evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
Initial Preventive Physical  Exam (G0402)  The IPPE is a face- to-face one- time exam that must occur within the first 12 months  following the benefic iarys enrollment.  The IPPE can be billed as a stand -alone visit if it is the only medical  service provided on that day with an RHC practitioner.  If an IPPE  visit is furnished on the same day as another billable visit, two visits may be billed.  The beneficiary  coinsurance and deductible are waived.   Annual  Wellness  Visit  (G0438 and G0439)  The AWV is a face- to-face personalized prevention visit for beneficiaries who are not within the first 12 months of their first Part B coverage period and have not received an  IPPE or AWV within the past12 months. The AWV can be billed as a stand -alone visit if  it is the only medical service provided on that day with an RHC practitioner. If the AWV  is furnished on the same day as another medical visit, it is not a separately billable visit.  The beneficiary  coinsurance and deductible are waived.   Diabetes Self -Management Training (G0108) and Medical Nutrition Therapy (97802 and 97803)  Diabetes self -management training or medical nutrition therapy provided by a regis tered  dietician or nutritional professional at an RHC may be considered incident to a visit with  an RHC  practitioner  provided all  applicable conditions are met. DSMT  and MNT  are not billable visits in an RHC, although the cost may be allowable on the cost report.  RHCs  cannot bill a visit for services furnished by registered dieticians or nutritional professionals. However, RHCs are permitted to become certified providers of DSMT services and report the cost of such services on their cost report for inclusion in the computation of their  AIR.  The beneficiary  coinsurance and deductible apply.  Screening  Pelvic  and Clinical Breast  Examination (G0101)  Screening pelvic and clinical breast examination can be billed as a stand -alone visit if it is  the only medical service provided on that day with an RHC practitioner. If it is furnished  on the same day as another medical visit, it is not a separately billable visit.  The beneficiary  coinsurance and deductible are waived.
(Medicare Benefit Policy Manual)
Screening  Papanicolaou Smear  (Q0091)  Screen ing Papanicolaou  smear  can be billed  as a stand -alone visit if  it is the only medical  service provided on that day with an RHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit.  The beneficiary  coinsurance  and deductible are waived.   Prostate  Cancer Screening  (G0102)  Prostate cancer screening can be billed as a stand -alone visit if it is the only medical service provided on that day with an RHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit.  The beneficiary coinsurance and deductible apply.  Glaucoma  Screening  (G0117 and G0118)Glaucoma screening for high risk patients can be billed as a stand -alone visit if it is the only medical service provided on that day with an RHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit.  The beneficiary  coinsurance and deductible apply.  Lung  Cancer Screening  Using  Low Dose  Computed  Tomography (LDCT)  (G0296)  LDCT  can be billed  as a stand -alone visit if  it is the  only medical  service provided on that day with an RHC practitioner. If it is furnished on the same day as another medical visit,  it is not a separately billable visit.  The beneficiary coinsurance and deductible are waived.   NOTE : Hepatitis  C Screening  (GO472)  is a technical  service only and therefore  it is not  paid as part of  the RHC visit.
(Medicare Benefit Policy Manual)
NOTE : Hepatitis  C Screening  (GO472)  is a technical  service only and therefore  it is not  paid as part of  the RHC visit.   220.2 - Copayment and Deductible for RHC Preventive Health Services  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  When one or more qualified preventive service is provided as part of an RHC visit, charges for these services must be deducted from the total charge for purposes of calculating benef iciary copayment and deductible.  For example, if the total charge for the visit is $150, and $50 of that is for a qualified preventive service, the beneficiary copayment and deductible is based on $100 of the total charge, and Medicare would pay 80 percen t of the $100, and 100 percent of the $50 (minus any deductible).  If no other RHC service took place along with the preventive service, there would be no copayment or deductible applied, and Medicare would pay 100 percent of the payment amount.  220.3 - Preventive Health Services in FQHCs  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)
(Medicare Benefit Policy Manual)
220.3 - Preventive Health Services in FQHCs  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)  FQHCs must provide preventive health services on site or by arrangement with another provider. These services must be furnished by or under the direct supervision of a physician, NP, PA, CNM, CP, or CSW. Section 330(b)(1)(A)(i)(III) of the Public Health Service (PHS) Act required preventive health services can be found at http://bphc.hrsa.gov/policies regulations/legislation/index.html, and include:  prenatal and perinatal services;   appropriate cancer screening;   well-child services;   immunizations against vaccine -preventable diseases;   screenings for elevated blood lead levels, communicable diseases, and   cholesterol;   pediatric eye, ear, and dental screenings to determine the need for vision and hearing correction and dental care;   voluntary family planning services; and  preventive denta l services.  NOTE: The cost of providing these services may be included in the FQHC cost report but they do not necessarily qualify as FQHC billable visits or for the waiver of the beneficiary coinsurance.   Influenza (G0008), Pneumococcal (G0009) and COVID -19 vaccines and certain COVID -19 monoclonal antibody products  Influenza, pneumococcal and COVID-19 vaccines and covered monoclonal antibody products used as pre-exposure prophylaxis prevention of COVID-19 and their administration are paid at 100 percent of    reasonable cost through the cost report. The cost is included in the cost report and no visit is billed. FQHCs must include these charges on the claim if furnished as part of an  encounter. The beneficiary coinsurance is waived.   Hepatitis B Vaccine ( G0010)  Hepatitis B vaccine and its administration is included in the FQHC visit and is not separately billable. The cost of the vaccine and its administration can be included in the line item for the otherwise qualifying visit. A visit cannot be billed if  vaccine administration is the only service the FQHC provides. The beneficiary coinsurance is waived.
(Medicare Benefit Policy Manual)
Initial Preventive Physical Exam (G0402)  The IPPE is a face- to-face one- time exam that must occur within the first 12 months following the beneficiarys  enrollment. The IPPE can be billed as a stand -alone visit if it is the only medical service provided on that day with an FQHC practitioner. If an IPPE visit is furnished on the same day as another billable visit, FQHCs may not bill for a separate visit. T hese FQHCs will have an adjustment of 1.3416 to their PPS rate. The beneficiary coinsurance is waived.   Annual Wellness Visit (G0438 and G0439)  The AWV is a personalized face- to-face prevention visit for beneficiaries who are not within the first 12 months of their first Part B coverage period and have not received an IPPE or AWV within the past12 months. The AWV can be billed as a stand- alone visit if it is the only medical service provided on that day with an FQHC practitioner. If the AWV is furnish ed on the same day as another medical visit, it is not a separately billable visit. FQHCs that are authorized to bill under the FQHC PPS will have an adjustment of 1.3416 to their PPS rate. The beneficiary coinsurance is waived.  Diabetes Self -Management Training (G0108) and Medical Nutrition Therapy (97802 and 97803)  DSMT and MNT furnished by certified DSMT and MNT providers are billable visits in FQHCs when they are provided in a one-on- one, face- to-face encounter and all program requirements are met. Ot her diabetes counseling or medical nutrition services provided by a registered dietician at the FQHC may be considered incident to a visit with an FQHC provider. The beneficiary coinsurance is waived for MNT services and is applicable for DSMT.
(Medicare Benefit Policy Manual)
DSMT must be furnished by a certified DSMT practitioner, and MNT must be furnished by a registered dietitian or nutrition professional. Program requirements for DSMT services are set forth in 42 CFR 410 Subpart H for DSMT and in Part 410, Subpart G for MNT services, and additional guidance can be found at Pub. 100-02, chapter 15, section 300.  Screening Pelvic and Cli nical Breast Examination (G0101)  Screening pelvic and clinical breast examination can be billed as a stand -alone visit if it is the only medical service provided on that day with an FQHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit.  The beneficiary coinsurance is waived.   Screening Papanicolaou Smear (Q0091)  Screening Papanicolaou smear can be billed as a stand -alone visit if it is the only medical service provided on that day with an FQHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit. The beneficiary coinsurance is waived.   Prostate Cancer Screening (G0102)  Prostate cancer screening can be billed as a stand -alone visit if  it is the only medical service provided on that day with an FQHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit. The beneficiary coinsurance applies.   Glaucoma Screening (G0117 and G0118)  Glaucoma screening for high risk patients can be billed as a stand -alone visit if it is the only medical service provided on that day with an FQHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit. The beneficiary coinsurance applies.  Lung Cancer Screening Using Low Dose Computed Tomography (LDCT) (G0296)  LDCT can be billed as a stand -alone visit if it is the only medical service provided on that day with an FQHC practitioner. If it is furnished on the same day as another medical visit, it is not a separately billable visit. The beneficiary coinsurance is waived.
(Medicare Benefit Policy Manual)
NOTE:  Hepatitis C Screening (GO472) is a technical service only and therefore not paid as part of the FQHC visit.   220.4 - Copayment  for FQHC Preventive Health Services (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Under the FQHC PPS, coinsurance will generally be 20 percent of the lesser of the FQHCs charge or the PPS rate.  When one or more qualified preventive services are provided as part of an FQHC visit, the A/B MAC will use the lesser of the FQHCs charge for the specific FQHC payment code or the PPS rate to determine the total payment amount.  To determine the amount of Medicare payment and the a mount of coinsurance that should be waived, the A/B MAC  will use the FQHCs reported line -item charges and subtract the dollar value of the FQHC's reported line -item charge for the preventive services from the full payment amount. For FQHC claims that con sist solely of preventive services that are exempt from beneficiary coinsurance, Medicare pays 100 percent of the lesser of the FQHCs charge or the FQHC PPS rate, and no beneficiary coinsurance is assessed.  230  Care Management Services                                                                      (Rev. 11803; Issued: 01- 26-23; Effective: 01 -01-23; Implementation: 02- 27-23)
(Medicare Benefit Policy Manual)
Care management services are RHC and FQHC services  and include transitional care  management (TCM), chronic care management (CC M), principal care management  (PCM),  chronic pain management (CPM), general behavioral health integration (BHI), and psychiatric collaborative care  model (CoCM) services.  The RHC and FQHC face -to-face requirements are waived for  these care management servi ces. Effective January 1, 2017, care management services  furnished by auxiliary personnel may be furnished under general supervision. (Note:  General supervision does not require the RHC or FQHC practitioner to be in the same  building or immediately availab le, but it does require the services to be furnished under  the overall supervision and control of the RHC or FQHC practitioner.)  Except for TCM  services, care management services are paid separately from the RHC AIR or FQHC PPS  payment methodology. RHCs an d FQHCs may not bill for care management services for  a beneficiary if another practitioner or facility has already billed for care management  services for the same beneficiary during the same time period.   However effective January 1, 2022, RHCs and FQHCs may  bill for care management and TCM services and other  care management services  (outside  of the RHC AIR  or FQHC  PPS payment), for the same beneficiary during the same time period.  Coinsurance and  deductibles are applied as applicable to RHC claims, and coinsurance is applied as  applicable to FQHC claims.   230.1 - Transitional Care Management Services  (Rev. 11803; Issued: 01- 26-23; Effective: 01 -01-23; Implementation: 02- 27-23)  Effective January 1, 2013, RHCs and FQHCs are paid for TCM services furni shed by an RHC or FQHC practitioner when all TCM requirements are met.  TCM services must be  furnished within  30 days of the date  of the patients  discharge  from  a hospital  (including outpatient observation or partial hospitalization), SNF, or community mental health  center.
(Medicare Benefit Policy Manual)
Communication (direct contact, telephone, or electronic) with the patient or caregiver  must commence within 2 business days of discharge, and a face -to-face visit must occur  within 14 days of discharge for moderate complexity decisio n making (CPT code 99495), or within 7  days of  discharge  for high complexity  decision making  (CPT  code  99496).  The TCM visit is billed on the day that the TCM visit takes place, and only one TCM  visit may be paid per beneficiary for services furnished duri ng that 30 day post -discharge period.
(Medicare Benefit Policy Manual)
TCM services are billed by adding CPT code 99495 or CPT code 99496 to an RHC or FQHC claim, either alone or with other payable services. If it is the only medical service provided on that day with an RHC or FQHC pract itioner it is paid as a stand -alone  billable  visit.  If it is furnished on the  same day  as another  visit, only  one visit is paid.  230.2  General  Care  Management Services                                                    (Rev. 11803; Issued: 0 1-26-23; Effective: 01 -01-23; Implementation: 02- 27-23) General Care Management Services include: Chronic Care Management  (CCM ), Principal Care Management ( PCM ), Chronic Pain Management (CPM) and general Behavioral Health Integration ( BHI) services. A separately  billable initiating visit with an RHC or FQHC primary care practitioner (physician, NP,  PA, or CNM) is required before care management services can be furnished.  This visit can be an E/M, AWV, or IPPE visit, and must occur no more than one -year prior to  commencing care management services. Care management services do not need to have  been discussed during the initiating visit, and the same initiating visit can be used for  CCM , PCM, CPM  and general  BHI services as long as it occurs with an RHC or FQHC prim ary care practitioner within one year of commencement of care management services.  Beneficiary  consent to receive care management services must be obtained either by or under the  direct supervision of the RHC or FQHC primary care practitioner, may be written or  verbal and must be documented in the patients medical record before CCM , PCM, CPM  or general  BHI services  are furnished. The medical  record  should document  that the beneficiary has  been informed about the availability of care management services, ha s given permission  to consult with relevant specialists as needed, and has been informed of all of the  following:
(Medicare Benefit Policy Manual)
 There may be cost -sharing (e.g. deductible and coinsurance in RHCs, and  coinsurance in FQHCs) for both in- person and non- face- to-face services that are provided;   Only  one practitioner/facility  can furnish and be  paid for  these services during  a calendar  month; and  They can stop care management services at any time, effective at the end of the  calendar  month.  Beneficiary consent remains in effect unless the beneficiary opts out of receiving care  management services.  If the beneficiary chooses to resume care management services  after opting  out, beneficiary  consent  is required  before care management  services  can  resume.  If the beneficiary  has not opted out of care management services but there has  been a period where no care management services were furnished, a new beneficiary  consent  is not required.     230.2.1  Chronic Care  Management (CCM) Services  (Rev. 11803; Issued: 01- 26-23; Effective: 01 -01-23; Implementation: 02- 27-23)
(Medicare Benefit Policy Manual)
Effective January 1, 2016, RHCs and FQHCs are paid for CCM services when a  minimum of 20 minutes of qualifying CCM services during a calendar month is  furnished. CCM services may be furnished to patients with  multiple chronic conditions  that are expected to last at least 12 months or until the death of the patient, and that place  the patient at significant risk of death, acute exacerbation/decompensation, or functional  decline.  CCM  service requirements  include :  Structured recording of patient health information using Certified EHR  Technology including demographics, problems, medications, and medication  allergies  that inform  the care plan, care  coordination, and ongoing  clinical care;   24/7 access to physicians or other qualified health care professionals or clinical  staff including providing patients/caregivers with a means to make contact with  health care professionals in the practice to address urgent needs regardless of the  time of day or day of week, and continuity of care with a designated member of  the care team with whom the patient is able to schedule successive routine  appointments;   Comprehensive care management including systematic assessment of the patients  medical, functional, and psychosocial needs;  system -based approaches to ensure  timely receipt of all recommended preventive care services; medication  reconciliation with review of adherence and potential interactions; and oversight  of patient self -management of  medications;  Comprehensive  care plan including the creation,  revision, and/or  monitoring  of an  electronic care plan based on a physical, mental, cognitive, psychosocial,  functional, and environmental (re)assessment and an inventory of resources and  supports; a comprehensive care plan for all health issues with particular focus on  the chronic  conditions being  managed;   Care plan information made available electronically (including fax) in a timely  manner within and outside the RHC or FQHC as appropriate and a copy of the  plan of care  given to the  patient and/or  caregiver;   Management of care transitions between and among health care providers and  settings, including referrals to other clinicians; follow -up after an emergency  department  visit; and follow -up after discharges  from  hospitals, skilled  nursing  facilities, or other health care facilities; timely creation and exchange/transmit  continuity  of care document(s)  with  other  practitioners and  providers;   Coordination with home - and community -based clinical service providers, and documentation of co mmunication to and from home - and community -based  providers regarding the patients psychosocial needs and functional deficits in the
(Medicare Benefit Policy Manual)
other  practitioners and  providers;   Coordination with home - and community -based clinical service providers, and documentation of co mmunication to and from home - and community -based  providers regarding the patients psychosocial needs and functional deficits in the  patients  medical record;  and  Enhanced opportunities for the patient and any caregiver to communicate with the  practitione r regarding the patients care through not only telephone access, but  also through the use of secure messaging, Internet, or other asynchronous non-  face- to-face consultation methods.
(Medicare Benefit Policy Manual)
230.2.2  Principal Care  Management (PCM)  Services                             (Rev. 11803; Issued: 0 1-26-23; Effective: 01 -01-23; Implementation: 02- 27-23) Effective January 1, 2021, RHCs and FQHCs are paid for PCM services when a  minimum of 30 minutes of qualifying PCM services are furnished during a calendar  month. PCM  services  may  be furnished to patients  with  a single  high-risk or complex  condition that is expected to last at least 3 months and may have led to a recent  hospitalization,  and/or placed the  patient at significant risk  of death.  PCM  service requirements  include:   A single complex chronic condition lasting at least 3 months, which is the focus of  the care  plan;   The condition is  of sufficient  severity  to place patient  at risk of hospitalization  or have  been the  cause of a recent hospitalization;   The condition requires  development  or revision of  disease- specific care plan;   The condition requires  frequent  adjustments  in the medication  regiment; and  The condition is  unusually  complex  due to comorbidities.   230.2.3  Chronic Pain  Management (CPM) Services                           (Rev. 11803; Issued: 0 1-26-23; Effective: 01 -01-23; Implementation: 02- 27-23) Effective January 1, 2023, RHCs and FQHCs are paid for CPM services when a minimum of 30 minutes of qualifying non- face- to-face CPM services are furnished during a calendar month.  CPM services may be furnished to patients with multiple chronic conditions that involve chronic pain, and may include a person -centered plan of care, care coordination, medication management, and other aspects of pain care.  230.2. 4 General Behavioral Health Integration (BHI) Services            (Rev. 11803; Issued: 0 1-26-23; Effective: 01 -01-23; Implementation: 02- 27-23)