evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
The following are examples of common medical disorders and resulting communication deficits, which may necessitate active rehabilitative therapy.  This list is not all-inclusive:  Cerebrovascular disease such as cerebral vascular accidents presenting with dysphagia, aphasia/dysphasia, apraxia, and dysarthria;  Neurological disease such as Parkinsonism or Multiple Sclerosis with dysarthria, dysphagia, inadequate respiratory volume/control, or voice disorder; or  Laryngeal carcinoma requiring laryngectomy resulting in aphonia.  3.  Impairments of the Auditory System   The terms, aural rehabilitation, auditory rehabilitation, auditory processing, lipreading and speech reading are among the terms used to describe covered services related to perception and comprehension of sound through the auditory system.  See Pub. 100-04, chapter 12, section 30.3 for billing instructions.  For example:   Auditory processing evaluation and treatment may be covered and medically necessary.  Examples include but are not limited to services for certain neurological impairments or the absence of natural auditory stimulation that results in impaired ability to p rocess sound.  Certain auditory processing disorders require diagnostic audiological tests in addition to speech-language pathology evaluation and treatment.   Evaluation and treatment for disorders of the auditory system may be covered and medically necessary, for example, when it has been determined by a speech -language pathologist in collaboration with an audiologist that the hearing impaired beneficiarys cur rent amplification options (hearing aid, other amplification device or cochlear implant) will not sufficiently meet the patients functional communication needs.  Audiologists and speech-language pathologists both evaluate beneficiaries for disorders of the auditory system using different skills and techniques, but only speech-language pathologists may provide treatment.   Assessment for the need for rehabilitation of the auditory system (but not the vestibular system) may be done by a speech language pathologist.  Examples include but are not limited to: evaluation of comprehension and production of language in oral, signed or written modalities, speech and voice production, listening skills, speech reading, communications strategies, and the impact of the hearing loss on the patient/client and family.
(Medicare Benefit Policy Manual)
Examples of rehabilitation include but are not limited to treatment that focuses on comprehension, and production of language in oral, signed or written modalities; speech and voice production, auditory training, speech reading, multimodal (e.g., visual, auditory- visual, and tactile) training, communication strategies, education and counseling.  In determining the necessity for treatment, the beneficiarys performance in both clinical and natural environment should be considered.   4.  Dysphagia   Dysphagia, or difficulty in swallowing, can cause food to enter the airway, resulting in coughing, choking, pulmonary problems, aspiration or inadequate nutrition and hydration with resultant weight loss, failure to thrive, pneumonia and death.  It is most  often due to complex neurological and/or structural impairments including head and neck trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, dementias, and encephalopathies.  For these reasons, it is important that only qualified professionals with specific training and experience in this disorder provide evaluation and treatment.   The speech -language pathologist performs clinical and instrumental assessments and analyzes and integrates the diagnostic information to determine candidacy for intervention as well as appropriate compensations and rehabilitative therapy techniques.  The equipment that is used in the examination may be fixed, mobile or portable.  Professional guidelines recommend that the service be provided in a team setting with a physician/NPP who provides supervision of the radiological examination and interpretation of medical conditions revealed in it.   Swallowing assessment and rehabilitation are highly specialized services.  The professional rendering care must have education, experience and demonstrated competencies.  Competencies include but are not limited to: identifying abnormal upper aerodigestive  tract structure and function; conducting an oral, pharyngeal, laryngeal and respiratory function examination as it relates to the functional assessment of swallowing; recommending methods of oral intake and risk precautions; and developing a treatment plan employing appropriate compensations and therapy techniques.   230.4 - Services Furnished by a Therapist in Private Practice (TPP)  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  A.  General
(Medicare Benefit Policy Manual)
230.4 - Services Furnished by a Therapist in Private Practice (TPP)  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  A.  General   See section 220 of this chapter for definitions.  Therapist refers only to a qualified physical therapist, occupational therapist or speech- language pathologist.  TPP refers to therapists in private practice (qualified physical therapists, occupational the rapists and speech -language pathologists).  In order to qualify to bill Medicare directly as a therapist, each individual must be enrolled as a private practitioner and employed in one of the following practice types: an unincorporated solo practice, unincorporated partnership, unincorporated group practice, physician/NPP group or groups that are not professional corporations, if allowed by state and local law.  Physician/NPP group practices may employ TPP if state and local law permits this employee relationship.   For purposes of this provision, a physician/NPP group practice is defined as one or more physicians/NPPs enrolled with Medicare who may bill as one entity.  For further details on issues concerning enrollment, see the provider enrollment Web site at www.cms.hhs.gov/MedicareProviderSupEnroll and Pub. 100-08, Medicare Program Integrity Manual, chapter15, section 15.4.4.9.  Private practice also includes therapists who are practicing therapy as employees of another supplier, of a professional corporation or other incorporated therapy practice.  Private practice does not include individuals when they are working as employees of an institutional provider.  Services should be furnished in the therapists or groups office or in the patients home.  The office is defined as the location(s) where the practice is operated, in the state(s) where the therapist (and practice, if applicable) is legally authorized to  furnish services, during the hours that the therapist engages in the practice at that location.  If services are furnished in a private practice office space, that space shall be owned, leased, or rented by the practice and used for the exclusive purpose of operating the practice.  For descriptions of aquatic therapy in a community center pool see section 220C of this chapter.   Therapists in private practice must be approved as meeting certain requirements, but do not execute a formal provider agreement with the Secretary.
(Medicare Benefit Policy Manual)
Therapists in private practice must be approved as meeting certain requirements, but do not execute a formal provider agreement with the Secretary.   If therapists who have their own Medicare National Provider Identifier (NPI) are employed by therapist groups, physician/NPP groups, or groups that are not professional organizations, the requirement that therapy space be owned, leased, or rented may be satisfied by the group that employs the therapist.  Each therapist employed by a group should enroll as a TPP.  When therapists with a Medicare NPI provide services in the physicians/NPPs office in which they are employed, and bill using their NPI for each therapy service, then the direct supervision requirement for enrolled staff apply.  When the therapist who has a Medicare NPI is employed in a physicians/NPPs office the services are ordinarily billed as services of the therapist, with the therapist identified on the claim as the supplier of services.  However, services of the therapist who has a Medicare NPI may also be billed by the physician/NPP as services incident to the physicians/NPPs service.  (See  230.5 for rules related to therapy services incident to a physician.)  In that case, the physician/NPP is the supplier of service, the NPI of the supervising physician/NPP is reported on the claim with the service and all the rules for both therapy services and incident to services (230.5)  must be followed.   B.  Private Practice Defined   Reference:  Federal Register November, 1998, pages 58863- 58869; 42CFR 410.38(b), 42CFR410.59, 42CFR410.60, 42CFR410.62  The contractor considers a therapist to be in private practice if the therapist maintains office space at his or her own expense and furnishes services only in that space or the patients home.  Or, a therapist is employed by another supplier and furnishes  services in facilities provided at the expense of that supplier.   The therapist need not be in full -time private practice but must be engaged in private practice on a regular basis; i.e., the therapist is recognized as a private practitioner and for that purpose has access to the necessary equipment to provide an adequat e program of therapy.
(Medicare Benefit Policy Manual)
The therapy services must be provided either by or under the direct supervision of the TPP.  Each TPP should be enrolled as a Medicare provider.  If a therapist is not enrolled, the services of that therapist must be directly supervised by an enrolled ther apist.  Direct supervision requires that the supervising private practice therapist be present in the office suite at the time the service is performed.  These direct supervision requirements apply only in the private practice setting and only for therapis ts and their assistants.  In other outpatient settings, supervision rules differ.  The services of support personnel must be included in the therapists bill.  The supporting personnel, including other therapists, must be W -2 or 1099 employees of the TPP or other qualified employer.   Coverage of outpatient therapy under Part B includes the services of a qualified TPP when furnished in the therapists office or the beneficiarys home.  For this purpose, home includes an institution that is used as a home, but not a hospital, CAH or SN F, (Federal Register Nov. 2, 1998, pg 58869).  C.  Assignment   Reference:  Nov. 2, 1998 Federal Register, pg. 58863 See also Pub. 100- 04 chapter 1, 30.2.   When physicians, NPPs, or TPPs obtain provider numbers, they have the option of accepting assignment (participating) or not accepting assignment (nonparticipating).  In contrast, providers, such as outpatient hospitals, SNFs, rehabilitation agencies, and CORFs, do not have the option.  For these providers, assignment is mandatory.  If physicians/NPPs, or TPPs accept assignment (are participating), they must accept the Medicare Physician Fee Schedule amount as payment. Medicare pays 80% and the patient is responsible for 20%.  In contrast, if they do not accept assignment, Medicare will only pay 95% of the fee schedule amount.  However, when these services are not furnished on an assignment- related basis, the limiting charge applies.  (See 1848(g)(2)(c)  of the Act.)
(Medicare Benefit Policy Manual)
NOTE :  Services furnished by a therapist in the therapists office under arrangements with hospitals in rural communities and public health agencies (or services provided in the beneficiarys home under arrangements with a provider of outpatient physical or occupational therapy services) are not covered under this provision.  See section 230.6.  230.5 - Physical Therapy, Occupational Therapy and Speech-Language Pathology Services Provided Incident to the Services of Physicians and Non-Physician Practitioners (NPP)  (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)  References: 1861(s)(2)(A)  of the Act  42 CFR 410.10(b) 42 CFR 410.26 Pub. 100-02, ch. 15, 60.  The Benefit.   Therapy services have their own benefit under 1861 of the Social Security Act and shall be covered when provided according to the standards and conditions of the benefit described in Medicare manuals.  The statute 1862(a)(20)  requires that payment be made for a therapy service billed by a physician/NPP only if the service meets the standards and conditions --other than licensing-- that would apply to a therapist.  (For example, see coverage requirements in Pub. 100-08, chapter 13, 13.5.1(C), Pub. 100-04, chapter 5 , and also the requirements of this chapter, 220 and 230.  Incident to a Therapist.  There is no coverage for services provided incident to the services of a therapist.  Although PTAs and OTAs work under the supervision of a therapist and their services may be billed by the therapist, their services are covered under the benefit for therapy services and not by the benefit for services incident to a physician/NPP.  The services furnished by PTAs and OTAs are not incident to the therapists service.
(Medicare Benefit Policy Manual)
Qualifications of Auxiliary Personnel.  Therapy services appropriately billed incident to a physicians/NPPs service shall be subject to the same requirements as therapy services that would be furnished by a physical therapist, occupational therapist or speech-language pathologist in any other outpatient setting with one exception.  When therapy services are performed incident to a physicians/NPPs service, the qualified personnel who perform the service do not need to have a license to practice therapy, unless it is required by state law.  The qualified personnel must meet all the other requirements except licensure.  Qualifications for therapists are found in 42CFR484.4 and in section 230.1, 230.2, and 230.3 of this chapter.  In effect, these rules require that the person who furnishes the service to the patient must, at least, be a graduate of a program of training for one of the therapy services as described above.  Regardless of any state licensing that al lows other health professionals to provide therapy services, Medicare is authorized to pay only for services provided by those trained specifically in physical therapy, occupational therapy or speech -language pathology.  That means that the services of athletic trainers, massage therapists, recreation therapists, kinesiotherapists, low vision specialists or any other profession may not be billed as therapy services.  The services of PTAs and OTAs also may not be billed incident to a physicians/NPPs service.  However, if a PT and PTA (or an OT and OTA) are both employed in a physicians office, the services of the PTA, when directly supervised by the PT or the services of the OTA, when directly supervised by the OT may be billed by the physician group as PT or OT services using the PIN/NPI of the enrolled PT (or OT).  (See Section 230.4 for private practice rules on billing services performed in a physicians office.)  If the PT or OT is not enrolled, Medicare shall not pay for the services of a PTA or OTA billed incident to the physicians service, because they do not meet the qualifica tion standards in 42CFR484.4 .
(Medicare Benefit Policy Manual)
Therapy services provided and billed incident to the services of a physician/NPP also must meet all incident- to requirements in 60 of this chapter.  Where the policies have different requirements, the more stringent requirement shall be met.  For example, when therapy services are billed as incident to a physician/NPP services, the requirement for direct supervision by the physician/NPP and other incident to requirements must be met, even though the service is provided by a licensed therapist who may perform the services unsupervised in other settings.  The mandatory assignment provision does not apply to therapy services furnished by a physician/NPP or "incident to" a physician's/NPPs service.  However, when these services are not furnished on an assignment -related basis; the limiting charge applies.   For emphasis, following are some of the standards that apply to therapy services billed incident -to the services of a physician/NPP in the physicians/NPPs office or the beneficiarys residence.   A.  Therapy services provided to the beneficiary must be covered and payable outpatient rehabilitation services as described, for example, in this section as well as Pub. 100- 08, chapter 13, 13.5.1.  B.  Therapy services must be provided by, or under the direct supervision of a physician (a doctor of medicine or osteopathy; a doctor of podiatry or a doctor of optometry when treating patients within the state scope of practice in the state in which the services are provided) or NPP who is legally authorized to practice therapy services by the state in which he or she performs such function or action.  Direct supervision requirements are the same as in 42CFR410.32(b)(3).  The supervisor must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure.  It does not mean that the physician/NPP must be present in the same room in the office where the service is performed.
(Medicare Benefit Policy Manual)
C.  The services must be of a level of complexity that require that they be performed by a therapist or under the direct supervision of the therapist, physician/NPP who is licensed to perform them.  Services that do not require the performance or supervisi on of the therapist, physician/NPP, are not considered reasonable or necessary therapy services even if they are performed or supervised by a physician/NPP or other qualified professional.   D.  Services must be furnished under a plan of treatment as in 220.1.2 of this chapter.  The services provided must relate directly to the physician/NPP service to which it is incident.   230.6 - Therapy Services Furnished Under Arrangements With Providers and Clinics (Rev. 36, Issued: 06- 24-05, Effective: 06 -06-05, Implementation: 06- 06-05)  References:   See also  Pub. 100- 01, chapter 5, 10.3.  A.  General   For rules regarding services provided under arrangement, see Pub. 100- 01, chapter 5, 10.3.  A provider may have others furnish outpatient therapy (physical therapy, occupational therapy, or speech -language pathology) services through arrangements under which receipt of payment by the provider for the services discharges the liability of the beneficiary or any other person to pay for the service.   However, it is not intended that the provider merely serve as a billing mechanism for the other party.  For such services to be covered the provider must assume professional responsibility for the services.  The providers professional supervision over the services requires application of many of the same controls that are applied to services furnished by salaried employees.  The provider must:    Accept the patient for treatment in accordance with its admission policies;    Maintain a complete and timely clinical record on the patient which includes diagnosis, medical history, orders, and progress notes relating to all services received;    Maintain liaison with the attending physician/NPP with regard to the progress of the patient and to assure that the required plan of treatment is periodically reviewed by the physician/NPP;    Secure from the physician/NPP the required certifications and recertifications; and    Ensure that the medical necessity of such service is reviewed on a sample basis by the agencys staff or an outside review group.
(Medicare Benefit Policy Manual)
 Secure from the physician/NPP the required certifications and recertifications; and    Ensure that the medical necessity of such service is reviewed on a sample basis by the agencys staff or an outside review group.   In addition, when a provider provides outpatient services under an arrangement with others, such services must be furnished in accordance with the terms of a written contract, which provides for retention by the provider of responsibility for and control a nd supervision of such services.  The terms of the contract should include at least the following:    Provide that the therapy services are to be furnished in accordance with the plan of care established according to Medicare policies for therapy plans of care in section 220.1.2 of this chapter;    Specify the geographical areas in which the services are to be furnished;    Provide that contracted personnel and services meet the same requirements as those which would be applicable if the personnel and services were furnished directly by the provider;    Provide that the therapist will participate in conferences required to coordinate the care of an individual patient;    Provide for the preparation of treatment records, with progress notes and observations, and for the prompt incorporation of such into the clinical records of the clinic;   Specify the financial arrangements.  The contracting organization or individual may not bill the patient or the health insurance program; and    Specify the period of time the contract is to be in effect and the manner of termination or renewal.   B.  Special Rules for Hospitals    A hospital may bill Medicare for outpatient therapy (physical therapy, occupational therapy, or speech- language pathology) services that it furnishes to its outpatients either directly or under arrangements in the hospital's outpatient department.  If a hospital furnishes medically necessary therapy services in its outpatient department to individuals who are registered as its outpatients, those services must be billed directly by the hospital using bill type 13X or 85X for critical access hospitals.  Note that services provided to residents of a Medicare- certified SNF may not be billed by the hospital as services to its outpatients.