evekhm/cms_iom_500 huggingface dataset:
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and select the relevant section.   20.4.4 - Supplies  (Rev. 1, 10-01-03) B3-15900.2  A/B MACs (B) make a separate payment for supplies furnished in connection with a procedure only when one of the two following conditions exists: A. HCPCS code A4300 is billed in conjunction with the appropriate procedure in the Medicare Physician Fee Schedule Data Base (place of service is physicians office).  However, A4550, A4300, and A4263 are no longer separately payable as of 2002.  Supplies have been incorporated into the practice expense RVU for 2002.  Thus, no payment may be made for these supplies for services provided on or after January 1, 2002. B. The supply is a pharmaceutical or radiopharmaceutical diagnostic imaging agent (including codes A4641 through A4647); pharmacologic stressing agent (code J1245); or therapeutic radionuclide (CPT code 79900).  Other agents may be used which do not have an assigned HCPCS code.  The procedures performed are:  Diagnostic radiologic procedures (including diagnostic nuclear medicine) requiring pharmaceutical or radiopharmaceutical contrast media and/or pharmacologic stressing agent;  Other diagnostic tests requiring a pharmacologic stressing agent;  Clinical brachytherapy procedures (other than remote after-loading high intensity brachytherapy procedures (CPT codes 77781 through 77784) for which the expendable source is included in the TC RVUs); or  Therapeutic nuclear medicine procedures.  Drugs are not supplies, and may be paid incidental to physicians services as described in Chapter 17. 20.4.5 - Allowable Adjustments (Rev. 1, 10-01-03) B3-15055
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Effective January 1, 2000, the replacement code (CPT 69990) for modifier -20 - microsurgical techniques requiring the use of operating microscopes may be paid separately only when submitted with CPT codes: 61304 through 61546  61550 through 61711 62010 through 62100  63081 through 63308 63704 through 63710  64831 64834 through 64836 64840 through 64858 64861 through 64871 64885 through 64891 64905 through 64907. 20.4.6 - Payment Due to Unusual Circumstances (Modifiers -22 and  -52) (Rev. 1, 10- 01-03) B3-15028  The fees for services represent the average work effort and practice expenses required to provide a service.  For any given procedure code, there could typically be a range of work effort or practice expense required to provide the service.  Thus, A/B MACs (B) may increase or decrease the payment for a service only under very unusual circumstances based upon review of medical records and other documentation.  20.4.7  Technical Component Payment Reduction for X- Rays and Other Imaging Services  (Rev. 3820, Issued: 11- 21-17, Effective: 01 -01-18, Implementation; 01- 02-18) Several provisions provide for a payment reduction to the technical component (and the technical component of the global fee) for X -rays and imaging services under certain circumstances.  Please see Chapter 13, Section 20.2 of this publication for more inf ormation.
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20.5 - No Adjustments in Fee Schedule Amounts  (Rev. 1, 10- 01-03) B3-15054 A/B MACs (B) may not make adjustments in fee schedule amounts provided by CMS for:   Inherent reasonableness;   Comparability;  Multiple visits to nursing homes (i.e., when more than one patient is seen during the same trip);  Refractions -  If A/B MACs (B) receive a claim for a service that also indicates that a refraction was done, A/B MACs (B) do not reduce payment for the service.  The CMS has already made the reduction in the fee for refractions provided to A/B MACs (B);   HCPCS alpha -numeric modifiers AT (acute treatment), ET (emergency treatment), LT (left side of body), RT (right side of body), and SF (second opinion ordered by PRO);   CPT modifiers - 23 (unusual anesthesia), -32 (mandated services), - 47 (anesthesia by surgeon), - 76 (repeat procedure by same physician), and - 90 (reference laboratory); and   A/B MAC (B) -unique local modifiers (HCPCS Level 3 modifiers beginning with the letters w through z).   20.6- Update Factor for Fee Schedule Services  (Rev. 2464, Issued: 05 -04-12, Effective: 10 -01-11-MCS/10 -01-12-VMS, Implementation: 10-03-11-MCS, VMS Analysis and Design /10-01-12- VMS implementation)
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The CMS provides updates to the MPFSDB and other fee schedules annually or as otherwise necessary.  C laims processing A/B MACs (B) must maintain at least five full calendar years of fee schedules and related pricing data (i.e., the current and four prior calendar years) , regardless of the number of updates or pricing periods within those five years.  20.7 - Comparability of Payment Provision of Delegation of Authority by CMS to Railroad Retirement Board  (Rev. 1, 10-01-03) B3-15064 The delegation of authority, under which the Railroad Retirement Board (RRB) administers the Supplementary Medical Insurance Benefits Program for qualified railroad retirement beneficiaries, requires that:  The Railroad Retirement Board shall take such action as may be necessary to assure that payments made for services by the A/B MACs (A) it selects will conform as closely as possible to the payment made for comparable services in the same locality by an A/B  MAC (A) acting for CMS.  The purpose of this comparability of payment is to reduce to the extent possible disparities between the payments made by the A/B MAC (B) under the RRB delegation and the payments made by the regular A/B MACs (B) for services or items furnished by the same physicians, including provider-based physicians, or suppliers.  For all services paid for under the physician fee schedule, A/B MACs (B) under the RRB delegation pay based on the same fee schedule amount used by the A/B MAC (B).  20.8 - Payment for Teleradiology Physician Services Purchased by the Indian Health Service (IHS) Providers and Physicians  (Rev. 1643, Issued: 12- 05-08, Effective: 01-01-07, Implementation: 03-09-09)
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The IHS providers may choose to purchase or otherwise contract with non-IHS physicians or practitioners for teleradiology interpretations services.  These services may be paid using either contractual reassignment or purchased test methodologies.  See Chapter 19, 120 of this manual for further information.  30 - Correct Coding Policy (Rev. 1, 10-01-03) B3-15068 The Correct Coding Initiative was developed to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims.  Refer to Chapter 23 for additional information on the initiative. The principles for the correct coding policy are:  The service represents the standard of care in accomplishing the overall procedure;   The service is necessary to successfully accomplish the comprehensive procedure.  Failure to perform the service may compromise the success of the procedure; and   The service does not represent a separately identifiable procedure unrelated to the comprehensive procedure planned.  For a detailed description of the correct coding policy, refer to http://www.cms.gov/Outreach-and-Education/Medicare- Learning -Network -MLN/MLNProducts/downloads/How- To-Use-NCCI -Tools.pdf .  The CMS as well as many third party payers have adopted the HCPCS/CPT coding system for use by physicians and others to describe services rendered.  The system contains three levels of codes.  Level I contains the American Medical Associations Current Pro cedural Terminology (CPT) numeric codes.  Level II contains alpha -numeric codes primarily for items and services not included in CPT.  Level III contains A/B MAC (B) specific codes that are not included in either Level I or Level II.  For a list of CPT and  HCPCS codes refer to the CMS Web site.
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The following general coding policies encompass coding principles that are to be applied in the review of Medicare claims.  They are the basis for the correct coding edits that are installed in the claims processing systems effective January 1, 1996. A. Coding Based on Standards of Medical/Surgical Practice  All services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code.  Many of these generic activities are common to virtually all procedures and, on other occasions, some are integral to only a certain group of procedures, but are still essential to accomplish these particular procedures.  Accordingly, it is inappropriate to separately report these services based on standard medical and surgical principles.  Because many services are unique to individual CPT coding sections, the rationale for rebundling is described in that particular section of the detailed coding narratives that are transmitted to A/B MACs (B) periodically.  B. CPT Procedure Code Definition  The format of the CPT manual includes descriptions of procedures, which are, in order to conserve space, not listed in their entirety for all procedures.  The partial description is indented under the main entry.  The main entry then encompasses the portion of the description preceding the semicolon.  The main entry applies to and is a part of all indented entries, which follow with their codes.  In the course of other procedure descriptions, the code definition specifies other procedures that are included in this comprehensive code.  In addition, a code description may define a rebundling relationship where one code is a part of another based on t he language used in the descriptor.  C. CPT Coding Manual Instruction/Guideline  Each of the six major subsections include guidelines that are unique to that section.  These directions are not all inclusive of nor limited to, definitions of terms, modifiers, unlisted procedures or services, special or written reports, details about reporting separate, and multiple or starred procedures and qualifying circumstances. D. Coding Services Supplemental to Principal Procedure (Add -On Codes) Code  Generally, these are identified with the statement list separately in addition to code for primary procedure in parentheses, and other times the supplemental code is used only with certain primary codes, which are parenthetically identified.  The reason for these CPT codes is to enable physicians and others to separately identify a service that is performed in certain situations as an additional service.  Incidental services that are necessary to accomplish the primary procedure (e.g., lysis
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identified.  The reason for these CPT codes is to enable physicians and others to separately identify a service that is performed in certain situations as an additional service.  Incidental services that are necessary to accomplish the primary procedure (e.g., lysis of adhesions in the course of an open cholecystectomy) are not separately billed.  E. Separate Procedures  The narrative for many CPT codes includes a parenthetical statement that the procedure represents a separate procedure.  The inclusion of this statement indicates that the procedure, while possible to perform separately, is generally included in a more comprehensive procedure, and the service is not to be billed when a related, more comprehensive, service is performed.  The separate procedure designation is used with codes in the surgery (CPT codes 10000- 69999), radiology (CPT codes 70000- 79999), and medicine (CPT codes 90000- 99199) sections.  When a related procedure from the same section, subsection, category, or subcategory is performed, a code with the designation of separate procedure is not to be billed with the primary procedure.  F. Designation of Sex
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Many procedure codes have a sex designation within their narrative.  These codes are not billed with codes having an opposite sex designation because this would reflect a conflict in sex classification either by the definition of the code descriptions themselves, or by the fact that the performance of these procedures on the same beneficiary would be anatomically impossible.   G. Family of Codes   In a family of codes, there are two or more component codes that are not billed separately because they are included in a more comprehensive code as members of the code family.  Comprehensive codes include certain services that are separately identifiable by other component codes.  The component codes as members of the comprehensive code family represent parts of the procedure that should not be listed separately when the complete procedure is done.  However, the component codes are considered individually if performed independently of the complete procedure and if not all the services listed in the comprehensive codes were rendered to make up the total service.  H. Most Extensive Procedures   When procedures are performed together that are basically the same or performed on the same site but are qualified by an increased level of complexity, the less extensive procedure is bundled into the more extensive procedure.  I. Sequential Procedures  An initial approach to a procedure may be followed at the same encounter by a second, usually more invasive approach.  There may be separate CPT codes describing each service.  The second procedure is usually performed because the initial approach was unsuccessful in accomplishing the medically necessary service.  These procedures are considered sequential procedures.  Only the CPT code for one of the services, generally the more invasive service, should be billed.  J. With/Without Procedures
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In the CPT manual, there are various procedures that have been separated into two codes with the definitional difference being with versus without (e.g., with and without contrast).  Both procedure codes cannot be billed.  When done together, the without procedure is bundled into the with procedure.  K. Laboratory Panels  When components of a specific organ or disease oriented laboratory panel (e.g., codes 80061 and 80059) or automated multi -channel tests (e.g., codes 80002 -  80019) are billed separately, they must be bundled into the comprehensive panel or automated multi -channel test code as appropriate that includes the multiple component tests.  The individual tests that make up a panel or can be performed on an automated multi -channel test analyzer are not to be separately billed.  L. Mutually Exclusive Procedures  There are numerous procedure codes that are not billed together because they are mutually exclusive of each other.  Mutually exclusive codes are those codes that cannot reasonably be done in the same session.  An example of a mutually exclusive situation is when the repair of the organ can be performed by two different methods.  One repair method must be chosen to repair the organ and must be billed.  Another example is the billing of an initial service and a subsequent service.  It is contradictory for a service to be classified as an initial and a subsequent service at the same time.  CPT codes which are mutually exclusive of one another based either on the CPT definition or the medical impossibility/improbability that the procedures could be performed at the same session can be identified as code pairs.  These codes are not necessarily  linked to one another with one code narrative describing a more comprehensive procedure compared to the component code, but can be identified as code pairs which should not be billed together.  M. Use of Modifiers  When certain component codes or mutually exclusive codes are appropriately furnished, such as later on the same day or on a different digit or limb, it is appropriate that these services be reported using a HCPCS code modifier.  Such modifiers are modifier s E1 -  E4, FA, F1 -  F9, TA, T1 -  T9, LT, RT, LC, LD, RC, - 58, -78, -79, and - 94. Modifier - 59 is not appropriate to use with weekly radiation therapy management codes (77427) or with evaluation and management services codes
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LT, RT, LC, LD, RC, - 58, -78, -79, and - 94. Modifier - 59 is not appropriate to use with weekly radiation therapy management codes (77427) or with evaluation and management services codes (99201 - 99499). Application of these modifiers prevent erroneous denials of claims for several procedures performed on different anatomical sites, on different sides of the body, or at different sessions on the same date of service.  The medical record must reflect that t he modifier is being used appropriately to describe separate services.  30.1 - Digestive System (Codes 40000 - 49999)  (Rev. 3368, Issued: 10- 09-15, Effective: 01 -01-16, Implementation: 01- 01-16)
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A.  Upper Gastrointestinal Endoscopy Including Endoscopic Ultrasound (EUS) (Code 43259)   If the person performing the original diagnostic endoscopy has access to the EUS and the clinical situation requires an EUS, the EUS may be done at the same time.  The procedure, diagnostic and EUS, is reported under the same code, CPT 43259.  This code conforms to CPT guidelines for the indented codes.  The service represented by the indented code, in this case code 43259 for EUS, includes the service represented by the unintended code preceding the list of indented codes.  Therefore, when a diagnostic exa mination of the upper gastrointestinal tract including esophagus, stomach, and either the duodenum or jejunum as appropriate, includes the use of endoscopic ultrasonography, the service is reported by a single code, namely 43259.   Interpretation, whether by a radiologist or endoscopist, is reported under CPT code 76975- 26.  These codes may both be reported on the same day.  B.  Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121)
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An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon- small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier  -53.  (Code 44388 is valid with modifier 53 beginning January 1, 2016.)  The Medicare physician fee schedule database has specific values for codes 44388 -53, 45378- 53, G0105- 53 and G0121- 53.  An incomplet e colonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy.  Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one -half the value of the inputs for the codes. 30.2 - Urinary and Male Genital Systems (Codes 50010 - 55899)  (Rev. 1, 10- 01-03) B3-15200
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A. Cystourethroscopy With Ureteral Catheterization (Code 52005)  Code 52005 has a zero in the bilateral field (payment adjustment for bilateral procedure does not apply) because the basic procedure is an examination of the bladder and urethra (cystourethroscopy), which are not paired organs.  The work RVUs assigned take  into account that it may be necessary to examine and catheterize one or both ureters.  No additional payment is made when the procedure is billed with bilateral modifier  -50.  Neither is any additional payment made when both ureters are examined and code 52005 is billed with multiple surgery modifier  -51.  It is inappropriate to bill code 52005 twice, once by itself and once with modifier  -51, when both ureters are examined.  B. Cystourethroscopy With Fulgration and/or Resection of Tumors (Codes 52234, 52235, and 52240)  The descriptors for codes 52234 through 52240 include the language tumor(s).  This means that regardless of the number of tumors removed, only one unit of a single code can be billed on a given date of service.  It is inconsistent to allow payment for removal of a small (code 52234) and a large (code 52240) tumor using two codes whe n only one code is allowed for the removal of more than one large tumor.  For these three codes only one unit may be billed for any of these codes, only one of the codes may be billed, and the billed code reflects the size of the largest tumor removed.   30.3 - Audiology Services  (Rev. 2044, Issued: 09- 03-10, Effective: 09 -30-10, Implementation: 09- 30-10)
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30.3 - Audiology Services  (Rev. 2044, Issued: 09- 03-10, Effective: 09 -30-10, Implementation: 09- 30-10)  Section 1861(ll)(3)of the Social Security Act (the Act) defines audiology services as such hearing and balance assessment services furnished by a qualified audiologist as the audiologist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law), as would otherwise by covered if furnished by a physician.  In this section, these hearing and balance assessment services are termed audiology services, regardless of whether they are furnished by an audiologist, physician, nonphysician practitioner (NPP), or hospital.  Because audiology services are diagnostic tests, when furnished in an office or hospital outpatient department, they must be furnished by or under the appropriate level of supervision of a physician as established in 42 CFR 410.32(b)(1) and 410.28(e).  If not personally furnished by a physician, audiologist, or NPP, audiology services must be performed under direct physician supervision.  As specified in 42 CFR 410.32(b)(2)(ii) or (v), respectively, these services are excepted from physician supervision whe n they are personally furnished by a qualified audiologist or performed by a  nurse practitioner or clinical nurse specialist authorized to perform the tests under applicable State laws.   References to technicians apply also to other qualified clinical staff.  See Pub. 100- 02, chapter 15, section 80.3.D.   A. Correct Reporting
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References to technicians apply also to other qualified clinical staff.  See Pub. 100- 02, chapter 15, section 80.3.D.   A. Correct Reporting   1. General.  Contact the A/B MAC (B) for guidance if the CPT codebook changes the description of codes mentioned in this section.  Other policies concerning audiological services are found in Pub. 100- 02, chapter 15, section 80.3.  See chapter 26 of this manual for place of service and type of service coding.  Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105- 33), which added section 1834(k)(5) to (the Act), required that all claims for certain audiology services be reported using a uniform coding system.  CMS chose HCPCS (Healthcare Common Procedure  Coding System) as the coding system for the reporting of these services.  This coding requirement is effective for all claims for audiology services submitted on or after April 1, 1998.  The BBA also required payment under a prospective payment system for audiology services.  Effective for claims with dates of service on or after January 1, 1999, the Medicare Physician Fee Schedule (MPFS) became the method of payment for audiology services  furnished in the office setting and for the associated professional services furnished in physicians office and hospital outpatient settings.