evekhm/cms_iom_500 huggingface dataset:
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Physicians, NPPs, and audiologists cannot bill and be paid for the TC of PC/TC split codes when these services are furnished to hospital outpatients.  The associated professional services (represented by the PC or the CPT code for the audiology test which has no PC/TC split) of an enrolled audiologist, physician, or NPP who has reassigned benefits may be billed by the hospital to the A/B MAC (B), as appropriate.  Alternatively, if the physician, NPP, or audiologist has not assigned benefits, the professional would bill his/her A/B M AC (B) for the professional services furnished.  The appropriate revenue code for reporting audiology services is 0470 ( Audiology; General Classification ).  Providers are required to report a line -item date of service per revenue code line for audiology services.  3. Billing for Audiology Services Furnished to Skilled Nursing Facility (SNF) Patients.   Payment for the facility resources (including the TC of PC/TC split codes) of audiology services provided to Part A inpatients of SNFs is included in the PPS rate.  For SNFs, if the beneficiary has Part B but not Part A coverage (e.g., Part A benefits are exhausted), the SNF may elect to bill for audiology services but is not required to do so.  As explained in Pub. 100-04, chapter 7, section 40.1, since audiology services furnished during a noncovered SNF stay are not bundled with speech- language pathology services, payment can be made either to the SNF or to the audiology service provider/supplier.   Audiologists, physicians, and NPPs enrolled in Medicare may bill directly for services rendered to Medicare beneficiaries who are in a SNF stay that is not covered by Part A but who have Part B eligibility.  Payment is made based on the MPFS, whether on an institutional or professional claim.  For beneficiaries in a noncovered SNF stay, audiology services
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are payable under Part B when billed by the SNF on an institutional claim as type of bill 22X, or when billed directly by the provider or supplier of the service (the audiologist, physician, or NPP who personally furnishes the test) on a professional claim.  For PC/TC split codes, the SNF may elect to bill for the TC of the test on an institutional claim but is not required to bill for the service.   C. Implant Processing   Payment for diagnostic testing of implants, such as cochlear, osseointegrated or brainstem implants, including programming or reprogramming following implantation surgery is not included in the global fee for the surgery.   The diagnostic analysis of a cochlear implant shall be billed using CPT codes 92601 through 92604.  Osseointegrated prosthetic devices should be billed and paid for under provisions of the applicable payment system.  For example, payment may differ depending upon whether the device is furnished on an inpatient or outpatient basis, and by a hospital subje ct to the OPPS, or by a Critical Access Hospital, physicians clinic, or a Federally Qualified Health Center.   D. Aural Rehabilitation Services   General policy for evaluation and treatment of conditions related to the auditory system.  For evaluation  of auditory processing disorders and speech- reading or lip- reading by a speech-language pathologist, use the untimed code 92506 with 1 as the unit of service, regardless of the duration of the service on a given day.  This always therapy evaluation code must be provided by speech- language pathologists according to the policies in Pub. 100- 02, chapter 15, sections 220 and 230.  The codes 92620 and 92621 are diagnostic audiological tests and may not be used for SLP services.
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For treatmen t of auditory processing disorders or auditory rehabilitation/auditory training (including speech- reading or lip- reading), 92507, and 92508 are used to report a single encounter with 1 as the unit of service, regardless of the duration of the service on a given day.  These codes always represent SLP services.  See Pub. 100 -02, chapter 15, sections 220 and 230 for SLP policies.  These SLP evaluation and treatment services are not covered when performed or billed by audiologists, even if they are supervised by phys icians or qualified NPPs.   For evaluation  of auditory rehabilitation to instruct the use of residual hearing provided by an implant or hearing aid related to hearing loss, the timed codes 92626 and 92627 are used.  These are not always therapy codes.  Evaluation of auditory rehabilitation shall  be appropriately provided and billed by an audiologist or speech- language pathologist.  Also, these services may be provided incident to a physicians or qualified NPPs service by a speech -language pathologist, or personally by a physician or qualified NPP within their scope of practice.  Evaluation of auditory rehabilitation is a covered diagnostic test when performed and billed by an audiologist and is an SLP evaluation service covered under the SLP benefit when performed by a speech- langu age pathologist.  General policies for post implant services.   The services of a speech -language pathologist may be covered for SLP services provided after implantation of auditory devices.  For example, a speech- language pathologist may provide evaluation and treatment of speech, language, cognition, voice, and audit ory processing using code 92506 and 92507.  Use 92626 and 92627 for auditory (aural) rehabilitation evaluation following cochlear implantation or for other hearing impairments.  For diagnostic testing of cochlear implants, audiologists use codes 92601, 92602, 92603 and 92604.  These services may not be provided by speech- language pathologists or others, with the exception of physicians and NPPs who may personally provide the servi ces that are within their scope of practice.   30.4 - Cardiovascular System (Codes 92950 -93799)  (Rev. 979, Issued: 06- 09-06, Effective: 07 -10-06, Implementation: 07- 10-06)
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30.4 - Cardiovascular System (Codes 92950 -93799)  (Rev. 979, Issued: 06- 09-06, Effective: 07 -10-06, Implementation: 07- 10-06)  A. Echocardiography Contrast Agents  Effective October 1, 2000, physicians may separately bill for contrast agents used in echocardiography.  Physicians should use HCPCS Code A9700 (Supply of Injectable Contrast Material for Use in Echocardiography, per study).  The type of service code is 9.  This code will be A/B MAC (B) -priced.  B. Electronic Analyses of Implantable Cardioverter- defibrillators and Pacemakers  The CPT codes 93731, 93734, 93741 and 93743 are used to report electronic analyses of single or dual chamber pacemakers and single or dual chamber implantable cardioverter -defibrillators.  In the office, a physician uses a device called a programmer to obt ain information about the status and performance of the device and to evaluate the patients cardiac rhythm and response to the implanted device.  Advances in information technology now enable physicians to evaluate patients with implanted cardiac devices without requiring the patient to be present in the physicians office.  Using a manufacturers specific monitor/transmitter, a patient can send com plete device data and specific cardiac data to a distant receiving station or secure Internet server.  The electronic analysis of cardiac device data that is remotely obtained provides immediate and long- term data on the device and clinical data on the pat ients cardiac functioning equivalent to that obtained during an in- office evaluation.  Physicians should report the electronic analysis of an implanted cardiac device using remotely obtained data as described above with CPT code 93731, 93734, 93741 or 93743, depending on the type of cardiac device implanted in the patient.  30.5 - Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions  (Rev. 968. Issued:  05 -26-06; Effective/Implementation Dates:  06 -26-06)
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Review (and administration if needed) of a health risk assessment,    Establishment of the individuals medical/family history,    Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual,   Measurement of the individuals height, weight, body mass index (or waist circumference, if appropriate), blood pressure (BP), and other routine measurements as deemed appropriate, based on the individuals medical and family history,    Detection of any cognitive impairment that the individual may have,    Review of an individuals potential risk factors for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, w hich the health professional may select from various available standardized screening tests designed for this purpose and recognized by national professional medical organizations,    Review of the individuals functional ability and level of safety, based on direct observation of the individual, or the use of appropriate screening questions or a screening questionnaire, which the health professional may select from various available sc reening questions or standardized questionnaires designed for this purpose and recognized by national professional medical organizations,    Establishment of a written screening schedule for the individual, such as a checklist for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force (USPSTF) and Advisory Committee of Immunizations Practices (ACIP), and the individuals health risk assessment, health status, screening history, and age -appropriate preventive services covered by Medicare,    Establishment of a list of risk factors and conditions of which primary, secondary, or tertiary interventions are recommended or underway for the individual, including any mental health conditions or any such risk factors or conditions that have been ident ified through an IPPE, and a list of treatment options and their associated risks and benefits,    Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs aimed at reducing identified risk factors and improving self -management or community- based lifestyl e interventions to reduce health risks and promote self -management and wellness, including weight loss, physical activity, smoking cessation, fall prevention, and nutrition, and,   Any other element(s) determined appropriate by the Secretary through the national coverage determinations process.
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F. HCPCS Codes Used to Bill the IPPE or AWV  1. HCPCS Codes Used to Bill the IPPE   For IPPE and EKG services provided prior to January 1, 2009, the physician or qualified NPP shall bill HCPCS code G0344 for the IPPE performed face -to-face, and HCPCS code G0366 for performing a screening EKG that includes both the interpretation and repor t.  If the primary physician or qualified NPP performs only the IPPE, he/she shall bill HCPCS code G0344 only.  The physician or entity that performs the screening EKG that includes both the interpretation and report shall bill HCPCS code G0366.  The physi cian or entity that performs the screening EKG tracing only (without interpretation and report) shall bill HCPCS code G0367.  The physician or entity that performs the interpretation and report only (without the EKG tracing) shall bill HCPCS code G0368. Me dicare will pay for a screening EKG only as part of the IPPE.  HCPCS codes G0344, G0366, G0367 and G0368 will not be billable codes effective on or after January 1, 2009.   Effective for a beneficiary who has the IPPE on or after January 1, 2009, and within his/her 12-month enrollment period of Medicare Part B, the IPPE and screening EKG services are billable with the appropriate HCPCS G code(s).  The physician or qualified NPP shall bill HCPCS code G0402 for the IPPE performed face -to-face with the patient.
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The physician or entity shall bill HCPCS code G0403 for performing the complete screening EKG that includes the tracing, interpretation and report.  The physician or entity that performs the screening EKG tracing only (without interpretation and report) shall bill HCPCS code G0404.  The physician or entity that performs the screening EKG interpretation and report only, (without the EKG tracing) shall bill HCPCS code G0405.  2. HCPCS Codes Used to Bill the AWV  For the first AWV provided on or after January 1, 2011, the health professional shall bill HCPCS G0438 (Annual wellness visit, including PPPS, first visit).  This is a once per beneficiary per lifetime allowable Medicare Part B benefit.   All subsequent AWVs shall be billed with HCPCS G0439 (Annual Wellness Visit, including PPPS, subsequent visit). In the event that a beneficiary selects a new health professional to complete a subsequent AWV, the new health professional will continue to bil l the subsequent AWV with HCPCS G0439.   NOTE:  For an IPPE or AWV performed during the global period of surgery, refer to chapter 12, 30.6.6 of this chapter for reporting instructions.  G. Documentation for the IPPE or AWV   Practitioners eligible to furnish an IPPE or an AWV are required to use the 1995 and 1997 E/M documentation guidelines to document the medical record with the appropriate clinical information. (http://xmarks.com/site/www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp).  All referrals and a written medical plan must be included in this documentation.   H. Reporting a Medically Necessary E/M Service Furnished During the Same Encounter as an IPPE or AWV
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H. Reporting a Medically Necessary E/M Service Furnished During the Same Encounter as an IPPE or AWV   When the physician or qualified NPP, or for AWV the health professional, provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or an AWV, CPT codes 99201 -  99215 may be reported depending on the clinical appropriateness of the circumstances. CPT Modifier - 25 shall be appended to the medically necessary E/M service identifying this service as a significant, separately identifiable service from the IPPE or AWV code reported (HCPCS code G0344 or G0402, whicheve r applies based on the date the IPPE is performed, or HCPCS code G0438 or G0439 whichever AWV code applies).   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)
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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 benefici ary, as a charge for the noncovered remainder of the service, the amount by which the physicians current established charge for the preventive medicine service exceeds his/her current established charge for the covered visit.  Pay for the covered visit ba sed 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.
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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. 11842; Issued; 02- 09-23 Effective:01 -01-23; Implementation: 05 -09-23)  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 patient remains a new patient for the initial visit.  An interpretatio n 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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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, or complex condition. (Add- on code, list separately in addition to office/outpatient evaluation and management visit, new or established)).   The Consolidated Appropriations Act, 2021 delayed PFS payment for this code until January 1, CY 2024 or later. Practitioners may report this code for qualifying visits furnished on or after January 1, 2021, although we assigned a PFS payment status indicat or of B (Bundled) until 2024.    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.
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 Reporting is not restricted based on specialty, but certain specialties will likely furnish these types of visits more than other specialties. HCPCS code G2211 may be reported with any visit level.    Example 1: In the context of primary care, HCPCS code G2211 could recognize the resources inherent in holistic, patient -centered care that integrates the treatment of illness or injury, management of acute and chronic health conditions, and coordination of specialty care in a collaborative relationship with the clinical care team.    Example 2: In the context of specialty care, HCPCS code G2211 could recognize the resources inherent in engaging the patient in a continuous and active collaborative plan of care related to an identified health condition the management of which requires the direction of a clinician with specialized clinical knowledge, skill, and experience. Such collaborative care includes patient education, expectations and responsibilities, shared decision- making around therapeutic goals, and shared commitments to achieve those goals.     Example 3: We do not expect reporting of HCPCS code G2211 when the office/outpatient E/M visit is reported with payment modifiers such as a modifier - 24, -25, or -53.   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.