evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Code  Description  R0070  Transportation of Portable x -ray Equipment and Personnel to Home or Nursing Home, Per Trip to Facility or Location, One Patient Seen.  R0075  Transportation of Portable x -ray Equipment and Personnel to Home or Nursing Home, Per Trip to Facility or Location, More than One Patient Seen, Per Patient.   These HCPCS codes are subject to the fee schedule.   Effective April 1, 2006, SNFs are required to report the appropriate modifiers to identify the number of patients served when billing for R0075.  See section 90.3, of this chapter for the list of modifiers used to identify on the claim the number of patients served.   MACs shall ensure that payment for R0075 is consistent with the definition of the modifiers.   NOTE:  When a SNF resident receives a portable x -ray service during the course of a Medicare- covered stay in the SNF, only the services professional component (representing the physicians interpretation of the test results) is a separately billable physician se rvice under Part B (see 20.1 of this chapter and 20.1.1 of Chapter 6).  By contrast, the technical component representing the procedure itself, including any associated transportation and setup costs, would be subject to consolidated billing (the SNF bundling requirement for services furnished to the SNFs Part A residents), and must be included on the SNFs Part A bill for the residents covered stay (Bill Type 21x) rather than being billed separately under Part B (see 20.2.1of this chapter).  100 - Interpretation of Diagnostic Tests  (Rev. 1, 10- 01-03)  100.1 - X-rays and EKGs Furnished to Emergency Room Patients  (Rev. 1, 10- 01-03)  The professional component of a diagnostic procedure furnished to a beneficiary in a hospital includes an interpretation and written report for inclusion in the beneficiarys medical record maintained by the hospital.  (See 42 CFR 415.120(a) .)
(Medicare Claims Processing Manual)
A/B MACs (B) generally distinguish between an interpretation and report of an x- ray or an EKG procedure and a review of the procedure.  A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service. This is because the review is already included in the emergency department evaluation and management (E/M) payment.  For example, a notation in the medical records saying fx- tibia or EKG -normal would not suffice as a separately payable interpretation and report of the procedure and should be  considered a review of the findings payable through the E/M code.  An interpretation and report should address the findings, relevant clinical issues, and comparative data (when available).   Generally, A/B MACs (B) must pay for only one interpretation of an EKG or x- ray procedure furnished to an emergency room patient.  They pay for a second interpretation (which may be identified through the use of modifier  -77) only under unusual circumsta nces (for which documentation is provided) such as a questionable finding for which the physician performing the initial interpretation believes another physicians expertise is needed or a changed diagnosis resulting from a second interpretation of the results of the procedure.   When A/B MACs (B) receive only one claim for an interpretation, they must presume that the one service billed was a service to the individual beneficiary rather than a quality control measure and pay the claim if it otherwise meets any applicable reasonabl e and necessary test.
(Medicare Claims Processing Manual)
When A/B MACs (B) receive multiple claims for the same interpretation, they must generally pay for the first bill received. A/B MACs (B) must pay for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient.  Consideration is not given to physician specialty as the primary factor in deciding which interpretation and report to pay regardless of when the service is performed. Consideration is not given to designation as the hospitals official interpret ation as a factor in determining which claim to pay.  A/B MACs (B) pay for the interpretation billed by the cardiologist or radiologist if the interpretation of the procedure is performed at the same time as the diagnosis and treatment of the beneficiary.   (This interpretation may be an oral report to the treating physician that will be written at a later time.)   If the first claim received is from a radiologist, A/B MACs (B) generally pay the claim because they would not know in advance that a second claim would be forthcoming.  When A/B MACs (B) receive the claim from the emergency room (ER) physician and can identify that the two claims are for the same interpretation, they must determine whether the claim from the ER physician was the interpretation that contributed to the diagnosis and treatment of the patient and, if so, they pay that claim.  In such cases, A/ B MACs (B) must determine that the radiologists claim was actually quality control and institute recovery action.  The two parties should reach an accommodation about who should bill for these interpretations.  The following examples apply to A/B MACs (B):   EXAMPLE A:   A physician sees a beneficiary in the ER on January 1 and orders a single view chest x-ray.  The physician reviews the x- ray, treats, and discharges the beneficiary.  An A/B MAC (B) receives a claim from a radiologist for CPT code 71010- 26 indicating an interpretation with written report with a date of service of January 3.  The A/B MAC (B) will pay the radiologists claim as the first bill received.  A/B MACs (B) do not have to develop the claim to determine whether the interpretation was a quality control  service.   EXAMPLE B:
(Medicare Claims Processing Manual)
EXAMPLE B:   Same circumstances as Example A, except that the physician who sees the beneficiary in the ER also bills for CPT code 71010- 26 with a date of service of January 1.  The A/B MAC (B) will pay the first claim received.  If the first claim is from the treating phys ician in the ER, and there is no indication the claim should not be paid, e.g., no reason to think that a complete, written interpretation has not been performed, payment of the claim is appropriate.  The A/B MAC (B) will deny a claim subsequently received from a radiologist for the same interpretation as a quality control service to the hospital rather than a service to the individual beneficiary.   EXAMPLE C:   Same as Example B except that the claim from the radiologist uses modifier  -77 and indicates that, while the ER physicians finding that the patient did not have pneumonia was correct, there was also a suspicious area of the lung suggesting a tumor that required further testing.  In such situations, the A/B MAC (B) pays for both claims under the fee schedule.   EXAMPLE D:   The A/B MAC (B) receives separate claims for CPT code 71010 -26 from a radiologist and a physician who treated that patient in the ER, both with a date of service of January 1.  The first claim processed in the system is paid and the second claims will be i dentified and denied as a duplicate.  If the denied provider is the radiologist and he raises an issue the A/B MAC (B) will develop the claim to determine whether the findings of the radiologists interpretation were conveyed to the treating physician (orally or in writing) in time to contribute to the diagnosis and treatment of the patient. If the radiologists interpretation was furnished in time to serve this purpose, that claim should be paid, and the claim from the other physician should be denied as  not reasonable and necessary.   110 - Special Billing Instructions for Claims Submitted to A/B MACs (A) (Rev. 1, 10- 01-03)
(Medicare Claims Processing Manual)
110 - Special Billing Instructions for Claims Submitted to A/B MACs (A) (Rev. 1, 10- 01-03)  Transmittal 368 (CR 1323 issued May 24- 01) which revised the following SNF sections of the manual but not incorporated in the master manual.  SNF-533.1, SNF -533.1.A, SNF -533.1.B, SNF -533.1.C, SNF -533.1.D, SNF -533.1.E   For billing instructions, see chapter 25.   110.1 - Aborted Procedure  (Rev. 1, 10- 01-03)  When a procedure is not completed, the SNF should bill an unlisted code (e.g., CPT code ending in 99) and show the actual charges for the procedure.  The A/B MAC (A)  will request additional data from the SNF to determine applicable payment.  Deductible and coinsurance apply based on fee schedule rules.   110.2 - Combined Procedures (Radiology)  (Rev. 1, 10- 01-03)  There are no separate codes covering certain combined procedures, e.g., a hand and forearm included in a single x- ray.  The code with the higher fee schedule amount should be used.   110.2 - Combined Procedures (Radiology)  (Rev. 1, 10- 01-03)  There are no separate codes covering certain combined procedures, e.g., a hand and forearm included in a single x- ray.  The code with the higher fee schedule amount should be used.   110.3 - Payment for Radiopharmaceuticals (Rev. 1, 10- 01-03)  Radiopharmaceuticals are not subject to the fee schedule, but are paid based on reasonable cost when given in a SNF.  SNFs report HCPCS codes 79900, A4641, A4642, A9500, A9503, and A9505, as appropriate, with revenue codes 0333, 034X, or 0636.   NOTE:  The correct code to report is A4641.  It replaced HCPCS code 78990.  HCPCS code 78990 should not be reported because this code is not valid for Medicare purposes.
(Medicare Claims Processing Manual)
NOTE:  The correct code to report is A4641.  It replaced HCPCS code 78990.  HCPCS code 78990 should not be reported because this code is not valid for Medicare purposes.   EXCEPTION: HCPCS codes 77781, 77782, 77783, and 77784 include payment for the radiopharmaceutical in the technical component.  When these procedures are performed, SNFs do not report radiopharmaceutical codes 79900, A4641, A4642, A9500, A9503, and A9505.  The A/B MAC (A)  will reject codes 79900, A4641, A4642, A9500, A9503, and A9505 when they are billed for supplies used in conjunction with procedure codes 77781, 77782, 77783, and 77784.  120 - Radiology or Other Diagnostic Unlisted Service or Procedure Billing Instructions for A/B MAC (A)  Claims  (Rev. 1, 10- 01-03)  Some radiology and other diagnostic services may not have a corresponding HCPCS code.  This is because these are typically services that are rarely provided, unusual, or new.  The provider should assign the appropriate unlisted procedure code to any such service. The following list contains the unlisted procedure codes along with the suggested revenue code for billing.  These services are paid on a fee schedule if one exists or cost if a fee has not been established for SNFs. However, before billing any of these codes the provider needs to furnish a complete description of the radiology procedure to the A/B MAC (A)  for review and analysis.  The description should include a narrative definition of the procedure and a description of the nature, extent and need for the procedure and the time, effort, and equipment necessary.  The A/B MAC (A)  will determine if the provider has correctly identified the procedure as unlisted.  If the procedure is not identified correctly, the A/B MAC (A) will inform the provider of the correct HCPCS code to assign to the procedure. If there is no fee schedule amount established, these services are paid based on cost to SNFs.   For Radiology:
(Medicare Claims Processing Manual)
For Radiology:   Revenue Code  HCPCS  Definition  032x 76499 Unlisted diagnostic radiologic procedure  0402 76999 Unlisted ultrasound procedure  0333 77299 Unlisted procedure, therapeutic radiology clinical treatment planning  0333 77399 Unlisted procedure, medical radiation physics, dosimetry and treatment devices  0333 77499 Unlisted procedure, therapeutic radiology clinical treatment management  0333 77799 Unlisted procedure, clinical brachytherapy  034x 78099 Unlisted endocrine procedure, diagnostic nuclear medicine  034x 78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear medicine  034x 78299 Unlisted gastrointestinal procedure, diagnostic nuclear medicine  034x 78399 Unlisted musculoskeletal procedure, diagnostic nuclear medicine  Revenue Code  HCPCS  Definition  034x 78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine  034x 78599 Unlisted respiratory procedure, diagnostic nuclear medicine  034x 78699 Unlisted nervous system procedure, diagnostic nuclear medicine  034x 78799 Unlisted genitourinary procedure, diagnostic nuclear medicine  034x 78999 Unlisted miscellaneous procedure, diagnostic nuclear medicine  034x 79999 Unlisted radiopharmaceutical therapeutic procedure  For Other Diagnostic Procedures:   Revenue Code  HCPCS  Definition  075x 91299 Unlisted diagnostic gastroenterology procedure  047x 92599 Unlisted otorhinolaryngological service or procedure  048x 93799 Unlisted cardiovascular service or procedure  073x 93799 Unlisted cardiovascular service or procedure  0921 93799 Unlisted cardiovascular service or procedure  046x 94799 Unlisted pulmonary service or procedure  074x 95999 Unlisted neurological or neuromuscular diagnostic procedure  0922 95999 Unlisted neurological or neuromuscular diagnostic procedure
(Medicare Claims Processing Manual)
130 - EMC Formats (Rev. 3227, Issued: 04- 02-15, Effective; ASC -X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  June 11, 2013, ICD -10: Upon Implementation of ICD -10 Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  May 19, 2014 -  MAC Non -Shared System Edits; July 7, 2014 -  CWF development/testing, FISS requirement development; October 6, 2014 -  CWF, FISS, MCS Shared System Edits), ICD -10: Upon Implementation of ICD -10)  Billing instructions for the ASC X12 837 institutional claim format can be found in chapter 24 of this manual or, for Form CMS -1450 can be found in chapter 25 of this manual.  Each revenue code requires a HCPCS code, modifier if applicable, units, line -item date of service, and charge.   Billing instructions for the ASC X12 837 professional claim format can be found in chapter 24 of this manual or for Form CMS -1500 can be found in this manual, Chapter 26, Instructions for Completing Form CMS -1500."   140 - Bone Mass Measurements (BMMs)  (Rev. 1416; Issued:  01- 18-08; Effective:  01 -01-07; Implementation:  02 -20-08)
(Medicare Claims Processing Manual)
140 - Bone Mass Measurements (BMMs)  (Rev. 1416; Issued:  01- 18-08; Effective:  01 -01-07; Implementation:  02 -20-08)  Sections 1861(s)(15)  and (rr)(1) of the Social Security Act (the Act) (as added by 4106 of the Balanced Budget Act (BBA) of 1997) standardize Medicare coverage of medically necessary bone mass measurements by providing for uniform coverage under Medicare Part B.  This coverage is effect ive for claims with dates of service furnished on or after July 1, l998.  Effective for dates of service on and after January 1, 2007, the CY 2007 Physician Fee Schedule final rule expanded the number of beneficiaries qualifying for BMM by reducing the dosage requirement for glucocorticoid (steroid) therapy from 7.5 mg of predni sone per day to 5.0 mg.  It also changed the definition of BMM by removing coverage for a single- photon absorptiometry as it is not considered reasonable and necessary under section 1862 (a)(1)(A) of the Act.  Finally, it required that in the case of monit oring and confirmatory baseline BMMs, they be performed with a dual -energy x-ray absorptiometry (axial) test.  Conditions of Coverage for BMMs are located in Pub.100- 02, Medicare Benefit Policy Manual, chapter 15   140.1 - Payment Methodology and HCPCS Coding (Rev.  4150, Issued: 10- 26-2018, Effective: 04 -01-19, Implementation: 04- 01-19)
(Medicare Claims Processing Manual)
140.1 - Payment Methodology and HCPCS Coding (Rev.  4150, Issued: 10- 26-2018, Effective: 04 -01-19, Implementation: 04- 01-19)  A/B MACs (B) pay for BMM procedures based on the Medicare physician fee schedule.  Claims from physicians, other practitioners, or suppliers where assignment was not taken are subject to the Medicare limiting charge.  The A/B MACs (A) pay for BMM procedures under the current payment methodologies for radiology services according to the type of provider. Do not pay BMM procedure claims for dual photon absorptiometry, CPT procedure code 78351. Deductible and coinsurance do not apply.  Any of the following CPT procedure codes may be used when billing for BMMs through December 31, 2006.  All of these codes are bone densitometry measurements except code 76977, which is bone sonometry measurements.  CPT procedure codes are applicable to billing A/B MACs (A and B).  76070 76071 76075 76076 76078 76977 78350 G0130  Effective for dates of services on and after January 1, 2007, the following changes apply to BMM:   New 2007 CPT bone mass procedure codes have been assigned for BMM.  The following codes will replace current codes, however the CPT descriptors for the services remain the same:  77078 replaces 76070  77079 replaces 76071  77080 replaces 76075  77081 replaces 76076  77083 replaces 76078  Effective for dates of service on and after January 1, 2015, contractors shall pay for bone mass procedure code 77085 ( Dual -energy X -ray absorptiometry (DXA), bone density study, 1 or more sites, axial skeleton, (e.g., hips, pelvis, spine), including vertebral fracture assessment.)   Certain BMM tests are covered when used to screen patients for osteoporosis subject to the frequency standards described in chapter 15, section 80.5.5 of the Medicare Benefit Policy Manual. Contractors will pay claims for screening tests when coded as follows:   Contains CPT procedure code 77078, 77079, 77080, 77081, 77083, 76977 or  G0130, and
(Medicare Claims Processing Manual)
Contains a valid diagnosis code indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.  Contractors are to maintain local lists of valid codes for the benefits screening categories.  Contractors will deny claims for screening tests when coded as follows:  Contains CPT procedure code 77078, 77079, 77081, 77083, 76977 or G0130, but  Does not contain a valid diagnosis code from the local lists of valid diagnosis codes maintained by the contractor for the benefits screening categories indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.  Dual -energy x- ray absorptiometry (axial) tests are covered when used to monitor FDA -approved osteoporosis drug therapy subject to the 2- year frequency standards described in chapter 15, section 80.5.5 of the Medicare Benefit Policy Manual . Contractors will pay  claims for monitoring tests when coded as follows:  Contains CPT procedure code 77080 or 77085, and Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0 as the ICD -9-CM diagnosis code or M81.0, M81.8, M81.6 or M94.9 as the ICD -10-CM diagnosis code. Contractors will deny claims for monitoring tests when coded as follows:  Contains CPT procedure code 77078, 77079, 77081, 77083, 76977 or G0130, and  Contains 733.00, 733.01, 733.02, 733.03, 733.09, 733.90, or 255.0 as the ICD -9-CM diagnosis code, but  Does not contain a valid ICD -9-CM diagnosis code from the local lists of valid ICD -9-CM diagnosis codes maintained by the contractor for the benefits screening categories indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.
(Medicare Claims Processing Manual)
Does not contain a valid ICD -10-CM diagnosis code from the local lists of valid ICD -10-CM diagnosis codes maintained by the contractor for the benefits screening categories indicating the reason for the test is postmenopausal female, vertebral fracture, hyperparathyroidism, or steroid therapy.   Single photon absorptiometry tests are not covered.  Contractors will deny CPT procedure code 78350.  The A/B MACs (A) are billed using the ASC X12 837 institutional claim format or hardcopy Form CMS -1450.  The appropriate bill types are: 12X, 13X, 22X, 23X, 34X, 71X (Provider -based and independent), 72X, 77X (Provider -based and freestanding), 83X, and 85X.  Effective April 1, 2006, type of bill 14X is for non- patient laboratory specimens and is no longer applicable for bone mass measurements.  Information regarding the claim form locators that correspond to the HCPCS/CPT code or Type of Bill ar e found in chapter 25.  Providers must report HCPCS codes for bone mass measurements under revenue code 320 with number of units and line item dates of service per revenue code line for each bone mass measurement reported.   A/B MACs (B) are billed for bone mass measurement procedures using the ASC X12 837 professional claim format or hardcopy Form CMS -1500.  140.2 - Denial Messages for Noncovered Bone Mass Measurements  (Rev. 3650, Issued: 11- 10-16, Effective: 02 -10-17, Implementation: 02- 10-17)  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under the conditions described in 140.1.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: PR (if claim is received with a GA modifier) otherwise CO  CARC: 50  RARC: Alert M38 (if ABN was issued) or M27 (if ABN was not issued)  MSN: 16.10 and 36.1 (if ABN was issued) or 36.2 (if ABN was not issued)   NOTE:   A/B MACs (A) are not to include MSN 16.10.
(Medicare Claims Processing Manual)
NOTE:   A/B MACs (A) are not to include MSN 16.10.  140.4  Advance Beneficiary Notices (ABNs)  (Rev. 1236, Issued: 05- 11-07, Effective: 01 -01-07, Implementation: 07- 02-07)  For the denial situations listed in Section 140.1, physicians, practitioners  and hospitals are liable for payment unless they issue an appropriate ABN.  Contractors will utilize the appropriate messages, see sections 140.2 and 140.3.  150 - Place of Service (POS) Instructions for the Professional Component (PC or Interpretation) and the Technical Component (TC) of Diagnostic Tests (Rev. 3315, Issued: 08- 06-15, Effective: 01 -01-16, Implementation: 01- 04-16)  Many of the diagnostic services, including radiology services, provided by physicians/practitioners contain both a technical component (TC) and a professional component (PC).  Often, the PC and TC of diagnostic services are furnished in different settings.   As a general policy, the POS code assigned by the physician/practitioner for the PC of a diagnostic service shall be the setting in which the beneficiary received the TC service.   A.  Interpretation Provided Telephonically by Wireless Remote   Teleradiology services (radiology services that do not require a face -to-face encounter with the patient furnished through the use of a telecommunications system) are discussed in Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15, section 30.  The interpretation of an x -ray, electrocardiogram, electroencephalogram and tissue samples are listed as examples of these services.