evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
BHI is a team -based, collaborative approach to care that focuses on integrative treatment  of patients with primary care and mental or behavioral health conditions. Effective  January 1, 2018, RHCs and FQHCs are paid for general BHI services when a minimum  of 20 minutes of qualifying general BHI services during a calendar month is furni shed to patients with one or more new or pre -existing behavioral health or psychiatric conditions  being treated by the RHC or FQHC primary care practitioner, including substance use  disorders, that, in the clinical judgment of the RHC or FQHC primary care practitioner,  warrants  BHI  services.  General BHI  service requirements  include:   An initial assessment and ongoing monitoring using validated clinical rating  scales;   Behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status  changes;   Facilitating  and coordinating  treatment such as psychotherapy,  pharmacotherapy,  counseling  and/or  psychiatric  consultation; and  Continuity  of care with a designated member  of the care  team.  230.2. 5 Payment for General Care Management Services                    (Rev. 11803; Issued: 0 1-26-23; Effective: 01 -01-23; Implementation: 02- 27-23) CCM services furnished between January 1, 2016, and December 31, 2017, are paid based on the PFS national average non- facility payment rate when CPT code 99490 is  billed  alone  or with other payable  services on  an RHC  or FQHC claim.  CCM or general BHI services furnished between January 1, 2018, and December 31, 2018, are paid at the average of the national  non- facility  PFS payment  rate for CPT codes  99490 (30 minutes or more of CCM services), 99487 (60 minutes or more of complex  CCM services), and 99484 (20 minutes or more of general behavioral health integration services), when general care man agement HCPCS code G0511 is on an RHC or FQHC  claim,  either  alone  or with  other  payable  services.  CCM or general BHI services furnished on or after January 1, 2019, are paid at the  average of the national non- facility PFS payment rate for CPT codes 99490, 99487, 99484, and 99491(30 minutes or more of CCM furnished by a physician or other  qualified
(Medicare Benefit Policy Manual)
are paid at the  average of the national non- facility PFS payment rate for CPT codes 99490, 99487, 99484, and 99491(30 minutes or more of CCM furnished by a physician or other  qualified  health  care professional), when general  care management  HCPCS  code  G0511 is on an RHC or  FQHC  claim, either  alone  or with  other  payable  services.
(Medicare Benefit Policy Manual)
CCM, PCM or general BHI services furnished on or after January 1, 2021 are paid at  the average of the national non- facility PFS payment rate for CPT codes 99490, 99487, 99484, and 99491, and CPT  codes  99424 (30 minutes or more of PCM services  furnished by physicians o r non- physician practitioners (NPPs)) and 99426 (30 minutes  or more of PCM services furnished by clinical staff under the direct supervision of a  physician or NPP), when general care management HCPCS code G0511 is on an RHC  or FQHC claim, either alone or with other payable services.    CCM, PCM, CPM or general BHI services furnished on or after January 1, 2023 are paid at the average of the national non- facility PFS payment rate for CPT codes 99490, 99487, 99484, 99491, 99424 and 99426 when general care management HCPCS code G0511 is on an RHC or FQHC claim, either alone or with other payable services. The payment rate for  HCPCS  code  G0511 is updated annually  based  on the  PFS amounts for  these codes.  Coinsurance for care management services is 20 percent of  lesser of submitted charges or  the payment rate for G0511. Care management costs are reported in the non- reimbursable section of the cost report and are not used in determining the RHC AIR or  the FQHC  PPS rate.  G0511 can be billed once  per month per  beneficiary  when  at least 20  minutes of CCM services, at least 30 minutes of PCM services, or at least 20 minutes of  general  BHI  services  have  been  furnished and  all other  requirements  have  been  met.  Only services furnished by an RHC or FQHC practitioner or auxiliary personnel that are within the scope of service elements can be counted toward the minimum 20 minutes that  is required to bill for CCM and general BHI  services and the minimum 30 minutes that is  required to bill for PCM services, and does not include administrative activities such as  transcription  or translation services.      230.3  Psychiatric Collaborative Care Model (CoCM) Services  (Rev. 263, Issued: Effective: 01- 01-20, Implementation: 01- 23-20)
(Medicare Benefit Policy Manual)
230.3  Psychiatric Collaborative Care Model (CoCM) Services  (Rev. 263, Issued: Effective: 01- 01-20, Implementation: 01- 23-20)  Psychiatric CoCM is a specific model of car e provided by a primary care team consisting of a primary care provider and a health care manager who work in collaboration with a psychiatric consultant to integrate primary health care services with care management support for patients receiving behavior al health treatment.  It includes regular psychiatric inter-specialty consultation with the primary care team, particularly regarding patients whose conditions are not improving.  The primary care team regularly reviews the beneficiarys treatment plan and  status with the psychiatric consultant and maintains or adjusts treatment, including referral to behavioral health specialty care, as needed.  Patients with mental health, behavioral health, or psychiatric conditions, including substance use disorders, who are being treated by an RHC or FQHC practitioner may be eligible for psychiatric CoCM services, as determined by the RHC or FQHC primary care practitioner.  A separately billable initiating visit with an RHC or FQHC primary care practitioner (physician, NP, PA, or CNM) is required before psychiatric CoCM services can be furnished.  This visit can be an E/M, AWV, or IPPE visit, and must occur no more than one -year prior to commencing care management services.   Psychiatric CoCM services do not need to have  been discussed during the initiating visit, and the same initiating visit can be used for psychiatric CoCM as for CCM and BHI services, as long as it occurs with an RHC or FQHC primary care practitioner within one year of commencement of psychiatric CoCM services.  Beneficiary consent to receive care management services must be obtained either by or under the direct supervision of the RHC or FQHC primary care practitioner, may be written or verbal and must be documented in the patients medical record before psychiatric CoCM services are furnished.  The medical record should document that the beneficiary has been informed about the availability of care management services, has given permission to consult with relevant specialists as needed, and has been inf ormed of all of the following:
(Medicare Benefit Policy Manual)
 There may be cost -sharing (e.g. deductible and coinsurance in RHCs, and coinsurance in FQHCs) for both in-person and non- face- to-face services that are provided;  Only one practitioner/facility can furnish and be paid for these services during a calendar month; and   They can stop care management services at any time, effective at the end of the calendar month.   Beneficiary consent remains in effect unless the benef iciary opts out of receiving care management services.  If the beneficiary chooses to resume care management services after opting out, beneficiary consent is required before care management services can resume.  If the beneficiary has not opted out of car e management services but there has been a period where no care management services were furnished, a new beneficiary consent is not required.  RHC or FQHC Practitioner Requirements   The RHC or FQHC practitioner is a primary care physician, NP, PA, or CNM who:  Directs the behavioral health care manager and any other clinical staff;   Oversees the beneficiarys care, including prescribing medications, providing treatments for medical conditions, and making referrals to specialty care when needed; and   Remains i nvolved through ongoing oversight, management, collaboration and reassessment.
(Medicare Benefit Policy Manual)
Behavioral Health Care Manager Requirements  The behavioral health care manager is a designated individual with formal education or specialized training in behavioral health, in cluding social work, nursing, or psychology, and has a minimum of a bachelors degree in a behavioral health field (such as in clinical social work or psychology), or is a clinician with behavioral health training, including RNs and LPNs.  The behavioral health care manager furnishes both face- to-face and non-face- to-face services under the general supervision of the RHC or FQHC practitioner and may be employed by or working under contract to the RHC or FQHC.  The behavioral health care manager:   Provides assessment and care management services, including the administration of validated rating scales;   Provides behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whos e status changes;   Provides brief psychosocial interventions;   Maintains ongoing collaboration with the RHC or FQHC practitioner;   Maintains a registry that tracks patient follow -up and progress;   Acts in consultation with the psychiatric consultant;  Is available to provide services face -to-face with the beneficiary; and   Has a continuous relationship with the patient and a collaborative, integrated relationship with the rest of the care team.   Psychiatric Consultant Requirements   The psychiatric consultant is a medical professional trained in psychiatry and qualified to prescribe the full range of medications.  The psychiatric consultant is not required to be on site or to have direct contact with the patient and does not prescribe medications or furni sh treatment to the beneficiary directly.  The psychiatric consultant:    Participates in regular reviews of the clinical status of patients receiving psychiatric CoCM services;   Advises the RHC or FQHC practitioner regarding diagnosis and options for resolvi ng issues with beneficiary adherence and tolerance of behavioral health treatment; making adjustments to behavioral health treatment for beneficiaries who are not progressing; managing any negative interactions between beneficiaries behavioral health and medical treatments; and   Facilitates referral for direct provision of psychiatric care when clinically indicated.  Payment for Psychiatric CoCM
(Medicare Benefit Policy Manual)
Psychiatric CoCM services furnished on or after January 1, 2019, are paid at the average of the national non- facility PFS payment rate for CPT codes 99492 (70 minutes or more of initial psychiatric CoCM services) and CPT code 99493 (60 minutes or more of subsequent psychiatric CoCM services) when psychiatric CoCM HCPCS code, G0512, is on an RHC or FQHC claim, either alone or with other payable services.  This rate is updated annually based on the PFS amounts for these codes.  At least 70 minutes in the first calendar month, and at least 60 minutes in subsequent calendar months, of psychiatric CoCM services must have b een furnished in order to bill for this service.  Coinsurance for psychiatric CoCM services is 20 percent of the lesser of submitted charges or the payment rate for G0512.  Psychiatric CoCM costs are reported in the non-reimbursable section of the cost report and are not used in determining the RHC AIR or the FQHC PPS rate.  G0512 can be billed once per month per beneficiary when all requirements have been met.   Only services furnished by an RHC or FQHC practitioner or auxiliary personnel that are within the scope of service elements can be counted toward the minimum 60 minutes that is required to bill for psychiatric CoCM services and does not include administrative activities such as transc ription or translation services.    240  Virtual Communication Services  (Rev. 252, Issued: 12-07-18, Effective: 01-01-19, Implementation: 01- 02 -19)  Virtual communication services are RHC and FQHC services and include communications-based technology and remote evaluation services.  The RHC and FQHC face-to-face requirements are waived when these services are furnished to an RHC or FQHC patient.   Effec tive January 1, 2019, RHCs and FQHCs receive an additional payment for the costs of communication technology- based services or remote evaluation services that are not already captured in the RHC AIR or the FQHC PPS payment when the requirements for these s ervices are met.  Coinsurance and deductibles apply to RHC claims, and coinsurance applies to FQHC claims for these services.  Requirements
(Medicare Benefit Policy Manual)
The following requirements must be met for RHCs and FQHCs to bill for virtual communication services:   At least 5 minutes of communications-based technology or remote evaluation services are furnished by an RHC or FQHC practitioner to a patient that has had a billable visit in the RHC or FQHC within the previous year; and   The medical discussion or remote evaluation is  for a condition not related to an RHC or FQHC service provided within the previous 7 days, and does not lead to an RHC or FQHC service within the next 24 hours or at the soonest available appointment.  If the discussion between the patient and the RHC or FQHC practitioner is related to a billable visit furnished by the RHC or FQHC within the previous 7 days or within the next 24 hours or at the soonest available appointment, the cost of the RHC or FQHC practitioners time would be included in the RHC AIR or the FQHC PPS payment and is not separately billable.   Payment for Virtual Communication Services  Virtual communication services furnished by RHCs and FQHCs on or after January 1, 2019, are paid at the  average of the national non- facility PFS payment rate for HCPCS code G2012 (communication technology -based services), and HCPCS code G2010 (remote evaluation services), when the virtual communication HCPCS code, G0071, is on an RHC or FQHC claim, either alone or with other payable services. The payment rate for HCPCS code G0071 is updated annually based on the PFS amounts for these codes.     Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R11803BP  01/26/2023  Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update 02/27/2023  13063  R10729BP  04/26/2021  Updates to Medicare Benefit Policy Manual for Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services (Manual Updates Only)  05/26/2021  12252
(Medicare Benefit Policy Manual)
12/20/2019  Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update 01/23/2020  11575  R252BP  12/07/2018  Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update 01/02/2019  11019  R239BP  01/09/2018  Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update 01/22/2018  10350  R238BP  11/17/2017  Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Medicare Benefit Policy Manual Chapter 13 Update  02/15/2018  10350  R230BP  12/09/2016  Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Updates  03/09/2016  9864 R220BP  01/15/2016  Rural Health Clinic and Federally Qualified Health Center - Medicare Benefit Policy Manual Update 02/01/2016  9442 R217BP  12/31/2015  Rural Health Clinic and Federally Qualified Health Center - Medicare Benefit Policy Manual Update  Rescinded and replaced by Transmittal 220 02/01/2016  9442 R201BP  12/12/2014  Medicare Benefit Policy Manual - RHC and FQHC Update - Chapter 13 01/05/2015  8981 R173BP  11/22/2013  Medicare Benefit Policy Manual - RHC and FQHC Update - Chapter 13 01/06/2014  8504 R166BP  01/31/2013  Reorganization of Chapter 13 03/01/2013  7824 R114BP  10/30/2009  Outpatient Mental Health Treatment Limitation  01/04/2010  6686 R49BP  03/31/2006  Payment of Federally Qualified Health Centers (FQHCs) for Diabetes Self- Management Training Services (DSMT) and Medical Nutrition Therapy (MNT) Services  06/29/2006  4385 R40BP  11/18/2005  Skilled Nursing Facility Prospective Payment System  02/16/2006  4079 R1BP  10/01/2003  Introduction to the Benefit Policy Manual N/A N/A Back to top of Chapter
(Medicare Claims Processing Manual)
Medicare Claims Processing Manual  Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims   Table of Contents (Rev. 10640, 08-06-21)  Transmittals for Chapter 8   10 - General Description of  the End Stage Renal Disease Prospective Payment System (ESRD PPS)  10.1 - Billing for Additional Treatments  10.2 - Uncompleted Treatments  10.3 - No -Shows  10.4 - Deductible and Coinsurance  10.5 - Hospital Services  10.6 - Amount of Payment  10.7 - ESRD Services Not Provided Within the United States  10.8 - Transportation Services  10.9 - Dialysis Provider Number Series  20 - Calculation of the End Stage Renal Disease Prospective Payment System (ESRD PPS)  Per Treatment Payment Amount   20.1 - Calculation of the Basic Case-Mix Adjusted Composite Rate and the ESRD Prospective Payment System Rate 20.1.1 - Calculation for Double Amputee Dialysis Patients  20.2 - Pediatric Payment Model for ESRD PPS         20.3 - End Stage Renal Disease  Quality Incentive Program (QIP)  30 - Publication of the Prospective Payment System (PPS) Base Rate   40 - Acute Kidney Injury (AKI) Claims   50 - In-Facility Dialysis Bill Processing Procedures  50.1  Lab Service Included in the End Stage Renal Dis ease Prospective Payment System (ESRD PPS)
(Medicare Claims Processing Manual)
50.1.1 - Laboratory Services Performed During Emergency Room Service  50.1.5 - Lab Services Included in the Prospective Payment System 50.1.6 - Laboratory Services Performed During Emergency Room Service  50.2 - Drugs and Biologicals Included in the End Stage Renal Disease   50.2.5 - Drugs and Biologicals Included in the PPS  50.3 -  Required Information for In- Facility Claims Paid Under  the  End Stage Renal   Disease Prospective Payment System (ESRD PPS)  50.3.1 -  Submitting Corrected Bills  50.4 -  Line Item Detail Billing and Automated Claim Adjustments  50.5 -  Intermittent Peritoneal Dialysis (IPD)  in the Facility  50.6-  In-Facility Back -Up Dialysis  50.6.1 -  Payment for In -Facility Maintenance Dialysis Sessions Furnished to Continuous Ambulatory Peritoneal Dialysis (CAPD) Continuous Cycling Peritoneal Dialysis (CCPD)  Home Dialysis Patients  50.6.2 -  Payment for Hem odialysis Sessions  50.7 -  Ultrafiltration  50.8 -  Training and Retraining 50.9 -  Coding for Adequacy of Dialysis, Vascular Access and Infection  60 - Separately Billable ESRD Items and Services  60.1 -  Lab Services  60.2 -  Drugs Furnished in Dialysis Facilities  60.2.1 -  Billing Procedures for Drugs for Facilities  60.2.1.1 -  Separately Billable ESRD Drugs  60.2.1.2 -  Facilities Billing for ESRD Oral Drugs as Injectable Drug Equivalents  60.2.2 -  Drug Payment Amounts for Facilities
(Medicare Claims Processing Manual)
60.2.3 -  Facility Billing Requirements to the A/B MAC (A)  60.2.4 -  Physician Billing Requirements to the A/B MAC (B)  60.2.4.1 -  Facility Billing Requirements to the A/B MAC (A)  60.2.4.2 -  Physician Billing Requirements to the A/B MAC (B)  60.3 -  Blood and Blood Products  Furnished in Hospital Based and Independent Dialysis Facilities  60.4 -  Erythropoietin Stimulating Agents (ESAs)  60.4.1 -  ESA Claims Monitoring Policy  60.4.2 -  Facility Billing Requirements for ESAs  60.4.2.1 -  Other Information Required on the Form CMS -1500 for Epoetin Alfa (EPO  60.4.2.2 -  Completion of Subsequent Form CMS -1500 Claims for Epoetin Alfa (EPO)  60.4.3.1 -  Other Information Requi red on the Form CMS -1500 for Epoetin Alfa (EPO)  60.4.3.2 -  Completion of Subsequent Form CMS -1500 Claims for Epoetin Alfa (EPO)
(Medicare Claims Processing Manual)
60.4.3 Reserved for Future Use  60.4.4 -  Payment Amount for ESAs  60.4.4.1 -  Payment for Epoetin Alfa (EPO) in Other Settings  60.4.4.2 -  Epoetin Alfa (EPO) Provided in the Hospital Outpatient Departments  60.4.5.1 -  Self Administered ESA Supply  60.4.6.1 -   Reserved for Future Use  60.4.6.2 -   Reserved for Future Use  60.4.6.3 -  Payment for Darbepoetin Alfa (Aranesp)  60.4.6.4 -  Payment for Darbepoetin Alfa (Aranesp) in Other Settings  60.4.6.5 -  Payment for Darbepoetin Alfa (Aranesp) in the Hospital Outpatient Department  60.4.7 -  Payment for Peginesatide in the Hospital Outpatient Department  60.5-  Intradialytic Parenteral/Enteral Nutrition (IDPN)  60.6 -  Vaccines Furnished to ESRD Patients  60.7-  Reserved  for Future Use  60.8-  Shared Systems Changes for Medicare Part B Drugs for ESRD Independent Dialysis Facilities  70 - Payment for Home Dialysis  70.1 -  Method Selection for Home Dialysis Payment  70.1.1 -  Change in Method 70.2 -  - Prevention of Double Billing Under Method I and II  70.3 -  Overpayments  80 - Home Dialysis Method I Billing to the A/B MAC ( A) 80.1 -  Items and Services Included in the ESRD PPS payment  for Home Dialysis  80.2 -  General A/B MAC (A) Bill Processing Procedures for Method I Home Dialysis Services  80.2.1 -  Required Billing Information for Method I Claims  80.3 -  Calculating Payment for Intermittent Peritoneal Dialysis (IPD) for Method I Claims Submitted to the A/B MAC (A)  80.3.1 -  IPD at Home for Method  I Claims Submitted to the A/B MAC (A)   80.4 -  Calculating Payment for Continuous Ambulatory Peritoneal Dialysis (CAPD) and Continuous Cycling Peritoneal Dialysis (CCPD) Under the ESRD PPS    90 - Reserved f or Future Use   90.1 -  DME MAC Denials for Beneficiary Submitted Claims Under Method II  90.2 -  Requirements for Payment by the DME MAC
(Medicare Claims Processing Manual)
Dialysis (CCPD) Under the ESRD PPS    90 - Reserved f or Future Use   90.1 -  DME MAC Denials for Beneficiary Submitted Claims Under Method II  90.2 -  Requirements for Payment by the DME MAC  90.2.1 -  Supplier Documentation Required  90.2.2 -  DME MAC Letter Explaining Requirements to Method II Supplier  90.3-  Amount of Payment by the DME MAC  90.3.1 -  Billing Instructions for Method II to DME MACs  90.3.2 -  Home Dialysis Supplies and Equipment HCPCS Codes Used to Bill the DME MAC  90.3.3 -  DME MAC Claims Processing Instructions  90.4 -  Equipment and Equipment Related Servic es Provided to Direct Dealing Beneficiary  90.5-  Method II Support Services Billed to the A/B MAC (A) by the Facility  90.5.1 -  Billable Revenue Codes Under Method II  90.5.1.1 -  Unbillable Revenue Codes Under Method II   100 -  Dialysis Sessions Furnished to Patients Who Are Traveling 100.1 -  Traveling Patients Who Are Normally In -Facility Dialysis Patients  100.2 -  Traveling Patients Who are Normally Home Dialysis  100.3 -  Physicians Services Furnished to a Dialysis Patient Away From Home or Usual Facility  110 -  Reduction in Medicare Program Payment t o Fund ESRD Networks   120 -  Renal Transplantation and Related Services  120.1 -  Payment for Immunosuppressive Drugs Furnished to Transplant Patients   130 -  Physicians and Supplier (Nonfacility) Billing for ESRD Services -  General  130.1 -  Initial Method for Physicians Services to Maintenance Dialysis Patients  140 -  Monthly Capitation Payment Method for Physicians Services Furnished to Patients on Maintenance Dialysis  140.1 -  Payment for ESRD -Related Services Under the Monthly Capitation Payment (Center Based Patients)  140.1.1 -  Payment for Managing Patients on Home Dia lysis 140.1.2 -  Patients That Switch Modalities (Center to Home and Vice Versa)  140.2 -  Payment for ESRD -Related Services (Per Diem)  140.2.1 -  Guidelines for Physician or Practitioner Billing (Per Diem)  140.3-  Data Elements Required on Claim for Monthly Capitation Payment  140.4 -  Controlling Claims Paid Under the Monthly Capitation Payment Method  150 -  Physicians Self -Dialysis Training Services  160 -  Payment for Physicians Services Furnished to Dialysis Inpatients