskeletal procedure is not separately reportable.The debridement code submitted should reflect the type and amount of tissue removed during the procedure as well as the depth, size, or other characteristics of the wound. Submitting documentation substantiating depth of debridement when billing the debridement procedure described by CPT code 11044 is encouraged.For example, if a wound involves exposed bone but the debridement procedure did not remove bone, CPT code 11044 cannot be billed.
Article - Billing and Coding: Wound and Ulcer Care (A58567)
Paring and Cutting for the Management of a Symptomatic Hyperkeratosis - 11055-11057Codes 11055-11057 represent paring. The medical record must reflect the symptomatic nature of the lesion that makes this a coverable service, as the treatment of asymptomatic hyperkeratotic lesions are within the scope of Routine Foot Care. Please refer to Groups 2 and 3 in the ICD 10 Codes That Support Medical Necessity section for further information.