evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
An independent laboratory that has acquired another independent laboratory that had an arrangement of July 22, 1999, with a covered hospital, can bill the TC of physician pathology services for that hospitals inpatients and outpatients under the physician fee schedule.   An independent laboratory that furnishes the TC of physician pathology services to inpatients or outpatients of a hospital that is not a covered hospital may not bill the A/B MAC (B) for the TC of physician pathology services during the time 542 is in eff ect.  If the arrangement between the independent laboratory and the covered hospital limited the provision of TC physician pathology services to certain situations or at particular times, then the independent laboratory can bill the A/B MAC (B) only for these li mited services.   The A/B MAC (B) shall require independent laboratories that had an arrangement, on or prior to July 22, 1999 with a covered hospital, to bill for the technical component of physician pathology services to provide a copy of this agreement, or other document ation substantiating that an arrangement was in effect between the hospital and the independent laboratory as of this date.  The independent laboratory must submit this documentation for each covered hospital that the independent laboratory services.   C. Physician Laboratory and Pathology Services   Physician laboratory and pathology services are limited to:    Surgical pathology services;    Specific cytopathology, hematology and blood banking services that have been identified to require performance by a physician and are listed below;    Clinical consultation services that meet the requirements in subsection 3 below; and    Clinical laboratory interpretation services that meet the requirements and which are specifically listed in subsection 4 below.   1. Surgical Pathology Services   Surgical pathology services include the gross and microscopic examination of organ tissue performed by a physician, except for autopsies, which are not covered by Medicare.   Depending upon circumstances and the billing entity, the A/B MACs (B) may pay professional component, technical component or both.  2. Specific Hematology, Cytopathology and Blood Banking Services
(Medicare Claims Processing Manual)
Depending upon circumstances and the billing entity, the A/B MACs (B) may pay professional component, technical component or both.  2. Specific Hematology, Cytopathology and Blood Banking Services   Cytopathology services include the examination of cells from fluids, washings, brushings or smears, but generally excluding hematology.  Examining cervical and vaginal smears are the most common service in cytopathology.  Cervical and vaginal smears do not  require interpretation by a physician unless the results are or appear to be abnormal.  In such cases, a physician personally conducts a separate microscopic evaluation to determine the nature of an abnormality.  This microscopic evaluation ordinarily doe s require performance by a physician.  When medically necessary and when furnished by a physician, it is paid under the fee schedule.   For services furnished prior to January 1, 1999, A/B MACs (B)  pay separately under the physician fee schedule for the interpretation of an abnormal pap smear furnished to a hospital inpatient by a physician.  They must pay under the clinical laboratory fee schedule for pap smears furnished in all other situations.  This  policy also applies to screening pap smears requiring a physician interpretation.  For services furnished on or after January 1, 1999, A/B MACs (B)  allow separate payment for a physicians interpretation of a pap smear to any patient (i.e., hospital or n on-hospital) as long as:  (1) the laboratorys screening personnel suspect an abnormality; and (2) the physician reviews and interprets the pap smear.   This policy also applies to screening pap smears requiring a physician interpretation and described in the National Coverage Determination Manual and Chapter 18.  These services are reported under codes P3000 or P3001.  Physician hematology services include microscopic evaluation of bone marrow aspirations and biopsies.  It also includes those limited number of peripheral blood smears which need to be referred to a physician to evaluate the nature of an apparent abnormali ty identified by the technologist. These codes include 85060, 38220, 85097, and 38221.  A/B MACs (B) pay the PC for the interpretation of an abnormal blood smear (code 85060) furnished to a hospital inpatient by a hospital physician or an independent laboratory.
(Medicare Claims Processing Manual)
For other hematology codes, payment may be made for the PC component if the service is furnished to a patient by a hospital physician or independent laboratory.  In addition, payment may be made for these services furnished to patients by an independent la boratory.   Blood banking services of hematologists and pathologists are paid under the physician fee schedule when analyses are performed on donor and/or patient blood to determine compatible donor units for transfusion where cross matching is difficult or where contamination with transmissible disease of donor is suspected.   The blood banking codes are 86077, 86078, and 86079 and represent professional component only services.   3. Clinical Consultation Services   Clinical consultations are paid under the physician fee schedule only if they:   a. Are requested by the patients attending physician;   b. Relate to a test result that lies outside the clinically significant normal or expected range in view of the condition of the patient;   c. Result in a written narrative report included in the patients medical record; and   d. Require the exercise of medical judgment by the consultant physician.  Clinical consultations are professional component services only, i.e., there is no TC service. The clinical consultation codes are 80500 and 80502.  Routine conversations held between a laboratory director and an attending physician about test orders or results do not qualify as consultations unless all four requirements are met.  Laboratory personnel, including the director, may from time to time cont act attending physicians to report test results or to suggest additional testing or be contacted by attending physicians on similar matters.  These contacts do not constitute clinical consultations.  However, if in the course of such a contact, the attendi ng physician requests a consultation from the pathologist, and if that consultation meets the other criteria and is properly documented, it is paid under the fee schedule.   EXAMPLE:  A pathologist telephones a surgeon about a patients suitability for surgery based on the results of clinical laboratory test results.  During the course of their conversation, the surgeon asks the pathologist whether, based on test results, patient histor y and medical records, the patient is a candidate for surgery.  The surgeons request requires the pathologist to render a medical judgment and provide a consultation.  The pathologist follows up his/her oral advice with a written report and the surgeon notes in the patients medical record that he/she requested a consultation.  This consultation is paid under the fee schedule.
(Medicare Claims Processing Manual)
In any case, if the information could ordinarily be furnished by a nonphysician laboratory specialist, the service of the physician is not a consultation payable under the fee schedule.   See the Program Integrity Manual for guidelines for related data analysis to identify inappropriate patterns of billing for consultations.  4. Clinical Laboratory Interpretation Services   Only clinical laboratory interpretation services, which meet the criteria in subsections C.3.a, c, and d, are billable under the physician fee schedule.  These codes have a PC/TC indicator of 6 on the Medicare Physician Fee Schedule database.  These serv ices are reported under the clinical laboratory code with modifier 26.  These services can be paid under the physician fee schedule if they are furnished to a patient by a hospital pathologist or an independent laboratory.  Note that a hospitals standing order policy can be used as a substitute for the individual request by the patients attending physician.  A/B MACs (B) are not allowed to revise CMSs list to accommodate local medical practice.  The CMS periodically reviews this list and adds or deletes clinical laboratory codes as warranted.   D. Global Billing   Billing globally for services that are split into separate PC and TC services is only possible when the PC and TC are furnished by the same physician or supplier entity.  For example, where the PC and the TC of a diagnostic service are provided in the same service location, this is reflected as the address entered into Item 32 on CMS Form 1500, which provides the ZIP Code to pay the right locality/GPCI.  In this case, the physician/entity may bill globally.  However, if the PC and the TC are each provided in different service locations (enrolled practice locations), the PC and the TC must be separately billed.   Merely applying the same place of service (POS) code to the PC and the TC does not permit global billing for any diagnostic procedure.  70 - Payment Conditions for Radiology Services  (Rev. 1, 10-01-03) B3-15022 See chapter 13, for claims processing instructions for radiology. 80 - Services of Physicians Furnished in Providers or to Patients of Providers  (Rev. 1, 10-01-03) B3-15014
(Medicare Claims Processing Manual)
This section sets forth special conditions that govern payments for services that physicians furnish in, or to patients of, providers of services including hospitals, SNFs, or Comprehensive Outpatient Rehabilitation Facilities ( CORFs).  If physicians are compensated for their services by a provider or another entity, the compensation they receive must be allocated among the various types of services they furnish. The A/B MAC (A) pays for services that physicians furnish to the provider.  Physician services to the provider include, but are not limited to, standby surgical services.  Payment for physicians services to individual patients that meet the conditions in subsection A is made under the physicians fee schedule.  However:  Payment for physicians services furnished in teaching settings is subject to the additional conditions in 100;  Payment for physicians services furnished to ESRD patients is subject to additional requirements in Chapter 8, and  The A/B MAC (A) pays for the services of residents, as well as for physicians who are licensed to practice only in the provider setting, as provider services.  (See 100.2)  A. Conditions for Physician Fee Schedule Payment for Physicians Services to Patients in Providers   1. General  A/B MACs (B) pay for physicians services to patients of providers on a fee schedule basis only if the following requirements are met:   The services are personally furnished for an individual patient by a physician;  The services contribute directly to the diagnosis or treatment or an individual patient;  The services ordinarily require performance by a physician; and  In the case of anesthesiology, radiology, or pathology/laboratory services, certain additional requirements in 50, 60, and 70
(Medicare Claims Processing Manual)
are met.  2. Services of Physicians to Patients in Providers  If a physician furnishes services to a patient in a hospital or SNF that do not meet the requirements in 80.A.1 , above, but are related to patient care, the services may be covered as provider services and paid by the A/B MAC (A) within the applicable Prospective Payment System (PPS) rate.  3. Effect of Billing Charges for Physician Services to Provider  If services furnished by a physician to a provider may be paid by the A/B MAC (A), neither the provider nor the physician may seek fee schedule payments from the A/B MAC (B), the beneficiary, or another insurer.  A/B MACs (B) must report any situation in which this happens to the RO unless it is clearly an isolated case of billing error.  4. Effect of Assumption of Operating Costs  If a physician or an entity enters into an agreement (such as a lease or concession) with a provider under which the physician (or entity) assumes some or all of the operating costs of the provider department:  A/B MACs (B) make fee schedule payments only for physicians services to individual patients;  The physician (or other entity) must make its books and records available to the provider and the A/B MAC (A), as necessary, to verify the nature and extent of the costs of the services furnished by the physician (or other entity); and  The lessees costs associated with producing these services, including overhead, supplies, equipment, and the costs of employing nonphysician personnel are payable by the A/B MAC (A) as provider services.  80.1 - Coverage of Physicians Services Provided in Comprehensive Outpatient Rehabilitation Facility  (Rev. 1, 10-01-03) B3-2220  Rehabilitation services furnished by comprehensive outpatient rehabilitation facilities (CORFs) are covered by Medicare Part B.   Under 1832(a)(2)(E), and 1861(cc)(2) (go to http://www.ssa.gov/OP_Home/ssact/title18/1800.htm
(Medicare Claims Processing Manual)
Under 1832(a)(2)(E), and 1861(cc)(2) (go to http://www.ssa.gov/OP_Home/ssact/title18/1800.htm and select the applicable title) and related provisions of the Act, a CORF is recognized as a provider of services on the basis of its reasonable costs.  Except for diagnostic and therapeutic services provided by physicians to individual patients, payment is made to the CORF by A/B MACs (A) (acting in the role of the A/B MAC (B).)  Physicians diagnostic and therapeutic services furnished to a CORF patient are not considered CORF physicians services.  Instead they are services that the physician must bill to the A/B MAC (B).  If covered services, payment is made according to the Medicare Physician Fee Schedule.  When physicians diagnostic and therapeutic services are furnished in a CORF, the claim must be annotated to show the CORF as the place of treatment.  Services considered administrative services provided by the physician associated with the CORF are considered CORF services reimbursable to the CORF by the A/B MACs (A).  Administrative services include consultation with and medical supervision of nonphysi cian staff, establishing and reviewing the plan of treatment, and other medical and facility administration activities.  80.2 - Rural Health Clinic and Federally Qualified Health Center Services  (Rev. 1, 10-01-03) B3-2260-2260.3
(Medicare Claims Processing Manual)
Payment may be made under Part B for the medical and other health services furnished by a qualified rural health clinic (RHC) and Federally qualified health centers (FQHCs).  The covered services RHCs/FQHCs may offer are divided into two basic groups:  RHC /FQHC services (defined below) and other medical and other health services covered under Part B.  Items and services which meet the definition of RHC services or FQHC services are reimbursed either by designated RHC intermediaries, or a national FQHC FI in the case of independent RHCs/FQHCs, or by the providers A/B MAC (A) in the case of provider base d clinics.  In either case, the A/B MAC (B) does not pay claims for services defined as RHC/FQHC services.  The A/B MAC (A) pays for such services through a prospectively determined encounter rate.  Where an RHC or a FQHC is approved for billing other medical and health services to the A/B MAC (B), the RHC or FQHC bills the A/B MAC (B) and is paid according to the method of payment for the service provided. Rural health clinic and Federally qualified health center services are described in the Medicare Benefit Policy Manual, Chapter 13.  That chapter provides that the following services usually performed by physicians are included as services included in the encounter rate and therefore are not separately billable for RHC/FQHC patients.  They are:   Professional services performed by a physician for a patient including diagnosis, therapy, surgery, and consultation (See the Medicare Benefit Policy Manual, Chapter 15);   Services and supplies incident to a physicians services, as described in the Benefit Policy Manual, Chapter 15;   Nurse practitioner and physician assistant services (including the services of specialized nurse practitioners and nurse midwives) that would be covered if furnished by a physician, provided the nurse practitioner or physician assistant is legally permitte d to perform the services by the State in which they are performed;   Services and supplies incident to the services of nurse practitioners and physician assistants that would be covered if furnished incident to a physicians services, and   Visiting nurse  services to the homebound. However, the technical component of diagnostic services may be billed separately by the physician to the A/B MAC (B), if provided.  See Chapter 9, and the
(Medicare Claims Processing Manual)
a physicians services, and   Visiting nurse  services to the homebound. However, the technical component of diagnostic services may be billed separately by the physician to the A/B MAC (B), if provided.  See Chapter 9, and the Medicare Benefit Policy Manual, Chapter 13, for additional information on the definition of RHC/FQHC services.  Also, an RHC or FQHC may provide other items and services which are covered under Part B, but which are not defined as RHC or FQHC services.  They are listed in the Medicare Benefit Policy Manual, Chapter 13.  Independent RHCs/FQHCs bill the A/B MAC (B) for such services.  Provider -based RHC/FQHC services are billed to the A/B MAC (A) as services of the parent provider.  Independent RHCs/FQHCs must enroll with the A/B MAC (B) in order to bill.  (See the Medicare Program Integrity Manual, Chapter 10, for enrollment instructions). 80.3 - Unusual Travel (CPT Code 99082)  (Rev. 1, 10- 01-03) B3-15026 In general, travel has been incorporated in the MPFSDB individual fees and is thus not separately payable.  A/B MACs (B) must pay separately for unusual travel (CPT code 99082) only when the physician submits documentation to demonstrate that the travel wa s very unusual. 90 - Physicians Practicing in Special Settings  (Rev. 1, 10- 01-03) 90.1 - Physicians in Federal Hospitals  (Rev. 1, 10- 01-03) B3-2020.5 There are many physicians performing services in hospitals operated by the Federal Government, e.g., military, Veterans Administration, and Public Health Service hospitals.  Normally Medicare does not pay for the services provided by a physician in a Feder al hospital except when the hospital provides services to the public generally as a community institution.  Such a physician working in the scope of his Federal employment may be considered as coming within the statutory definition of physician even though he may not have a license to practice in the State in which he is employed.  90.2 - Physician Billing for End -Stage Renal Disease Services  (Rev. 1, 10- 01-03) See the Medicare Benefit Policy Manual, Chapter 11, for a description of ESRD policy. See chapter 8, for
(Medicare Claims Processing Manual)
is employed.  90.2 - Physician Billing for End -Stage Renal Disease Services  (Rev. 1, 10- 01-03) See the Medicare Benefit Policy Manual, Chapter 11, for a description of ESRD policy. See chapter 8, for billing requirements for physicians and facilities.  90.2.1 - Inpatient Hospital Visits With Dialysis Patients  (Rev. 1, 10- 01-03) B3-15062- 15062.1 Global billing practices that involve the submission of charges for each day that a patient is hospitalized are allowed.  Therefore, A/B MACs (B) may make payment for inpatient hospital visits that are specified relative to time, place, day, and services d irectly provided to inpatients.  This guideline may, however, differ with respect to daily visit charges for inpatient hospital visits with dialysis inpatients.  When an ESRD patient is hospitalized, the hospitalization may or may not be due to a renal -related condition.  In either case, the patient must continue to be dialyzed.  Chapter 8 provides policy and payment instructions for physicians services furnished to dialysis inpatients.  It also provides instructions for billing physicians renal -related medical services furnished on dialysis days and for dialysis and evaluation a nd management services performed on the same day.
(Medicare Claims Processing Manual)
90.3 - Physicians Services Performed in Ambulatory Surgical Centers (ASC)  (Rev. 1604, Issued: 09- 26-08, Effective: 01 -08-08, Implementation: 01- 05-09)  See Chapter 14, for a description of services that may be billed by an ASC and services separately billed by physicians.  The ASC payment does not include the professional services of the physician. These are billed separately by the physician. Physicians services include the services of anesthesiologists administering or supervising the administration of anesthesia to ASC patients and the patients recovery from the anesthesia. The term physicians services also includes any routine pre - or postoperative services, such as office visits, consultations, diagnostic tests, removal of stitches, changing of dressings, and other se rvices which the individual physician usually performs.   The physician must enter the place of service code (POS) 24 on the claim to show that the procedure was performed in an ASC.   The A/B MAC (B) pays the facility fee from the MPFSDB to the physician. The facility fee is for services done in a facility other than the physicians office and is typically less than the nonfacility fee for services performed in the physicians office.   90.4 - Billing and Payment in a Health Professional Shortage Area (HPSA)  (Rev. 1273; Issued:  06 -29-07; Effective/Implementation Dates:  10 -01-07)  In accordance with 1833(m)  of the Act, physicians who provide covered professional services in any rural or urban HPSA are entitled to an incentive payment.  Beginning January 1, 1989, physicians providing services in certain classes of rural HPSAs were entitled to a 5- percent incentive payment.  Effective January 1, 1991, physicians providing services in either rural or urban HPSAs are eligible for a 10- percent incentive payment.
(Medicare Claims Processing Manual)
Eligibility for receiving the 10 percent bonus payment is based on whether the specific location at which the service is furnished is within an area that is designated (under section 332(a)(1)(A) of the Public Health Services Act) as a HPSA. The Health Res ources and Services Administration (HRSA), within the Department of Health & Human Services, is responsible for designating shortage areas.  HRSA designates three types of HPSAs:  geographic, population, and facility-based.  Geographic-based HPSAs are areas with shortages of primary care physicians, dentists or psychiatrists.  Population-based HPSAs are designations based on underserved populations within an area.  Facility -based HPSAs are designations based on a public or non-profit private facility that is providing services to an underserved area or population and has an insufficient capacity to meet their needs.   Section 1833(m) of the Social Security Act (the Act) provides incentive payments for physicians who furnish services in areas designated as HPSAs under section 332 (a)(1)(A) of the Public Health Service (PHS) Act.  This section of the PHS Act pertains to g eographic-based HPSAs.  Consequently, Medicare incentive payments are available only in geographic HPSAs.