evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The CPT SNF/NF code definition includes intermediate care facilities (ICFs) and long term care facilities (LTCFs).  These codes are limited to the specific 2 -digit POS 31 (SNF), 32 (Nursing Facility), 54 (Intermediate Care Facility/Individuals with Intelle ctual Disabilities) and 56 (Psychiatric Residential Treatment Center).   The CPT nursing facility codes should be used with POS 31 (SNF) if the patient is in a Part A SNF stay and POS 32 (nursing facility) if the patient does not have Part A SNF benefits.  There is no longer a different payment amount for a Part A or Part B benefit period in these POS settings.   30.6.14.1 - Home or Residence Services (Codes 99341 - 99350) When Performed in Place of Service 12 (Home)   (Rev. 11732, Issued: 12 -08-22, Effective: 01- 01-23, Implementation: 01- 03-23)  A. Requirement for Physician Presence in Place of Service 12 (Home)  A home visit using codes 99341- 99350 with POS 12 cannot be billed by a physician unless the physician was actually present in the beneficiarys home.  Section 10.1.1 in Chapter 1 of this manual provides additional information on billing with POS 12.
(Medicare Claims Processing Manual)
B. Homebound Status  Under the home health benefit the beneficiary must be confined to the home for services to be covered.  For home services provided by a physician using 99341- 99350 with POS 12, the beneficiary does not need to be confined to the home.    C. Fee Schedule Payment for Services to Homebound Patients under General Supervision  Payment may be made in some medically underserved areas where there is a lack of medical personnel and home health services for injections, EKGs, and venipunctures that are performed for homebound patients under general physician supervision by nurses and paramedical employees of physicians or physician- directed clinics.  Section 60.4 in Chapter 15 of the Medicare Benefit Policy Manual (Pub. 100- 02) provides additional information on the provision of services to homebound Medicare patients.  30.6.15 - Prolonged Services, Standby Services, and  Evaluation and Management Service for Power Mobility Devices (PMDs) (G0372)            (Rev. 11842; Issued; 02- 09-23 Effective:01 -01-23; Imple(mentation: 05 -09-23)  30.6.15.1 - Prolonged Services   General Rules  (Rev. 11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)  Prolonged E/M services may be reported for certain E/M visit families, when the total visit time spent by the practitioner exceeds a certain time threshold. Prolonged E/M services are reported using Medicare -specific coding.   See section 30.6.18 for rules regarding billing of E/M visits that are split (or shared) and involve prolonged service time.   30.6.15.2 Prolonged Office/Outpatient E/M Visits  (Rev. 11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)  When the practitioner selects visit level using time, the practitioner may report prolonged office/outpatient E/M visit time using HCPCS add -on code G2212 (Prolonged office/outpatient E/M services). The following table provides reporting examples.
(Medicare Claims Processing Manual)
HCPCS Code(s)  Total Time Required for Reporting*  99205  60-74 minutes  99205 x 1 and G2212 x 1  89-103 minutes  99205 x 1 and G2212 x 2  104-118 minutes  99215  40-54 minutes  99215 x 1 and G2212 x 1  69-83 minutes  99215 x 1 and G2212 x 2  84-98 minutes  99215 x 1 and G2212 x 3 or more for each additional 15 minutes.  99 or more   *Total time is the sum of all time, including prolonged time, spent by the reporting practitioner on the date of service of the visit.  HCPCS code G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215, 99483 for office or other outpatient evaluation and management services). (Do not report G2212 on the same d ate of service as 99354, 99355, 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes)).   Qualifying activities are listed in the CPT Codebooks E/M Service Guidelines (Guidelines for Selecting Level of Service Based on Time). These activities may be counted when time is used to select visit level, when performed and medically reasonable and ne cessary.   30.6.15.3 Prolonged Other E/M Visits  (Rev. 11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)  Beginning January 1, 2023, prolonged Other E/M visit services are reported as discussed in this section. Other E/M visits include inpatient/observation visits, nursing facility visits, home/residence visits, and cognitive impairment assessment and care pla nning. Prolonged Other E/M services may be reported with the highest visit level, for timed visits, when the total visit time spent by the practitioner exceeds a certain time threshold.   Prolonged services are not reported in conjunction with emergency department visits or critical care services.
(Medicare Claims Processing Manual)
Prolonged services are created to provide payment for additional practitioner time that is not already accounted for in the valuation of the primary service. Accordingly, practitioner time spent in qualifying activities can be counted when performed on any date within the surveyed timeframe for the visit, and when the total time (in the physician time file) is exceeded by 15 or more minutes. We show this in the following table.  Primary E/M Service  Prolonged Code*  Time Threshold to Report Prolonged  Count physician/NPP time spent within this time period (surveyed timeframe)  Initial IP/Obs. Visit (99223)  G0316  90 minutes  Date of visit  Subsequent IP/Obs. Visit (99233)   G0316  65 minutes  Date of visit  IP/Obs. Same -Day Admission/Discharge (99236)  G0316  110 minutes  Date of visit to 3 days after  IP/Obs. Discharge Day Management (99238 -9) n/a n/a n/a Emergency Department Visits  n/a n/a n/a Initial NF Visit (99306)  G0317  95 minutes  1 day before visit + date of visit + 3 days after  Subsequent NF Visit (99310)  G0317  85 minutes  1 day before visit + date of visit + 3 days after  NF Discharge Day Management  n/a n/a n/a Home/Residence Visit New Pt (99345)  G0318  140 minutes  3 days before visit + date of visit + 7 days after  Home/Residence Visit Estab. Pt (99350)  G0318  110 minutes  3 days before visit + date of visit + 7 days after  Cognitive Assessment and Care Planning (99483)  G2212  100 minutes  3 days before visit + date of visit + 7 days after  Consults  n/a n/a n/a * Time must be used to select visit level. Prolonged service time can be reported when furnished on any date within the primary visits surveyed timeframe and includes time with or without direct patient contact by the physician or NPP. Consistent with CPT s approach, we do not assign a frequency limitation.   Qualifying activities are listed in the CPT Codebooks E/M Service Guidelines (Guidelines for Selecting Level of Service Based on Time). These activities may be counted when time is used to select visit level, when performed and medically reasonable and ne cessary.
(Medicare Claims Processing Manual)
30.6.15.4 - Power Mobility Devices (PMDs) (Code G0372)  (Rev. 748, Issued:  11- 04-05; Effective/Implementation Dates:  10 -25-05)  Section 302(a)(2)(E)(iv) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) sets forth revised conditions for Medicare payment of Power Mobility Devices (PMDs).  This section of the MMA states that payment for motorized or power wheelchairs may not be made unless a physician (as defined in 1861(r)(1) of the Act), a physician assistant, nurse practitioner, or a clinical nurse specialist (as those terms are defined in 1861(aa)(5)) has conducted a face -to-face examination of the beneficiary and written a prescriptio n for the PMD.  Payment for the history and physical examination will be made through the appropriate evaluation and management (E&M) code corresponding to the history and physical examination of the patient.  Due to the MMA requirement that the physician or treating practitioner create a written prescription and a regulatory requirement that the physician or treating practitioner prepare pertinent parts of the medical record for submission to the durable medical equipment supplier, code G0372 (physician service required t o establish and document the need for a power mobility device)  has been established to recognize additional physician services and resources required to establish and document the need for the PMD.   The G code indicates that all of the information necessary to document the PMD prescription is included in the medical record, and the prescription and supporting documentation is delivered to the PMD supplier within 30 days after the face -to-face examinat ion.  Effective October 25, 2005, G0372 will be used to recognize additional physician services and resources required to establish and document the need for the PMD and will be added to the Medicare physician fee schedule.   30.6.17  Physician Management Associated with Superficial Radiation Treatment  (Rev.4339, Issued: 07- 25-19, Effective: 01 -01-19, Implementation: 08- 27-19)
(Medicare Claims Processing Manual)
30.6.17  Physician Management Associated with Superficial Radiation Treatment  (Rev.4339, Issued: 07- 25-19, Effective: 01 -01-19, Implementation: 08- 27-19)   Evaluation and management codes for levels I through III (99211, 99212, and 99213) may be billed with modifier 25 when performed for the purpose of reporting physician work associated with radiation therapy planning, radiation treatment device construction, and radiation treatment management when performed on the same date of service as superficial radiation treatment delivery.   See chapter 13, section 70.2, of  this manual for information regarding services bundled into treatment management codes.  30.6.18 - Split (or Shared) Visits  (Rev. 11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)  A. Definition of Split (or Shared) Visit   A split (or shared) visit is an evaluation and management (E/M) visit in the facility setting that is performed in part by both a physician and a nonphysician practitioner (NPP) who are in the same group, in accordance with applicable law and regulations such that the service could be  could be billed by either the physician or NPP if furnished independently by only one of them. Payment is made to the practitioner who performs the substantive portion of the visit.   Facility setting means an institutional setting in which payment for services and supplies furnished incident to a physician or practitioners professional services is prohibited under our regulations.    B. Definition of Substantive Portion   (1) More Than Half of the Total Time   Beginning January 1, 2024, substantive portion means more than half of the total time spent by the physician and NPP performing the split (or shared) visit.
(Medicare Claims Processing Manual)
B. Definition of Substantive Portion   (1) More Than Half of the Total Time   Beginning January 1, 2024, substantive portion means more than half of the total time spent by the physician and NPP performing the split (or shared) visit.   During the transitional year from January 1, 2023 through December 31, 2023, except for critical care visits, the substantive portion can be one of the three key E/M visit components (a medically appropriate history or exam, or medical decision- making (MDM )), or more than half of the total time spent by the physician and NPP performing the split (or shared) visit.  In other words, for calendar year 2023, the practitioner who spends more than half of the total time, or performs the medically appropriate hist ory or exam described in the code descriptor, or MDM can be considered to have performed the substantive portion and can bill for the split (or shared) E/M visit.  When one of the three key components is used as the substantive portion in 2023, the practit ioner who bills the visit must perform that component in its entirety in order to bill.  For example, if history is used as the substantive portion, the billing practitioner must perform the history as described in the code descriptor in order to bill.  If  physical exam is used as the substantive portion, the billing practitioner must perform the exam as described in the code descriptor in order to bill.  If MDM is used as the substantive portion, each practitioner could perform certain aspects of MDM, but the billing practitioner must perform all portions or aspects of MDM that are required to select the visit level billed.   For critical care visits, starting for services furnished in CY 2022, the substantive portion will be more than half of the total time.  A unique listing of qualifying activities for purposes of determining the substantive portion of critical care visits a pplies (see below).   We summarize these policies in the following table.   Definition of Substantive Portion for E/M Visit Code Families
(Medicare Claims Processing Manual)
We summarize these policies in the following table.   Definition of Substantive Portion for E/M Visit Code Families   E/M Visit Code Family  2022 -2023 Definition of Substantive Portion  2024 Definition of Substantive Portion  Other Outpatient*  History, or exam, or MDM, or more than half of total time  More than half of total time  Inpatient/Observation/Hospital/SNF*  History, or exam, or MDM, or more than half of total time  More than half of total time  Emergency Department  History, or exam, or MDM, or more than half of total time  More than half of total time  Critical Care  More than half of total time  More than half of total time  Acronyms: E/M (Evaluation and Management), MDM (medical decision- making), SNF (Skilled Nursing Facility)  *Office visits and Nursing Facility visits are not billable as split (or shared) services.   (2) Distinct Time   In accordance with the CPT E/M Guidelines, only distinct time can be counted.  When the practitioners jointly meet with or discuss the patient, only the time of one of the practitioners can be counted.   Example: I f the NPP first spent 10 minutes with the patient and the physician then spent another 15 minutes, their individual time spent would be summed to equal a total of 25 minutes. The physician would bill for this visit, since they spent more than half of the total time (15 of 25 total minutes).  If, in the same situation, the physician and NPP met together for five additional minutes (beyond the 25 minutes) to discuss the patients treatment plan, that overlapping time could only be counted once for purposes of establishing total time and who provided the substantive portion of the visit.  The total time would be 30 minutes, and the physician would bill for the visit, since  they spent more than half of the total time (20 of 30 total minutes).    (3) Qualifying Time   Drawing on the  CPT E/M Guidelines, except for critical care visits, the following listing of activities can be counted toward total time for purposes of determining the substantive portion, when performed and whether or not the activities involve direct patient contact:
(Medicare Claims Processing Manual)
Drawing on the  CPT E/M Guidelines, except for critical care visits, the following listing of activities can be counted toward total time for purposes of determining the substantive portion, when performed and whether or not the activities involve direct patient contact:    Preparing to see the patient (for example, review of tests).   Obtaining and/or reviewing separately obtained history.  Performing a medically appropriate examination and/or evaluation.   Counseling and educating the patient/family/caregiver.  Ordering medications, tests, or procedures.   Referring and communicating with other health care professionals (when not separately reported).   Documenting clinical information in the electronic or other health record.   Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver.   Care coordination (not separately reported).   Practitioners cannot count time spent on the following:    The performance of other services that are reported separately.   Travel.   Teaching that is general and not limited to discussion that is required for the management of a specific patient.   See section 30.6.12 for a listing of qualifying activities for purposes of determining the substantive portion of critical care services.   For all split (or shared) visits, one of the practitioners must have face -to-face (in -person) contact with the patient, but it does not necessarily have to be the physician, nor the practitioner who performs the substantive portion and bills for the visit.  The substantive portion can be entirely with or without direct patient contact, and is determined by the proportion of total time, not whether the time involves patient contact.    (4) Application to Prolonged Services
(Medicare Claims Processing Manual)
(4) Application to Prolonged Services   For 2022 and 2023 transitional years, the billing practitioner reports the codes for the primary service and the prolonged services, regardless of the amount of time the billing practitioner spent.  Starting in 2024, since the substantive portion is more than half of the practitioners total time, the physician or practitioner who spent more than half the total time (the substantive portion starting in 2024) will bill for the primary E/M visit and the  prolonged service code(s) when the service is furnished as a split (or shared) visit, if all other requirements to bill for split (or shared) services are met. The physician and NPP will add their time together, and whomever furnished more than half of the total time, including prolonged time, (that is, the substantive portion) will report both the primary service code and the prolonged services add- on code(s), assuming the time threshold for reporting prolonged services is met (see Prolonged Services section above).    During the transitional calendar years 2022- 2023, when practitioners use a key component as the substantive portion, Emergency department and critical care visits are not reported as prolonged services.    We summarize these policies in the following table.   Reporting Prolonged Services for Split (or Shared) Visits   E/M Visit Code Family  2022 -2023  2024  If Substantive Portion is a Key Component  If Substantive Portion is Time  Substantive Portion Must Be Time Other Outpatient*  Combined time of both practitioners must meet the threshold for reporting prolonged services  Combined time of both practitioners must meet the threshold for reporting prolonged services  Combined time of both practitioners must meet the threshold for reporting prolonged services  Inpatient/Observation/Hospital/SNF*  Combined time of both practitioners must meet the threshold for reporting prolonged services  Combined time of both practitioners must meet the threshold for reporting prolonged services  Combined time of both practitioners must meet the threshold for reporting prolonged services  Emergency Department  N/A N/A N/A Critical Care  N/A N/A N/A Acronyms: E/M (Evaluation and Management); SNF (Skilled Nursing Facility)  *Office visits and Nursing Facility visits are not billable as split (or shared) services.   C. New and Established Patients, and Initial and Subsequent Visits   Split (or shared) visits may be billed for new and established patients , as well as for initial and subsequent visits, that otherwise meet the requirements for split (or shared) visit payment.
(Medicare Claims Processing Manual)
C. New and Established Patients, and Initial and Subsequent Visits   Split (or shared) visits may be billed for new and established patients , as well as for initial and subsequent visits, that otherwise meet the requirements for split (or shared) visit payment.  D. Settings of Care   Split (or shared) visits are furnished only in the facility setting, meaning institutional settings in which payment for services and supplies furnished incident to a physician or practitioners professional services is prohibited under our regulations at 42 CFR  410.26.    Accordingly, split (or shared) visits are billable for E/M visits furnished in hospital and skilled nursing facility (SNF) settings. Visits in these settings that are required by our regulations to be performed in their entirety by a physician are not bill able as split (or shared) services. For example, our Conditions of Participation require certain SNF visits to be performed directly and solely by a physician; accordingly, those SNF visits cannot be billed as a split (or shared) visit (see Section 30.6.13).   E.  Medical Record Documentation   Documentation in the medical record must identify the physician and NPP who performed the visit.  The individual who performed the substantive portion of the visit (and therefore bills for the visit) must sign and date the medical record.   F. Claim Identification   Modifier -FS (Split or Shared E/M Visit) must be reported on claims for split (or shared) visits, to identify that the service was a split (or shared) visit.    The modifier identified by CPT for purposes of reporting partial services (modifier - 52 (reduced services)) cannot be used to report partial E/M visits, including any partial services furnished as split (or shared) visits. Medicare does not pay for partial  E/M visits.     30.6.19  Office/Outpatient Evaluation and Management  (O/O E/M) Complexity Add- on Paymen t (Code G2211)  (Rev. 12370; Issued: 11- 21-23; Effective: 01 -01-24; Implementation: 01 -02-24)
(Medicare Claims Processing Manual)
Starting on January 1, 2024 O/O E/M visit complexity add- on code, G2211 to describe intensity and complexity inherent to O/O E/M visits not accounted for in the valuation of the primary service codes is unbundled and separately payable as an additional payment to the payment for O/O E/M visit primary service codes (99202- 99205, 99211- 99215).   The full descriptor, refined in the calendar year (CY) 2021 PFS final rule, is code G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition. (Add -on code, list separately in addition to office/outpatient evaluation and management visit, new or established )). (See the CY 2021 Medicare Physician Fee Schedule final rule in the Federal Register (85 FR 84571)).   The A/B MACs (A & B) shall not pay code G2211 on the same date of service as an office/outpatient evaluation and management visit (codes 99202- 99205, 99211- 99215) reported with Modifier 25, to the same beneficiary by the same practitioner or nonphysician practitioner.    40 - Surgeons and Global Surgery  (Rev. 1, 10- 01-03) B3-4820