evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
(3) 99341 through 99350 for new and established patient home E/M visits.   250.12.2 - Identifying Primary Care Services Eligible for the PCIP  (Rev. 3019, Issued: 08- 07-14, Effective: 01- 01-12,  ICD -10: Upon Implemen tation of ICD-  10, Implementation: 09- 08-14, ICD -10: Upon Implementation of ICD - 10)  CAHs paid under the optional method billing on TOB 85X for professional primary care services (revenue code 96X, 97X or 98X) furnished by primary care physicians and nonphysician practitioners who have reassigned their billing rights to the CAH are eligible for PCIP payments.   The National Provider Identifier (NPIs) of  primary care practitioners eligible for PCIP payment in a given calendar year (CY) are posted on Medicar e contractor Web sites in the Primary Care Incentive Payment Program Eligibility File by January 31 of  the applicable incentive payment CY.   Eligible practitioners for PCIP payment in a given calendar year who were newly enrolled in Medicare in the year immediately preceding the PCIP payment year will be identified later in the payment year and posted on their Medicare contractors Web site at that point in time.  CAHs paid under the optional method should contact their contractor with any questions regar ding the eligibility of physician and nonphysician practitioners for PCIP payments.  Primary care practitioners furnishing primary care services will be identified on CAH claims by the NPI of the rendering practitioner as follows:    Line level Rendering P rovider field when populated or,    Claim level Rendering Provider field where a line level Rendering Provider field is blank or,   Claim level Attending Provider field if the claim level Rendering Provider field is blank.  In order for a primary care service to be eligible for PCIP payment, the CAH paid under the optional method must be billing for the professional services of physicians under their NPIs or of physician assistants, clinical nurse specialists, or nurse practitioners  under their ow n NPIs because they are not furnishing services incident to physicians services.
(Medicare Claims Processing Manual)
Multiple primary care services rendered by different physicians may be present on a single claim.  Providers shall ensure they identify each physician on the claim form per the ASC X12 837 Institutional Claim Implementation Guide.  250.12.3 - Coordination with Other Payments  (Rev. 2169, Issued: 03- 03-11, Effective: 04- 01-11, Implementation: 04- 04-11)  Section 5501(a)(3) of the ACA authorizes payment under the PCIP as an addit ional payment amount for specified primary care services without regard to any additional  payment for the service under Section 1833(m) of the Social Security Act, the established Health Professional Shortage Area (HPSA) Medicare physician bonus program.  Therefore, a CAH paid under the optional method and billing for the professional services of an eligible primary care physician or nonphysician practitioner furnishing a primary care service in a health professional shortage area (HPSA) may receive both a HPSA physician bonus payment (as described in the Medicare Claims Processing Manual, Pub. 100- 04, Chapter 4, Section 250.2) under the HPSA physician bonus program and a PCIP incentive payment under the new program beginning in CY 2011.  250.12.4 - Claims P rocessing and Payment for Critical Access Hospitals Paid Under the Optional Method  (Rev. 2169, Issued: 03- 03-11, Effective: 04- 01-11, Implementation: 04- 04-11)  A. General Overview   Incentive payments will be made on a quarterly basis and shall be equal to  10 percent of the amount paid for such services under the Medicare Physician Fee Schedule (PFS) times 1.15 percent for those services furnished during the incentive payment year.  PCIP payments for newly enrolled practitioners may be delayed due to the la g in claims data processing.  PCIP payments for services by a newly enrolled primary care practitioner will be paid in the quarter following eligibility determination, and then quarterly for all subsequent incentive payments. Retroactive payments will be provided from the beginning of the PCIP year once these primary care practitioners are deemed eligible.
(Medicare Claims Processing Manual)
On an annual basis Medicare contractors shall receive a Primary Care Incentive Payment Program Eligibility File that they shall post to their websites.  The file will list the NPIs of all physicians and nonphysician practitioners who are eligible to receive PCIP payments for the upcoming CY.  The NPIs of eligible newly enrolled primary care practitioners will be posted to the contractors websites later in the payment year.   On an annual basis Medicare contractors shall receive a Physician/Practitioner Specialty File. This file it to be used by contractors to answer provider inquiries regarding eligibility for the PCIP.   The PCIP payments will be calculated by Medicare contractors and made quarterly to CAHs  paid under the optional method on behalf of the  eligible primary care physician or nonphysician practitioner for the  primary care services furnished by the practitioner in that quarter.  The PCIP paym ents will be based on 10 percent of 115 percent of the PFS amount that the CAH was paid for the professional service.   B. Method of Payment  Calculate and pay a CAH paid under the optional method based on primary care services furnished by qualifying primar y care physicians and nonphysician practitioners an additional 10 percent incentive payment;     Calculate the payment based on 115 percent of the PFS amounts that were paid to the CAH for the services; not the Medicare approved amounts;    Combine the PCIP incentive payments, when appropriate, with other incentive payments, including the physician HPSA bonus payment and the HPSA Surgical Incentive Payment Program (HSIP) payment;    Provide a special remittance for CAHs form that is forwarded with the incentive  payment so that CAHs paid under the optional method can identify which type of incentive payment was paid for which services.    CAHs paid under the optional method should contact their contractor with any questions regarding PCIP payments.  C.  Changes for  Contractor Systems   The Fiscal Intermediary Standard System (FISS), Common Working File (CWF) and National Claims History (NCH) shall be modified to accept a new PCIP indicator on the claim line. Once the type of incentive payment has been identified by t he shared systems, the shared system shall modify their systems to set the indicator on the claim line as follows:   1 = HPSA  2 = PSA  3 = HPSA and PSA  4 = HSIP  5 = HPSA and HSIP  6 = PCIP  7 = HPSA and PCIP  Space = Not Applicable
(Medicare Claims Processing Manual)
1 = HPSA  2 = PSA  3 = HPSA and PSA  4 = HSIP  5 = HPSA and HSIP  6 = PCIP  7 = HPSA and PCIP  Space = Not Applicable   The FISS shall send the HIGLAS 810 invoice for incentive payment invoices, including the new PCIP payment.  The contractor shall also combine the CAHs HPSA bonus, physician scarcity (PSA) bonus (if it should become available at a later date), HSIP payment and/or PCIP payment invoice per CAH.  The contractor shall receive the HIGLAS 835 payment file from HIGLAS showing a single incentive payment per CAH.   250.13 - Health Professional Shortage Areas (HPSA) Surgical Incentive Payment Program (HSIP) for Surgical Services Rendered in Critical Access Hospitals (CAHs) Paid under the Optional Method  (Rev. 2078, Issued: 10- 28-10, Effective: 04- 01-11, Implementation: 04- 04-11)  There are two methods of payment for outpatient services furnished by Critical Access Hospitals (CAHs).  The amount of payment for outpatient services furnished by a CAH under the traditional method is equal to 101 percent of the reasonable cost of the facility service and payment to the physician/practitioner under the Physician Fee Schedule(PFS)  for the professional  service or a CAH may elect to receive amounts that are equal to 101 percent of the reasonable cost of the facility service plus, with respect to the professional service, 115 percent of the amount otherwise paid for the professional service under the PFS.   This election is sometimes referred to as "method II" or "the optional method."  Section 5501(b) (2) of the ACA is a conforming amendment, which refers to payments to the CAH for professional services under the optional method.  As such, section 5501(b)( 2) requires that, under the optional method, the 115 percent adjusted payment to the CAH for professional services does apply to the incentive payment for major surgical services furnished by general surgeons in HPSAs.
(Medicare Claims Processing Manual)
For major surgical services furnishe d by general surgeons on or after January 1, 2011 and before January 1, 2016, the additional incentive amount specified is to be included in the determination of payment for professional services made to CAHs  paid under the optional method, but will be pr ovided as a separate incentive payment to the CAH, on behalf of the qualified general surgeon, when they furnish a 10 -  or 90 - day global surgical procedure in an identified HPSA.  Therefore, the 10 percent incentive payment will be made based on 115 perc ent of the amount that would be paid for the surgeons professional services under the PFS.   250.13.1 Overview of the HSIP  (Rev. 2078, Issued: 10- 28-10, Effective: 04- 01-11, Implementation: 04- 04-11)  The incentive payment applies to major surgical procedures, defined as 10 - and 90 -  day global procedures under the PFS and furnished on or after January 1, 2011 and before January 1, 2016, furnished by an 02 -general surgeon in an area designated under section 332(a)(1)(A) of the Public Health Service Act as a HPSA.   To be consistent with the Medicare HPSA physician program (Publication 100- 04, Chapter 12, Section 90.4), HSIP payments will be calculated by Medicare contractors on a quarterly basis, on behalf of the qualifying 02- general surgeon for the qualify ing surgical procedures.   250.13.2 - HPSA Identification  (Rev. 2078, Issued: 10- 28-10, Effective: 04- 01-11, Implementation: 04- 04-11)  For HSIP payments to be applicable, the 10 -  or 90 -  day global surgical procedure must be furnished in an area designate d by the Secretary as of December 31 of the prior year as a HPSA.
(Medicare Claims Processing Manual)
For HSIP payments to be applicable, the 10 -  or 90 -  day global surgical procedure must be furnished in an area designate d by the Secretary as of December 31 of the prior year as a HPSA.   Each year, a list of ZIP codes eligible for automatic payment of the HPSA physician bonus is published.  This list is also utilized for automatic payments of the incentive for eligible serv ices furnished by general surgeons.  Modifier AQ is used to identify circumstances when general surgeons furnish services in areas that are designated as HPSAs as of December 31 of the prior year, but that are not on the list of ZIP codes eligible for auto matic payment.  Modifier AQ should be appended to the major surgical  procedure on claims submitted for payment for professional services furnished in a HPSA that is not recognized as such for the purpose of automatic payment.  250.13.3 - Coordination with Other Payments  (Rev. 2078, Issued: 10- 28-10, Effective: 04-01-11, Implementation: 04-04-11)  Section 5501(b)(4) of the ACA provides payment under the HSIP as an additional payment amount for specified surgical services without regard to any additional payment for the service under section 1833(m) of the Act.  Therefore, a general surgeon may receive both a HPSA physician bonus payment under the established program and an HSIP payment under the new program beginning in CY 2011.  250.13.4 - General Surgeon and Surgical Procedure Identification for Professional Services Paid under the Physician Fee Schedule (PFS)  (Rev. 2078, Issued: 10- 28-10, Effective: 04-01-11, Implementation: 04-04-11)
(Medicare Claims Processing Manual)
Qualifying general surgeons will be identified on a claim for a 10 - or 90 - day global surgical procedure based on the NPI listed in the operating provider field on the claim and the associated primary enrolled specialty of the operating physician of 02 - general surgery.  Major surgical procedures are those procedures for which a 10 - or 90 - day global period is used for payment under the PFS.  The specific procedure codes eligible for the HSIP are identified in column U (global period) of the Physician Fee Schedule Relative Value Update (RVU) file lo cated at:  http://www.cms.gov/Medicare/Medicare -Fee-for-Service -Payment/PhysicianFeeSched/PFS -Relative -Value- Files.html, with a glo ba l period designation of 10 - or 90 day.  250.13.5 - Claims Processing and Payment  (Rev. 2078, Issued: 10- 28-10, Effective: 04-01-11, Implementation: 04-04-11)  A. General Overview   The HPSA physician bonus program guidelines are contained in Publication 100-04, Chapter 12, and Section 90.4.  Refer to that manual for payment and claims processing guidance for the HPSA physician bonus program that was established in 2005.  The following guidelines pertain only to qualifying 02- general surgeons  who have reassigned their billing rights to CAHs paid under the optional method, and who are eligible to receive the additional 10 percent HSIP payment for major surgical procedures furnished  in HPSAs from January 1, 2011 through December 31, 2015.  Contractors shal l only identify eligible services with a 10 - or 90 - day global period rendered in eligible zip code areas based on the HPSA physician bonus program ZIP code file for the appropriate date of service.    Providers may report modifier AQ when submitting claims for major surgical procedures that were furnished in approved HPSAs, where those HPSAs are not recognized for automatic payment.  The modifier must be appended to the major surgical procedure HCPCS code in order for the CAH paid under the optional method to be paid the 10 percent additional incentive payment for the surgical procedure on behalf of the general surgeon.   B. Method of Payment:
(Medicare Claims Processing Manual)
B. Method of Payment:    Calculate and pay CAHs paid under the optional method on behalf of  02-  general surgeons furnishing  10 -  and 90 -  day global surgical procedures in a recognized HPSA an additional 10 percent incentive payment based on 115 percent of the amount that would be paid for the surgeons professional services under the PFS;    Calculate the payment based on the amount actually paid for the service, not the Medicare approved amount;    Combine the additional payment with the HPSA physician bonus payment;    Accept and pay services submitted with modifier AQ and;    Revise the special incentive remittance for CAHs that is forwarded wi th the incentive check so that physicians can identify which type of incentive payment (HPSA physician, HSIP, or PCIP) was paid for which service.   C. Changes for Contractor Systems   The Medicare Carrier System, (MCS), Common Working File (CWF,) and National Claims History (NCH) shall be modified to accept a new HSIP and a new PCIP indicator on the claim line.   Once the type of incentive payment has been identified by the shared systems, the shared system shall modify their systems to set the indicator on the claim line as follows:  1 = HPSA;  2 = PSA;  3 = HPSA and PSA;  4 = HSIP;  5 = HPSA and HSIP  6 = PCIP;  7 = HPSA and PCIP;  Space = Not Applicable.   The contractor shared system shall send the HIGLAS 810 invoice for incentive payment invoices, including the new HSIP payment.  The contractor shall also combine the practitioners HPSA physician bonus, Physician Scarcity (PSA) bonus (if it should  become available at a later date), and HSIP payment invoice per practitioner.  The contractor shall receive the HIGLA S 835 payment file from HIGLAS showing a single incentive payment per practitioner.   250.14 - Payment of Licensed Clinical Social Workers (LCSWs) in a Method II CAH  (Rev. 2202, Issued: 04- 27-11, Effective: 10- 01-11, Implementation: 10- 03-11)
(Medicare Claims Processing Manual)
The services of a LCSW that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is billed on type of bill 85X with revenue code (RC) 96X, 97X, and/or 98X and the AJ modifier (clinical social worker).   Under Section 1834(g)( 2)(B) of the Act, outpatient professional services performed in a Method II CAH are paid 115 percent of such amounts as would otherwise be paid under the Act if the services were not included in the outpatient CAH services.   Section 1833 (a)(1)(F) of the A ct stipulates that payment for services performed by a LCSW shall be 80 percent of the lesser of the actual charges for the services or 75 percent of the amount determined for the payment of a psychologist.  Payment is calculated as follows:   ((Facility sp ecific MPFS amount times the LCSW reduction (75%)) minus (deductible and coinsurance)) times 115%.  250.15 - Coding and Payment of Multiple Surgeries Performed in a Method II CAH  (Rev. 2333, Issued: 10- 28-11, Effective: 04- 01-12, Implementation: 04- 02-12)  Multiple surgeries rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedures are eligible and billed on type of bill 85x with revenue code (RC) 096x, 097x and/or 098x.   Multiple surgeri es are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co -surgeons, surgical teams, or assistants- at-surgery may participate in performing multiple surgeries on the same patient on the same day.
(Medicare Claims Processing Manual)
Medicare pays for multiple surgeries by ranking from the highest MPFS amount to the lowest MPFS amount. When the same physician performs more than one surgical service at the same session, the allowed amount is 100% for the surgical code with the highest MPFS amount. The allowed amount for the subsequent surgical codes is based on 50% of the MPFS amount.  In addition, special endoscopic pricing rules are applied prior to the multiple surgery rules, if applicable. CAH Method II providers may review the multi ple surgery and special endoscopic pricing rules in Pub. 100- 04, Chapter 12, Section 40.6.  In  addition, section 40.6.D addresses rare situations where the above payment rules may be bypassed using modifier 22. Providers shall be aware that CAH claims bill ed with Modifier 22 may be subject to medical review.   250.16 - Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Imaging Procedures Rendered by Physicians  (Rev. 3578, Issued:  08- 05 Effective:  01- 01-17, Implementation:  01- 03-17)  Diagnostic imaging procedures rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedures are eligible and billed on type of bill 85x with revenue code (RC) 096x, 097x and/or 098x.   The MP PR on diagnostic imaging applies when multiple services are furnished by the same physician to the same patient in the same session on the same day. Full payment is made for each service with the highest payment under the MPFS.  Effective for dates of services on or after January 1, 2012, payment is made at 75 percent for each subsequent service; and effective for dates of services on or after January 1, 2017, payment is made at 95 percent for each subsequent service.   250.17  - Payment of Global Surgical Sp lit Care in a Method II CAH Submitted with Modifier 54 and/or 55  (Rev. 2574, Issued: 10- 26-12 , Effective:01- 01-13 , Implementation:01- 07-13)
(Medicare Claims Processing Manual)
Global surgical procedures rendered by a physician that has reassigned their billing rights to a CAH Method II pr ovider is payable by Medicare only when billed on an 85x type of bill (TOB) with revenue code (RC) 096x, 97x, and/or 98x and modifier 54 (surgical care only) and/or 55 (postoperative management only).   There are occasions when more than one physician provi des services included in the global surgical period, i.e., when the physician who performs the surgical procedure does not furnish the follow -up care. If this occurs, payment for the postoperative or post -discharge care should be split between the physicians when they agree on the transfer of care.   When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provides all services (except where stated policies, e.g., the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative care, result in payment that is higher than the global allowed amount).   CAH Met hod II providers may review the Global Surgical pricing rules in Pub. 100- 04, Chapter 12, sections 40.1 -40.5.  260 - Outpatient Partial Hospitalization Services  (Rev. 1, 10- 03-03)   A3-3661, A-01-93  Medicare Part B coverage is available for outpatient partial hospitalization services provided by hospitals, CAHs, and CMHCs.  260.1 - Special Partial Hospitalization Billing Requirements for Hospitals, Community Mental Health Centers, and Critical Access Hospitals  (Rev. 4204, Issued: 01- 17-19, Effective: 01-01-19, Implementation: 01-07-19)   Medicare Part B coverage is available for hospital outpatient partial hospitalization services.   A. Billing Requirement   Section 1861 ( http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm ) of the Act defines the services under the partial hospitalization benefit in a hospital.
(Medicare Claims Processing Manual)
Section 1861 ( http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm ) of the Act defines the services under the partial hospitalization benefit in a hospital.  Section 1866(e)(2) of the Act (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm)recognizes CMHCs as providers of services but only for furnishing partial hospitalization services.  See 261.1.1  of this cha pter for CMHC partial hospitalization bill review directions.   Hospitals and CAHs report condition code 41 in FLs 18-28 (or electronic equivalent) to indicate the claim is for partial hospitalization services.  They must also report a revenue code and the charge for each individual covered service furnished.  In addition, hospital outpatient departments are required to report HCPCS codes.  CAHs are not required to report HCPCS code for this benefit.  Under component billing, hospitals are required to report a revenue code and the charge for each individual covered service furnished under a partial hospitalization program.  In addition, hospital outpatient departments are required to report HCPCS codes.  Component billing assures that only those partial hospitalization services covered under 1861(ff) of the Act are paid by the Medicare program.  Effective January 1, 2017, non- excepted off -campus provider- based departments of a hospital are required to report a PN modifier on each claim line for non- excepted  items  and services.  The use of modifier PN will trigger a payment rate under the Medicare Physician Fee Schedule.  We expect the PN modifier to be reported with each non -excepted item and service including those for which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services.   Excepted off -campus provider -based departments of a hospital must continue to report existing modifier PO (Services, procedures and/or surgeries provided at off -campus provider -based outpatient departments)  for all excepted items and services furnished. Use of the off -campus PBD modifier became mandatory beginning January 1, 2016.