evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Home Health Occupational Therapy (A53057)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Title XVIII of the Social Security Act,1835(a)(2)(A)procedure for payment of claims of providers of services42 CFR 484.2 DefinitionsCMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, 40.2.4 Application of the General Principles to Occupational TherapyCMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2,160.2 Treatment of Motor Function Disorders with Electric Nerve Stimulation and 160.15 Electrotherapy for Treatment of Facial Nerve Palsy (Bells Palsy)CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, 6.2.4 CodingArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Home Health Occupational Therapy L34560.Coding Guidelines1. Outcome and Information Set (OASIS) data should support the medical necessity of the services documented in the medical records. For therapy services the OASIS M2200 should be filled out completely. An updated and completed OASIS for the billing period should be in the patient's medical records and made available to the Medicare Administrative Contractor (MAC) upon request.2. HCPCS code G0152 (services of occupational therapist in home health setting, each 15 minutes) is the only required HCPCS code in home health. All others are for informational purposes only.3. It is usually not reasonable and necessary to have more than 1 form of heat treatment (paraffin bath, contrast baths) for a single condition per day. Therefore, documentation of the medical necessity of multiple heating modalities on the same date of service must be in the patient's medical records and made available to the MAC upon request.4. CPTcode 97140 (Manual Therapy Techniques) includes different treatment techniques. The patient's medical records should indicate which modalities were performed and this documentation made available to the MAC upon request.
Article - Billing and Coding: Home Health Occupational Therapy (A53057)
4. CPTcode 97140 (Manual Therapy Techniques) includes different treatment techniques. The patient's medical records should indicate which modalities were performed and this documentation made available to the MAC upon request.5. ICD-10 codes for Migraines (G43.XX codes) are included in this billing and coding articlefor patients that require training in how to reduce pain during basic activities of daily living (BADLs) and instrumental activities of daily living (IADLs) by training in adaptive techniques, instruction in use of adaptive equipment and positioning. This can usually be done in 3-4 sessions.6. An Occupational Therapist can only re-certify a patient under a plan of care if:The services that the patient requires meet the definition of "occupational therapy" services of CMS Internet-Only Manual,Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, 40.2.4 Application of the General Principles to Occupational Therapy,and;The patient's eligibility for home health services has been established by virtue of a prior need for skilled nursing care (other than solely venipuncture for the purposes of obtaining a blood sample), speech-language pathology services or physical therapy in the current or prior certification period.Other Comments1. The related policy is based on impairments of structure/function and functional limitations. While the pathophysiology is an important factor, the purpose of the related Home Health Occupational Therapy L34560 policy is to show the specific functional limitation of the patient.2. "Clinical note means a notation of a contact with a patient that is written and dated by a member of the health team and that describes signs and symptoms, treatment and drugs administered and the patient's reaction and any changes in physical or emotional condition". (42 CFR 484.2)
Article - Billing and Coding: Home Health Occupational Therapy (A53057)
3. "Progress note means a written notation, dated and signed by a member of the health team, that summarizes facts about care furnished and the patient's response during a given period of time". (42 CFR 484.2)Fabrication/Application of Casts, Splints and Strapping (CPTcodes 29065-29280, 29345, 29365-29405, 29505-29550)Note:When identifying orthotics fitting and training see CPTcode 97760.Range of Motion (ROM) Measurements (CPTcodes 95851 and 95852)To use CPTcode 95851 for extremity ROM testing, every joint of an extremity would need to be tested with documentation of why such a thorough assessment was warranted.Therapeutic Exercise (CPTcode 97110)An occupational therapist may use this code when addressing impairments of exercise tolerance due to cardiopulmonary impairments.Self-Care/Home Management Training (CPTcode 97535)This code should not be used globally for all home instructions. When instructing the patient in a self-management program, use the code that best describes the focus of the self-management activity.Wheelchair Management Training (CPTcode 97542)This code is used for reporting the time associated with training the patient/client and/or caregiver in transfers in and out of the chair as well as propulsion on all surfaces.When billing CPTcode 97542 for wheelchair propulsion training, documentation must relate the training to expected functional goals that are attainable by the patient.Electrical Stimulation Therapy (CPTcode 97032)CPTcode 97032 requires "visual, verbal and/or manual contact" (i.e., constant attendance).Non-Covered ICD-10 CodesAny ICD-10 code not listed in theICD-10-CM Codes that Support Medical Necessitysection of this billing and coding article may be subject to medical review.Non-covered Indications
Article - Billing and Coding: Home Health Occupational Therapy (A53057)
Non-covered IndicationsElectrical Stimulation (CPTcode 97032) used in the treatment of facial nerve paralysis, commonly known as Bells palsy (CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, 160.15Electrotherapy for Treatment of Facial Nerve Palsy (Bells Palsy))Electrical Stimulation (CPTcode 97032) used to treat motor function disorders such as multiple sclerosis (CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2,160.2 Treatment of Motor Function Disorders with Electric Nerve Stimulation)Electrical Stimulation (CPTcode 97032) for the treatment of strokes when it is determined there is no potential for restoration of functionElectrical Stimulation when it is an isolated intervention utilized purely for strengthening of a muscle with at least fair graded strength. Most muscle strengthening is more efficiently accomplished through a treatment program that includes active procedures such as therapeutic exercises and therapeutic activitiesSupportive Documentation Recommendations for CPTcode 97032Type of electrical stimulation used (in addition to the description specifying manual and attended)Area(s) being treatedIf used for muscle weakness, objective rating of strength and functional deficitsIf used for pain include pain rating, location of pain, effect of pain on functionHCPCS G0283 - Electrical stimulation (unattended), to 1 or more areas for indication(s) other than wound care, as part of a therapy plan of care. See CPTcode 97032 for instructions in manual electrical stimulationMost non-wound care electrical stimulation treatment provided as part of a therapy plan of care should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/assistive personnel) without constant, direct contact required throughout the treatment. Code G0283 is classified as a supervised modality. A supervised modality does not require direct (1-on-1) patient contact by the provider. Typically, electrical stimulation conducted via the application of electrodes is considered unattended electrical stimulation.Examples of unattended electrical stimulation modalities include, but are not limited to, Interferential Current (IFC), Transcutaneous Electrical Nerve Stimulation (TENS), cyclical muscle stimulation (Russian stimulation).
Article - Billing and Coding: Home Health Occupational Therapy (A53057)
Examples of unattended electrical stimulation modalities include, but are not limited to, Interferential Current (IFC), Transcutaneous Electrical Nerve Stimulation (TENS), cyclical muscle stimulation (Russian stimulation).Utilization of electrical stimulation may be necessary during the initial phase of treatment but there must be an improvement in function. These modalities should be utilized with appropriate therapeutic procedures to effect continued improvement.Note:Coverage for this indication is limited to those patients where the nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves and other non-neurological reasons for disuse are causing the atrophy (e.g., post-casting or splinting of a limb, and contracture due to soft tissue scarring).Documentation must clearly support the medical necessity of unattended electrical stimulation used for control of pain and swelling, with objective and/or subjective changes noted in swelling and/or pain within 12 visits. If no improvement is noted, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of this modality. Typically, patients can be trained in the use of a TENS unit for self-management of their pain. Up to 2 visits should be necessary to complete the training. Once training is successfully completed, this procedure should not be billed as a treatment modality in the clinic, as the patient would be independent in application and use of the modality.
Article - Billing and Coding: Home Health Physical Therapy (A53058)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Title XVIII of the Social Security Act, 1835(a)(2)(A) addresses procedure for payment of claims of providers of services.42 CFR 484.2 DefinitionsCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, 11.2 Electromagnetic Therapy - National Coverage Decision was made to allow for Medicare coverage of electromagnetic therapy for the treatment of certain types of wounds.CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, 6.2.4 CodingArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Home Health Physical Therapy L34564.Coding Guidelines1. For CPTcodes 97010 (Hot or Cold Packs), 97018 (Paraffin Bath), 97022 (Whirlpool), and 97026 (Infrared Application), documentation must reflect medical necessity and be made available to the Medicare Administrative Contractor (MAC) upon request.2. When both a modality/procedure and an evaluation service are billed on the same day, the evaluation may be reimbursed only if the medical necessity for the evaluation is clearly documented.3. CPTcodes 95851 (range of motion measurements and report), 95852 (Range of motion measurements hand, with or without comparison with normal side) and 97750 (Physical performance test or measurement [e.g., musculoskeletal, functional capacity], with written report, each 15 minutes) should not be billed with an initial evaluation.4. CPTcode 97140 (Manual therapy techniques) excludes manipulation performed in the home setting.5. When billing a z code as a diagnosis code, documentation should include the name of the orthotic/prosthetic device, date the patient received the device, and the date training/teaching began.6. Associated with several procedure codes are guidelines on the number of visits generally needed to accomplish the task. If more visits are needed the documentation should support the necessity of the additional visits.
Article - Billing and Coding: Home Health Physical Therapy (A53058)
6. Associated with several procedure codes are guidelines on the number of visits generally needed to accomplish the task. If more visits are needed the documentation should support the necessity of the additional visits.7. As of July 1999, Physical Therapy must report time spent with the patient in 15-minute increments. The following code should be used by Physical Therapy:G0151 Physical therapy8. The related LCD is based on impairments of structure/function and functional limitations. While the pathophysiology is an important factor, the purpose of the related LCD is to show the specific functional limitation of the patient.9. "Clinical note means a notation of a contact with a patient that is written and dated by a member of the health team, and that describes signs and symptoms, treatment and drugs administered and the patient's reaction, and any changes in physical or emotional condition." (42 CFR484.2)10. "Progress note means a written notation, dated and signed by a member of the health team, that summarizes facts about care furnished and the patient's response during a given period of time." (42 CFR484.2)Therapeutic Exercises (CPTcode 97110)A physical therapist may use this code when addressing impairments of exercise tolerance due to cardiopulmonary impairments.Self-Care/Home Management Training (CPTcode 97535)This code should not be used globally for all home instructions. When instructing the patient in a self-management program, use the code that best describes the focus of the self-management activity.Wheelchair Management Training (CPTcode 97542)When billing 97542 for wheelchair propulsion training, documentation must relate the training to expected functional goals that are attainable by the patient and/or caregiver.
Article - Billing and Coding: Ophthalmology: Extended Ophthalmoscopy and Fundus Photography (A53060)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 280.1 Glaucoma ScreeningCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, 40.1.A Components of a Global Surgical PackageCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 18, 70 Glaucoma Screening Services,70.1 Claims Submission Requirements and Applicable HCPCS Codes,70.1.1 HCPCS and Diagnosis Coding,70.1.1.1 Additional Coding Applicable to Claims Submitted to A/B MACs (A),70.1.1.2 Special Billing Instructions for RHCs and FQHCs,70.1.2 Edits,70.2 Payment Methodology,70.3 Determining the 11-Month Period,70.4 Remittance Advice Notices,70.5 MSN MessagesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) fortheOphthalmology: Extended Ophthalmoscopy and Fundus PhotographyL33467.General ophthalmoscopy and biomicroscopy are part of an ophthalmologic examination. These codes are included in and are not separately payable when an extended ophthalmoscopy code is billed, but these should still be documented in the patients medical record.If extended ophthalmoscopy is done without a drawing or does not meet indicated standards, the service is not separately payable and will be considered part of a general ophthalmologic exam or E&M service.PART BFundus photography is a bilateral service on the Medicare Physician Fee Schedule Data Base. Services performed unilaterally are subject to a reduction in fee. [Use 52 modifier to indicate unilateral service; -RT and LT are not required in this circumstance.]CPTcodes92201 and 92202 should not be billed if fundus photography is performed.
Article - Billing and Coding: Ophthalmology: Extended Ophthalmoscopy and Fundus Photography (A53060)
Extended ophthalmoscopy (CPTcodes 92201, 92202) performed during the global surgery period of an ophthalmologic surgery procedure, by the same provider performing the surgery, will not be separately payable unless unrelated to the condition for which the surgery was performed. This circumstance can be indicated by reporting a modifier -76 or -79 depending on the date of service.CPTcode 92227 is not for routine screening, but is covered for evaluation of asymptomatic patients at risk with known disease (e.g., diabetes mellitus) that is likely to cause retinal disease when the test is ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).CPTcode 92228 is a covered service when ordered by the treating physician(or other treating practitioner acting within the scope of his or her license and Medicare requirements).
Article - Billing and Coding: Outpatient Occupational Therapy (A53064)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.Title XVIII of the Social Security Act, 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 12, 30 Rules for Provision of Services and 30.1 Rules for Payment of CORF ServicesCMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.3 Audiology Services, 220.1 Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services, 220.2 Reasonable and Necessary Outpatient Rehabilitation Therapy Services, 230 Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology, 230.2 Practice of Occupational Therapy, 230.4 Services Furnished by a Therapist in Private Practice (TPP) and 230.6 Therapy Services Furnished Under Arrangements With Providers and ClinicsCMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, 160.2 Treatment of Motor Function Disorders with Electric Nerve Stimulation and 160.15 Electrotherapy for Treatment of Facial Nerve Palsy (Bells Palsy)CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, 230.8 Non-Implantable Pelvic Floor Electrical Stimulator, 270.1 Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of WoundsCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 5, 10.6 Functional Reporting and 100.5 Off-Site CORF ServicesArticle Text
Article - Billing and Coding: Outpatient Occupational Therapy (A53064)
Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Outpatient Occupational Therapy L34427.Electrical Stimulation (CPTcode 97032, HCPCS codes G0281 and G0283), and Electromagnetic Therapy (HCPCS code G0329)NOTE:The coverage/non-coverage indications for Electrical Stimulation Therapy and Electromagnetic Therapy and definition are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, 270.1.CPTcode 97032- Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutesAttended electrical stimulation requires direct (1-on-1) contact with the patient by the qualified professional/qualified personnel in providing electrical stimulation manually through the use of probes or other devices.Types of electrical stimulation that may require constant attendance and direct 1-on-1 contact by the qualified professional/qualified personnel include but are not limited to: Direct motor point stimulation Functional Electrical Stimulation (FES) or Neuromuscular Electrical Stimulation (NMES)-if performed with therapeutic exercise, neuromuscular reeducation or functional activities, 97032 may be billed for the time the qualified professional/qualified personnel spends applying/instructing and adjusting the FES application, but 97110, 97112, or 97530 should not be billed during the same time period Ultrasound (US) with electrical stimulation provided concurrently should be billed as US (97035)-do not bill for both US and electrical stimulation for the same time period Determining trigger points associated with application of a transcutaneous electrical nerve stimulation (TENS) unit using a handheld probe, would be reported by 97032The actual application of a TENS unit including the instruction in use and appropriate settings would be described by reporting 97032.TENS is not reasonable and necessary for the treatment of Chronic Low Back Pain (CLBP) under 1862(a)(1)(A) of the Social Security Act.
Article - Billing and Coding: Outpatient Occupational Therapy (A53064)
TENS is not reasonable and necessary for the treatment of Chronic Low Back Pain (CLBP) under 1862(a)(1)(A) of the Social Security Act.Non-Implantable Pelvic Floor Electrical Stimulator (CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, 230.8). Non-implantable pelvic floor electrical stimulators provide neuromuscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor musculature. Stimulation is generally delivered by vaginal or anal probes connected to an external pulse generator and may be billed as 97032.Stimulation delivered via electrodes should be billed as G0283.The methods of pelvic floor electrical stimulation vary in location, stimulus frequency (Hz), stimulus intensity or amplitude (mA), pulse duration (duty cycle), treatments per day, number of treatment days per week, length of time for each treatment session, overall time period for device use and between clinic and home settings. In general, the stimulus frequency and other parameters are chosen based on the patient's clinical diagnosis.Pelvic floor electrical stimulation with a non-implantable stimulator is covered for the treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training.A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing 4 weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength.The patient's medical record must indicate that the patient receiving a non-implantable pelvic floor electrical stimulator was cognitively intact, motivated, and had failed a documented trial of PME training.