evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Foot Care (A56232)
Covered exceptions to routine foot care services are considered medically necessary once (1) in 60 days. More frequent services will be denied as not reasonable and necessary.The exclusion of foot care is determined by the nature of the service, regardless of the clinician who performs the service.Medicare allows payment for routine foot care only if the conditions under indications are met. These conditions describe the systemic diseases and their peripheral complications that increase the danger for infection and injury if a non-professional provides these services.Services not meeting the criteria in this statement of national coverage will be denied as statutory non-covered services. For diagnosis codes designated by an asterisk (*), we will require the date the patient was last seen (DPLS) and the NPI of the Doctor of Medicine or Doctor of Osteopathic Medicine actively managing the patients systemic condition.Nail debridement procedures are considered non-covered routine foot care when these services do not meet the guidelines outlined above for mycotic nail services or are not based on the presence of a systemic condition. If the nail debridement procedures are performed in the absence of mycotic nails and as part of foot care, they must meet the same criteria as all other routine foot care services to be considered for payment.Foot care services that do not require a professional would be considered routine and not a Medicare benefit. Professional in this situation is defined as an M.D., D.O., D.P.M., Nurse Practitioner, Clinical Nurse Specialist, or Physician Assistant.A Registered Nurse that holds foot care certification (CFCN) may perform covered foot care services when all the following requirements are met:Services are performed under direct supervision of a physician or other practitionerAll requirements of the incident to provision are met per the CMS Medicare Benefit Policy ManualProof of accredited Foot Care Nurse certification must be included in the documentationAll other coverage provisions outlined in this Billing and Coding Article are met
Article - Billing and Coding: Foot Care (A56232)
Loss of protective sensation (LOPS) is not the subject of this coverage article. Please refer to CMS Publication, 100-03, Medicare National Coverage Determination Manual 70.2.1 Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy).General InformationDocumentation RequirementsDocumentation in the medical record must support the services as billed, meet the criteria in the indications section above, and be available upon request.Utilization GuidelinesReview Benefit Policy Manual (Pub. 100-02), Chapter 15, Section 290 G. Application of Foot Care Exclusions to Physicians Services for an explanation of situations that would require medical record review.Services performed for a localized condition that created a painful condition/complication that could not be otherwise managed by the patient and would place the patient at risk if not performed by a professional, would require medical record review.Services for debridement of more than five nails in a single day may be subject to medical review.
SUBPART - Subpart A—General Exclusions and Exclusion of Particular Services
htmlSUBPART - Subpart AGeneral Exclusions and Exclusion of Particular Services
SUBPART - Subpart A—General Exclusions and Exclusion of Particular Services
U.S. CodeRegulationsConstitutionJournalAppsRegulationsU.S. CodeRegulationsmenuRegulationsAll Titlestitle 42Public Healthchapter IVCHAPTER IVCENTERS FOR MEDICARE &amp; MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICESpart 411PART 411EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENTsubpart ASubpart AGeneral Exclusions and Exclusion of Particular Services  411.15Particular services excluded from coverage.Collapse to view only  411.15 - Particular services excluded from coverage. 411.1 - Basis and scope. 411.2 - Conclusive effect of QIO determinations on payment of claims. 411.4 - Services for which neither the beneficiary nor any other person is legally obligated to pay. 411.6 - Services furnished by a Federal provider of services or other Federal agency. 411.7 - Services that must be furnished at public expense under a Federal law or Federal Government contract. 411.8 - Services paid for by a Government entity. 411.9 - Services furnished outside the United States. 411.10 - Services required as a result of war. 411.12 - Charges imposed by an immediate relative or member of the beneficiary's household. 411.15 - Particular services excluded from coverage. 411.1 - Basis and scope.(a)Statutory basis.Sections 1814(a) and 1835(a) of the Act require that a physician certify or recertify a patient's need for home health services but, in general, prohibit a physician from certifying or recertifying the need for services if the services will be furnished by an HHA in which the physician has a significant ownership interest, or with which the physician has a significant financial or contractual relationship. Sections 1814(c), 1835(d), and 1862 of the Act exclude from Medicare payment certain specified services. The Act provides special rules for payment of services furnished by the following: Federal providers or agencies (sections 1814(c) and 1835(d)); hospitals and physicians outside of the U.S. (sections 1814(f) and 1862(a)(4)); and hospitals and SNFs of the Indian Health Service (section 1880 of the Act). Section 1877 of the Act sets forth limitations on referrals and payment for designated health services furnished by entities with which the referring physician (or an immediate family member
SUBPART - Subpart A—General Exclusions and Exclusion of Particular Services
hospitals and SNFs of the Indian Health Service (section 1880 of the Act). Section 1877 of the Act sets forth limitations on referrals and payment for designated health services furnished by entities with which the referring physician (or an immediate family member of the referring physician) has a financial relationship.
SUBPART - Subpart A—General Exclusions and Exclusion of Particular Services
(b)Scope.This subpart identifies:(1) The particular types of services that are excluded;(2) The circumstances under which Medicare denies payment for certain services that are usually covered; and(3) The circumstances under which Medicare pays for services usually excluded from payment.[54 FR 41734, Oct. 11, 1989, as amended at 60 FR 41978, Aug. 14, 1995; 60 FR 45361, Aug. 31, 1995; 66 FR 952, Jan. 4, 2001]AUTHORITY:42 U.S.C. 1302,1395w-101 through 1395w-152, 1395hh, and 1395nn.SOURCE: 54 FR 41734, Oct. 11, 1989, unless otherwise noted.CITE AS: 42 CFR 411.1 411.2 - Conclusive effect of QIO determinations on payment of claims.If a utilization and quality control quality improvement organization (QIO) has assumed review responsibility, in accordance with part 466 of this chapter, for services furnished to Medicare beneficiaries, Medicare payment is not made for those services unless the conditions of subpart C of part 466 of this chapter are met.AUTHORITY:42 U.S.C. 1302,1395w-101 through 1395w-152, 1395hh, and 1395nn.SOURCE: 54 FR 41734, Oct. 11, 1989, unless otherwise noted.CITE AS: 42 CFR 411.2 411.4 - Services for which neither the beneficiary nor any other person is legally obligated to pay.(a)General rule.Except as provided in  411.8(b) (for services paid by a governmental entity), Medicare does not pay for a service if(1) The beneficiary has no legal obligation to pay for the service; and(2) No other person or organization (such as a prepayment plan of which the beneficiary is a member) has a legal obligation to provide or pay for that service.
SUBPART - Subpart A—General Exclusions and Exclusion of Particular Services
(2) No other person or organization (such as a prepayment plan of which the beneficiary is a member) has a legal obligation to provide or pay for that service.(b)Special conditions for services furnished to individuals in custody of penal authorities.Individuals who are in custody include, but are not limited to, individuals who are under arrest, incarcerated, imprisoned, escaped from confinement, under supervised release, on medical furlough, required to reside in mental health facilities, required to reside in halfway houses, required to live under home detention, or confined completely or partially in any way under a penal statute or rule. Payment may be made for services furnished to individuals or groups of individuals who are in the custody of police or other penal authorities or in the custody of a government agency under a penal statute only if the following conditions are met:(1) State or local law requires those individuals or groups of individuals to repay the cost of medical services they receive while in custody.(2) The State or local government entity enforces the requirement to pay by billing all such individuals, whether or not covered by Medicare or any other health insurance, and by pursuing collection of the amounts they owe in the same way and with the same vigor that it pursues the collection of other debts.[54 FR 41734, Oct. 11, 1989, as amended at 72 FR 47410, Aug. 22, 2007]AUTHORITY:42 U.S.C. 1302,1395w-101 through 1395w-152, 1395hh, and 1395nn.SOURCE: 54 FR 41734, Oct. 11, 1989, unless otherwise noted.CITE AS: 42 CFR 411.4 411.6 - Services furnished by a Federal provider of services or other Federal agency.(a)Basic rule.Except as provided in paragraph (b) of this section, Medicare does not pay for services furnished by a Federal provider of services or other Federal agency.(b)Exceptions.Payment may be made(1) For emergency hospital services, if the conditions of  424.103 of this chapter are met;(2) For services furnished by a participating Federal provider which CMS has determined is providing services to the public generally as a community institution or agency;(3) For services furnished by participating hospitals and SNFs of the Indian Health Service; and
SUBPART - Subpart A—General Exclusions and Exclusion of Particular Services
(2) For services furnished by a participating Federal provider which CMS has determined is providing services to the public generally as a community institution or agency;(3) For services furnished by participating hospitals and SNFs of the Indian Health Service; and(4) For services furnished under arrangements (as defined in  409.3 of this chapter) made by a participating hospital.AUTHORITY:42 U.S.C. 1302,1395w-101 through 1395w-152, 1395hh, and 1395nn.SOURCE: 54 FR 41734, Oct. 11, 1989, unless otherwise noted.CITE AS: 42 CFR 411.6 411.7 - Services that must be furnished at public expense under a Federal law or Federal Government contract.(a)Basic rule.Except as provided in paragraph (b) of this section, payment may not be made for services that any provider or supplier is obligated to furnish at public expense, in accordance with a law of, or a contract with, the United States.(b)Exception.Payment may be made for services that a hospital or SNF of the Indian Health Service is obligated to furnish at public expense.AUTHORITY:42 U.S.C. 1302,1395w-101 through 1395w-152, 1395hh, and 1395nn.SOURCE: 54 FR 41734, Oct. 11, 1989, unless otherwise noted.CITE AS: 42 CFR 411.7 411.8 - Services paid for by a Government entity.(a)Basic rule.Except as provided in paragraph (b) of this section, Medicare does not pay for services that are paid for directly or indirectly by a government entity.(b)Exceptions.Payment may be made for the following:(1) Services furnished under a health insurance plan established for employees of the government entity.(2) Services furnished under a title of the Social Security Act other than title XVIII.(3) Services furnished in or by a participating general or special hospital that(i) Is operated by a State or local government agency; and(ii) Serves the general community.(4) Services furnished in a hospital or elsewhere, as a means of controlling infectious diseases or because the individual is medically indigent.(5) Services furnished by a participating hospital or SNF of the Indian Health Service.
SUBPART - Subpart A—General Exclusions and Exclusion of Particular Services
(4) Services furnished in a hospital or elsewhere, as a means of controlling infectious diseases or because the individual is medically indigent.(5) Services furnished by a participating hospital or SNF of the Indian Health Service.(6) Services furnished by a public or private health facility that(i) Is not a Federal provider or other facility operated by a Federal agency;(ii) Receives U.S. government funds under a Federal program that provides support to facilities that furnish health care services;(iii) Customarily seeks payment for services not covered under Medicare from all available sources, including private insurance and patients' cash resources; and(iv) Limits the amounts it collects or seeks to collect from a Medicare Part B beneficiary and others on the beneficiary's behalf to:(A) Any unmet deductible applied to the charges related to the reasonable costs that the facility incurs in providing the covered services;(B) Twenty percent of the remainder of those charges;(C) The charges for noncovered services.(7) Rural health clinic services that meet the requirements set forth in part 491 of this chapter.[54 FR 41734, Oct. 11, 1989, as amended at 56 FR 2139, Jan. 22, 1991]AUTHORITY:42 U.S.C. 1302,1395w-101 through 1395w-152, 1395hh, and 1395nn.SOURCE: 54 FR 41734, Oct. 11, 1989, unless otherwise noted.CITE AS: 42 CFR 411.8 411.9 - Services furnished outside the United States.(a)Basic rule.Except as specified in paragraph (b) of this section, Medicare does not pay for services furnished outside the United States. For purposes of this paragraph (a), the following rules apply:(1) The United States includes the 50 States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, The Northern Mariana Islands, and for purposes of services rendered on board ship, the territorial waters adjoining the land areas of the United States.
SUBPART - Subpart A—General Exclusions and Exclusion of Particular Services
(2) Services furnished on board ship are considered to have been furnished in United States territorial waters if they were furnished while the ship was in a port of one of the jurisdictions listed in paragraph (a)(1) of this section, or within 6 hours before arrival at, or 6 hours after departure from, such a port.(3) A hospital that is not physically situated in one of the jurisdictions listed in paragraph (a)(1) of this section is considered to be outside the United States, even if it is owned or operated by the United States Government.(b)Exception.Under the circumstances specified in subpart H of part 424 of this chapter, payment may be made for covered inpatient services furnished in a foreign hospital and, on the basis of an itemized bill, for covered physicians' services and ambulance service furnished in connection with those inpatient services, but only for the period during which the inpatient hospital services are furnished.AUTHORITY:42 U.S.C. 1302,1395w-101 through 1395w-152, 1395hh, and 1395nn.SOURCE: 54 FR 41734, Oct. 11, 1989, unless otherwise noted.CITE AS: 42 CFR 411.9 411.10 - Services required as a result of war.Medicare does not pay for services that are required as a result of war, or an act of war, that occurs after the effective date of a beneficiary's current coverage for hospital insurance benefits or supplementary medical insurance benefits.AUTHORITY:42 U.S.C. 1302,1395w-101 through 1395w-152, 1395hh, and 1395nn.SOURCE: 54 FR 41734, Oct. 11, 1989, unless otherwise noted.CITE AS: 42 CFR 411.10 411.12 - Charges imposed by an immediate relative or member of the beneficiary's household.(a)Basic rule.Medicare does not pay for services usually covered under Medicare if the charges for those services are imposed by(1) An immediate relative of the beneficiary; or(2) A member of the beneficiary's household.(b)Definitions.As used in this sectionImmediate relativemeans any of the following:(1) Husband or wife.(2) Natural or adoptive parent, child, or sibling.
SUBPART - Subpart A—General Exclusions and Exclusion of Particular Services
(b)Definitions.As used in this sectionImmediate relativemeans any of the following:(1) Husband or wife.(2) Natural or adoptive parent, child, or sibling.(3) Stepparent, stepchild, stepbrother, or stepsister.(4) Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law.(5) Grandparent or grandchild.(6) Spouse of grandparent or grandchild.Member of the householdmeans any person sharing a common abode as part of a single family unit, including domestic employees and others who live together as part of a family unit, but not including a mere roomer or boarder.Professional corporationmeans a corporation that is completely owned by one or more physicians and is operated for the purpose of conducting the practice of medicine, osteopathy dentistry, podiatry, optometry, or chiropractic, or is owned by other health care professionals as authorized by State law.(c)Applicability of the exclusion.The exclusion applies to the following charges in the specified circumstances:(1)Physicians' services.(i) Charges for physicians' services furnished by an immediate relative of the beneficiary or member of the beneficiary's household, even if the bill or claim is submitted by another individual or by an entity such as a partnership or a professional corporation.(ii) Charges for services furnished incident to a physician's professional services (for example by the physician's nurse or technician), only if the physician who ordered or supervised the services has an excluded relationship to the beneficiary.(2)Services other than physicians' services.(i) Charges imposed by an individually owned provider or supplier if the owner has an excluded relationship to the beneficiary; and(ii) Charges imposed by a partnership if any of the partners has an excluded relationship to the beneficiary.
SUBPART - Subpart A—General Exclusions and Exclusion of Particular Services
(ii) Charges imposed by a partnership if any of the partners has an excluded relationship to the beneficiary.(d)Exception to the exclusion.The exclusion does not apply to charges imposed by a corporation other than a professional corporation.AUTHORITY:42 U.S.C. 1302,1395w-101 through 1395w-152, 1395hh, and 1395nn.SOURCE: 54 FR 41734, Oct. 11, 1989, unless otherwise noted.CITE AS: 42 CFR 411.12 411.15 - Particular services excluded from coverage.The following services are excluded from coverage:(a) Routine physical checkups such as:(1) Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, except for screening mammography, colorectal cancer screening tests, screening pelvic exams, prostate cancer screening tests, glaucoma screening exams, ultrasound screening for abdominal aortic aneurysms (AAA), cardiovascular disease screening tests, diabetes screening tests, a screening electrocardiogram, initial preventive physical examinations that meet the criteria specified in paragraphs (k)(6) through (k)(15) of this section, additional preventive services that meet the criteria in  410.64 of this chapter, or annual wellness visits providing personalized prevention plan services.(2) Examinations required by insurance companies, business establishments, government agencies, or other third parties.(b)Low vision aid exclusion(1)Scope.The scope of the eyeglass exclusion encompasses all devices irrespective of their size, form, or technological features that use one or more lens to aid vision or provide magnification of images for impaired vision.(2)Exceptions.(i) Post-surgical prosthetic lenses customarily used during convalescence for eye surgery in which the lens of the eye was removed (for example, cataract surgery).(ii) Prosthetic intraocular lenses and one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens.(iii) Prosthetic lenses used by Medicare beneficiaries who are lacking the natural lens of the eye and who were not furnished with an intraocular lens.
SUBPART - Subpart A—General Exclusions and Exclusion of Particular Services
(iii) Prosthetic lenses used by Medicare beneficiaries who are lacking the natural lens of the eye and who were not furnished with an intraocular lens.(c)Eye examinationsfor the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive error only and procedures performed in the course of any eye examination to determine the refractive state of the eyes, without regard to the reason for the performance of the refractive procedures. Refractive procedures are excluded even when performed in connection with otherwise covered diagnosis or treatment of illness or injury.(d)Hearing aidsor examinations for the purpose of prescribing, fitting, or changing hearing aids.(1)Scope.The scope of the hearing aid exclusion encompasses all types of air conduction hearing aids that provide acoustic energy to the cochlea via stimulation of the tympanic membrane with amplified sound and bone conduction hearing aids that provide mechanical stimulation of the cochlea via stimulation of the scalp with amplified mechanical vibration or by direct contact with the tympanic membrane or middle ear ossicles.(2)Devices not subject to the hearing aid exclusion.Paragraph (d)(1) of this section shall not apply to the following devices that produce the perception of sound by replacing the function of the middle ear, cochlea, or auditory nerve:(i) Osseointegrated implants in the skull bone that provide mechanical energy to the cochlea via a mechanical transducer, or(ii) Cochlear implants and auditory brainstem implants that replace the function of cochlear structures or auditory nerve and provide electrical energy to auditory nerve fibers and other neural tissue via implanted electrode arrays.(e)Immunizations, except for(1) Vaccinations or inoculations directly related to the treatment of an injury or direct exposure such as antirabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenom sera, or immune globulin;(2) Pneumococcal vaccinations that are reasonable and necessary for the prevention of illness;(3) Hepatitis B vaccinations that are reasonable and necessary for the prevention of illness for those individuals, as defined in  410.63(a) of this chapter, who are at high or intermediate risk of contracting hepatitis B;
SUBPART - Subpart A—General Exclusions and Exclusion of Particular Services
(3) Hepatitis B vaccinations that are reasonable and necessary for the prevention of illness for those individuals, as defined in  410.63(a) of this chapter, who are at high or intermediate risk of contracting hepatitis B;(4) Influenza vaccinations that are reasonable and necessary for the prevention of illness; and(5) COVID-19 vaccinations that are reasonable and necessary for the prevention of illness.(f)Orthopedic shoesor other supportive devices for the feet,except whenshoes are integral parts of leg braces.(g)Custodial care, except as necessaryfor the palliation or management of terminal illness, as provided in part 418 of this chapter. (Custodial care is any care that does not meet the requirements for coverage as SNF care as set forth in  409.31 through 409.35 of this chapter.)(h)Cosmetic surgery and related services,except as required for the prompt repair of accidental injury or to improve the functioning of a malformed body member.(i)Dental services(1)Basic rule. Dental servicesin connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth.(2)Exception. Except for inpatient hospital services in connection with such dental procedures when hospitalization is required because of(i) The individual's underlying medical condition and clinical status; or(ii) The severity of the dental procedures.577