evekhm/cms_iom_500 huggingface dataset:
Article - Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians – Medical Policy Article (A52825)
Doctorate or Masters level Clinical Psychologist: 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90880, 90899Doctorate or Masters level Clinical Social Worker: 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899Clinical Nurse Specialist (CNS): 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899Nurse Practitioner (NP): 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90846, 90847, 90849, 90853, 90899Marriage and Family Therapist (MFT): 90832, 90834, 90837, 90839, 90840, 90846, 90847, 90849, 90853, 90899, 96105, 96112, 96113, 96116, 96121, 96130, 96131, 96136, 96137, 96138, 96139, 96146, G0451Mental Health Counselor (MHC): 90832, 90834, 90837, 90839, 90840, 90846, 90847, 90849, 90853, 90899, 96105, 96112, 96113, 96116, 96121, 96130, 96131, 96136, 96137, 96138, 96139, 96146, G0451
Article - Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians – Medical Policy Article (A52825)
The psychological services referenced in the above HCPCS codes may only be delegated to employees who qualify for one of the categories of individuals listed above. For example, a psychiatrist may hire a clinical social worker to perform services designated by the HCPCS codes listed in #2 above. Individuals who are performing services "incident to" a qualified Medicare practitioner are not required to be separately enrolled as an independent practitioner in Medicare.It is not permissible for the billing provider to hire and supervise a professional whose scope of practice is outside the provider's own scope of practice as authorized under State law, or whose professional qualifications exceed those of the "supervising" provider. For example, a certified nurse-midwife (CNM) may not hire a psychologist and bill for that psychologist's services under the "incident to" provision, because a psychologist's services are not integral to a CNM's personal professional services and are not regularly included in the CNM's bill. Even though sections 1861(s)(2)(l) and 1861(gg) (l) of the Social Security Act authorize coverage for services furnished "incident to" a CNM's services, psychological services are not commonly furnished in CNM's offices nor within their scope of practice. Similarly, even though section 1861(s)(2)(K)(iv) authorizes coverage for services furnished "incident to" a physician assistant's services, a physician assistant would not be qualified to supervise psychological services performed by the types of individuals listed above.Individuals who are not licensed or otherwise authorized by state law to provide psychological services may not provide psychological services under the "incident to" provision. This level of professional credentialing is necessary to furnish appropriate medically necessary services under the "incident to" provision.
Article - Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians – Medical Policy Article (A52825)
Psychological services furnished to Medicare beneficiaries under the "incident to" provision by individuals other than those listed above are not covered. (Note: the standards for professional credentialing are higher for these services billed to Medicare Part B than for similar services performed by other mental health professionals not under the "incident to" provision and billed to Medicare Part A. Under the "incident to" provision, services are performed in the place of the billing provider. In order for services performed and billed under the "incident to" provision to be commensurate with the services performed by the billing provider, and therefore medically necessary, this higher standard of professional credentialing is necessary.)Coverage of services and supplies "incident to" the professional services of a physician in private practice is limited to situations in which there is general physician supervision of auxiliary personnel.(CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60.1B. This also applies to the services of certain non - physician practitioners who are being licensed by the states under various programs to assist or act in the place of the physician, including nurses, clinical psychologists, clinical social workers, marriage and family therapists, mental health counselors and other therapists.General Supervision - means the procedure is furnished under the physicians overall direction and control, but the physicians presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.(CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15).Services and supplies incident to a physicians service in a physician directed clinic or group association are generally the same as those described for the office setting(CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60.3).For hospital patients and for SNF patients who are in a Medicare covered stay, there is no Medicare Part B coverage of the services of physician-employed auxiliary personnel as services incident to physicians' services undersection 1891(s)(2)(A)of the Act. Such services can be covered only under the hospital outpatient or inpatient benefit and payment for such services can be made to only the hospital by a Medicare Part A MAC (CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60).
Article - Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians – Medical Policy Article (A52825)
For "incident to" services to be covered when a physician's office is in an institution, theauxiliary medical personnel must be members of the office staff rather than of the institution's staff, and the cost of supplies must represent an expense to the physician's office practice. In addition, services performed by the employees of the physician outside the "office" area must be generally supervised by the physician. (In any setting, of course, supervision of auxiliary personnel in and of itself is not considered a "physician's professional service" to which the services of the auxiliary personnel could be an incidental part, i.e., in addition to supervision, the physician must perform or have performed a personal professional service to the patient to which the services of the auxiliary personnel could be considered an incidental part). Denials for failure to meet any of these requirements would be based on 1861(s)(2)(A) of the Act.(CMS Pub 100-03;Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 1, 70.3)If auxiliary personnel perform services outside the office setting, e.g., in a patient's home or in an institution (other than a hospital or SNF), their services are covered incident to a physician's service only if there is general supervision.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed.Advance Beneficiary Notice of Noncoverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04,Medicare Claims Processing Manual,Chapter 30, for complete instructions.General Coding Guidelines for Psychiatry and Psychology Services:
Article - Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians – Medical Policy Article (A52825)
General Coding Guidelines for Psychiatry and Psychology Services:Individual psychotherapy codes should be used only when the focus of treatment involves individual psychotherapy. These codes should not be used as generic psychiatric service codes when other codes such as an evaluation and management (E/M) service or pharmacological codes would be more appropriate.Charges for certain psychiatric services provided by hospital outpatient departments are submitted to the Part A MAC. Services of physicians, clinical psychologists, physician assistants, nurse practitioners, and clinical nurse specialists are billed to the Part B MAC. Services furnished incident to the professional services of clinical psychologists to hospital patients remain bundled with the facility services for payment purposes, with payment made to the hospital for such "incident to" services.For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.Claims for Psychological Services Coverage Under the "Incident to" Provision are payable under Medicare Part B in settings other than a hospital or to a resident of a skilled nursing facility who are in a Part A stay.For claims submitted to the Part A MAC:Hospital Inpatient Claims:The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04.The principal diagnosis is the condition established after study to be chiefly responsible for this admission.The hospital enters ICD-9-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04,Medicare Claims Processing Manual,Chapter 25, Section 75 for additional instructions.)Hospital Outpatient Claims:
Article - Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians – Medical Policy Article (A52825)
Hospital Outpatient Claims:The hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67.If no definitive diagnosis is made during the outpatient evaluation, the patient's symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the providershould report an ICD-9-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9).The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.Information on state specific providers licensed or authorized to provide psychological services "incident to" a physician, clinical psychologist, clinical nurse specialist, or nurse practitioner (as defined in the "Indications" section above), can be found at respective State Web sites regarding the licensing and certification of mental health providers.Sources of Information:CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA):Section 1833(e) of Title XVIII of the Social Security Act prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1861(s)(2)(A) of Title XVIII of the Social Security Act defines'medical and other health services' as "any of the following items or services: services and supplies (including drugs and biologicals which cannot, as determined in accordance with regulations, be self  aministered) furnished as an incident to a physician's professional service, of kinds which are commonly furnished in physicians' offices and are commonly either rendered without charge or included in the physicians' bills;"Sections 1861(s)(2)(l) and 1861(gg)(l) of Title XVIII "incident to" a certified nurse midwife's(CNMW's)services.Section 1861(s)(2)(K)(iv) of Title XVIII of the Social Security Act authorizes coverage for services furnished "incident to" a physician assistant's services.
Article - Psychological Services Coverage under the Incident to Provision for Physicians and Non-physicians – Medical Policy Article (A52825)
Section 1861(s)(2)(K)(iv) of Title XVIII of the Social Security Act authorizes coverage for services furnished "incident to" a physician assistant's services.Section 1862(a)(1)(A) of Title XVIII of the Social Security Act excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.CMS Publications:CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15:60.1 Incident to Physician's Professional Services60.2 Services of Nonphysician Personnel Furnished Incident to Physician's Services60.3 Incident to Physician's Service in Clinic60.4 Services Incident to a Physician's Service to Homebound Patients under General Physician Supervision160 Clinical Psychological Services170 Clinical Social Worker (CSW) Services210 Clinical Nurse Specialist (CNS) ServicesCMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1:70.3 Physician's Office Within an Institution - Coverage of Services and Supplies Incident to a Physicians ServicesCMS Publication 100-04,Medicare Claims Processing Manual,Chapter 12:110 Physician Assistant (PA) Services Payment Methodology110.3 PA Billing to Carrier120 Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) Services.120.1 Direct Billing and Payment for Nonphysician Practitioner Services Furnished to Hospital Inpatients and Outpatients150 Clinical Social Worker (CSW) Services160 Independent Psychologist Services160.1 Payment for Independent Psychologist Services170 Clinical Psychologist Services.170.1 Payment for Clinical Psychologist Services
Article - Billing and Coding: Hospice: Determining Terminal Status (A52830)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Hospice - Determining Terminal Status.
Article - Billing and Coding: Hospice: Determining Terminal Status (A52830)
National Coverage Provisions:With passage of the Affordable Care Act in March 2010, Congress required hospice physicians or hospice nurse practitioners to have a face-to-face encounter with Medicare hospice patients prior to the 180th-day recertification and every recertification thereafter, and to attest that the encounter occurred. CMS proposed and implemented policies related to this new requirement in the Home Health Prospective Payment System Rate Update for CY 2011; Changes in Certification Requirements for Home Health Agencies and Hospices Final Rule (75 FR 70372). This new face-to-face encounter requirement became effective on January 1, 2011.Hospice certifications and recertifications must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less, either as part of the form or as an addendum. Physicians must briefly synthesize the clinical information supporting the terminal diagnosis, and attest that they composed the narrative after reviewing the clinical information, and where applicable, examining the patient. The narrative must reflect the patients individual clinical circumstances. Narratives associated with the third and later benefit period must also include an explanation of why the clinical findings of the face-to-face encounter support a life expectancy of 6 months or less. (CMS Pub 100-02. Medicare Benefit Policy Manual,Chapter 9, Section 20.1)For recertifications on or after January 1, 2011, a hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient prior to the beginning of the patients third benefit period, and prior to each subsequent benefit period. (CMS Pub 100-02. Medicare Benefit Policy Manual,Chapter 9, Section 20.1)
Article - Billing and Coding: Hospice: Determining Terminal Status (A52830)
A hospice physician or hospice nurse practitioner must have a face-to-face encounter with patients prior to the third benefit period recertification and each subsequent recertification. This encounter can occur up to 30 calendar days prior to recertification, and the hospice physician or nurse practitioner must attest that the visit occurred. The certification or recertification must include the benefit period dates to which it applies, and be signed and dated by the certifying or recertifying physician. Initial certifications may be prepared no more than 15 calendar days prior to the effective date of election. Recertifications may be prepared no more than 15 calendar days prior to the start of the subsequent benefit period. (CMS Pub 100-02, Medicare Benefit Policy Manual,Chapter 9, Section 20.1)Hospice nurse practitioners may conduct face-to-face encounters as described in 20.1(5) as part of the certification process, but are still prohibited by statute from certifying the terminal illness. (CMS Pub 100-02. Medicare Benefit Policy Manual,Chapter 9, Section 20.1)Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Article - Billing and Coding: Hospice: Determining Terminal Status (A52830)
For claims submitted to the fiscal intermediary or Part A MAC:The patient's principal diagnosis, i.e., the terminal illness, should be reported in Form Locator (FL) 67 of the UB-04. Additional or secondary diagnoses, i.e., comorbidities, may be reported in FLs 67A  67Q.Reasons for DenialMedical review of records of hospice patients that do not document that patients meet the guidelines set forth in the LCD may result in denial of coverage unless other clinical circumstances reasonably predictive of a life expectancy of six months or less are provided.The condition of some patients receiving hospice care may stabilize or improve during or due to that care, with the expectation that the stabilization or improvement will not be brief and temporary. In such circumstances, if the patients condition changes such that he or she no longer has a prognosis of life expectancy of six months or less, and that improvement can be expected to continue outside the hospice setting, then that patient should be discharged from hospice.Documentation Guidelines:
Article - Billing and Coding: Hospice: Determining Terminal Status (A52830)
Documentation certifying terminal status must contain enough information to support terminal status upon review. Documentation of the applicable criteria listed under the Indications section ofthe LCD would meet this requirement. If other clinical indicators of decline not listed in tthe LCD form the basis for certifying terminal status, they should be documented as well. Recertification for hospice care requires the same clinical standards be met as for initial certification, but they need not be reiterated. They may be incorporated by specific reference as part (or all) of the indication for recertification.Documentation should paint a picture for the reviewer to clearly see why the patient is appropriate for hospice care and the level of care provided, i.e., routine home, continuous home, inpatient respite, or general inpatient. The records should include observations and data, not merely conclusions. However, documentation should comport with normal clinical documentation practices. Unless elements in the record require explanation, such as a non-morbid diagnosis or indicators of likely greater than six month survival, as stated below, no extra or additional record entries should be needed to show hospice benefit eligibility.The amount and detail of documentation will differ in different situations. A patient with metastatic small cell CA may be demonstrated to be hospice eligible with less documentation than one with chronic lung disease. Patients with chronic lung disease, long term survival in hospice, or apparent stability can still be eligible for hospice benefits, but sufficient justification for a less than six-month prognosis should appear in the record.If the documentation includes any findings inconsistent with or tending to disprove a less than six-month prognosis, they should be answered or refuted by other entries, or specifically addressed and explained. Most facts and observations tending to suggest a greater than six month prognosis are predictable and apparent, such as a prolonged stay in hospice or a low immediate mortality diagnosis, as stated above. But specific entries can also call for an answer, such as an opinion by one team member or recovery of ADLs when they were part of the basis for the initial declaration of eligibility. Also the lack of certain elements such as a tissue diagnosis for cancer will not negate eligibility, but does necessitate other supportive documentation.
Article - Billing and Coding: Hospice: Determining Terminal Status (A52830)
Documentation submitted may include information from periods of time outside the billing period currently under review. Include supporting events such as a change in the level of activities of daily living, recent hospitalizations, and the known date of death (if you are billing for a period of time prior to the billing period in which death occurred).Submitted documentation should always include the admission assessment, as well as any evaluations and Interdisciplinary Group (IDG) discussions used for recertification. Records that show the progression of the patients illness are very helpful.Documentation should support the level of care being provided to the patient during the time period under review, i.e. routine or continuous home or inpatient, respite or general. The reviewer should be able to easily identify the dates and times of changes in levels of care and the reason for the change.