evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Wound Care (A55909)
When hydrotherapy (whirlpool) is billed by a therapist with CPT codes 97597 or 97598, the documentation must reflect the clinical reasoning why hydrotherapy was a necessary component of the total wound care treatment for removing of devitalized and/or necrotic tissue. The documentation must also reflect that the skill set of a therapist was required to perform this service in the given situation.Separate billing of whirlpool (97022) is not permitted with 97597-97598 unless it is provided for a different body part than the wound care treatment body part.Local infiltration, such as a metatarsal/digital block or topical anesthesia, is included in the reimbursement for debridement services and is not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable.CPT Codes 97597 and 97598 are considered sometimes therapy codes. If billed by a therapist when the patient is under a home health benefit, it may be covered by the Home Health agency, if part of their plan of care. If it is a physician or non-physician practitioner that is billing these sometimes therapy codes, it is paid under Part B even if the beneficiary is under an active home health plan of care. CMS Publication 100-02,Medicare Coverage Policy Manual, Chapter 7  Home Health Services, Section 10.10  Consolidated Billing, C. Relationship Between Consolidated Billing Requirements and Part B Supplies and Part B Therapies Included in the Baseline Rates That Could Have Been Unbundled Prior to HH PPS That No Longer Can Be Unbundled.For Part B, CPT code 97602 has been assigned a status indicator "B"(Bundled) in the Medicare Physician Fee Schedule Database (MPFSDB), meaning that it is not separately payable under Medicare Part B. For Part A, CPT code 97602 is designated as a sometimes therapy service.Documentation must support the CPT/HCPCS Code(s) being billed.CPT code 97026 Infrared is not covered per NCD 270.6 Infrared Therapy Devices.Ultra-sound (97035) for Wound Care and phototherapy-ultraviolet (97028) modalities are not payable per the LCD.Coding Guidelines
Article - Billing and Coding: Wound Care (A55909)
Coding GuidelinesDebridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042-11047 (Wound debridements) are reported by depth of tissue that is removed and by surface area of the wound. See CPT Manual for coding guidance: When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths.Do not report 11042 -11047 in conjunction with 97597-97602 for the same wound.CPT codes 11044 and 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory surgical center (ASC).CPT codes 11043, 11046 and 11044, 11047 are codes that describe deep debridement of the muscle and/or bone.Reasons for DenialPerforming bony debridement in POS other than inpatient hospital, outpatient hospital or ASCBilling of debridement by unqualified personal.
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CMS Manual System  Department of Health & Human Services (DHHS)  Pub 100 -04 Medicare Claims Processing  Centers for Medicare & Medicaid Services (CMS)  Transmittal  3921  Date: November 17, 2017   Change Request 10220    SUBJECT: Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)   I. SUMMARY OF CHANGES: The purpose of this Change Request (CR) is to inform MACs that effective April 3, 2017, coverage of topical oxygen for the treatment of chronic wounds will be determined by the loca l contractors.   EFFECTIVE DATE: April 3, 2017  *Unless otherwise specified, the effective date is the date of service.  IMPLEMENTATION DATE: December 18, 2017  Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.  II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated)  R=REVISED, N=NEW, D=DELETED- Only One Per Row.   R/N/D  CHAPTER / SECTION / SUBSECTION / TITLE  R 32/Table of Contents  N 32/30.2/Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)   III. FUNDING:  For Medicare Administrative Contractors (MACs):  The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e -mail, and request formal directions regarding continued performance requirements.  IV. ATTACHMENTS:   Business Requirements  Manual Instruction       Attachment - Business Requirements   Pub. 100 -04 Transmittal: 3921  Date: November 17, 2017  Change Request: 10220    SUBJECT: Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)
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Business Requirements  Manual Instruction       Attachment - Business Requirements   Pub. 100 -04 Transmittal: 3921  Date: November 17, 2017  Change Request: 10220    SUBJECT: Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)   EFFECTIVE DATE:  April 3, 2017 *Unless otherwise specified, the effective date is the date of service.  IMPLEMENTATION DATE:  December 18, 2017  I. GENERAL INFORMATION    A. Background:   The Centers for Medicare &  Medicaid Services (CMS) received a reconsideration request to remove the coverage exclusion of Continuous Diffusion of Oxygen Therapy (CDO) from National Coverage Determination (NCD) Manual 20.29, Hyperbaric Oxygen (HBO) Therapy, Section C. This section of the NCD (Topical Application of Oxygen) considers treatment known as CDO as the application of topical oxygen and currently nationally non- covers this treatment. CMS asserts that the topical application of oxygen does not meet the definition of HBO thera py as stated in NCD 20.29.  B. Policy:   Effective April 3, 2017, CMS decided that no NCD is appropriate at this time concerning the use of topical oxygen for the treatment of chronic wounds. As a result, CMS will amend NCD 20.29 by removing Section C, Topical Application of Oxygen, and Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by the local Medicare Administrative Contractors (MACs).   Though a MAC may decide to cover this procedure, there shall be no coverage  for any separate or additional payment for any physicians professional services related to this procedure.   Associated claims processing instructions can be found at chapter 32, section 30.2, of Pub. 100- 04, Claims Processing Manual.   II. BUSINESS REQUIREMENTS TABLE    "Shall" denotes a mandatory requirement, and "should" denotes an optional requirement.    Number  Requirement  Responsibility     A/B MAC  DME  MAC Shared -System Maintainers  Other  A B HHH FISS MCS VMS CWF 10220 - 04.1 Effective April 3, 2017, Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by the local Medicare Administrative Contractors (MACs).   X X  X      10220 - 04.2 Contractors shall adjust claims in the interim period that are brought to their attention.   X X  X         III. PROVIDER EDUCATION TABLE   Number  Requirement  Responsibility     A/B MAC  DME
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X X  X      10220 - 04.2 Contractors shall adjust claims in the interim period that are brought to their attention.   X X  X         III. PROVIDER EDUCATION TABLE   Number  Requirement  Responsibility     A/B MAC  DME  MAC CEDI A B HHH 10220 - 04.3 MLN Article: A provider education article related to this instruction will be available at http://www.cms.gov/Outreach -and-Education/Medicare- Learning -Network -MLN/MLNMattersArticles/ shortly after the CR is released. You will receive notification of the article release via the established "MLN Matters" listserv. Contractors shall post this artic le, or a direct link to this article, on their Web sites and include information about it in a listserv message within 5 business days after receipt of the notification from CMS announcing the availability of the article.  In addition, the provider educati on article shall be included in the contractor's next regularly scheduled bulletin. Contractors are free to supplement MLN Matters articles with localized information that would benefit their provider community in billing and administering the Medicare pro gram correctly.  X X  X   IV. SUPPORTING INFORMATION   Section A:  Recommendations and supporting information associated with listed requirements: N/A    "Should" denotes a recommendation.  X-Ref  Requirement  Number  Recommendations or other supporting information:   Section B:  All other recommendations and supporting information: N/A  V. CONTACTS   Pre-Implementation Contact(s): Wanda Belle, 410 -786-7491 or wanda.belle@cms.hhs.gov (Coverage) , Kimberly Long, 410 -786-5702 or kimberly.long@cms.hhs.gov (Coverage) , Patricia Brocato- Simons, 410-786-0261 or patricia.brocatosimons@cms.hhs.gov (Coverage) , Valeri Ritter, 410- 786-8652 or valeri.ritter@cms.hhs.gov (Part A) , Thomas Dorsey, 410 -786-7434 or thomas.dorsey@cms.hhs.gov (Part B)   Post-Implementation Contact(s): Contact your Contracting Officer's Representative (COR).           VI. FUNDING
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Post-Implementation Contact(s): Contact your Contracting Officer's Representative (COR).           VI. FUNDING   Section A: For Medicare Administrative Contractors (MACs):  The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unl ess and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediate ly notify the Contracting Officer, in writing or by e -mail, and request formal directions regarding continued performance requirements.  ATTACHMENTS: 0                                                      Medicare Claims Processing Manual  Chapter 32  Billing Requirements for Special Services   Table of Contents  (Rev3921, Issued: 11- 17-17)  30.2 Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)
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Medicare Claims Processing Manual  Chapter 32  Billing Requirements for Special Services   Table of Contents  (Rev3921, Issued: 11- 17-17)  30.2 Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)        30.2 Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)  (Rev.3921, Issued: 11 -17-17, Effective: 04 -03-17, 12 -18-17) CMS considers topical oxygen therapy (TOT) to be a method whereby a local supply of oxygen is applied to a wound. I. Billing Requirements for A/B MACs (A)  Claims for HBO therapy should be submitted using the ASC X12 837 institutional claim format or, in rare cases, on Form CMS- 1450. II.   Payment Requirements for A/B MACs (A)  As of April 3, 2017, Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by the local c ontractors. NOTE:  Regardless of whether an A/B MAC (A) has made a determination to cover this service, there shall be no coverage for any separate or additional physicians professional services related to this procedure.  III.  Billing Requirements for A/B MACs (B)  As of April 3, 2017, Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by the local contractors . NOTE:  Reg ardless of whether an A/B MAC (B ) has made a determination to cover this service, there shall be no coverage for any separate or additional physicians professional services related to this procedure.
(Medicare Benefit Policy Manual)
Medicare Benefit Policy Manual  Chapter 7 - Home Health Services   Table of Contents  (Rev. 12382; Issued: 11-28-23) (Rev. 1 2425 Issued: 12- 21-23)   Transmittals for Chapter 7   10 - Home Health Prospective Payment System (HH PPS ) 10.1 - National 30- Day Period Payment Rate  10.2 - Adjustments to the 30- Day Episode Rates  10.3 - Continuous 60- Day Episode Recertification s 10.4 -  Submission of the Notice of Admission (NOA)   10.5  Requirements for Submission of NOA  10.6 - Low Utilization Payment Adjustment (LUPA)  10.7 - Partial Payment Adjustment  10.8 - Outlier Payments  10.9 -  Discharge Issues  10.10 - Consolidated Billing  10.11 - Change of Ownership Relationship to Periods Under the HH PPS  10.12 - Change of Ownership Relationship to Episodes Under PPS  20 - Conditions To Be Met for Coverage of Home Health Services  20.1 - Reasonable and Necessary Services  20.1.1 - Background  20.1.2 - Determination of Coverage  20.2 - Impact of Other Available Caregivers and Other Available Coverage on Medicare Coverage of Home Health Services  20.3 - Use of Utilization Screens and "Rules of Thumb"  30 - Conditions Patient Must Meet to Qualify for Coverage of Home Health Services  30.1 - Confined to the Home  30.1.1 - Patient Confined to the Home  30.1.2 -  Patient's Place of Residence  30.2 -  Services Are Provided Under a Plan of Care Established and Approved by a Physician  or Allowed Practitioner
(Medicare Benefit Policy Manual)
30.2.1 -  Definition of Allowed Practitioner  30.2. 2 -  Content of the Plan of Care  30.2.3 -  Specificity of Orders  30.2.4 -  Who Signs the Plan of Care  30.2.5 -  Timeliness of Signature  30.2. 6 -  Use of Oral (Verbal) Orders  30.2.7 -  Frequency of Review of the Plan of Care  30.2.8 -  Facsimile Signatures   30.2. 9 -  Alternative Signatures   30.2.10 -  Termination of the Plan of Care -  Qualifying Services  30.2.11 -  Sequence of Qualifying Services and Other Medicare Covered Home Health Services  30.3 -  Under the Care of a Physician  or Allowed Practitioner  30.4 -  Needs Skilled Nursing Care on an Intermittent Basis (Other than Solely Venipuncture for the Purposes of Obtaining a Blood Sample), Physical Therapy, Speech -Language Pathology Services, or Has Continued Need for Occupational Therapy  30.5 -  Physician  or Allowed Practitioner  Certification  and Recertification of Patient Eligibility for Medicare Home Health Services  30.5.1 -  Physician or Allowed Practitioner Certification  30.5.1.1 -  Face -to-Face Encounter  30.5.1.2 -  Supporting Documentation Requirements  30.5.2 -  Physician  or Allowed Practitioner  Recertification  30.5.3 -  Who May Sign the Certification or Recertification  30.5.4 -  Physician or Allowed Practitioner Billing for Certification and Recertification  40 - Covered Services Under a Qualifying Home Health Plan of Care  40.1 -  Skilled Nursing Care  40.1.1 -  General Principles Governing Reasonable and Necessary Skilled Nursing Care  40.1.2 -  Application of the Principles to Skilled Nursing Services  40.1.2.1 -  Observation and Assessment of the Patient's Condition When Only the Specialized Skills of a Medical Professional Can Determine Patient's Status  40.1.2.2 -  Management and Evaluation of a Patient Care Plan  40.1.2.3 -  Teaching and Training Activities  40.1.2.4 -  Administration of Medications  40.1.2.5 -  Tube Feedings  40.1.2.6 -  Nasopharyngeal and Tracheostomy Aspiration  40.1.2.7 -  Catheters  40.1.2.8 -  Wound Care  40.1.2.9 -  Ostomy Care  40.1.2.10 -  Heat Treatments  40.1.2.11 -  Medical Gases
(Medicare Benefit Policy Manual)
-  Catheters  40.1.2.8 -  Wound Care  40.1.2.9 -  Ostomy Care  40.1.2.10 -  Heat Treatments  40.1.2.11 -  Medical Gases  40.1.2.12 -  Rehabilitation Nursing  40.1.2.13 -  Venipuncture  40.1.2.14 -  Student Nurse Visits  40.1.2.15 -  Psychiatric Evaluation, Therapy, and Teaching  40.1.3 -  Intermittent Skilled Nursing Care  40.2 -  Skilled Therapy Services  40.2.1 -  General Principles Governing Reasonable and Necessary Physical Therapy, Speech- Language Pathology Services, and Occupational Therapy  40.2.2 -  Application of the Principles to Physical Therapy Services  40.2.3 -  Application of the General Principles to Speech -Language Pathology Services  40.2.4 -  Application of the General Principles to Occupational Therapy  40.2.4.1 -  Assessment  40.2.4.2 -  Planning, Implementing, and Supervision of Therapeutic Programs  40.2.4.3 -  Illustration of Covered Services  50 - Coverage of Other Home Health Services  50.1 -  Skilled Nursing, Physical Therapy, Speech -Language Pathology Services, and Occupational Therapy  50.2 -  Home Health Aide Services  50.3 -  Medical Social Services  50.4 -  Medical Supplies (Except for Drugs and Biologicals Other Than Covered Osteoporosis Drugs), the Use of Durable Medical Equipment and Furnishing Negative Pressure Wound Therapy Using a Disposable Device  50.4.1 -  Medical Supplies  50.4.1.1 -  The Law, Routine and Nonroutine Medical Supplies, and the Patient's Plan of Care  50.4.1.2 -  Routine Supplies (Nonreportable)  50.4.1.3 -  Nonroutine Supplies (Reportable)  50.4.2 -  Durable Medical Equipment  50.4.3  Covered Osteoporosis Drugs  50.4.4 -  Negative Pressure Wound Therapy Using a Disposable Device  50.5 -  Services of Interns and Residents  50.6 -  Outpatient Services  50.7 -  Part-Time or Intermittent Home Health Aide and Skilled Nursing Services  50.7.1 -  Impact on Care Provided in Excess of "Intermittent" or "Part -Time" Care  50.7.2 -  Application of this Policy Revision  60 - Special Conditions for Coverage of Home Health Services Under Hospital Insurance (Part A) and Supplementary Medical Insurance
(Medicare Benefit Policy Manual)
-  Impact on Care Provided in Excess of "Intermittent" or "Part -Time" Care  50.7.2 -  Application of this Policy Revision  60 - Special Conditions for Coverage of Home Health Services Under Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B)  60.1 -  Post -Institutional Home Health Services Furnished During A Home Health Benefit Period -  Beneficiaries Enrolled in Part A and Part B  60.2 -  Beneficiaries Who Are Enrolled in Part A and Part B, but Do Not Meet Threshold for Post -Institutional Home Health Services  60.3 -  Beneficiaries Who Are Part A Only or Part B Only  60.4 -  Coinsurance, Copayments, and Deductibles  70 - Duration of Home Health Services  70.1 -  Number of Home Health Visits Under Supplementary Medical Insurance (Part B) 70.2 -  Counting Visits Under the Hospital and Medical Plans  80 - Specific Exclusions From Coverage as Home Health Services  80.1 -  Drugs and Biologicals  80.2 -  Transportation 80.3 -  Services That Would Not Be Covered as Inpatient Services  80.4 -  Housekeeping Services  80.5 -  Services Covered Under  the End Stage Renal Disease (ESRD) Program  80.6 -  Prosthetic Devices  80.7 -  Medical Social Services Furnished to Family Members  80.8 -  Respiratory Care Services  80.9 -  Dietary and Nutrition Personnel  80.10-  Telecommunications Technology
(Medicare Benefit Policy Manual)
90 - Medical and Other Health Services Furnished by Home Health Agencies  100 -  Physician or or Allowed Practitioner Certification f or Medical and Other Health Services Furnished by Home Health Agency (HHA)  110 -  Use of Telehealth in Delivery of Home Health Services  10 - Home Health Prospective Payment System ( HH PPS)  (Rev. 265, Issued: 01- 10-20, Effective: 01 -01-20, Implementation: 02 -11-20)  The unit of payment under the HH PPS is a national 30- day period rate with applicable adjustments.  The periods, rate, and adjustments to the rates are detailed in the following sections.   10.1 - National 30 -Day Period Payment Rate                                                                                     (Rev. 12382; Issued: 11- 28-23; Effective: 01 -01-24; Implementation:01- 02-24)  A. Services Included   The law requires the 30 -day period to include all covered home health services, including medical supplies, paid on a reasonable cost basis. That means the 30 -day period payment  rate includes costs for the six home health disciplines and the costs for routine and nonroutine medical supplies. The six home health disciplines included in the 30- day period payment rate are:   1. Skilled nursing services;  2. Home health aide services;  3. Physical therapy;  4. Speech -language pathology services;  5. Occupational therapy services; and  6. Medical social services.  The 30- day period payment rate also includes amounts for nonroutine medical supplies  and therapies that could have been unbundled to Part B prior to HH PPS. (See 10.11.C  for those services.)  B. Excluded Services  The law specifically excludes durable medical equipment (DME) from the 30-day period payment rate and consolidated billing requirements. DME continues to be paid the fee  schedule amounts or through the DME competitive bidding program outside of the HH  PPS rate.
(Medicare Benefit Policy Manual)
Certain injectable osteoporosis drugs which are covered where a woman is postmenopausal and has a bone fracture are also excluded from the 30- day period payment rate, but must be billed by the home health agency (HHA) while a patient is under a home health plan of care since the law requires consolidated billing of these osteoporosis drugs. These osteoporosis drugs continue to be paid on a reasonable cost basis. Negative pressure wound therapy using a disposable device (d NPWT) that is an integrated  system comprised of a non-manual vacuum pump, a receptacle for collecting exudate,  and dressings for the purposes of wound therapy (in lieu of a conventional NPWT DME system), is also excluded from the 30-day period payment rate, but must be billed by the home health agency (HHA) while a patient is under a home health plan of care since the law requires consolidated billing of NPWT using a disposable device.  Furnishing NPWT using a disposable device means the application of a new applicable disposable device, as that term is defined in 1834 of the Social Security Act (the Act), which includes only the device paid separately (specified by the assigned HCPCS code) and does not include payment for the professional services.  10.2 - Adjustments to the 30 -Day Period Payment Rate  (Rev. 265, Issued: 01-10-20, Effective: 01-01-20, Implementation: 02-11-20)   A.  Case -Mix Adjustment