evekhm/cms_iom_500 huggingface dataset:
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Body  Braces   Includes  leg, arm,  back,  and neck  braces  and their  replacements.   Practitioner services at certain other Medicare facility   Includes services furnished to inpatients or outpatients in a hospital (including CAHs), ambulatory surgical center, Medicare Comprehensive Outpatient Rehabilitation Facility, etc., or other facility whose  requirements pre clude RHC or FQHC services.  (NOTE: Covered services provided to a Medicare beneficiary by an RHC or FQHC practitioner in a SNF may be an RHC or  FQHC  service.)   Telehealth  distant- site services  - See section  200 of  this chapter  for additional information  on telehealth  services in RHCs  and FQHCs.   Hospice Services  (with the exception of hospice attending physician services)   See section 210 of this chapter for additional information on hospice  services  in RHCs and FQHCs.   Group Services   Includes group or mass  information programs, health  education  classes,  group therapy, or group education activities, including media productions and publications. 70 - RHC and FQHC Payment  (Rev. 252, Issued: 12-07-18, Effective: 01-01-19, Implementation: 01- 02 -19)  RHCs and FQHCs must submit claims for RHC or FQHC services under the RHC or FQHC payment methodologies and are not authorized to submit claims under the Physician Fee Schedule (PFS) for RHC or FQHC services.  Newly certified RHCs or FQHCs should work with their  A/B MAC to ensure that all claims filed for RHC or FQHC services are paid as RHC or FQHC claims as of the date of their certification.
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70.1 - RHC Payment  (Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Medicare pays 80 percent o f the RHC AIR, subject to a payment limit, for medically -necessary medical, and qualified preventive, face- to - face (one-on- one) visits with an RHC practitioner (as defined in section 30) for RHC services (as defined in section 50.1), unless otherwise noted.  The rate is subject to a payment limit, except for RHCs that have an exception to the payment limit (see section 70.2).  An interim rate for newly certified RHCs is established based on the RHCs anticipated average cost for direct and supporting services.  At the end of the reporting period, the A/B MAC determines the total payment due and reconciles payments made during the period with the total payments due. In general, the AIR for an RHC is calculated by the A/B MAC by dividing total allowable costs by the total number of visits for all patients.  Productivity, payment limits, and other factors are also considered in the calculation.  Allowable costs must be reasonable and necessary and include practitioner compensation, overhead, equipment, space, supplies, personnel, and other costs incident to the delivery of RHC services. Services furnished incident to an RHC professional service are included in the AIR and are not billed as a separate visit.  The professional component of a procedure is usually a covered service, but is not a stand-alone billable visit.  The costs of covered services provided incident to a billable visit may be included on the RHC cost report.  To receive payment for qualified services, HCPCS coding is required on all claims.  70.2 - RHC Payment Limit  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)  Prior to April 1, 2021, t he RHC payment limit was set by Congress in 1988 and was  adjusted annually based on     the Medicare Economic Index (MEI).  The payment limit was  released annually via Recurring  Update Notifications.   Prior to April 1, 2021, a provider-based RHC that is an integral and subordinate part of a hospital (including a CAH), as described in regulations at 42 CFR 413.65,
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Prior to April 1, 2021, a provider-based RHC that is an integral and subordinate part of a hospital (including a CAH), as described in regulations at 42 CFR 413.65, could receive an exception to the per- visit payment limit if:    the hospital had fewer  than  50 beds as  determined  at 42 CFR 412.105(b) ; or   the hospital's average daily patient census count of those beds described in 42 CFR 412.105(b) did not exceed 40 and the hospital meets both of the following conditions:  o it was  a sole community hospital as determined  in accordance with  42 CFR  412.92 or an essential access community hospital as determined in accordance with 42 CFR 412.109(a), and  o it was  located in a level 9 or level 10 Rural-Urban Commuting Area (RUCA).  (For additional information on RUCAs, see http://depts.washington.edu/uwruca/.  The exception to the payment limit applied only during the time that the RHC met  the  requirements  for the exception.  70.2.1  Payment Limits Applicable to Independent RHCs, Provider-Based RHCs in a Hospital with 50 or More Beds, and New RHCs  (Rev. 11803; Issued: 01-26-23; Effective: 01 -01-23; Implementation: 02-27-23)  Beginning April 1, 2021, independent RHCs, provider-based RHCs in a hospital with 50 or more beds, and RHCs enrolled under Medicare on or after January 1, 2021 will receive a prescribed national statutory pay ment limit per visit increase over an 8 -year period for each year from 2021 through 2028.    The national statutory payment limit for RHCs over the 8-year period is as follows:    In 2021, after March 31, at $100 per visit;    In 2022, at $113 per visit;     In 2023, at $126 per visit;    In 2024, at $139 per visit;    In 2025, at $152 per visit;    In 2026, at $165 per visit;    In 2027, at $178 per visit; and    In 2028, at $190 per visit.
(Medicare Benefit Policy Manual)
Beginning in 2029 and each year thereafter the limit established for the previous year is increased by the percentage increase in MEI applicable to primary care services furnished as of the first day of such year.  We note that new RHCs are those that have submitted an application and are enrolled under Medicare on or after January 1, 2021.  70.2.2  Payment Limits Applicable to Provider -Based RHCs in a Hospital with Less than 50 Beds  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)  Beginning April 1, 2021, provider- based RHCs that meet a specified criteria are entitled to special payment rules that establish a payment limit based on the provider-based RHCs per visit payment amount (or AIR) instead of the national statutory payment limit.  For purposes of this section of the manual, we use the term specified interchangeably with the term grandfathered since those RHCs that meet the specified criteria are considered to be grandfathered into the establishment of their payment limi t per visit.   The specified criteria that an RHC must meet in order to be eligible for the special payment rules are as follows:   As of December 31, 2020, was in a hospital with less than 50 beds (not taking into account any increase in the number of beds pursuant to a waiver during the Public Health Emergency (PHE) for COVID -19); and one of the following circumstances: o As of December 31, 2020, was enrolled in Medicare (including temporary enrollment during the PHE for COVID -19); or  o Submitted an application for enrollment in Medicare (or a request for temporary enrollment during the PHE for COVID-19) that was received not later than December 31, 2020.   Medicare Administrative Contractors (MACs) will calculate the payment limit per visit for speci fied provider-based RHCs (that is, grandfathered RHCs) as discussed in sections 70.2.2.1 and 70.2.2.2 below.   A grandfathered provider-based RHC will lose this designation if the hospital does not continue to have less than 50 beds. If this occurs, the provider-based RHC will be subject to the statutory payment limit per visit applicable for such year for RHCs discussed in section 70.2.1 of this manual.
(Medicare Benefit Policy Manual)
70.2.2.1  Determining Payment Limits for Specified Provider -Based RHCs with an AIR Established for RHC Services Furnished in 2020  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)  Beginning April 1, 2021, specified provider-based RHCs that had a per visit payment amount (that is, AIR) established for services furnished in 2020, the payment limit per visit shall be set at an amount equal to the greater of :  1. the per visit payment amount applicable to such RHC for services furnished in 2020, increased by the percentage increase in the MEI applicable to primary care services furnished as of the first day of 2021; or  2. the national statutory payment limit for RHCs  per visit  (see section 70.2.1 of this chapter).  For subsequent years, the specified provider-based RHCs payment limit per visit shall be set at an amount equal to the gr eater of :  1. the payment limit per visit established for the previous year, increased by the percentage increase in the MEI applicable to primary care services furnished as of the first day of such subsequent year; or  2. the national statutory payment limit for RHCs (see section 70.2.1 of this chapter).  Note: For purposes of establishing the payment limit effective April 1, 2021 for specified provider-based RHCs defined in section 1833(f)(3)(A)(i)(I) of the Act, that is, had an AIR established for services f urnished in 2020, MACs shall use the cost report ending in 2020 that reports costs for 12 -consecutive months. If the RHC does not have a 12- consecutive month cost report ending in 2020, the MACs shall use the next available 12-consecutive month cost report that reports costs for RHC services furnished in 2020. MACs should not combine cost report data to equal a 12-consecutive month cost report.  70.2.2.2   Determining Payment Limits for Specified Provider -Based RHCs that did not have an AIR Established for RHC Services Furnished in 2020                                                                                                          (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)
(Medicare Benefit Policy Manual)
Beginning April 1, 2021, specified provider -based RHCs that did not have a per visit payment amount (that is, AIR) established for services furnished in 2020, the payment limit per visit shall be at an amount equal to the greater of :   1. the per visit payment amount applicable to the provider-based RHC for services furnished in 2021; or 2. the national statutory payment limit for RHCs (see section 70.2.1 of this chapter).
(Medicare Benefit Policy Manual)
For subsequent years, the provider-based RHCs payment limit per visit shall be set at an amount equal to the greater of :  1. the payment limit per visit established for the previous year, increased by the percentage increase in MEI applicable to primary care services furnished as of the first day of such subsequent year; or  2. the national statutory payment limit for RHCs (see sec tion 70.2.1 of this chapter). Note: For purposes of establishing the payment limit effective April 1, 2021 for specified provider-based RHCs defined in section 1833(f)(3)(A)(i)(II) of the Act (that is, those that did not have an AIR established for services furnished in 2020), the MACs shall use the cost report ending in 2021 that reports costs for 12 consecutive months. If the RHC does not have a 12-consecutive month cost report ending in 2021, the MACs shall use the next most -recent final settled cost rep ort that reports cost for 12- consecutive months. MACs should not combine cost report data to equal a 12-consecutive month cost report.  70.3 - FQHC PPS Payment Rate and Adjustments (Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Medicare pays 80 percent of the lesser of the FQHCs charge or the FQHC PPS payment rate for the specific payment code, unless otherwise noted.  Except for grandfathered tribal FQHCs, the FQHC PPS payment rate reflects a base rate that is the same for all FQHCs, a geographic adjustment based on the location where services are furnished, and other applicable adjustments as described below.  The 2015 and 2016 FQHC PPS base rates were updated by the MEI.  Beginning in 2017, the FQHC PPS rate is updated annuall y by the FQHC market basket.  To receive payment for qualified services, HCPCS coding is required on all claims. Geographic Adjustment:   The PPS base rate is adjusted for each FQHC based on its location by the FQHC Geographic Adjustment Factor (FQHC GAF).  The PPS payment rate is the PPS base rate multiplied by the FQHC GAF for the location where the service is furnished.  Since the FQHC GAF is based on where the services are furnished, the
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GAF).  The PPS payment rate is the PPS base rate multiplied by the FQHC GAF for the location where the service is furnished.  Since the FQHC GAF is based on where the services are furnished, the FQHC payment rate may differ among FQHC sites within the same organ ization.  FQHC GAFs are updated periodically and can be found at: https://www.cms.gov/Center/Provider- T
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ype/Federally -Qualified -Health -Centers -FQHC -Center.html .  New Patient Adjustment:  The PPS payment rate is adjusted by a factor of 1.3416 when an FQHC furnishes care to a patient who is new to the FQHC.  A new patient is someone who has not received any Medicare- covered professional health service ( medical or mental health) from any site within the FQHC organization, or from any practitioner within the FQHC organization, within the past 3 years from the date of service. IPPE and AWV Adjustment:   The PPS payment rate is adjusted by a factor of 1.3416 when an FQHC furnishes an IPPE or an AWV to a Medicare beneficiary.  NOTE:   These adjustments do not apply to grandfathered tribal FQHCs.
(Medicare Benefit Policy Manual)
70.4 - FQHC Payment Codes  (Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  FQHCs set their own  charges for services they provide and determine which services are included in the bundle of services associated with each FQHC G code based on a typical bundle of services that they would furnish per diem to a Medicare beneficiary.  The FQHC should maint ain records of the services included in each FQHC G code and the charges associated with the service at the time the service was furnished.  Each FQHC decides what documentation is appropriate to record the services included in each G -code pursuant to its own determination.  Charges must be reasonable and uniform for all patients, regardless of insurance status.  G code services and charges can be changed by the FQHC, but must be the same for all patients and cannot be changed retrospectively.  FQHCs must in clude one or more of the FQHC payment codes listed below on claims to receive payment for services furnished:  1. G0466  FQHC visit, new patient:  A medically -necessary medical, or a qualified preventive health, face- to-face encounter (one- on-one) between a new patient (as defined in section 70.3), and an FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare -covered services that would be furnished per diem to a patient receiving an FQHC visit.  2. G0467  FQHC visit, established patient:  A medically -necessary medical, or a qualifying preventive health, face -to-face encounter (one- on-one) between an established patient and an FQHC practitioner during which time one or more FQHC services are rende red and includes a typical bundle of Medicare -covered services that would be furnished per diem to a patient receiving an FQHC visit.  3. G0468  FQHC visit, IPPE or AWV:  An FQHC visit that includes an IPPE or AWV and includes a typical bundle of Medicare -covered services that would be furnished per diem to a patient receiving an IPPE or AWV. 4. G0469 FQHC visit, mental health, new patient:  A medically
(Medicare Benefit Policy Manual)
and includes a typical bundle of Medicare -covered services that would be furnished per diem to a patient receiving an IPPE or AWV. 4. G0469 FQHC visit, mental health, new patient:  A medically -necessary, face -to-face mental health encounter (one -on-one) between a new patient (as defined in sectio n 70.3), and an FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare -covered services that would be furnished per diem to a patient receiving a mental health visit.  5. G0470  FQHC visit, mental health, established patient:  A medically -necessary, face- to-face mental health encounter (one- on-one) between an established patient and an FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medi care- covered services that would be furnished per diem to a patient receiving a mental health visit.  80 - RHC and FQHC Cost Reports (Rev. 220, Issued: 01- 15-16, Effective: 02- 01-16, Implementation: 02- 01-16)
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80.1 - RHC and FQHC Cost Report Requirements (Rev. 11803; Issued: 01- 26-23; Effective: 01 -01-23; Implementation: 02- 27-23)  RHCs are required to file a cost report annually in order to determine their payment rate  and reconcile interim payments, including  adjustments  for GME  payments, bad  debt, and  influenza , pneumococcal and COVID -19 vaccines , and covered monoclonal antibody products used as pre -exposure prophylaxis prevention of COVID -19  and their administration.  If in its initial reporting  period, the RHC submits a budget that estimates the allowa ble costs and number of visits  expected during the reporting period. The A/B MAC calculates an interim rate based on  a percentage of the per-visit limit,  which  is then  adjusted  when the  cost report  is filed.   FQHCs are required to file a cost report annually and are paid for the costs of GME, bad debt, and influenza , pneumococcal  and COVID-19  vaccines , and covered monoclonal antibody products used as pre-exposure prophylaxis prevention of COVID-19 and their administration through the cost report. All FQHCs,  including an FQHC  that does not have GME  costs,  bad debt, or costs  associated with  influenza , pneumococcal and COVID-19 vaccines , or covered monoclonal antibody products used as pre- exposure prophylaxis prevention of COVID-19 and their  administration,  must file  a cost report. The RHC and FQHC cost reports were updated to reflect costs related to COVID-19 shots and COVID-19 monoclonal antibody products and their administration.
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Note : Until the end of the calendar year in which the Emergency Use Authorization (EUA) declaration for drugs and biological products with respect to COVID-19 ends, CMS covers and pays for these infusions or injections the same way it covers and pays for COVID-19 vaccines when furnished consistent with the EUA. That is, for RHCs and FQHCs COVID-19 monoclonal antibody products (when purchased from the manufacturer) and their administration are paid at 100 percent of reasonable cost through the cost report. Effective January 1 of the year following the year in which the EUA declaration ends, CMS will cover and pay for monoclonal antibody products used for the treatment or for post- exposure prophylaxis of COVID-19 in the same way we pay for other Part B drugs and biological products.  For RHCs, payment is through the All-Inclusive Rate and for FQHCs payment is through the FQHC Prospective Payment System.  RHCs  and FQHCs  must maintain  and provide adequate cost data based  on financial  and statistical records that can be verified  by qualified  auditors. RHCs and FQHCs are allowed to claim bad debts in accordance with 42 CFR 413.89 . RHCs may claim unpaid coinsurance and deductible, and FQHCs may claim unpaid coinsurance. RHCs and FQHCs that claim bad debt must establish that reasonable efforts  were made to collect these amounts Coinsurance or deductibles that are waived, either  due to a statutory  waiver  or a sliding  fee scale, ma y not be claimed.   80.2 - RHC and FQHC Consolidated Cost Reports  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)
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80.2 - RHC and FQHC Consolidated Cost Reports  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)  RHCs  and FQHCs  with  more  than one site may file consolidated cost reports if  approved by the A/B MAC in advance of the reporting period for which the consolidated report is to be used. Once having elected to use a consolidated cost report, the RHC or FQHC may  not revert to  individual reporting without the prior approval of the A/B MAC.  New RHCs (enrolled under section 1866(j) of the Act on or after January 1, 2021) are permitted to file consolidated cost reports with:   New RHCs that are provider-based,  New RHCs that are independent,  Existing independent RHCs, and/or  Existing provider-based RHCs that are in a hospital that has more than 50 beds. In addition, specified provider-based RHCs are not allowed to file a consolidated cost report with a new RHC.  80.3  RHC and FQHC Cost Report Forms  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)   RHCs  and FQHCs  use one of the following  cost report forms:  Independent RHCs and  Freestanding FQHCs:  RHCs: Form CMS -222- 17, Independent Rural Health Clinic Cost Report.  FQHCs:  Form  CMS -224-14, Federally  Qualified  Health  Center  Cost Report.  Provider- based  RHCs  and FQHCs:   Hospital- based RHCs : Worksheet M of Form CMS-2552-10, Hospital and Hospital Care Complex Cost Report.  Hospital-based FQHCs: Worksheet N of Form CMS-2552-10, Hospital and Hospital Care Complex Cost Report.  Skilled Nursing Facility based: Worksheet I series of form CMS-2540-10, Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Cost Report.
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Skilled Nursing Facility based: Worksheet I series of form CMS-2540-10, Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Cost Report.   Information on these cost report forms is found in Chapters 44 and 46; and 40 and 41,  respectively, of the Provider Reimbursement Manual - Part 2 (Publication 15-2), which can be located  on the CMS Website at http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Paper -Based -Manuals.html .    the patients  condition without the interposition  of a third  persons judgment. Direct  visualization  includes review  of the patients  X-rays,  EKGs,  tissue  samples, etc.   Except for services that meet the criteria for authorized care management or virtual  communications services, telephone or electronic communication between a physician  and a patient,  or between  a physician  and someone on behalf of a patient,  are considered physicians services and are included in an otherwise billable visit. They do not constitute  a separately  billable  visit.   Qualified services furnished at an RHC or FQHC or other authorized site by an RHC or FQHC physician are payable only to the RHC or FQHC. RHC and FQHC physicians are paid according  to their  employment agreement or contract  (where  applicable).