evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Contact those affected by these instructions to learn the circumstances in individual teaching hospitals.  There may be some teaching hospitals in which A/B MACs (B) can apply a presumption about the availability of a qualified resident in a training progr am related to the medical specialty required for the surgical procedures, but there are other teaching hospitals in which there are often no qualified residents available.  This may be due to their involvement in other activities, complexity of the surgery, numbers of residents in the program, or other valid reasons. A/B MACs (B) process assistant at surgery claims for services furnished in teaching hospitals on the basis of the following certification by the assistant, or through the use of modifier - 82 which indicates that a qualified resident surgeon was not available.  This certification is for use only when the basis for payment is the unavailability of qualified residents.   I understand that 1842(b)(7)(D)  of the Act (follow the link and select the applicable title) generally prohibits Medicare physician fee schedule payment for the services of assistants at surgery in teaching hospitals when qualified residents are available to furnish such services. I cer tify that the services for which payment is claimed were medically necessary and that no qualified resident was available to perform the services. I further understand that these services are subject to post- payment review by the A/B MAC (B).  A/B MACs (B) retain the claim and certification for four years and conduct post-payment reviews as necessary.  For example, A/B MACs (B) investigate situations in which it is always certified that there are no qualified residents available, and undertake recovery if warranted.   Assistant at surgery claims denied based on these instructions do not qualify for payment under the limitation on liability provision.  B. Definition   An assistant at surgery is a physician who actively assists the physician in charge of a case in performing a surgical procedure.  (Note that a nurse practitioner, physician assistant or clinical nurse specialist who is authorized to provide such services under State law can also serve as an assistant at surgery).  The conditions for coverage of such services in teaching hospitals are more restrictive than those in other settings because of the availability of residents who are qualified to perform this type of service.  C. Exceptional Circumstances
(Medicare Claims Processing Manual)
Payment may be made for the services of assistants at surgery in teaching hospitals, subject to the special limitation in 20.4.3 notwithstanding the availability of a qualified resident to furnish the services.  There may be exceptional medical circumstances (e.g., emergency, life- threatening situations such as multiple traumatic injuries) which require immediate treatment.  There may be other situations in which the medical staff may find that exceptional medical circumstances justify the services of a ph ysician assistant at surgery even though a qualified resident is available.  D. Physicians Who Do Not Involve Residents in Patient Care  Payment may be made for the services of assistants at surgery in teaching hospitals, subject to the limitations in 20.4.3, above, if the primary surgeon has an across-the-board policy of never involving residents in the preoperative, operative, or postope rative care of his or her patients.  Generally, this exception is applied to community physicians who have no involvement in the hospitals GME program.  In such situations, payment may be made for reasonable and necessary services on the same basis as wou ld be the case in a nonteaching hospital.  However, if the assistant is not a physician primarily engaged in the field of surgery, no payment be made unless either of the criteria of subsection E is met.   E. Multiple Physician Specialties Involved in Surgery
(Medicare Claims Processing Manual)
Complex medical procedures, including multistage transplant surgery and coronary bypass, may require a team of physicians. In these situations, each of the physicians performs a unique, discrete function requiring special skills integral to the total proce dure.  Each physician is engaged in a level of activity different from assisting the surgeon in charge of the case.  The special payment limitation in 20.4.3 is not applied.  If payment is made on the basis of a single team fee, additional claims are deni ed.  The A/B MAC (B) will determine which procedures performed in the service area require a team approach to surgery.  Team surgery is paid for on a By Report basis.  The services of physicians of different specialties may be necessary during surgery when each specialist is required to play an active role in the patients treatment because of the existence of more than one medical condition requiring diverse, specialize d medical services.  For example, a patients cardiac condition may require a cardiologist be present to monitor the patients condition during abdominal surgery.  In this type of situation, the physician furnishing the concurrent care is functioning at a different level than that of an assistant at surgery, and payment is made on a regular fee schedule basis.  100.1.8 - Physician Billing in the Teaching Setting  (Rev. 2303, Issued: 09- 14-11, Effective: 06 -01-11, Implementation: 07- 26-11)  A. A/B MAC (B) Claims   The method by which services performed in a teaching setting must be billed is determined by the manner in which reimbursement is made for such services.  For A/B MACs (B), the shared system suspends claims submitted by a teaching physician, for review.   B. Billing Modifiers   Effective January 1, 1997, services furnished by teaching physicians involving a resident in the care of their patients must be identified as such on the claim.  To be payable, claims for services furnished by teaching physicians involving a resident must comply with the requirements in sections 100.1 through 100.1.6 of this chapter, as applicable.  Claims for services meeting these requirements must show either the GC or GE modifier as appropriate and described below.   1. Teaching Physician Services that Meet the Requirement for Presence During the Key/Critical Portion of the Service
(Medicare Claims Processing Manual)
1. Teaching Physician Services that Meet the Requirement for Presence During the Key/Critical Portion of the Service   Claims for teaching physician services in compliance with the requirements outlined in sections 100.1 - 100.1.6 of this chapter must include a GC modifier for each service, unless the service is furnished under the primary care center exception described in section 100.1.1C (refer to number 2, below).  When a physician (or other appropriate billing provider) places the GC modifier on the claim, he/she is certifying that the teaching physician has complied with the requirements in sections 100.1 through 100.1.6.  2. Teaching Physician Services Under the Exception for E/M Services Furnished in Primary Care Centers   Teaching physicians who meet the requirements in section 100.1.1C of this chapter must provide their A/B MAC (B) with an attestation that they meet the requirements. Claims for services furnished by teaching physicians under the primary care center excepti on must include the GE modifier on the claim for each service furnished under the primary care center exception.   100.2 - Interns and Residents  (Rev. 1, 10- 01-03) B3-2020.8, B3- 8030  An attending physicians services to beneficiaries in a teaching setting are covered under the supplementary medical insurance program.  Many physicians rendering such services are on the faculty of a medical school or have arrangements with providers to s upervise and teach interns and residents.  Payment may be made for professional services to a beneficiary by an attending physician where the attending physician provides personal identifiable direction to interns or residents who are participating in th e care of this patient.   See the Medicare Benefit Policy Manual, Chapter 15, for services furnished by interns and residents within and outside the scope of an approved training program.  110 - Physician Assistant (PA) Services Payment Methodology (Rev. 2656, Issuance: 02- 07-13, Effective: 02- 19-13, Implementation: 02- 19-13)
(Medicare Claims Processing Manual)
See chapter 15, section 190 of the Medicare Benefit Policy Manual, pub. 100- 02, for coverage policy for physician assistant (PA) services.  Physician assistant services are paid at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule. There is a separate payment policy for paying for PA assistant -at-surgery services.  See section 110.2 of this chapter.   110.1 - Global Surgical Payments (Rev. 2656, Issuance: 02- 07-13, Effective: 02- 19-13, Implementation: 02- 19-13)  When a PA furnishes services to a patient during a global surgical period, A/B MACs (B) shall determine the level of PA involvement in furnishing part of the surgeons global surgical package consistent with their current practice for processing such claim s.  PA services furnished during a global surgical period shall be paid at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule.  Billing requirements and adjudication of claims requirements for global surgeries are under chapter 12, sections 40.2 and 40.4 of the Medicare Claims Processing Manual, pub. 100-04.  110.2 - Limitations for Assistant -at-Surgery Services Furnished by Physician Assistants  (Rev. 2656, Issuance: 02-07-13, Effective: 02- 19-13, Implementation: 02-19-13)
(Medicare Claims Processing Manual)
Medicare law at section 1833(a)(1)(O) of the Social Security Act authorizes payment for  services that a PA furnishes as an assistant -at-surgery.  Specifically, when a PA actively assists a physician in performing a surgical procedure and furnishes more than just ancillary services, the PAs services are eligible for payment as assistant -at-surgery services.  For additional policy requirements concerning assistant- at-surgery services furnished by physicians and nonphysician practitioners, see chapter 12, section 20.4.3 of the Medicare Claims Processing Manual, pub. 100-04.  The A/B MAC (B) shall pay covered PA assistant -at-surgery services at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule.  Since physicians are paid at 16 percent of the surgical payment amount under the Medicare Physician Fee Schedule for assistant -at-surgery services, the actual payment amount that PAs receive for assistant -at-surgery services is 13.6 percent of the amount paid to physicians.  The AS modifier must be reported on the claim form when billing PA assistant- at-surgery services.    110.3 - Outpatient Mental Health Treatment Limitation  (Rev. 2656, Issuance: 02-07-13, Effective: 02- 19-13, Implementation: 02-19-13)  In general, payment for covered PA services is made at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule.  The A/B MAC (B) must apply the outpatient mental health treatment limitation (the limitation) to all covered mental health therapeutic services furnished by PAs.   Refer to 210 below for a complete discussion of the limitation.   110.4 - PA Billing to the A/B MAC (B)  (Rev. 11288; Issued: 03-04- 22; Effective: 01 -01-22; Implementation: 02-15-22)  A. PA Identification   Effective January 1, 2022, PAs must have their own nonphysician practitioner national provider identification (NPI) number for billing purposes.  Specialty code 97 applies for PAs enrolled in Medicare.   B. Assignment Requirement
(Medicare Claims Processing Manual)
A. PA Identification   Effective January 1, 2022, PAs must have their own nonphysician practitioner national provider identification (NPI) number for billing purposes.  Specialty code 97 applies for PAs enrolled in Medicare.   B. Assignment Requirement   All claims for PA services must be made on an assignment basis.  If any person or entity (PA employer or, a provider/supplier for whom the PA furnishes services as an independent contractor) knowingly and willfully bills the beneficiary an amount in excess  of the appropriate coinsurance and deductible, the responsible party is subject to a civil monetary penalty not to exceed $2,000 for each such bill or request for payment.  120 - Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) Services Payment Methodology (Rev. 2656, Issuance: 02- 07-13, Effective: 02- 19-13, Implementation: 02- 19-13)  See chapter 15, sections 200 and 210 of the Medicare Benefit Policy Manual, pub. 100-02, for coverage policy for NP and CNS services.   A. General Payment   In general, NPs and CNSs are paid for covered services at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule.  There is a separate payment policy for paying for NP and CNS assis tant-at-surgery services.  See section 120.1 of this chapter.  B. Global Surgical Payments   When a NP or CNS furnish services to a patient during a global surgical period, A/B MACs (B) shall determine the level of NP or CNS involvement in furnishing part of the surgeons global surgical package consistent with their current practice for processing such claims.  NP or CNS services furnished during a global surgical period shall be paid at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule.  Billing requirements and adjudication of claims requirements for global surgeries are under chapter 12, sections 40.2 and 40.4 of the Medicare Claims Processing Manual, Pub. 100- 04.  120.1 - Limitations for Assistant -at-Surgery Services Furnished by Nurse Practitioners and Clinical Nurse Specialists  (Rev. 2656, Issuance: 02- 07-13, Effective: 02- 19-13, Implementation: 02- 19-13)
(Medicare Claims Processing Manual)
Medicare law at section 1833(a)(1)(O) of the Social Security Act authorizes payment for  services that NPs and CNSs furnish as an assistant -at-surgery.  Specifically, when a NP or CNS actively assists a physician in performing a surgical procedure and furnishes more than just ancillary services, the NPs and CNSs services are eligible for payment as assistant -at-surgery services.  For additional policy requirements concerning assistant -at-surgery services furnished by physicians and nonphysician practitioners, see chapter 12, section 20.4.3 of the Medicare Claims Processing Manual, Pub. 100- 04.  The A/B MAC (B) shall pay covered NP and CNS assistant- at-surgery services at 80 percent of the lesser of the actual charge or 85 percent of the 16 percent that a physician is paid under the Medicare Physician Fee Schedule.  Since physicians are paid at 16 percent of the surgical payment amount under the Medicare Physician Fee Schedule for assistant -at-surgery services, the actual payment amount that NPs and CNSs receive for assistant -at-surgery services is 13.6 percent of the amount paid to physicians.  Only the AS modifier must be reported on the claim form when a NP or CNS bills assistant -at-surgery services.  120.2 - Outpatient Mental Health Treatment Limitation  (Rev. 2656, Issuance: 02-07-13, Effective: 02- 19-13, Implementation: 02-19-13)  The A/B MAC (B) must apply the outpatient mental health treatment limitation (the limitation) to all covered mental health therapeutic services furnished by NPs and CNSs.  Refer to 210, below, for a discussion of the limitation.  120.3 - NP and CNS Billing to the A/B MAC (B)  (Rev. 2656, Issuance: 02-07-13, Effective: 02- 19-13, Implementation: 02-19-13)  A. NP and CNS Identification  NPs and CNSs must have their own nonphysician practitioner national provider identification (NPI) number for billing purposes.  NPs enrolling in Medicare use specialty code 50 and CNSs use specialty code 89.  B. Assignment Requirement
(Medicare Claims Processing Manual)
All claims for NP and CNS services must be made on an assignment basis.  Payment may be made directly to a NP or CNS for their professional services when furnished in collaboration with a physician.  If any person or entity (employer, NP or CNS) knowingly and willfully bills the beneficiary an amount in excess of the appropriate coinsurance and deductible, the responsible party is subject to a civil monetary penalty not to exceed $2,000 for each such bill or request for payment.  130 - Nurse -Midwife Services  (Rev. 1, 10-01-03)  B3-16004, 5257  See the Medicare Benefit Policy Manual, Chapter 15, for coverage policy for nurse-midwife services.   130.1 - Payment for Certified Nurse-Midwife Services  (Rev. 2024, Issued: 08- 06-10, Effective: 01-01-11, Implementation: 01-03-11)  Payment for certified nurse -midwife (CNM) services is made directly to CNMs for their professional services, and for services furnished incident to their professional services.  Also, CNMs are required to accept assigned payment for their services.  Accordingly, when CNMs bill for their services under specialty code 42, billing does not have to flow through a physician or facility unless the CNM reassigns their benefits to another billing entity.  For reassigned CNM services, the entity bills for CNM services using the specialty code 42 to signify that payment for CNM services is being claim ed.
(Medicare Claims Processing Manual)
Prior to December 31, 1991, Medicare Part B payment for CNM services was made at 80 percent of the lesser of the actual charge or, under a fee schedule that did not exceed 65 percent of the prevailing charge.  This payment methodology changed and effective  January 1, 1992, until December 31, 2010, payment for CNM services is made at 80 percent of the lesser of the actual charge, or 65 percent of the physician fee schedule amount for the same service performed by a physician.  However, effective on and after  January 1, 2011, payment for CNM services is made at 80 percent of the lesser of the actual charge, or 100 percent of the physician fee schedule amount for the same service performed by a physician.  Payment for covered drugs and biologicals furnished incident to CNMs services is made according to the Part B drug/biological payment methodology.  Covered clinical diagnostic lab services furnished by CNMs are paid according to the clinical diagnostic lab fee schedule.  Also, when CNMs furnish outpatient treatment services for mental illnesses, these services could be subject to the outpatient mental health treatment limitation (the limitation).  The appropriate percentage payment reduction under the limitation is applied first to the approved amount for the mental health treatment services before the actual payment amount is determined for the CNMs services.  Please refer to 210 of this manual to determine the appropriate percentage payment reduction under the limitation.   130.2 - Global Allowances  (Rev. 2024, Issued: 08- 06-10, Effective: 01 -01-11, Implementation: 01- 03-11)  When a certified nurse- midwife is providing most of the care to a Medicare beneficiary that is part of a global service and a physician also provides a portion of the care for this same global service, the fee paid to the CNM for his or her care is based o n the portion of the global fee that would have been paid to the physician for the care provided by the CNM.   For example, a CNM requests that the physician examine the beneficiary prior to delivery.  The CNM has furnished the ante partum care and intends to perform the delivery and post partum care.  The physician fee schedule amount for the physicians total obs tetrical care (global fee) is $1, 000.  The physician fee schedule amount for the physicians office visit is $30.  The following calculation shows the maximum allowance for the CNMs service:
(Medicare Claims Processing Manual)
Physician fee schedule amount for total obstetrical care  $1,000.00  Physician fee schedule amount for visit  - $30.00  Result  $ 970.00  Fee schedule amount for certified nurse -midwife (65% x $970, effective January 1, 1992 thru December 31, 2010.)  $ 630.50   Fee schedule amount for certified nurse -midwife (100% x 970, effective January 1, 2011.)  $970.00   Therefore, the certified nurse- midwife would be paid no more than 80 percent of $630.50, or   80 percent of $970.00 for services furnished on or after January 1, 2011, for the care of the beneficiary.   This calculation also applies when a physician provides most of the services and calls in a certified nurse- midwife to provide a portion of the care.   Physicians and certified nurse -midwives use reduced service modifiers to report that they have not provided all the services covered by the global allowance.   140 - Qualified Nonphysician Anesthetist Services  (Rev. 3883; Issued: 10- 13-17; Effective: 01 -16-18; Implementation: 01 -16-18)   Section 9320 of OBRA 1986 authorized payment under a fee schedule to certified registered nurse anesthetists (CRNAs) and anesthesiologists assistants. CRNAs and anesthesiologists assistants may bill Medicare directly for their services or have payment made to any individual or entity (such as a hospital, critical access hospital, physician, group practice, or ambulatory surgical center) with which the CRNA or anesthesiologists assistant has an employment or contractor relationship that provides for payme nt to be made to the individual or entity.     140.1  - Qualified Nonphysician  Anesthetists  (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17) For payment purposes, the term qualified nonphysician anesthetist is used to refer to both certified registered nurse anesthetists (CRNAs) and anesthesiologists assistants unless otherwise separately discussed.     An anesthesiologists assistant means a person who:    Works under the direction of an anesthesiologist;
(Medicare Claims Processing Manual)
An anesthesiologists assistant means a person who:    Works under the direction of an anesthesiologist;    Is in compliance with  all applicable requirements of State law, including any licensure requirements the state imposes on nonphysician anesthetists; and    Is a graduate of a medical school based anesthesiologist assistant educational program that    o Is accredited by the Committee on Allied Health Education and Accreditation;   And   o Includes approximately two years of specialized basic science and clinical education in anesthesia at a level that builds on a premedical undergraduate science background.    A CRNA is a registered nurse who:    is licensed as a registered professional nurse by the State in which the nurse practices;    Meets any licensure requirements the State imposes with respect to nonphysician anesthetists;    Has graduated from a nurse anesthesia educational program that meets the standards of the Council on Accreditation of Nurse Anesthesia Programs; and   Meets the following criteria: o Has passed a certification examination of the Council on Certification of Nurse Anesthetists or the Council on Recertification of Nurse Anesthetists;   Or   o Is a graduate of a nurse anesthesia educational program that meets the standards of the Council of Accreditation of Nurse Anesthesia Educational Programs, and within 24 months of graduation, has passed a certification examination of the Council on Certification of Nurse Anesthetists or the Council on Recertification of Nurse Anesthetists.    140.2  - Entity or Individual to Whom Fee Schedule is Payable for Qualified Nonphysician  Anesthetists  (Rev. 3883; Issued: 10- 13-17; Effective: 01 -16-18; Implementation: 01 -16-18)   Payment for the services of a qualified nonphysician anesthetist may be made directly to the qualified nonphysician anesthetist who furnished the anesthesia services or have payment made to any individual or entity (such as a hospital, critical access hospital, physician, group practice, or ambulatory surgical center) with which the CRNA or anesthesiologists assistant has an employment or contractor relationship that provides for payment to be made to the individual or entity.