evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
 An NP or PA is not currently employed by the RHC.   An NP, PA, or CNM is not furnishing patient care at least 50 percent of the time the RHC operates.  To receive a temporary staffing waiver, an RHC must demonstrate that it has made a good faith effort to recruit and retain the required practitioner(s) in the 90 day period prior to the waiver request.  Recruitment activities should begin as soon as the RH C becomes aware that they will no longer be in compliance with this requirement.  Good faith efforts can include activities such as advertising in an appropriate newspaper or professional journal, conducting outreach to an NP, PA, or CNM school, or other a ctivities.  Staffing waivers are for a period not to exceed 1 year.  The waiver cannot be extended beyond 1 year, and another waiver cannot be granted until a minimum of 6 months have elapsed since the prior waiver expired.  RHCs should continue their recruitment activities during the waiver period to avoid termination when the waiver period ends. An RHC will be terminated if any of the following occur:   The RHC does not meet the staffing requirements and does not request a temporary staffing waiver;    The RHC requests a temporary staffing waiver and the request is denied due to a lack of good faith effort to meet the requirements;   The RHC does not meet the staffing requirements and is not eligible for a temporary staffing waiver because less than 6 months have passed since the expiration of the previous waiver;    The RHC reaches the expiration date of the temporary staffing waiver and has not come into compliance; or    Other non- compliance issue.   30.3 - FQHC Staffing Requirements  (Rev. 239, Issued: 01 -09-18 , Effective: 1-22-18, Implementation: 1-22-18)  FQHCs must have a core staff of appropriately trained primary care practitioners and meet other clinical requirements.  It is the responsibility of the FQHC to assure that all staffing requirements are met and that FQHC practitioners provide services in accordance with State and Federal laws and regulations.  Additional information on FQHC staffing requirements can be found at: http://bphc.hrsa.gov/about/requirements/index.html.
(Medicare Benefit Policy Manual)
40 - RHC and FQHC Visits (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23) An RHC or FQHC visit is a medically -necessary medical or mental health visit, or a  qualified preventive health visit. The visit must be a face -to-face (one -on-one) encounter between  the patient  and a physician,  NP, PA, CNM,  CP, or a CSW  during which  time one or more RHC or FQHC services are rendered . However, effective January 1, 2022,  a mental health visit is a face -to-face encounter or an encounter furnished using interactive, real -time, audio and video telecommunications technology or audio-only interactions in cases where the patient is not capable of, or does not consent to, the use of video technology for the purposes of diagnosis, evaluation or treatment of a mental health disorder.  A Transitional Care Management  (TCM) service can also be an RHC or FQHC visit.  Services furnished must be within the  practitioners state scope of practice, and only services that require the skill level of the RHC  or FQHC practitioner  are considered RHC or FQHC visits.  An RHC or FQHC visit can also be a visit between a home-bound patient and an RN or LPN under certain conditions. See section 190 of this chapter for information on visiting nursing services to home-bound patients.  Under certain conditions, an FQHC visit also may be provided by qualified pr actitioners  of outpatient DSMT  and MNT  when  the FQHC  meets  the relevant  program requirements  for provision of these services.   RHC  and FQHC  visits  are typically  evaluation  and management  (E/M) type  of services  or screenings for certain preventive services. A list of qualifying visits for FQHCs is  located  on the FQHC  web page at https://www.cms.gov/Center/Provider- Type/Federally - Qualified -Health -Centers -FQHC -Center.html.   40.1  Location  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)
(Medicare Benefit Policy Manual)
RHC  or FQHC  visits may  take place  in:  the RHC  or FQHC,   the patients  residence (including  an assisted  living  facility),   a Medicare-covered Part A SNF (see Pub. 100- 04, Medicare Claims Processing  Manual,  chapter  6, section 20.1.1),   the scene of an accident , or  the location of the patient during a Hospice election, including a patients residence or a Medicare certified facility  RHC  and FQHC visits may  not take place in:  an inpatient or outpatient department  of a hospital, including a CAH,  or  a facility which has specific requirements that preclude RHC or FQHC visits  (e.g., a Medicare comprehensive outpatient rehabilitation facility, a hospice facility (except when the RHC/FQHC is furnishing hospice attending physician services during a hospice election),  etc.) . Qualified  services  provided to a RHC  or FQHC  patient are considered  RHC  or FQHC  services  if:  the practitioner  is compensated by the RHC  or FQHC  for the services provided;  the cost of the service  is included in  the RHC  or FQHC cost  report;  and;  other requirements  for furnishing services are met. This applies to full and part time practitioners, and it applies regardless of whether the  practitioner is an employee of the RHC or FQHC, working under contract to the RHC or  FQHC,  or is compensated  by the RHC  or FQHC  under  another  type  of arrangement.  RHCs and FQHCs should have clear policies regarding the provision of services in other  locations and include this in a practitioners employment agreement or contract. RHCs  and FQHCs providing RHC or FQHC service s in locations other than the RHC or FQHC  facility must continue to meet all certification and cost reporting requirements.  Services  in other locations may be subject to review by the A/B MAC. RHC or FQHC services  furnished by an RHC or FQHC practitioner m ay not be billed separately by the RHC or  FQHC practitioner, or by another practitioner or an entity other than the RHC or FQHC, even  if the service is not a stand -alone  billable  visit.  Services  furnished to  patients  in any type of hospital setting (inpatient, outpatient, or emergency department) are
(Medicare Benefit Policy Manual)
practitioner or an entity other than the RHC or FQHC, even  if the service is not a stand -alone  billable  visit.  Services  furnished to  patients  in any type of hospital setting (inpatient, outpatient, or emergency department) are statutorily  excluded  from  the RHC/FQHC  benefit and  may  not be billed  by the RHC  or FQHC.
(Medicare Benefit Policy Manual)
40.2 - Hours of Operation  (Rev. 239, Issued: 01 -09-18, Effective: 1-22- 18, Implementation: 1-22-18)  RHCs and FQHCs are required to post their hours of operations at or near the entrance in a manner that clearly states the days of the week and the hours that RHC or FQHC services are furnished, and days of the week and the hours that the building is open solely for  administrative or other purposes, if applicable.  This information should be easily readable, including by people with vision problems and people who are in wheel chairs.  Qualified services provided to an RHC or FQHC patient other than during the posted hours of operation are considered RHC or FQHC services when the practitioner is compensated by the RHC or FQHC for the services provided, and when the cost of the service is included in the RHCs cost report.  Services furnished at times other than the RHC or FQHC posted hours of operation to Medicare beneficiaries who are RHC or FQHC patients may not be billed to Medicare Part B if the practitioners compensation for these services is included in the RHC/FQHC cost report.  (See Section 100 on Commingling).  This applies to full and part time practitioners, practitioners who are employees, practitioners working under contract to the RHC or FQHC, and practitioners who are compensated by the RHC or FQHC under another type of arrangement.  RHCs and FQHCs should have clear policies regarding the provision of services at other times, and include this in a practitioners employment agreement or contract.   40.3 - Multiple Visits on Same Day  (Rev. 11803; Issued: 01- 26-23; Effective: 01 -01-23; Implementation: 02- 27-23)
(Medicare Benefit Policy Manual)
40.3 - Multiple Visits on Same Day  (Rev. 11803; Issued: 01- 26-23; Effective: 01 -01-23; Implementation: 02- 27-23)  Except as noted below, encounters with more than one RHC or FQHC practitioner on the  same day, or multiple encounters with the same RHC or FQHC practitioner on the same  day, constitute a single RHC or FQHC visit and is payable as one visit. This policy  applies regardless of the length or complexity of the visit, the number or type of  practitioners seen, whether the second visit is a scheduled or unscheduled appointment, or  whether the first visit is related or unrelated to the subsequent visit. This would include  situations where an RHC or FQHC patient has a medically -necessary face- to-face visit  with an RHC or FQHC practitioner, and is then seen by another RHC or FQHC  practitioner, including a specialist, for further evaluation of the same condition on the same day, or is then seen by another RHC or FQHC practitioner, including a specialist,  for evaluation of a different condition on the same day.   Exceptions are for the following circumstances  only:  The patient, subsequent to the first visit , suffers an illness or injury that requires  additional diagnosis or treatment on the same day (for example, a patient sees their practitioner in the morning for a medical condition and later in the day has a fall and returns to the RHC or FQHC). In this situation only , the FQHC would  use modifier 59 on the claim and the RHC would use modifier 59 or 25 to attest that the conditions being treated qualify as 2 billable  visits;    The patient has a medical visit and a mental health visit on the same day (2 billable visits ); or   For RHCs only, the patient has an initial preventive physical exam (IPPE) and a separate medical and/or mental health  visit on  the same day (2 or 3 billable  visits).   NOTE:  These exceptions  do not apply to grandfathered  tribal FQHCs.
(Medicare Benefit Policy Manual)
NOTE:  These exceptions  do not apply to grandfathered  tribal FQHCs.   40.4 - Global Billing  (Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Surgical procedures furnished in an RHC or FQHC by an RHC or FQHC practitioner are considered RHC or FQHC services.  Procedures are included in the payment of an otherwise qualified visit and are not separately billable.  If a procedure is associated with a qualified visit, the charges for the procedure go on the claim with the visit.  Payment is included in the AIR when the procedure is furnished in an RHC, and payment is included in the PPS methodology when furnished in an FQHC.  The Medicare global billing requirements do not apply to RHCs and FQHCs, and global billing codes are not accepted for RHC or FQHC billing or payment. Surgical procedures furnished at locations other than RHCs or FQHCs may be subject to Medicare global billing requirements.  If an RHC or FQHC furnishes services to a patient who has had surgery elsewhere and is still in the global billing period, the RHC or FQHC must determine if these serv ices have been included in the surgical global billing.  RHCs and FQHCs may bill for a visit during the global surgical period if the visit is for a service not included in the global billing package.  If the service furnished by the RHC or FQHC was included in the global payment for the surgery, the RHC or FQHC may not also bill for the same service.  Services not included in the global surgical package are listed in Pub. 100- 04, Medicare Claims Processing Manual, chapter 12, section 40.1.B, and include, but are not limited to: initial consultation by the surgeon to determine the need for major surgery; visits unrelated to the diagnosis for which the surgical procedure is performed (unless the visit occurs due to complications of the surgery); treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery; etc.  For additional information on global billing, see http://www.cms.gov/Regulations- and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf
(Medicare Benefit Policy Manual)
40.5 - 3-Day Payment Window  (Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Medicares 3 -day payment window applies to outpatient services furnished by a hospital (or an entity that is wholly owned or wholly operated by the hospital).  The statute requires that hospitals bundle the technical component of all outpatient diagnostic services and related non-diagnostic services (e.g., t herapeutic) with the claim for an inpatient stay when services are furnished to a Medicare beneficiary in the 3 days (or, in the case of a hospital that is not a subsection (d) hospital, during the 1- day) preceding an inpatient admission in compliance with  section 1886 of the Act. RHCs and FQHC services are not subject to the Medicare 3 - day payment window requirements.  For additional information on the 3 day payment window, see http://www.cms.gov/Outreach -and-Education/Medicare- Learning -Network -MLN/MLNMattersArticles/downloads/MM7502.pdf   50 - RHC and FQHC Services (Rev. 166, Issued: 01-31-13, Effective: 03-01- 13, Implementation: 0 3-01-13)   50.1 - RHC Services (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)  RHC  services  include:  Physicians'  services,  as described  in section  110;  Services  and supplies incident to a physicians  services,  as described  in section  120;  Services  of NPs,  PAs,  and CNMs,  as described  in section  130;  Services and supplies incident to the services of NPs, PAs, and CNMs, as described  in section 140;  CP and CSW services,  as described  in section  150;  Services and supplies incident to the services of CPs, as described in section 160; and  Visiting nurse services to patients confined to the home, as described in section 190.  Certain  care management  services,  as described  in section  230.  Certain  virtual communication  services,  as described  in section  240.
(Medicare Benefit Policy Manual)
RHC  services  also include certain  preventive services  when  specified  in statute  or when  established  through the National  Coverage Determination  (NCD)  process  and not specifically  excluded  (see section  220  Preventive  Health  Services).  These services  include:   Influenza,  Pneumococcal,  Hepatitis  B, COVID -19 vaccinations , and covered monoclonal antibody products used as pre -exposure prophylaxis prevention of COVID -19;  IPPE;   Annual  Wellness  Visit  (AWV);  and  Medicare- covered  preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) with a grade of A or B, as appropriate for the  09individual. Influenza , pneumococcal and COVID -19 vaccines , and covered monoclonal antibody products used as pre -exposure p rophylaxis prevention of COVID -19 and  their administration are paid through the cost         report, and payment for the hepatitis B vaccine and its administration is included in an otherwise billable visit.  The professional component of the IPPE, AWV, and other  qualified  preventive  services is paid  based on the AIR.  Note: Monoclonal antibody products used for the treatment or for post -exposure prophylaxis of COVID -19 (when they are not purchased by the government) and their administration are paid through t he cost report until the end of the calendar year in which the Emergency Use Authorization declaration for drugs and biological products with respect to COVID -19 ends.  50.2 - FQHC Services  (Rev. 11803; Issued: 01- 26-23; Effective: 01 -01-23; Implementation: 02- 27-23) FQHC services include all of the RHC services listed in section 50.1 of this chapter.  While the following services may also be furnished in an RHC, the statute specifically  lists certain services  as FQHC  services, including  but not  limited to:   Screening  mammography;    Screening  pap smear  and screening  pelvic  exam;    Prostate  cancer  screening  tests;    Colorectal  cancer  screening  tests;    DSMT  services;    Diabetes  screening  tests;    MNT  services;    Bone  mass  measurement;    Screening  for glaucoma;    Cardiovascular  screening  blood tests;  and
(Medicare Benefit Policy Manual)
 Prostate  cancer  screening  tests;    Colorectal  cancer  screening  tests;    DSMT  services;    Diabetes  screening  tests;    MNT  services;    Bone  mass  measurement;    Screening  for glaucoma;    Cardiovascular  screening  blood tests;  and   Ultrasound screening  for abdominal  aortic  aneurysm.  Influenza , pneumococcal  and COVID -19 vaccines , and covered monoclonal antibody products used as pre -exposure prophylaxis prevention of COVID -19 their administration are paid through the cost  report, and payment for the hepatitis B vaccine and its administration is included in an  otherwise billable visit.  The professional component of the IPPE, AWV, and other  qualified preventive services is paid based on the lesser of the FQHCs charge or the PPS  rate for the specific payment  code,  with  an adjustment  for IPPE  and AWV  (see section 70.4  FQHC  Payment  Codes).   Note: Monoclonal antibody products used for the treatment or for post -exposure prophylaxi s of COVID -19 (when they are not purchased by the government) and their administration are paid through the cost report until the end of the calendar year in which the Emergency Use Authorization declaration for drugs and biological products with respect t o COVID -19 ends.
(Medicare Benefit Policy Manual)
50.3 - Emergency Services  (Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  RHCs provide outpatient services that are typically furnished in a physicians office or outpatient clinic and generally provide only limited emergency care.  Neither independent nor hospital -based RHCs are subject to Emergency Medical Treatment and Active Labor Act regulations.  However, RHC practitioners are required to provide medical emergency procedures as a first response to common life threatening injuries and acute illnesses and to have available the drugs and biologicals commonly used in life -saving procedures.  The definition of a first response is a service that is commonly provided in a physicians office.  If a patient presents at the RHC with an emergency when the RHC is not open for patient care because a physician, NP, PA, CNM, CP, or CSW is not present, other staff may attend to the patient until care of the individual can be transferred.  Any care provided in this situat ion must be within the individuals ability, training, and scope of practice, and in accordance with state laws, and would not be considered an RHC service. During their regular hours of operations, FQHC practitioners are required to provide medical proced ures as a first response to common life threatening injuries and acute illnesses and to have available the drugs and biologicals commonly used in life -saving procedures.  After their operating hours, FQHCs must provide telephone access to an individual who has the qualifications and training to exercise professional judgment in assessing a patients need for emergency medical care, and if appropriate, to refer the patient to an appropriate provider or facility that is open.  Additional information on emergen cy preparedness requirements for RHCs and FQHCs can be found 42 CFR 491.12.
(Medicare Benefit Policy Manual)
60 - Non RHC/FQHC Services (Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  RHCs and FQHCs must be primarily engaged in furnishing primary care services, but may also furnish certain services that are beyond the scope of the RHC or FQHC benefit, such as laboratory services or the technical component of an RHC or FQHC service.  If these services are authorized to be furnished by the RHC or FQHC and are cover ed under a separate Medicare benefit category, the services must be billed separately (not by the RHC or FQHC) to the appropriate A/B MAC under the payment rules that apply to the service.  RHCs and FQHCs must identify and remove from allowable costs on the Medicare cost report all costs associated with the provision of non-RHC/FQHC services such as space, equipment, supplies, facility overhead, and personnel.  60.1 - Description of Non RHC/FQHC Services (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)  Certain services are not considered RHC or FQHC services either because they 1) are not  included in the RHC or FQHC benefit, or 2) are not a Medicare benefit. Non- RHC/FQHC  services include, but are not limited to:   Medicare excluded services  - Includes routine physical checkups, dental care, hearing tests, routine eye exams, etc.  For additional information, see Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage, at http://www.cms.gov/Regulations- a nd-Guidance/Guidance/Manuals/downloads/bp102c16.pdf   Technical component of an RHC or FQHC service - Includes diagnostic te sts such as x - rays, electrocardiograms (EKGs), and other tests authorized by Medicare statute or the NCD process.  These services may  be billed  separately  to the A/B MAC  by the facility).  (The professional component is an RHC or FQHC service if performed by an RHC or FQHC  practitioner  or furnished incident to an RHC or  FQHC  visit).
(Medicare Benefit Policy Manual)
Laboratory services  - Although RHCs and FQHCs are required to furnish certain laboratory services (for RHCs see section 1861(aa)(2)(G) of the Act, and for FQHCs see section 330(b)(1)(A)(i)(II) of the PHS Act), laboratory services are not within the scope of the RHC or FQHC benefit.  When clinics and centers separately bill laboratory  services, the cost of associated space, equipment, supplies, facility overhead and personnel f or these services must be adjusted out of the RHC or FQHC cost report. This  does not include venipuncture, which is included in the AIR when furnished in an RHC by an RHC practitioner or furnished incident to an RHC service, and it is included in the per-diem payment when furnished in an FQHC by an FQHC practitioner or furnished incident to an FQHC service.   Durable medical equipment - Includes crutches, hospital beds, and wheelchairs used in the patients place of  residence, whether rented or  purchased.  Ambulance services  - The ambulance transport benefit under Medicare Part B covers a medically necessary transport of a beneficiary by ambulance to the nearest appropriate  facility that can treat the patient's condition, and any other methods of transportation are contraindicated.  See https://www.cms.gov/Regulations- and- Guidance/Guidance/Manuals/downloads/bp102c10.pdf for additional information on covered  ambulance services.  Prosthetic devices  - Prosthetic devices are included in the definition of medical and other health services in section 1861(s)(8) of the Act and are defined as devices (other than  dental)  which  replace all or  part of an  internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of such devices,  and including one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an intraocular lens.  Other examples of  prostheti c devices include cardiac pacemakers, cochlear implants, electrical continence  aids,  electrical nerve stimulators, and  tracheostomy  speaking  valves.   Body  Braces   Includes  leg, arm,  back,  and neck  braces  and their  replacements.