evekhm/cms_iom_500 huggingface dataset:
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surgeries.  Field 22 of the MFSDB indicates whether the payment adjustment rules apply to a surgical procedure.  B. Billing Instructions for Bilateral Surgeries  If a procedure is not identified by its terminology as a bilateral procedure (or unilateral or bilateral), physicians must report the procedure with modifier  -50.  They report such procedures as a single line item.  ( NOTE :  This differs from the CPT coding guidelines which indicate that bilateral procedures should be billed as two line items.)  If a procedure is identified by the terminology as bilateral (or unilateral or bilateral), as in codes 27395 and 52290, physicians do not report the procedure with modifier  -50. C. Claims Processing System Requirements  A/B MACs (B) must be able to: 1. Identify bilateral surgeries by the presence on the claim form or electronic submission of the  -50 modifier or  of the same code on separate lines reported once with modifier -LT and once with modifier  -RT;  2. Access Field 34 or 35 of the MFSDB to determine the Medicare payment amount;  3. Access Field 22 of the MFSDB:   If Field 22 contains an indicator of 0, 2, or 3, the payment adjustment rules for bilateral surgeries do not apply.  Base payment on the lower of the billed amount or 100 percent of the fee schedule amount (Field 34 or 35) unless other payment adjust ment rules apply.   NOTE:   Some codes which have a bilateral indicator of 0 in the MFSDB may be performed more than once on a given day.  These are services that would never be considered bilateral and thus should not be billed with modifier  -50.  Where such a code is billed o n multiple line items or with more than 1 in the units field and A/B MACs (B) have determined that the code may be reported more than once, bypass the 0 bilateral indicator and refer to the multiple surgery field for pricing;   If Field 22 contains an indicator of 1, the standard adjustment rules apply.  Base payment on the lower of the billed amount or 150 percent of the fee schedule amount (Field 34 or 35).  (Multiply the payment amount in Field 34 or 35 for the surgery by 150 percent and round to the nearest cent.)  4. Apply the requirements 40 -  40.4
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percent of the fee schedule amount (Field 34 or 35).  (Multiply the payment amount in Field 34 or 35 for the surgery by 150 percent and round to the nearest cent.)  4. Apply the requirements 40 -  40.4 on global surgeries to bilateral surgeries; and 5. Retain the - 50 modifier in history for any bilateral surgeries paid at the adjusted amount. (NOTE:   The - 50 modifier is not retained for surgeries which are bilateral by definition such as code 27395.)  40.8. - Claims for Co -Surgeons and Team Surgeons  (Rev. 3721, Issued: 02 -24-17, Effective: 05 -25-17, Implementation: 05 -25-17)
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A.  General   Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session.  This may be required because of the complex nature of the procedure(s) and/or the patients condition.  In these cases, the additional physicians are not acting as assistants -at-surgery.   B.  Billing Instructions   The following billing procedures apply when billing for a surgical procedure or procedures that required the use of two surgeons or a team of surgeons:    If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier  -62.  Co- surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously, i.e., heart transplant or bilateral knee replacements.  Documentation of the medical necessity for two surgeons is required for certain services identified in the MFSDB.  (See 40.8.C.5 .);   If a team of surgeons (more than 2 surgeons of different specialties) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier -66.  Field 25 of the MFSDB identifies certain services submitted with a  -66 modifie r which must be sufficiently documented to establish that a team was medically necessary.  All claims for team surgeons must contain sufficient informatio n to allow pricing by report.    If surgeons of different specialties are each performing a different procedure (with specific CPT codes), neither co -surgery nor multiple surgery rules apply (even if the procedures are performed through the same incision).  If one of the surgeons performs  multiple procedures, the multiple procedure rules apply to that surgeons services.  (See 40.6 for multiple surgery payment rules.)   For co -surgeons (modifier 62), the fee schedule amount applicable to the payment for each  co-surgeon is 62.5 percent of the global surgery fee schedule amount.  Team surgery (modifier 66) is paid for on a By Report basis.  C.  Claims Processing System Requirements  Carriers must be able to:   1. Identify a surgical procedure performed by two surgeons or a team of surgeons by the presence on the claim form or electronic submission of the  -62 or  -66 modifier;   2. Access Field 34 or 35 of the MFSDB to determine the fee schedule payment amount for the surgery;
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2. Access Field 34 or 35 of the MFSDB to determine the fee schedule payment amount for the surgery;   3. Access Field 24 or 25, as appropriate, of the MFSDB.  These fields provide guidance on whether two or team surgeons are generally required for the surgical procedure;   4. If the surgery is billed with a  -62 or  -66 modifier and Field 24 or 25 contains an indicator of 0, payment adjustment rules for two or team surgeons do not apply:    Carriers pay the first bill submitted, and base payment on the lower of the billed amount or 100 percent of the fee schedule amount (Field 34 or 35) unless other payment adjustment rules apply;    Carriers deny bills received subsequently from other physicians and use the appropriate MSN message in 40.8.D .   As these are medical necessity denials, the instructions in the Program Integrity Manual regarding denial of unassigned claims for medical necessity are applied;   5. If the surgery is billed with a  -62 modifier and Field 24 contains an indicator of 1, suspend the claim for manual review of any documentation submitted with the claim.  If the documentation supports the need for co- surgeons, base payment for each physician on the lower of the billed amount or 62.5 percent of the fee schedule amount (Field 34 or 35);   6. If the surgery is billed with a  -62 modifier and Field 24 contains an indicator of 2, payment rules for two surgeons apply.  Carriers base payment for each physician on the lower of the billed amount or 62.5 percent of the fee schedule amount (Field 34 or 35);   7. If the surgery is billed with a  -66 modifier and Field 25 contains an indicator of 1, carriers suspend the claim for manual review.  If carriers determine that team surgeons were medically necessary, each physician is paid on a by report basis;  8. If the surgery is billed with a  -66 modifier and Field 25 contains an indicator of 2, carriers pay by report;
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NOTE:  A Medicare fee may have been established for some surgical procedures that are billed with the  -66 modifier.  In these cases, all physicians on the team must agree on the percentage of the Medicare payment amount each is to receive.  If carriers receive a bill with a  -66 modifier after carriers have paid one surgeon the full Medicare payment amount (on a bill without  the modifier), deny the subsequent claim.  9. Apply the rules global surgical packages to each of the physicians participating in a co-  or team surgery; and   10. Retain the - 62 and  -66 modifiers in history for any co-  or team surgeries.   D.  Beneficiary Liability on Denied Claims for Assistant, Co-  surgeon and Team Surgeons   When the procedure is subject to the statutory restriction against payment for assistants -at-surgery, such payment shall be denied.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.   Group Code: CO  CARC: 54  RARC: N/A  MSN: 15.11  Carriers include the following statement in the MSN: "You cannot be charged for this service. (Unnumbered add -on message.)   If Field 23 of the MFSDB contains an indicator of 0 or 1 (assistant -at-surgery may not be paid) for procedures CMS has determined that an assistant surgeon is not generally medically necessary.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.   Group Code: CO  CARC: 54  RARC: N/A  MSN: 15.12  For those procedures with an indicator of 0, the limitation on liability provisions described in Chapter 30 apply to assigned claims.  Therefore, carriers include the appropriate limitation of liability language from Chapter 21.  For unassigned claims, a pply the rules in the Program Integrity Manual concerning denial for medical necessity. Where payment may not be made for a co - or team surgeon, deny the claim
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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 ma y 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 (
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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)
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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
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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 dir ects 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 procedures in the anesthesia plan, including induction a nd 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).
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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 another 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 r ecognized if the physician can document he or she was present at  induction.  E. Billing and Payment for Multiple Anesthesia  Procedures
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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 se rvices include th e 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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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 anes thesia 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.