evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
NOTE:   Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE or AWV and should not be included when determining the most appropriate level of E/M service to be billed for  the medically necessary, separately identifiable, E/M service.   30.6.2 - Billing for Medically Necessary Visit on Same Occasion as Preventive Medicine Service  (Rev. 1, 10- 01-03)  See Chapter 18 for payment for covered preventive services.  When a physician furnishes a Medicare beneficiary a covered visit at the same place and on the same occasion as a noncovered preventive medicine service (CPT codes 99381- 99397), consider the covered visit to be provided in lieu of a part of the preventive medicine service of equal value to the visit.  A preventive medicine service (CPT codes 99381 -99397) is a noncovered service.  The physician may charge the beneficiary, as a charge for the noncovered remainder of the service, the amount by which the physic ians current established charge for the preventive medicine service exceeds his/her current established charge for the covered visit.  Pay for the covered visit based on the lesser of the fee schedule amount or the physicians actual charge for the visit.  The physician is not required to give the beneficiary written advance notice of noncoverage of the part of the visit that constitutes a routine preventive visit.  However, the physician is responsible for notifying the patient in advance of his/her liability for the charges for services that are not medically necessary to treat the illness or injury. There could be covered and noncovered procedures performed during this encounter (e.g., screening x -ray, EKG, lab tests.).  These are considered individually.  Those procedures which are for screening for asymptomatic conditions are considered noncovered a nd, therefore, no payment is made.  Those procedures ordered to diagnose or monitor a symptom, medical condition, or treatment are evaluated for medical necessity and, if covered, are paid.
(Medicare Claims Processing Manual)
30.6.3 - Payment for Immunosuppressive Therapy Management  (Rev. 1, 10- 01-03) B3-4820- 4824 Physicians bill for management of immunosuppressive therapy using the office or subsequent hospital visit codes that describe the services furnished.  If the physician who is managing the immunotherapy is also the transplant surgeon, he or she bills these visits with modifier  -24 indicating that the visit during the global period is not related to the original procedure if the physician also performed the transplant surgery and submits documentation that shows that the visit is for immunosuppressive thera py.  30.6.4 - Evaluation and Management (E/M) Services Furnished Incident to Physicians Service by Nonphysician Practitioners  (Rev. 1, 10- 01-03)  When evaluation and management services are furnished incident to a physicians service by a nonphysician practitioner, the physician may bill the CPT code that describes the evaluation and management service furnished.  When evaluation and management services are furnished incident to a physicians service by a nonphysician employee of the physician, not as part of a physician service, the physician bills code 99211 for the service. A physician is not precluded from billing under the incident to provision for services provided by employees whose services cannot be paid for directly under the Medicare program.  Employees of the physician may provide services incident to the physicians service, but the physician alone is permitted to bill Medicare.  Services provided by employees as incident to are covered when they meet all the requirements for incident to and are medically necessary for the individual needs of the patient. 30.6.5 - Physicians in Group Practice  (Rev. 1, 10- 01-03)
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Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.  If more than one evaluation and management (face -to-face) service is provided on the same day to the same patient by the same  physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems.  Instead of billing separately, the physicia ns should select a level of service representative of the combined visits and submit the appropriate code for that level.  Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group. 30.6.6 - Payment for Evaluation and Management Services Provided During Global Period of Surgery  (Rev. 954, Issued: 05- 19-06, Effective: 06 -01-06, Implementation: 08- 20-06)  A. CPT Modifier  -24 - Unrelated Evaluation and Management Service by Same Physician During Postoperative Period
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A/B MACs (B) pay for an evaluation and management service other than inpatient hospital care before discharge from the hospital following surgery (CPT codes 99221- 99238) if it was provided during the postoperative period of a surgical procedure, furnished by the same physician who performed the procedure, billed with CPT modifier  -24, and accompanied by documentation that supports that the service is not related to the postoperative care of the procedure.  They do not pay for inpatient hospital care that is furnished during the hospital stay in which the surgery occurred unless the doctor is also treating another medical condition that is unrelated to the surgery.  All care provided during the inpatient stay in which the surgery occurred is compensated through the global surgical payment.  B. CPT Modifier  -25 - Significant Evaluation and Management Service by Same Physician on Date of Global Procedure  Medicare requires that Current Procedural Terminology (CPT) modifier - 25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified nonphysician practitione r) to the same patient on the same day as another procedure or other service.  A/B MACs (B) pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately iden tifiable E/M service that is above and beyond the usual pre - and post -operative work of the procedure.  Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier - 25 is added to the E/M code on the claim.  Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patients medical record to support the claim for these services, even though the do cumentation is not required to be submitted with the claim.  If the physician bills the service with the CPT modifier  -25, A/B MACs (B) pay for the service in addition to the global fee without any other requirement for documentation unless one of the following conditions is met:   When inpatient dialysis services are billed (CPT codes 90935, 90945, 90947, and 93937), the
(Medicare Claims Processing Manual)
the global fee without any other requirement for documentation unless one of the following conditions is met:   When inpatient dialysis services are billed (CPT codes 90935, 90945, 90947, and 93937), the physician must document that the service was unrelated to the dialysis and could not be performed during the dialysis procedure;   When preoperative critical care codes are being billed on the date of the procedure, the diagnosis must support that the service is unrelated to the performance of the procedure; or   When an A/B MAC (B) has conducted a specific medical review process and determined, after reviewing the data, that an individual or a group has high use of modifier  -25 compared to other physicians, has done a case -by-case review of the records to verify  that the use of modifier was inappropriate, and has educated the individual or group, the A/B MAC (B) may impose prepayment screens or documentation requirements for that provider or group.  When a A/B MAC (B) has completed a review and determined that a high usage rate of modifier  -57, the A/B MAC (B) must complete a case -by-case review of the records.  Based upon this review, the A/B MAC (B) will educate providers regarding the appropriate use of modifier  -57.  If high usage rates continue, the A/B M AC (B) may impose prepayment screens or documentation requirements for that provider or group. A/B MACs (B) may not permit the use of CPT modifier  -25 to generate payment for multiple evaluation and management services on the same day by the same physician, notwithstanding the CPT definition of the modifier. C. CPT Modifier  -57 - Decision for Surgery Made Within Global Surgical Period
(Medicare Claims Processing Manual)
A/B MACs (B) pay for an evaluation and management service on the day of or on the day before a procedure with a 90- day global surgical period if the physician uses CPT modifier -57 to indicate that the service resulted in the decision to perform the proc edure.  A/B MACs (B) may not pay for an evaluation and management service billed with the CPT modifier  -57 if it was provided on the day of or the day before a procedure  with a 0 or 10- day global surgical period.    30.6.7 - Payment for Office or Other Outpatient Evaluation and Management (E/M)  Visits (Codes 9920 2 - 99215)  (Rev.  12461; Issued:01- 18-24; Effective:01 -01-24 Implementation: 02 -19-24)    A.  Definition of New Patient for Selection of E/M Visit Code  Interpret the phrase new patient to mean a patient who has not received any professional services, i.e., E/M service or other face -to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.  For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face -to-face service with the patient is performed, then this patie nt remains a new patient for the initial visit.  An interpretation of a diagnostic test, reading an x- ray or EKG etc., in the absence of an E/M service or other face -to-face service with the patient does not affect the designation of a new patient.   B.  Office/Outpatient E/M Visits Provided on Same Day for Unrelated Problems
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B.  Office/Outpatient E/M Visits Provided on Same Day for Unrelated Problems   As for all other E/M services except where specifically noted, the Medicare Administrative Contractors (MACs) may not pay two E/M  office visits billed by a physician (or physician of the same specialty from the same group practice) for the same beneficiary on the same day unless the physician documents that the visits were for unrelated problems in the office, off campus -outpatient hospital, or on campus -outpatient hospital setting which could not be provided during the same encounter (e.g., office visit for blood pressure medication evaluation, followed five hours later by a visit for evaluation of leg pain following an accident).   C.  Office/Outpatient or Emergency Department E/M Visit on Day of Admission to Nursing Facility   MACs may not pay a physician for an emergency department visit or an office visit and  a comprehensive nursing facility assessment on the same day.  Bundle E/M visits on the same date provided in sites other than the nursing facility into the initial nursing facility care code when performed on the same date as the nursing facility admission by the same physician (see section on Nursing Facility Services below).   D.  Drug Administration Services and E/M Visits Billed on Same Day of Service   MACs must advise physicians that CPT code 99211 cannot be paid if it is billed with a drug administration service such as a chemotherapy or nonchemotherapy drug infusion code (effective January 1, 2004).  This drug administration policy was expanded in the  Physician Fee Schedule Final Rule, November 15, 2004, to also include a therapeutic or diagnostic injection code (effective January 1, 2005).  Therefore, when a medically necessary, significant and separately identifiable E/M service (which meets a higher  complexity level than CPT code 99211) is performed, in addition to one of these drug administration services, the appropriate E/M CPT code should be reported with modifier -25.  Documentation should support the level of E/M service billed.  For an E/M ser vice provided on the same day, a different diagnosis is not required.   E. Prolonged Office/Outpatient E/M Visits
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E. Prolonged Office/Outpatient E/M Visits   When the practitioner selects office/outpatient E/M visit level using time, the practitioner reports prolonged office/outpatient E/M visit time using HCPCS add- on code G2212 (Prolonged office/outpatient E/M services). See Prolonged Services section for additional information.  F. Add -On Code for Office/Outpatient E/M Visit Complexity   Beginning January 1, 2021, Medicare established HCPCS add- on code G2211 describing visit complexity inherent to office/outpatient E/M visits associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition, or a complex condition.   HCPCS code G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patients single, serious  condition or  a complex condition. (Add- on code, list separately in addition to office/outpatient evaluation and management visit, new or established)).
(Medicare Claims Processing Manual)
The Consolidated Appropriations Act, 2021 delayed PFS payment for this code until January 1, CY 2024 or later. Effective January 1, 2024, Medicare is changing the status of HCPCS code G2211 to make it separately payable by assigning it an "active" status indicator.    HCPCS code G2211 includes services that enable practitioners to build longitudinal relationships with all patients (that is, not only those patients who have a chronic condition or single, high- risk disease) and to address the majority of patients health care needs with consistency and continuity over longer periods of time. This includes furnishing services to patients on an ongoing basis that result in care that is personalized to the pat ient. The services result in a comprehensive, longitudinal, and continuous relationship with the patient and involve delivery of team -based care that is accessible, coordinated with other practitioners and providers, and integrated with the broader health care landscape. The continuing focal point for all needed health care services and part of ongoing care related to a patients single, serious condition or a complex condition describe relationships between the patient and the practitioner.   Reporting is not restricted based on specialty. HCPCS code G2211 may be reported with any visit level.  HCPCS code G2211 may not be reported with an O/O E/M visit reported with Modifier - 25. See 30.6.19  Office/Outpatient Evaluation and Management (O/O E/M) Complexity Add -on Payment (Code G2211).
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 Example 1: A patient has a primary care practitioner that is the continuing focal point for all health care services, and the patient sees this practitioner to be evaluated for sinus congestion. The inherent complexity that this code (G2211) captures is not in the clinical condition itself  sinus congestion  but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient. There is previously unrecognized but important cognitive effort of utilizing the longitudinal relationship itself in the diagnosis and treatment plan and weighing the factors that affect a longitudinal doctor patient relationship. In this example, the primary care practitioner could recommend conservative treatment or prescri ption of antibiotics. If the practitioner recommends conservative treatment and no new prescriptions, some patients may think that the doctor is not taking the patients concerns seriously and it could erode the trust placed in that practitioner. In turn, an eroded primary care practitioner/ patient relationship may make it less likely that the patient would follow that practitioners advice on a needed vaccination at the next visit. The primary care practitioner must decide what course of action and choice  of words in the visit itself, would lead to the best health outcome in this single visit, while simultaneously building up an effective, trusting longitudinal relationship with this patient for all of their primary health care needs. Weighing these variou s factors, even for a seemingly simple condition like sinus congestion, makes the entire interaction inherently complex, and it is this complexity in the relationship between the doctor and patient that this code captures.
(Medicare Claims Processing Manual)
 Example 2: a patient with HIV has an office visit with their infectious disease physician, who is part of ongoing care. The patient with HIV admits to the infectious disease physician that there have been several missed doses of HIV medication in the las t month. The infectious disease physician has to weigh their response during the visit the intonation in their voice, the choice of words to not only communicate clearly that it is important to not miss doses of HIV medication, but also to create a sense of safety for the patient in sharing information like this in the future. If the interaction goes poorly, it could erode the sense of trust built up over time, and the patient may be less likely to share their medication adherence shortcomings in the future. If the patient isnt forthright about their medication adherence, it may lead to the infectious disease physician switching HIV medicines to another with greater side effects, even when there was no issue with the original medication. It is because the infectious disease physi cian is part of ongoing care, and has to weigh these types of factors, that the E/M visit becomes inherently more complex and the practitioner bills this code (G2211). Even though the infectious disease doctor may not be the focal point for all services, s uch as in the previous example, HIV is a single, serious condition, and/or a complex condition, and so as long as the relationship between the infectious disease physician and patient is ongoing, this E/M visit could be billed with the add- on.   The most important information used to determine whether or not the add- on code could be billed is the relationship between the practitioner and the patient. If the practitioner is the focal point for all needed services, such as a primary care practitione r, the HCPCS G2211 add- on code could be billed. Or, if the practitioner is part of ongoing care for a single, serious condition or a complex condition, e.g., sickle cell disease, then the add- on code could be billed. The add- on code captures the inherent c omplexity of the visit that is derived from the longitudinal nature of the practitioner and patient relationship.   G. Medical Review When Practitioners Use Time to Select Visit Level
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G. Medical Review When Practitioners Use Time to Select Visit Level   Our reviewers will use the medical record documentation to objectively determine the medical necessity of the visit and accuracy of the documentation of the time spent (whether documented via a start/stop time or documentation of total time) if time is relied upon to support the E/M visit.    30.6.8 - Payment for Hospital Observation Services and Observation or Inpatient Care Services (Including Admission and Discharge Services)  (Rev. 11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)  A. Who May Bill Observation Care Codes   Observation care is a well -defined set of specific, clinically appropriate services, which include ongoing short -term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further  treatment as hospital inpatients or if they are able to be discharged from the hospital.  Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring i n order to make a decision concerning their admission or discharge.   In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours.  In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the obse rvation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours.  A/B MACs (B) pay for initial observation care billed by only the physician who ordered hospital outpatient observation services and was responsible for the patient during his/her observation care.  A physician who does not have inpatient admitting privileges but who is authorized to furnish hospital outpatient observation services may bill these codes.   For a physician to bill observation care codes, there must be a medical observation record for the patient which contains dated and timed physicians orders regarding the observation services the patient is to receive, nursing notes, and progress notes prepared by the physician while the patient received observation services.  This record must be in addition to any record prepared as a result of an emergency department or outpatient cl inic encounter.
(Medicare Claims Processing Manual)
Payment for an initial observation care code is for all the care rendered by the ordering physician on the date the patients observation services began.  All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes.   For example, if an internist orders observation services and asks another physician to additionally evaluate the patient, only the internist may bill the initial and subsequent observation care codes.  The other physician who evaluates the patient must bil l the new or established office or other outpatient visit codes as appropriate.   For information regarding hospital billing of observation services, see Chapter 4, 290.   B. Physician Billing for Observation Care Following Initiation of Observation Services   Starting in CY 2023, hospital inpatient and observation care by practitioners will be billed using the same CPT codes, CPT codes 99221 through 99223, 99231 through 99233, and 99238 and 99239. (CPT 99234 through 99236 are already used for billing hospital i npatient or observation care (including admission or discharge.) Although observation care codes (CPT codes 99218 through 99220 and 99224 through 99226) are being deleted, practitioners will still be able to furnish and bill for observation services using the revised Hospital Inpatient or Observation Care Services code set. Where noted, the term observation care code applies to Hospital Inpatient or Observation Care Services codes (CPT codes 99221- 99223, 99231-99239.)   The time counted toward the Hospital Inpatient or Observation Care codes is per day. Per day, also referred to as date of encounter, means the calendar date. When using MDM or time for code selection, a continuous service that spans the transition of 2 calendar dates is a single service and is reported on one date, which is the date the encounter begins. If the service is continuous, before and through midnight, all the time may be applied to the reported date of the service (that is, the calendar d ate the encounter began).