evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Effective for claims submitted on or after April 1, 1998, providers that had not previously reported HCPCS/CPT for outpatient rehabilitation and CORF service s began using HCPCS to report these services.  This requirement does not apply to outpatient rehabilitation services provided by:    Critical access hospitals, which are paid on a cost basis, not MPFS;    RHCs, and FQHCs for which therapy is included in the al l-inclusive rate; or    Providers that do not furnish therapy services.   The following providers of services must bill the A/B MAC (A)  for outpatient rehabilitation services using HCPCS codes:    Hospitals (to outpatients and inpatients who are not in a covered Part A stay) ;     Skilled nursing facilities (SNFs) (to residents not in a covered Part A stay and to nonresidents who receive outpatient rehabilitation services from the SNF);    Home health agencies (HHAs) (to individuals who are not homebound or otherwise are not receiving services under a home health plan of care (POC).     Comprehensive outpatient rehabilitation facilities (CORFs); and    Providers of outpatient physical therapy and speech- language pathology services (OPTs), also known as rehabilitation agencies (previously termed outpatient physical therapy facilities in this instruction).   Note 1. The requirements for hospitals and SNFs apply to inpatient Part B and outpatient services only.  Inpatient Part A services are bundled into the respective prospective payment system payment; no separate payment is made.   Note 2.  For HHAs, HCPCS/CPT coding for outpatient rehabilitation services is required only when the HHA provides such service to individuals that are not homebound and, therefore, not under a home health plan of care.   The following practitioners must bill the A/B MAC (B)  for outpatient rehabilitation therapy services using HCPCS/CPT codes:    Physical therapists in private practice (PTPPs),    Occupational therapists in private practice (OTPPs),    Speech -language pathologists in private practice (SLPPs),    Physicians, including MDs, DOs, podiatrists and optometrists, and   Certain nonphysician practitioners (NPPs), acting within their State scope of practice, e.g., nurse practitioners and clinical n urse specialists.
(Medicare Claims Processing Manual)
 Certain nonphysician practitioners (NPPs), acting within their State scope of practice, e.g., nurse practitioners and clinical n urse specialists.   Providers billing to intermediaries shall report:   The date the therapy plan of care was either established or last reviewed (see 220.1.3B ) in Occurrence Code 17, 29, or 30.    The first day of treatment in Occur rence Code 35, 44, or 45.  B.  Applicable Outpatient Rehabilitation HCPCS Codes   The CMS identifies the codes listed at: http://www.cms.hhs.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage   as therapy services, regardless of the presence of a financial limitation.  Therapy services include only physical therapy, occupational therapy and speech -language pathology services.  Therapist means only a physical therapist, occupational therapist or speech -language pathologist. Therapy modifiers are GP for physical therapy, GO for occupational therapy, and GN for speech- language pathology.   When in effect, any financial limitation will also apply to services represented unless otherwise noted on the therapy page on the CMS Web site.  C.  Additional HCPCS Codes
(Medicare Claims Processing Manual)
Some HCPCS/CPT codes that are not on the list of therapy services should not be billed with a modifier.  For example, outpatient non- rehabilitation HCPCS codes G0237, G0238, and G0239 should be billed without therapy modifiers.  These HCPCS codes describe services for the improvement of respiratory function and may represent either incident to services or respiratory therapy services that may be appropriately billed in the CORF setting.  When the services described by these G -codes are provided by physica l therapists (PTs) or occupational therapists (OTs) treating respiratory conditions, they are considered therapy services and must meet the other conditions for physical and occupational therapy.  The PT or OT would use the appropriate HCPCS/CPT code(s) in the 97000 -  97799 series and the corresponding therapy modifier, GP or GO, must be used.  Another example of codes that are not on the list of therapy services and should not be billed with a therapy modifier includes the following HCPCS codes:  95860, 95861, 95863, 95864, 95867, 95869, 95870, 95900, 95903, 95904, and 95934.  These services represent diagnostic services -  not therapy services; they must be appropriately billed and shall not include therapy modifiers.  Other codes not on the therapy code li st, and not paid under another fee schedule, are appropriately billed with therapy modifiers when the services are furnished by therapists or provided under a therapy plan of care and where the services are covered and appropriately delivered (e.g., the therapist is qualified to provide the service).  One example of non- listed codes where a therapy modifier is indicated regards the provision of services described in the CPT code series, 29000 through 29590, for the application of casts and strapping.  Some of these codes previously appeared on the therapy code list, but were deleted because we determined that they represented services that are most often performed outside a therapy plan of care. However, when these services are provided by therapists or as an integral part of a therapy plan of care, the CPT code must be accompanied with the appropriate therapy modifier.  NOTE:  The above lists of HCPCS/CPT codes are intended to facilitate the contractors ability to pay claims under the MPFS.  It
(Medicare Claims Processing Manual)
therapy plan of care, the CPT code must be accompanied with the appropriate therapy modifier.  NOTE:  The above lists of HCPCS/CPT codes are intended to facilitate the contractors ability to pay claims under the MPFS.  It is not intend ed to be an exhaustive list of covered services, imply applicability to provider settings, and does not assure coverage of these services.
(Medicare Claims Processing Manual)
20.1 - Discipline Specific Outpatient Rehabilitation Modifiers - All Claims  (Rev. 11129, Issued: 11- 22-21, Effective : 01-01-22, Implementation: 01- 03-22)  Modifiers are used to identify therapy services whether or not financial limitations are in effect. When limitations are in effect, the CWF tracks the financial limitation based on the presence of therapy modifiers. P roviders/suppliers must continue to report one of these modifiers for any therapy code on the list of applicable therapy codes except as noted in 20 of this chapter. Consult 20 for the list of codes to which modifiers must be applied. These modifiers do not allow a provider to deliver services that they are not qualified and recognized by Medicare to perform.   The claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered:    GN Services delivered under an outpatient speech -language pathology plan of care;    GO Services delivered under an outpatient occupational therapy plan of care; or,    GP Services delivered under an outpatient physical therapy plan of care.   This is applicable to all claims from physicians, nonphysician practitioners (NPPs), PTPPs, OTPPs, SLPPs, CORFs, OPTs, hospitals, SNFs, and any others billing for physical therapy, speech -language pathology or occupational therapy services as noted on the applicable code list in 20 of this chapter.   Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy, occupational therapy and speech -language pathology services. They should never be used with codes that are not  on the list of applicable therapy services. For example, respiratory therapy services, or nutrition therapy services shall not be represented by therapy codes which require GN, GO, and GP modifiers.   Contractors edit institutional claims to ensure the fo llowing:   that a GN, GO or GP modifier is present for all lines reporting revenue codes 042X, 043X, or 044X.    that no more than one GN, GO or GP modifier is reported on the same service line.
(Medicare Claims Processing Manual)
 that no more than one GN, GO or GP modifier is reported on the same service line.   that revenue codes and modifiers are reported only in the following combinations:  o Revenue code 42x (physical therapy) lines may only contain modifier GP  o Revenue code 43x (occupational therapy) lines may only contain modifier GO  o Revenue code 44x (speech -language pathology) lines may only contain modifier GN.      that discipline -specific evaluation and re -evaluation HCPCS codes are always reported with the modifier for the associated discipline (e.g. modifier GP with a HCPCS code for a physical therapy evaluation).   Contractors return to the provider institutional claim s that do not meet one or more of these conditions.  CMS has established two modifiers, CQ and CO, for services furnished in whole or in part by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs). The modifiers are defined as f ollows:    CQ modifier:  Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant    CO modifier:  Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant   Effectiv e for claims with dates of service on and after January 1, 2020, the CQ and CO modifiers are required to be used, when applicable, for services furnished in whole or in part by PTAs and OTAs on the claim line of the service alongside the respective GP or GO therapy modifier, to identify those PTA and OTA services furnished under a PT or OT plan of care.
(Medicare Claims Processing Manual)
For those practitioners submitting professional claims who are paid under the PFS, the CQ/CO modifiers apply only to services of physical and occupationa l therapists in private practice (PTPPs and OTPPs); and not to the therapy services furnished by or incident to the services of physicians or nonphysician practitioners (NPPs)  including nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs)  because PTAs and OTAs do not meet the qualifications and standards of physical or occupational therapists, as required by  410.60 and 410.59, respectively.  However, the CQ and CO modifiers do apply to claims from physician or NPP groups when a PTPP or OTPP has reassigned their benefits to the group and their NPI appears as the rendering provider of the therapy service(s) on the claim.   For providers submitting institutional claims and paid at PFS rates for their outpatient PT and OT services, the CQ and CO modifiers apply to the following providers:  outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and CORFs.  However, the CQ and CO modifiers are not applicable to claims from criti cal access hospitals because they are paid on a reasonable cost basis, or from other providers for which payment for PT and OT services is not made under the PFS rates.   The CQ modifier must be paired to the GP therapy modifier and the CO modifier with the GO therapy modifier. Claims not so paired will be rejected/returned as unprocessable.     For dates of service, on and after January 1, 2022, claims billed with a CQ or CO modifier to indicate the services were furnished in whole or in part by a PTA or OTA are paid at an amount equal to 85 percent of the otherwise applicable Part B payment that s based on the MPFS.  The 15 percent reduction is taken last, e.g., after the MPPR (and other reductions where applicable) and right before sequestration. This reduction is taken from the paid amount, i.e., the actual amount paid not the MPFS allowed amount.
(Medicare Claims Processing Manual)
Regulations for the payment of therapy claims and the policy for assigning the therapy assistant modifiers (CO and CQ) for services provided in whole or in part by OTAs and PTAs are found at  410.59(a)(4) and 410.60(a)(4) for outpatient occupational and physical therapy services, respectively and at  410.105(d) for CORF OT and PT services.    20.2 - Reporting of Service Units With HCPCS  (Rev. 3670, Issued: 12- 01-16, Effective: 01- 01-17, Implementation: 01- 03-17)  A.  General   Effective with claims submitted on or after April 1, 1998, providers billing on the ASC X12 837 institutional claim format or Form CMS -1450 were required to report the number of units for outpatient rehabilitation services based on the procedure or service, e.g., based on the H CPCS code reported instead of the revenue code.  This was already in effect for billing on the Form CMS -1500, and CORFs were required to report their full range of CORF services on the institutional claim.  These unit- reporting requirements continue with t he standards required for electronically submitting health care claims under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) -  the currently adopted version of the ASC X12 837 transaction standards and implementation guides.  The Administrative Simplification Compliance Act mandates that claims be sent to Medicare electronically unless certain exceptions are met.   B.  Timed and Untimed Codes   When reporting service units for HCPCS codes where the procedure is not defined by a specifi c timeframe (untimed HCPCS), the provider enters 1 in the field labeled units.  For timed codes, units are reported based on the number of times the procedure is performed, as described in the HCPCS code definition.  EXAMPLE:  A beneficiary received a speech -language pathology evaluation represented by HCPCS untimed code 92521.  Regardless of the number of minutes spent providing this service only one unit of service is appropriately billed on the same day.
(Medicare Claims Processing Manual)
Several CPT codes used for therapy modaliti es, procedures, and tests and measurements specify that the direct (one on one) time spent in patient contact is 15 minutes.  Providers report these timed procedure codes for services delivered on any single calendar day using CPT codes and the appropria te number of 15 minute units of service.     EXAMPLE:  A beneficiary received a total of 60 minutes of occupational therapy, e.g., HCPCS timed code 97530 which is defined in 15 minute units, on a given date of service.  The provider would then report 4 unit s of 97530.  C.  Counting Minutes for Timed Codes in 15 Minute Units   When only one service is provided in a day, providers should not bill for services performed for less than 8 minutes.  For any single timed CPT code in the same day measured in 15 minute  units, providers bill a single 15- minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes.  If the duration of a single modality or procedure in a day is greater than or equal to 23 minutes, through and including 37 m inutes, then 2 units should be billed.  Time intervals for 1 through 8 units are as follows:   Units  Number of Minutes   1 unit:    8 minutes through 22 minutes   2 units:    23 minutes through 37 minutes   3 units:    38 minutes t hrough  52 minutes   4 units:    53 minutes t hrough 67 minutes   5 units:    68 minutes t hrough 82 minutes   6 units:    83 minutes t hrough 97 minutes   7 units:    98 minutes t hrough 112 minutes   8 units:    113 minutes t hrough 127 minutes   The pattern remains the same for treatment times in excess of 2 hours.   If a service represented by a 15 minute timed code is performed in a single day for at least 15 minutes, that service shall be billed for at least one unit.  If the service is performed for at least 30 minutes, that service sha ll be billed for at least two units, etc.  It is not appropriate to count all minutes of treatment in a day toward the units for one code if other services were performed for more than 15 minutes.  See examples 2 and 3 below.   When more than one service re presented by 15 minute timed codes is performed in a single day, the total number of minutes of service (as noted on the chart above) determines the number of timed units billed.  See example 1 below.
(Medicare Claims Processing Manual)
When more than one service re presented by 15 minute timed codes is performed in a single day, the total number of minutes of service (as noted on the chart above) determines the number of timed units billed.  See example 1 below.    If any 15 minute  timed service that is performed for 7 minutes or less than 7 minutes on the same day as another 15 minute timed service that was also performed for 7 minutes or less and the total time of the two is 8 minutes or greater than 8 minutes, then bill one unit for the service performed for the most minutes.  This is correct because the total time is greater than the minimum time for one unit.  The same logic is applied when three or more different services are provided for 7 minutes or less than 7 minutes. See e xample 5 below.  The expectation (based on the work values for these codes) is that a providers direct patient contact time for each unit will average 15 minutes in length.  If a provider has a consistent practice of billing less than 15 minutes for a uni t, these situations should be highlighted for review.   If more than one 15 minute timed CPT code is billed during a single calendar day, then the total number of timed units that can be billed is constrained by the total treatment minutes for that day .  See all examples below.   Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 15, Section 220.3B, Documentation Requirements for Therapy Services, indicates that the amount of time for each specific intervention/modality provided to the patient is not requir ed to be documented in the Treatment Note.  However, the total number of timed minutes must be documented.  These examples indicate how to count the appropriate number of units for the total therapy minutes provided.  Example 1    24 minutes of neuromuscul ar reeducation, code 97112, 23 minutes of therapeutic exercise, code 97110,  Total timed code treatment time was 47 minutes.   See the chart above.  The 47 minutes falls within the range for 3 units = 38 to 52 minutes.   Appropriate billing for 47 minutes is only 3 timed  units. Each of the codes is performed for more than 15 minutes, so each shall be billed for at least 1 unit.  The correct coding is 2 units of code 97112 and one unit of code 97110, assigning more timed units to the service that took the most time.
(Medicare Claims Processing Manual)
Example 2    20 minutes of neuromuscular reeducation (97112)  20 minutes therapeutic exercise (97110),  40 Total timed code minutes.  Appropriate billing for 40 minutes is 3 units.  Each service was done at least 15 minutes and should be billed for at  least one unit, but the total allows 3 units.  Since the time for each service is the same, choose either code for 2 units and bill the other for 1 unit.  Do not bill 3 units for either one of the codes.     Example 3    33 minutes of therapeutic exercise (97110),   7 minutes of manual therapy (97140),  40 Total timed minutes   Appropriate billing for 40 minutes is for 3 units.  Bill 2 units of 97110 and 1 unit of 97140. Count the first 30 minutes of 97110 as two full units.  Compare the remaining time for 97110 (33- 30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the larger, which is 97140.  Example 4    18 minutes of therapeutic exercise (97110),  13 minutes of manual therapy (97140),  10 minutes of gait training (97116),    8 minutes of ultrasound (97035),  49 Total timed minutes   Appropriate billing is for 3 units.  Bill the procedures you spent the most time providing.  Bill 1 unit each of 97110, 97116, and 97140.  You are unable to bill for the ultrasound because the total time of timed units th at can be billed is constrained by the total timed code treatment minutes (i.e., you may not bill 4 units for less than 53 minutes regardless of how many services were performed).  You would still document the ultrasound in the treatment notes.   Example 5   7  minutes of neuromuscular reeducation (97112)  7  minutes therapeutic exercise (97110)  7 minutes manual therapy (97140)    21 Total timed minutes   Appropriate billing is for one unit.  The qualified professional (See definition in Pub. 100-02, chapter 15, section 220) shall select one appropriate CPT code (97112, 97110, 97140) to bill since each unit was performed for the same amount of time and only one unit is allowed.
(Medicare Claims Processing Manual)
NOTE:  The above schedule of times is intended to provide assistance in rounding t ime into 15- minute increments.  It does not imply that any minute until the eighth should be excluded from the total count.  The total minutes of active treatment counted for all 15 minute timed codes includes all direct treatment time for the timed codes.   Total treatment minutes -  including minutes spent providing services represented by untimed codes -  are also documented.  For documentation in the medical record of the services provided see Pub. 100- 02, chapter 15, section 220.3.  D.  Specific Limits fo r HCPCS     The Deficit Reduction Act of 2005, section 5107 requires the implementation of clinically appropriate code edits to eliminate improper payments for outpatient therapy services.  The following codes may be billed, when covered, only at or below the  number of units indicated on the chart per treatment day.  When higher amounts of units are billed than those indicated in the table below, the units on the claim line that exceed the limit shall be denied as medically unnecessary (according to 1862(a)(1) (A)).  Denied claims may be appealed and an ABN is appropriate to notify the beneficiary of liability.   This chart does not include all of the codes identified as therapy codes; refer to section 20 of this chapter for further detail on these and other the rapy codes.  For example, therapy codes called always therapy must always be accompanied by therapy modifiers identifying the type of therapy plan of care under which the service is provided.  Use the chart in the following manner:   The codes that are al lowed one unit for Allowed Units in the chart below may be billed no more than once per provider, per discipline, per date of service, per patient.  The codes allowed 0 units in the column for Allowed Units, may not be billed under a plan of care indic ated by the discipline in that column.  Some codes may be billed by one discipline (e.g., PT) and not by others (e.g., OT or SLP).
(Medicare Claims Processing Manual)
When physicians/NPPs bill always therapy codes they must follow the policies of the type of therapy they are providing e.g ., utilize a plan of care, bill with the appropriate therapy modifier (GP, GO, GN), bill the allowed units on the chart below for PT, OT or SLP depending on the plan.  A physician/NPP shall not bill an always therapy code unless the service is provided under a therapy plan of care.  Therefore, NA stands for Not Applicable in the chart below.   When a sometimes therapy code is billed by a physician/NPP, but as a medical service, and not under a therapy plan of care, the therapy modifier shall not be use d, but the number of units billed must not exceed the number of units indicated in the chart below per patient, per provider/supplier, per day.   NOTE:  As of April 1, 2017, the chart below uses the CPT Consumer Friendly Code Descriptions which are intended only to assist the reader in identifying the service related to the CPT/HCPCS code.  The reader is reminded that these descriptions cannot be used in place of the CPT long descriptions which officially define each of the services.   The table below no lon ger contains a column noting whether a code is timed or untimed as this notation is not relevant to the number of units allowed per code on claims for the listed therapy services. We note that the official long descriptors for the CPT codes can be found in the latest CPT code book.  CPT/  HCPCS  Code  CPT Consumer Friendly Code Descriptions and PT  Allowed Units  OT  Allowed Units  SLP  Allowed Units  Physician/ NPP Not