evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Wound Care (A53001)
Use of Evaluation and Management (E/M) Codes in Conjunction with Surgical DebridementsE/M codes are not usually billed in conjunction with a debridement procedure. When providing and billing surgical debridement, the surgical debridement service is to include: the pre-debridement wound assessment, the debridement, and the post-procedure instructions provided to the patient on the date of the service. When a "reasonable and necessary" E/M service is provided and documented on the same day as a debridement service, it is payable by Medicare when the documentation clearly establishes the service as a "separately identifiable service" that was reasonable and necessary, as well as distinct, from the debridement service(s) provided.Low frequency, non-contact, non-thermal ultrasound (MIST Therapy)  CPT code 97610One 97610 service per day is allowable for a qualifying wound. CPT Code 97610 is not separately reportable for treatment of the same wound on the same day as other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (e.g., CPT codes 11042-11047, 97597, 97598).Debridement and Unna bootAll supply items related to the Unna boot are inclusive in the reimbursement for CPT code 29580. When both a debridement is performed and an Unna boot is applied, only the debridement may be reimbursed. If only an Unna boot is applied and the wound is not debrided, then only the Unna boot application may be eligible for reimbursement. The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services Chapter 4, section G states that debridement codes (11042-11047, 97597) should not be reported with codes 29580, 29581 for the same anatomic area.Debridement including removal of foreign material at the site of an open fracture or open dislocation may be reported with CPT codes 11010-11012. Since these codes would be reported with a CPT code for treatment of the open fracture or dislocation, a casting/splinting/strapping code should not be reported separately.
Social Security Act §1862
html  PUBLIC "-//W3C//DTD HTML 4.01//EN"SSA INTERNET HEAD SCRIPTSSocial Security Act 1862BANNERSkip to main contentSocial SecuritySearchMenuEspaolSign inSITE NAVIGATION#include virtual="/framework/includes/english/navigation.shtml"PAGE TITLECompilation of the Social Security LawsCONTENT
Social Security Act §1862
EXCLUSIONS FROM COVERAGE AND MEDICARE AS SECONDARY PAYER[547]Sec.1862.[42 U.S.C. 1395y](a)Notwithstandingany other provision of this title, no payment may be made under partA or part B for any expenses incurred for items or services(1)(A)which, exceptfor items and services described in a succeeding subparagraph, arenot reasonable and necessary for the diagnosis or treatment of illnessor injury or to improve the functioning of a malformed body member,(B)in the caseof items and services described in section 1861(s)(10), which are not reasonableand necessary for the prevention of illness,(C)in the caseof hospice care, which are not reasonable and necessary for the palliationor management of terminal illness,(D)in the caseof clinical care items and services provided with the concurrenceof the Secretary and with respect to research and experimentationconducted by, or under contract with, the Medicare Payment AdvisoryCommission or the Secretary, which are not reasonable and necessaryto carry out the purposes of section 1886(e)(6),(E)in the caseof research conducted pursuant to section 1142, which is not reasonable and necessaryto carry out the purposes of that section,(F)in the caseof screening mammography, which is performed more frequently thanis covered under section 1834(c)(2) or which is not conductedby a facility described in section 1834(c)(1)(B), in the case of screeningpap smear and screening pelvic exam, which is performed more frequentlythan is provided under section 1861(nn), and, in the case of screeningfor glaucoma, which is performed more frequently than is providedunder section 1861(uu),(G)in the caseof prostate cancer screening tests (as defined in section 1861(oo)), whichare performed more frequently than is covered under such section,(H)in the caseof colorectal cancer screening tests, which are performed more frequentlythan is covered under section 1834(d),(I)the frequencyand duration of home health services which are in excess of normativeguidelines that the Secretary shall establish by regulation,
Social Security Act §1862
(I)the frequencyand duration of home health services which are in excess of normativeguidelines that the Secretary shall establish by regulation,(J)in the caseof a drug or biological specified in section 1847A(c)(6)(C) for which paymentis made under part B that is furnished in a competitive area undersection 1847B, that is not furnished by an entity under a contract under suchsection,(K)in the caseof an initial preventive physical examination, which is performedmore than 1 year after the date the individuals first coverageperiod begins under part B;(L)in the caseof cardiovascular screening blood tests (as defined in section 1861(xx)(1)), whichare performed more frequently than is covered under section 1861(xx)(2),(M)in the caseof a diabetes screening test (as defined in section 1861(yy)(1)), whichis performed more frequently than is covered under section 1861(yy)(3), and(N)in the caseof ultrasound screening for abdominal aortic aneursym which is performedmore frequently than is provided for under section 1861(s)(2)(AA),(O)in the caseof kidney disease education services (as defined in paragraph (1)of section 1861(ggg)), which are furnished in excess of the number of sessions coveredunder paragraph (4) of such section, and(P)in the caseof personalized prevention plan services (as defined in section 1861(hhh)(1)), which are performedmore frequently than is covered under such section;(2)for which theindividual furnished such items or services has no legal obligationto pay, and which no other person (by reason of such individualsmembership in a prepayment plan or otherwise) has a legal obligationto provide or pay for, except in the case of Federally qualified healthcenter services;
Social Security Act §1862
(3)which are paidfor directly or indirectly by a governmental entity (other than underthis Act and other than under a health benefits or insurance planestablished for employees of such an entity), except in the case ofrural health clinic services, as defined in section 1861(aa)(1), inthe case of Federally qualified health center services, as definedin section 1861(aa)(3), in the case of services for which payment may be made under section 1880(e), and in suchother cases as the Secretary may specify;(4)which are notprovided within the United States (except for inpatient hospital servicesfurnished outside the United States under the conditions describedin section 1814(f) and, subject to such conditions, limitations, and requirements asare provided under or pursuant to this title, physicians servicesand ambulance services furnished an individual in conjunction withsuch inpatient hospital services but only for the period during whichsuch inpatient hospital services were furnished);(5)which are requiredas a result of war, or of an act of war, occurring after the effectivedate of such individuals current coverage under such part;(6)which constitutepersonal comfort items (except, in the case of hospice care, as isotherwise permitted under paragraph (1)(C));(7)where such expensesare for routine physical checkups, eyeglasses (other than eyeweardescribed in section 1861(s)(8)) or eye examinations for the purpose of prescribing,fitting, or changing eyeglasses, procedures performed (during thecourse of any eye examination) to determine the refractive state ofthe eyes, hearing aids or examinations therefor, or immunizations(except as otherwise allowed under section 1861(s)(10) and subparagraph (B),(F), (G), (H), or (K) or (P) of paragraph (1));(8)where such expensesare for orthopedic shoes or other supportive devices for the feet,other than shoes furnished pursuant to section 1861(s)(12);(9)where such expensesare for custodial care (except, in the case of hospice care, as isotherwise permitted under paragraph (1)(C));
Social Security Act §1862
(9)where such expensesare for custodial care (except, in the case of hospice care, as isotherwise permitted under paragraph (1)(C));(10)where such expensesare for cosmetic surgery or are incurred in connection therewith,except as required for the prompt repair of accidental injury or forimprovement of the functioning of a malformed body member;(11)where such expensesconstitute charges imposed by immediate relatives of such individualor members of his household;(12)where such expensesare for services in connection with the care, treatment, filling,removal, or replacement of teeth or structures directly supportingteeth, except that payment may be made under part A in the case ofinpatient hospital services in connection with the provision of suchdental services if the individual, because of his underlying medicalcondition and clinical status or because of the severity of the dentalprocedure, requires hospitalization in connection with the provisionof such services;(13)where such expensesare for(A)the treatmentof flat foot conditions and the prescription of supportive devicestherefor,(B)the treatmentof subluxations of the foot, or(C)routinefoot care (including the cutting or removal of corns or calluses,the trimming of nails, and other routine hygienic care);(14)which are otherthan physicians services (as defined in regulations promulgatedspecifically for purposes of this paragraph), services described bysection 1861(s)(2)(K), certified nurse-midwife services, qualified psychologist services,and services of a certified registered nurse anesthetist, and whichare furnished to an individual who is a patient of a hospital or criticalaccess hospital by an entity other than the hospital or critical accesshospital, unless the services are furnished under arrangements (asdefined in section 1861(w)(1)) with the entity made by the hospital or criticalaccess hospital;(15)(A)which arefor services of an assistant at surgery in a cataract operation (includingsubsequent insertion of an intraocular lens) unless, before the surgeryis performed, the appropriate quality improvement[548]organization (under part B of titleXI) or a carrier under section 1842 has approved of the use of such anassistant in the surgical procedure based on the existence of a complicatingmedical condition, or[549]
Social Security Act §1862
(B)which arefor services of an assistant at surgery to which section 1848(i)(2)(B) applies;(16)in the casein which funds may not be used for such items and services under theAssisted Suicide Funding Restriction Act of 1997;(17)where the expensesare for an item or service furnished in a competitive acquisitionarea (as established by the Secretary under section 1847(a)) by an entityother than an entity with which the Secretary has entered into a contractunder section 1847(b) for the furnishing of such an item or service in that area, unlessthe Secretary finds that the expenses were incurred in a case of urgentneed, or in other circumstances specified by the Secretary;(18)which are coveredskilled nursing facility services described in section 1888(e)(2)(A)(i) and which are furnished to an individual who is a resident of askilled nursing facility during a period in which the resident isprovided covered post-hospital extended care services (or, for servicesdescribed in section 1861(s)(2)(D), which are furnished to such an individual withoutregard to such period), by an entity other than the skilled nursingfacility, unless the services are furnished under arrangements (asdefined in section 1861(w)(1)) with the entity made by the skilled nursing facility;or(19)which are foritems or services which are furnished pursuant to a private contractdescribed in section 1802(b);(20)in the caseof outpatient physical therapy services, outpatient speech-languagepathology services, or outpatient occupational  therapy services[550]furnished as an incident to a physicians professionalservices (as described in section 1861(s)(2)(A)), that do not meetthe standards and conditions (other than any licensing requirementspecified by the Secretary) under the second sentence of section 1861(p) (or undersuch sentence through the operation of subsection (g) or (ll)(2) of section 1861(g)) as such standards and conditionswould apply to such therapy services if furnished by a therapist;
Social Security Act §1862
(21)where such expensesare for home health services (including medical supplies describedin section 1861(m)(5), but excluding durable medical equipment to the extent providedfor in such section), furnished to an individual who is under a planof care of the home health agency if the claim for payment for suchservices is not submitted by the agency; or(22)subject to subsection(h), for which a claim is submitted other than in an electronic formspecified by the Secretary;(23)[551]which are the technical component of advanceddiagnostic imaging services described in section 1834(e)(1)(B) forwhich payment is made under the fee schedule established under section1848(b) and that are furnished by a supplier (as defined in section1861(d)), if such supplier is not accredited by an accreditation organizationdesignated by the Secretary under section 1834(e)(2)(B);(24)where such expensesare for renal dialysis services (as defined in subparagraph (B) ofsection 1881(b)(14)) for which payment is made under such section unless such paymentis made under such section to a provider of services or a renal dialysisfacility for such services; or(25)[552]not later than January 1, 2014, for whichthe payment is other than by electronic funds transfer (EFT) or anelectronic remittance in a form as specified in ASC X12 835 HealthCare Payment and Remittance Advice[553]or subsequent standard.
Social Security Act §1862
Paragraph (7) shall not apply to Federally qualified healthcenter services described in section 1861(aa)(3)(B). In making a nationalcoverage determination (as defined in paragraph (1)(B) of section 1869(f)) the Secretaryshall ensure consistent with subsection (l) that the public is affordednotice and opportunity to comment prior to implementation by the Secretaryof the determination; meetings of advisory committees with respectto the determination are made on the record; in making the determination,the Secretary has considered applicable information (including clinicalexperience and medical, technical, and scientific evidence) with respectto the subject matter of the determination; and in the determination,provide a clear statement of the basis for the determination (includingresponses to comments received from the public), the assumptions underlyingthat basis, and make available to the public the data (other thanproprietary data) considered in making the determination.(b)Medicareas Secondary Payer.(1)Requirementsof group health plans.(A)Working aged under group health plans.(i)Ingeneral.A group health plan(I)may nottake into account that an individual (or the individuals spouse)who is covered under the plan by virtue of the individualscurrent employment status with an employer is entitled to benefitsunder this title under section 226(a), and(II)shallprovide that any individual age 65 or older (and the spouse age 65or older of any individual) who has current employment status withan employer shall be entitled to the same benefits under the planunder the same conditions as any such individual (or spouse) underage 65.(ii)Exclusionof group health plan of a small employer.Clause (i) shall not apply to a group health plan unless the planis a plan of, or contributed to by, an employer that has 20 or moreemployees for each working day in each of 20 or more calendar weeksin the current calendar year or the preceding calendar year.(iii)
Social Security Act §1862
(iii)Exception for small employers in multi-employer or multiple employergroup health plans.Clause (i) also shallnot apply with respect to individuals enrolled in a multiemployeror multiple employer group health plan if the coverage of the individualsunder the plan is by virtue of current employment status with an employerthat does not have 20 or more individuals in current employment statusfor each working day in each of 20 or more calendar weeks in the currentcalendar year and the preceding calendar year; except that the exceptionprovided in this clause shall only apply if the plan elects treatmentunder this clause.(iv)Exceptionfor individuals with end stage renal disease.Subparagraph (C) shall apply instead of clause (i) to an itemor service furnished in a month to an individual if for the monththe individual is, or (without regard to entitlement under section 226) would upon applicationbe, entitled to benefits under section 226A.(v)Grouphealth plan defined.In this subparagraph,and subparagraph (C), the term group health plan hasthe meaning given such term in section 5000(b)(1) of the InternalRevenue Code of 1986[554], without regard to section 5000(d)of such Code.(B)Disabled individuals in large group health plans.(i)Ingeneral.A large group health plan (asdefined in clause (iii)) may not take into account that an individual(or a member of the individuals family) who is covered underthe plan by virtue of the individuals current employment statuswith an employer is entitled to benefits under this title under section 226(b).(ii)Exceptionfor individuals with end stage renal disease.Subparagraph (C) shall apply instead of clause (i) to an itemor service furnished in a month to an individual if for the monththe individual is, or (without regard to entitlement under section 226) would upon applicationbe, entitled to benefits under section 226A.(iii)Large group health plan defined.Inthis subparagraph, the term large group health plan has the meaning given such term in section 5000(b)(2) of the InternalRevenue Code of 1986, without regard to section 5000(d) of such Code.(C)
Social Security Act §1862
(C)Individuals with end stage renal disease.A group health plan (as defined in subparagraph (A)(v))(i)may not takeinto account that an individual is entitled to or eligible for benefitsunder this title under section 226A  during the 12-month period whichbegins with the first month in which the individual becomes entitledto benefits under part A under the provisions of section 226A, or, if earlier,the first month in which the individual would have been entitled tobenefits under such part under the provisions of section 226A  if the individualhad filed an application for such benefits; and(ii)may not differentiatein the benefits it provides between individuals having end stage renaldisease and other individuals covered by such plan on the basis ofthe existence of end stage renal disease, the need for renal dialysis,or in any other manner;except that clause (ii) shall not prohibit a plan from payingbenefits secondary to this title when an individual is entitled toor eligible for benefits under this title under section 226A  after the endof the 12-month period described in clause (i). Effective for itemsand services furnished on or after February 1, 1991, and before thedate of enactment of the Balanced Budget Act of 1997[555](with respect to periods beginning on or after February 1, 1990),this subparagraph shall be applied by substituting 18-month for 12-month each place it appears. Effective foritems and services furnished on or after the date of enactment ofthe Balanced Budget Act of 1997, (with respect to periods beginningon or after the date that is 18 months prior to such date), clauses(i) and (ii) shall be applied by substituting 30-month for 12-month each place it appears.(D)Treatment of certain members of religious orders.In this subsection, an individual shall not be considered tobe employed, or an employee, with respect to the performance of servicesas a member of a religious order which are considered employment onlyby virtue of an election made by the religious order under section3121(r) of the Internal Revenue Code of 1986.(E)General provisions.For purposes ofthis subsection:
Social Security Act §1862
(E)General provisions.For purposes ofthis subsection:(i)Aggregationrules.(I)All employerstreated as a single employer under subsection (a) or (b) of section52 of the Internal Revenue Code of 1986 shall be treated as a singleemployer.(II)All employeesof the members of an affiliated service group (as defined in section414(m) of such Code) shall be treated as employed by a single employer.(III)Leasedemployees (as defined in section 414(n)(2) of such Code) shall betreated as employees of the person for whom they perform servicesto the extent they are so treated under section 414(n) of such Code.In applying sections of the Internal Revenue Code of 1986 underthis clause, the Secretary shall rely upon regulations and decisionsof the Secretary of the Treasury respecting such sections.(ii)Currentemployment status defined.An individualhas current employment status with an employer if theindividual is an employee, is the employer, or is associated withthe employer in a business relationship.(iii)Treatment of self-employed persons as employers.The term employer includes a self-employed person.(F)Limitation on beneficiary liability.An individual who is entitled to benefits under this title and isfurnished an item or service for which such benefits are incorrectlypaid is not liable for repayment of such benefits under this paragraphunless payment of such benefits was made to the individual.(2)Medicaresecondary payer.(A)In general.Payment under this titlemay not be made, except as provided in subparagraph (B), with respectto any item or service to the extent that(i)payment has beenmade, or can reasonably be expected to be made, with respect to theitem or service as required under paragraph (1), or(ii)payment hasbeen made or can reasonably be expected to be made under a workmenscompensation law or plan of the United States or a State or underan automobile or liability insurance policy or plan (including a self-insuredplan) or under no fault insurance.