evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Chiropractic Services (A56273)
The precise level of subluxation must be specified on the claim and must be listed as the primary diagnosis. The neuromusculoskeletal condition necessitating the treatment must be listed as the secondary diagnosis.All claims for chiropractic services must include the following information:Date of the initiation of the course of treatment.Symptom/condition/Secondary diagnosis code(s)Subluxation(s)/Primary diagnosis code(s)Date of ServicePlace of ServiceProcedure CodeFailure to report these items will result in claim denial or delay.Note:Date of last x-ray is no longer required. Any date placed in item 19 is considered date of last x-ray. It is recommended that providers do not place any date in item 19 of the CMS-1500 claim form.Limitation of Liability rules apply: The purpose of the Limitation of Liability provision is to protect the beneficiary from liability in denial cases under certain conditions when services rendered are found to be not reasonable and medically unnecessary.If the provider uses the AT Modifier and believes a service is likely to be denied by Medicare as not being medically necessary, the beneficiary must sign an Advance Beneficiary Notification (ABN) and the GA modifier must be used.Physician signature for progress notes and reports (handwritten, electronic). Initials if signed over a typed or printed name or accompanied by a signature log or attestation statement.
Article - Billing and Coding: Chiropractic Services (A56273)
Non-Covered Services:All services other than manual manipulation of the spine for treatment of subluxation of the spine are excluded when ordered or performed by a Doctor of Chiropractic. Chiropractors are not required to bill these to Medicare. Chiropractic offices may want to submit charges to Medicare to obtain a denial necessary for submitting to a secondary insurance carrier. The following are examples (not an all-inclusive list) of services that, when performed by a Chiropractor, are excluded from Medicare coverage:- Laboratory tests- X-rays- Office Visits (history and physical)- Physiotherapy- Traction- Supplies- Injections- Drugs- Diagnostic studies including EKGs- Orthopedic devices- Nutritional supplements and counselingMedicare does not cover chiropractic treatments to extraspinal regions (CPT 98943), which includes the head, upper and lower extremities, rib cage, and abdomen.Request for ReviewWhen requesting a review, submit documentation that supports the medical necessity of the denied service.
html  PUBLIC "-//W3C//DTD HTML 4.01//EN"SSA INTERNET HEAD SCRIPTSSocial Security Act 1833BANNERSkip to main contentSocial SecuritySearchMenuEspaolSign inSITE NAVIGATION#include virtual="/framework/includes/english/navigation.shtml"PAGE TITLECompilation of the Social Security LawsCONTENT
PAYMENT OF BENEFITS[71]Sec.1833.[42 U.S.C. 1395l](a)Except as providedin section 1876, and subject to the succeeding provisions of this section, thereshall be paid from the Federal Supplementary Medical Insurance TrustFund, in the case of each individual who is covered under the insuranceprogram established by this part and incurs expenses for serviceswith respect to which benefits are payable under this part, amountsequal to(1)in the case ofservices described in section 1832(a)(1)80 percent of thereasonable charges for the services; except that(A)an organizationwhich provides medical and other health services (or arranges fortheir availability) on a prepayment basis (and either is sponsoredby a union or employer, or does not provide, or arrange for the provisionof, any inpatient hospital services) may elect to be paid 80 percentof the reasonable cost of services for which payment may be made underthis part on behalf of individuals enrolled in such organization inlieu of 80 percent of the reasonable charges for such services ifthe organization undertakes to charge such individuals no more than20 percent of such reasonable cost plus any amounts payable by themas a result of subsection (b),(B)with respectto items and services described in section 1861(s)(10)(A), the amounts paidshall be 100 percent of the reasonable charges for such items andservices,(C)with respectto expenses incurred for those physicians services for whichpayment may be made under this part that are described in section 1862(a)(4), theamounts paid shall be subject to such limitations as may be prescribedby regulations,(D)[72]with respect to clinical diagnostic laboratorytests for which payment is made under this part(i)(I)on the basis[73]of a fee schedule under subsection(h)(1) (for tests furnished before January 1, 2017)[74]or section 1834(d)(1), the amount paid shall be equal to 80 percent (or 100 percent, inthe case of such tests for which payment is made on an assignment-relatedbasis) of the lesser of the amount determined under such fee schedule,the limitation amount for that test determined under subsection (h)(4)(B),or the amount of the charges billed for the tests, or
(II)undersection 1834A (for tests furnished on or after January 1, 2017), theamount paid shall be equal to 80 percent (or 100 percent, in the caseof such tests for which payment is made on an assignment-related basis)of the lesser of the amount determined under such section or the amountof the charges billed for the tests, or(ii)[75]for tests furnished before January 1, 2017,on the basis of a negotiated rate established under subsection (h)(6),the amount paid shall be equal to 100 percent of such negotiated rate[76],(E)with respectto services furnished to individuals who have been determined to haveend stage renal disease, the amounts paid shall be determined subjectto the provisions of section 1881,(F)with respectto clinical social worker services under section 1861(s)(2)(N), the amounts paidshall be 80 percent of the lesser of(i)the actual chargefor the services or(ii)75 percentof the amount determined for payment of a psychologist under clause(L),(G)with respectto facility services furnished in connection with a surgical procedurespecified pursuant to subsection (i)(1)(A) and furnished to an individualin an ambulatory surgical center described in such subsection, forservices furnished beginning with the implementation date of a revisedpayment system for such services in such facilities specified in subsection(i)(2)(D), the amounts paid shall be 80 percent of the lesser of theactual charge for the services or the amount determined by the Secretaryunder such revised payment system,(H)with respectto services of a certified registered nurse anesthetist under section 1861(s)(11), theamounts paid shall be 80 percent of the least of the actual charge,the prevailing charge that would be recognized (or, for services furnishedon or after January 1, 1992, the fee schedule amount provided undersection 1848)if the services had been performed by an anesthesiologist, or thefee schedule for such services established by the Secretary in accordancewith subsection (1),(I)with respectto covered items (described in section 1834(a)(13)), the amounts paid shallbe the amounts described in section 1834(a)(1), and
(I)with respectto covered items (described in section 1834(a)(13)), the amounts paid shallbe the amounts described in section 1834(a)(1), and(J)with respectto expenses incurred for radiologist services (as defined in section 1834(b)(6)), subjectto section 1848, the amounts paid shall be 80 percent of the lesser of the actualcharge for the services or the amount provided under the fee scheduleestablished under section 1834(b),(K)with respectto certified nursemidwife services under section 1861(s)(2)(L),the amounts paid shall be 80 percent of the lesser of the actual chargefor the services or the amount determined by a fee schedule establishedby the Secretary for the purposes of this subparagraph (but in noevent shall such fee schedule exceed 65 percent of the prevailingcharge that would be allowed for the same service performed by a physician,or, for services furnished on or after January 1, 1992, 65 percent(or 100 per cent for services furnished on or after January 1, 2011)of the fee schedule amount provided under section 1848 for the same serviceperformed by a physician),(L)with respectto qualified psychologist services under section 1861(s)(2)(M), the amounts paidshall be 80 percent of the lesser of the actual charge for the servicesor the amount determined by a fee schedule established by the Secretaryfor the purposes of this subparagraph,(M)with respectto prosthetic devices and orthotics (as defined in section 1834(h)(4)), the amounts paid shallbe the amounts described in section 1834(h)(1),(N)with respectto expenses incurred for physicians services (as defined insection 1848(j)(3)) other than personalized prevention plan services (as defined insection 1861(hhh)(1)), theamounts paid shall be 80 percent of the payment basis determined undersection 1848(a)(1),(O)with respectto services described in section 1861(s)(2)(K) (relating to servicesfurnished by physicians assistants, nurse practitioners, or clinicalnurse specialists), the amounts paid shall be equal to 80 percentof(i)the lesser ofthe actual charge or 85 percent of the fee schedule amount providedunder section 1848, or
(i)the lesser ofthe actual charge or 85 percent of the fee schedule amount providedunder section 1848, or(ii)in the caseof services as an assistant at surgery, the lesser of the actual chargeor 85 percent of the amount that would otherwise be recognized ifperformed by a physician who is serving as an assistant at surgery,(P)with respectto surgical dressings, the amounts paid shall be the amounts determinedunder section 1834(i),(Q)with respectto items or services for which fee schedules are established pursuantto section 1842(s), the amounts paid shall be 80 percent of the lesser of the actualcharge or the fee schedule established in such section,(R)with respectto ambulance services,(i)the amounts paidshall be 80 percent of the lesser of the actual charge for the servicesor the amount determined by a fee schedule established by the Secretaryunder section 1834(l) and(ii)with respectto ambulance services described in section 1834(l)(8), the amounts paid shallbe the amounts determined under section 1834(g) for outpatient critical accesshospital services ,(S)with respectto drugs and biologicals (including intravenous immune globulin (asdefined in section 1861(zz))) not paid on a cost or prospective payment basisas otherwise provided in this part (other than items and servicesdescribed in subparagraph (B)), the amounts paid shall be 80 percentof the lesser of the actual charge or the payment amount establishedin section 1842(o) (or, if applicable, under section 1847, 1847A, or 1847B),(T)with respectto medical nutrition therapy services (as defined in section 1861(vv)), the amountpaid shall be 80 percent (or 100 percent if such services are recommendedwith a grade of A or B by the United States Preventive Services TaskForce for any indication or population and are appropriate for theindividual) of the lesser of the actual charge for the services or85 percent of the amount determined under the fee schedule establishedunder section 1848(b) for the same services if furnished by a physician,(U)with respectto facility fees described in section 1834(m)(2)(B), the amounts paidshall be 80 percent of the lesser of the actual charge or the amountsspecified in such section,
(U)with respectto facility fees described in section 1834(m)(2)(B), the amounts paidshall be 80 percent of the lesser of the actual charge or the amountsspecified in such section,(V)notwithstandingsubparagraphs (I) (relating to durable medical equipment), (M) (relatingto prosthetic devices and orthotics and prosthetics), and (Q) (relatingto 1842(s) items), with respectto competitively priced items and services (described in section 1847(a)(2)) thatare furnished in a competitive area, the amounts paid shall be theamounts described in section 1847(b)(5),(W)with respectto additional preventive services (as defined in section 1861(ddd)(1) ),the amount paid shall be(i)in the case ofsuch services which are clinical diagnostic laboratory tests, theamount determined under subparagraph (D) (if such subparagraph wereapplied, by substituting 100 percent for 80percent, and(ii)in the caseof all other such services, 100 percent of the lesser of the actualcharge for the service or the amount determined under a fee scheduleestablished by the Secretary for purposes of this subparagraph;(X)with respectto personalized prevention plan services (as defined in section 1861(hhh)(1)),the amount paid shall be 100 percent of the lesser of the actual chargefor the services or the amount determined under the payment basisdetermined under section 1848,(Y)with respectto preventive services described in subparagraphs (A) and (B) of section1861(ddd)(3) that are appropriate for the individual and, in the caseof such services described in subparagraph (A), are recommended witha grade of A or B by the United States Preventive Services Task Forcefor any indication or population, the amount paid shall be 100 percentof(i)except as providedin clause (ii), the lesser of the actual charge for the services orthe amount determined under the fee schedule that applies to suchservices under this part, and(ii)in the caseof such services that are covered OPD services (as defined in subsection(t)(1)(B)), the amount determined under subsection (t),
(ii)in the caseof such services that are covered OPD services (as defined in subsection(t)(1)(B)), the amount determined under subsection (t),(Z)with respectto Federally qualified health center services for which payment ismade under section 1834(o), the amounts paid shall be 80 percent ofthe lesser of the actual charge or the amount determined under suchsection,(AA)with respectto an applicable disposable device (as defined in paragraph (2) ofsection 1834(s)) furnished to an individual pursuant to paragraph(1) of such section, the amount paid shall be equal to 80 percentof the lesser of the actual charge or the amount determined underparagraph (3) of such section; and[77](BB)with respectto home infusion therapy, the amount paid shall be an amount equalto 80 percent of the lesser of the actual charge for the servicesor the amount determined under section 1834(u), and[78](CC)[79]with respect toopioid use disorder treatment services furnished during an episodeof care, the amount paid shall be equal to the amount payable undersection 1834(w) less any copaymentrequired as specified by the Secretary(2)in the case ofservices described in section 1832(a)(2) (except those servicesdescribed in subparagraphs (C), (D), (E), (F), (G), (H), and (I) ofsuch section and unless otherwise specified in section 1881)(A)with respectto home health services (other than a covered osteoporosis drug) (asdefined in section 1861(kk)), the amount determined under the prospective paymentsystem under section 1895;(B)with respectto other items and services (except those described in subparagraph(C), (D), or (E) of this paragraph and except as may be provided insection 1886orsection 1888(e)(9))(i)furnished beforeJanuary 1, 1999, the lesser of(I)the reasonablecost of such services, as determined under section 1861(v), or(II)the customarycharges with respect to such services,
(i)furnished beforeJanuary 1, 1999, the lesser of(I)the reasonablecost of such services, as determined under section 1861(v), or(II)the customarycharges with respect to such services,less the amount a provider may charge as described in clause(ii) of section 1866(a)(2)(A), but in no case may the payment for such otherservices exceed 80 percent of such reasonable cost, or(ii)if such servicesare furnished before January 1, 1999, by a public provider of services,or by another provider which demonstrates to the satisfaction of theSecretary that a significant portion of its patients are low-income(and requests that payment be made under this clause), free of chargeor at nominal charges to the public, 80 percent of the amount determinedin accordance with section 1814(b)(2), or(iii)if such servicesare furnished on or after January 1, 1999, the amount determined undersubsection (t), or(iv)if (and forso long as) the conditions described in section 1814(b)(3) are met, the amounts determinedunder the reimbursement system described in such section;(C)with respectto services described in the second sentence of section 1861(p), 80 percentof the reasonable charges for such services;(D)with respectto clinical diagnostic laboratory tests for which payment is madeunder this part(i)
(I)on the basis[80]of a fee schedule determinedunder subsection (h)(1) (for tests furnished before January 1, 2017[81]) or section 1834(d)(1), the amount paid shall be equal to 80 percent (or100 percent, in the case of such tests for which payment is made onan assignment-related basis or to a provider having an agreement undersection 1866 ofthe lesser of the amount determined under such fee schedule, the limitationamount for that test determined under subsection (h)(4)(B), or theamount of the charges billed for the tests, or(II)undersection 1834A (for tests furnished on or after January 1, 2017), theamount paid shall be equal to 80 percent (or 100 percent, in the caseof such tests for which payment is made on an assignment-related basisor to a provider having an agreement under section 1866) of the lesserof the amount determined under such section or the amount of the chargesbilled for the tests, or(ii)[82]for testsfurnished before January 1, 2017, on the basis[83]ofa negotiated rate established under subsection (h)(6), the amountpaid shall be equal to 100 percent of such negotiated rate for suchtests; or (iii) on the basis of a rate established under a demonstrationproject under section 1847(e), the amount paid shall be equal to 100 percent ofsuch rate,(E)with respectto(i)outpatient hospitalradiology services (including diagnostic and therapeutic radiology,nuclear medicine and CAT scan procedures, magnetic resonance imaging,and ultrasound and other imaging services, but excluding screeningmammography and, for services furnished on or after January 1, 2005,diagnostic mammography), and(ii)effective forprocedures performed on or after October 1, 1989, diagnostic procedures(as defined by the Secretary) described in section 1861(s)(3) (otherthan diagnostic x-ray tests and diagnostic laboratory tests),the amount determined under subsection (n) or, for servicesor procedures performed on or after January 1, 1999, subsection (t);(F)with respectto a covered osteoporosis drug (as defined in section 1861(kk)) furnishedby a home health agency, 80 percent of the reasonable cost of suchservice, as determined under section 1861(v);
(G)with respectto items and services described in section 1861(s)(10)(A), the lesser of(i)the reasonablecost of such services, as determined under section 1861(v), or(ii)the customarycharges with respect to such services; andor, if such services are furnished by a public provider of services,or by another provider which demonstrates to the satisfaction of theSecretary that a significant portion of its patients are low-income(and requests that payment be made under this provision), free ofcharge or at nominal charges to the public, the amount determinedin accordance with section 1814(b)(2);(H)with respectto personalized prevention plan services (as defined in section 1861(hhh)(1)) furnished by an outpatientdepartment of a hospital, the amount determined under paragraph (1)(X),(3)in the case ofservices described in section 1832(a)(2)(D)(A)except asprovided in subparagraph (B), the costs which are reasonable and relatedto the cost of furnishing such services or which are based on suchother tests of reasonableness as the Secretary may prescribe in regulations,including those authorized under section 1861(v)(1)(A), less the amount aprovider may charge as described in clause (ii) of section 1866(a)(2)(A),but in no case may the payment for such services (other than for itemsand services described in section 1861(s)(10)(A)) exceed 80 percentof such costs; or(B)with respectto the services described in clause (ii) of section 1832(a)(2)(D) thatare furnished to an individual enrolled with a MA plan under partC pursuant to a written agreement described in section 1853(a)(4), theamount (if any) by which
(i)the amount ofpayment that would have otherwise been provided (I) under subparagraph(A) (calculated as if 100 percent were substitutedfor 80 percent in such subparagraph) for such servicesif the individual had not been so enrolled, or (II) in the case ofsuch services furnished on or after the implementation date of theprospective payment system under section 1834(o), under such section (calculated as if 100 percent were substituted for 80 percent in such section)for such services if the individual had not been so enrolled; exceeds(ii)the amountof the payments received under such written agreement for such services(not including any financial incentives provided for in such agreementsuch as risk pool payments, bonuses, or withholds), less the amountthe federally qualified health center may charge as described in section 1857(e)(3)(B);(4)in the case offacility services described in section 1832(a)(2)(F), and outpatient hospitalfacility services furnished in connection with surgical proceduresspecified by the Secretary pursuant to section 1833(i)(1)(A), the applicable amountas determined under paragraph (2) or (3) of subsection (i) or subsection(t);(5)in the case ofcovered items (described in section 1834(a)(13)) the amounts describedin section 1834(a)(1);(6)in the case ofoutpatient critical access hospital services, the amounts describedin section 1834(g);(7)in the case ofprosthetic devices and orthotics and prosthetics (as described insection 1834(h)(4)), the amounts described in section 1834(h);(8)in the case of(A)outpatientphysical therapy services, outpatient speech-language pathology servicesand outpatient occupational therapy services furnished(i)by a rehabilitationagency, public health agency, clinic, comprehensive outpatient rehabilitationfacility, or skilled nursing facility,(ii)by a home healthagency to an individual who is not homebound, or(iii)by anotherentity under an arrangement with an entity described in clause (i)or (ii); and(B)outpatientphysical therapy services, outpatient speech-language pathology services)and outpatient occupational therapy services furnished