evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
-  Radiation Physics Services (CPT Codes 77300 -  77399)  80 - Supervision and Interpretation (S&I) Codes and Interventional Radiology  80.1 -  Physician Presence 80.2 -  Multiple Procedure Reduction 90 - Services of Portable X -Ray Suppliers  90.1 -  Professional Component  90.2 -  Technical Component  90.3 -  Transportation Component (HCPCS Codes R0070 -  R0076)  90.4 -  Set-Up Component (HCPCS Code Q0092)  90.5 -  Transportation of Equipment Billed by a SNF to a MAC  100 -  Interpretation of Diagnostic Tests  100.1 -  X-rays and EKGs Furnished to Emergency Room Patients  110 -  Special Billing Instructions for Claims Submitted to A/B MACs (A)  110.1 -  Aborted Procedure  110.2 -  Combined Procedures (Radiology)  110.3 -  Payment for Radiopharmaceuticals  120 -  Radiology or Other Diagnostic Unlisted Service or Procedure Billing Instructions for A/B MAC (A) Claims  130 -  EMC Formats  140 -  Bone Mass Measurements  (BMMs)  140.1 -  Payment Methodology and HCPCS Coding 140.2 -  Denial Messages for Noncovered Bone Mass Measurements  140.4 -  Advance Beneficiary Notices (ABNs)  150 -  Place of Service (POS) Instructions for the Professional Component (PC or Interpretation) and the Technical Component (TC) of Diagnostic Tests  10 - ICD Coding for Diagnostic Tests  (Rev. 3227, Issued: 04- 02-15, Effective; ASC -X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  June 11, 2013, ICD -10: Upon Implementation of ICD -10 Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  May 19, 2014 -  MAC Non -Shared System Edits; July 7, 2014 -  CWF development/testing, FISS requirement development; October 6, 2014 -  CWF, FISS, MCS Shared System Edits), ICD -10: Upon Implementation of ICD -10)
(Medicare Claims Processing Manual)
The ICD Coding Guidelines for Outpatient Services (hospital -based and physician office) have instructed physicians to report diagnoses based on test results.  Instructions and examples for coding specialists, contractors, physicians, hospitals, and other health care providers to use in determining the use of ICD codes for coding diagnostic test results is found in chapter 23.   10.1 - Billing Part B Radiology Services and Other Diagnostic Procedures  (Rev. 1, 10- 01-03)  Acceptable HCPCS codes for radiology and other diagnostic services are taken primarily from the CPT -4 portion of HCPCS.  Payment is the lower of the charge or the Medicare physician fee schedule amount. Deductible and coinsurance apply, and coinsurance is based on the allowed amount .  For claims to A/B MACs (A) or (HHH), revenue codes, HCPCS code, line item dates of service, units, and applicable HCPCS modifiers are required.  Charges must be reported by HCPCS code.  If the same revenue code applies to two or more HCPCS codes, providers  should repeat the revenue code and show the line item date of service, units, and charge for each HCPCS code on a separate line.   20 - Payment Conditions for Radiology Services  (Rev. 1, 10- 01-03) B3-15022  20.1 - Professional Component (PC)  (Rev. 1, 10- 01-03)  A/B MACs (B) must pay for the PC of radiology services furnished by a physician to an individual patient in all settings under the fee schedule for physician services regardless of the specialty of the physician who performs the service.  For services furnished to hospital patients, A/B MACs (B) pay only if the services meet the conditions for fee schedule payment and are identifiable, direct, and discrete diagnostic or therapeutic services to an individual patient, such as an interpretation of diagnostic procedures and the PC of therapeutic procedures.  The interpretation of a diagnostic procedure includes a written report.   20.2 - Technical Component (TC)  (Rev. 1, 10- 01-03)  20.2.1 - Hospital and Skilled Nursing Facility (SNF) Patients  (Rev. 1782; Issued:  07- 30-09; Effective Date:  07 -01-09; Implementation Date:  07- 06-09)
(Medicare Claims Processing Manual)
20.2.1 - Hospital and Skilled Nursing Facility (SNF) Patients  (Rev. 1782; Issued:  07- 30-09; Effective Date:  07 -01-09; Implementation Date:  07- 06-09)  A/B MACs (B) may not pay for the technical component (TC) of radiology services furnished to hospital patients. Payment for physicians radiological services to the hospital, e.g., administrative or supervisory services, and for provider services needed to produce the radiology service, is made by the AB MAC (A) to the hospital as a provider service.   AB MACs (A) include the TC of radiology services for hospital inpatients, except Critical Access Hospitals (CAHs), in the prospective payment system (PPS) payment to hospitals.  Hospital bundling rules exclude payment to suppliers of the TC of a radiology service for beneficiaries in a hospital inpatient stay.  CWF performs reject edits to incoming claims from suppliers of radiology services.   Upon receipt of a hospital inpatient claim at the CWF, CWF searches paid claim history and compares the period between the hospital inpatient admission and discharge dates to the line item service date on a line item TC of a radiology service billed by a s upplier.  The CWF will generate an unsolicited response when the line item service date falls within the admission and discharge dates of the hospital inpatient claim.   Upon receipt of an unsolicited response, the A/B MAC (B) will adjust the TC of the radiology service and recoup the payment.   For CAHs, payment to the CAH for inpatients is made at 101 percent of reasonable cost.   Radiology and other diagnostic services furnished to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital. This applies to bill types 12X and 13X that are submitted to the AB MAC (A).  Effective 4/1/06, type of bill 14X is for non- patient laboratory specimens and is no longer applicable for radiology services.
(Medicare Claims Processing Manual)
As a result of SNF Consolidated Billing (Section 4432(b) of the Balanced Budget Act (BBA) of 1997), A/B MACs (B) may not pay for the TC of radiology services furnished to Skilled Nursing Facility (SNF) inpatients during a Part A covered stay.  The SNF must  bill radiology services furnished its inpatients in a Part A covered stay and payment is included in the SNF Prospective Payment System (PPS).   Radiology services furnished to outpatients of SNFs may be billed by the supplier performing the service or by the SNF under arrangements with the supplier.  If billed by the SNF, Medicare pays according to the Medicare Physician Fee Schedule.  SNFs submit  claims to the AB MAC (A) with type of bill 22X or 23X.  20.2.2 - Services Not Furnished in Hospitals  (Rev. 1, 10- 01-03)  A/B MACs (B) must pay under the fee schedule for the TC of radiology services furnished to beneficiaries who are not patients of any hospital, and who receive services in a physicians office, a freestanding imaging or radiation oncology center, or other s etting that is not part of a hospital.   20.2.3 - Services Furnished in Leased Departments  (Rev. 1, 10- 01-03)  In the case of procedures furnished in a leased hospital radiology department to a beneficiary who is neither an inpatient nor an outpatient of any hospital, e.g., the patient is referred by an outside physician and is not registered as a hospital outpatie nt, both the PC and the TC of the services are payable under the fee schedule by the A/B MAC (B).   20.2.4  Services That Do Not Meet the National Electrical Manufacturers Association (NEMA) Standard XR -29-2013 (Rev.  3820, Issued: 11- 21-17, Effective: 01 -01-18, Implementation; 01- 02-18)
(Medicare Claims Processing Manual)
Section 218(a) of the Protecting Access to Medicare Act of 2014 (PAMA) is titled Quality Incentives To Promote Patient Safety and Public Health in Computed Tomography Diagnostic Imaging.  It amends the Social Security Act (SSA) by reducing payment for the technical component (and the technical component of the global fee) of the Physician Fee Schedule service (5 percent in 2016 and 15 percent in 2017 and subsequent years) for computed tomography (CT) services identified by CPT codes 70450 -70498, 71250 -71275, 72125 -72133, 72191 -72194, 73200 -73206, 73700 -73706, 74150 -74178, 74261- 74263, and 75571 -75574 furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) Standard  XR-29-2013, entitled Standard Attributes on CT Equipment Related to Dose Optimization and Management.  The statutory provision requires that information be provided and attested to by a supplier and a hospital outpatient department that indicates whether an applicable CT service was furnished that was not consistent with the NEMA CT equipment standard, and that such information may be included on a claim and may be a modifier.  The statutory provision also provides that such information shall be verified, as appropriate, as part of the periodic accreditation of suppliers under SSA section 1834(e) and hospita ls under SSA section 1865(a).  Any reduced expenditures resulting from this provision are not budget neutral.  To implement this provision, CMS created modifier CT (Computed tomography services furnished using equipment that does not meet each of the att ributes of the National Electrical Manufacturers Association (NEMA) XR -29-2013 standard).  Beginning in 2016, claims for CT scans described by above -listed CPT codes (and any successor codes) that are furnished on non -NEMA Standard XR -29-2013- compliant CT scans must include modifier CT that will result in the applicable payment reduction.   A list of codes subject to the CT modifier will be maintained in the web supporting files for the annual rule.
(Medicare Claims Processing Manual)
A list of codes subject to the CT modifier will be maintained in the web supporting files for the annual rule.  Beginning January 1, 2016, a payment reduction of 5 percent applies to the technical component (and the technical component of the global fee) for Computed Tomography (CT) services furnished using equipment that is inconsistent with the CT equipment standard and for which payment is m ade under the physician fee schedule.  This payment reduction becomes 15 percent beginning January 1, 2017, and after.  20.2.5 - Special Rule to Incentivize Transition from Traditional X- Ray Imaging to Digital Radiography  (Rev. 3820, Issued: 11- 21-17, Effective: 01 -01-18, Implementation; 01- 02-18)  Section 502(a)(1) of the  Consolidated Appropriations  Act of 2016 is titled "Medicare Payment Incentive for the Transition from Traditional X -Ray Imaging to Digital Radiography and Other Medicare Imaging Payment Provision."   It amends the Social Security Act (SSA) by reducing the  payment amounts under the Physician Fee Schedule by 20 percent for the technical component (and the technical component of the global fee) of  imaging services that are X -rays taken using film, effective January 1, 2017, and after.    Modifier FX (X ray taken using film) was created to implement this provision.   Beginning January 1, 2017, claims for  X-rays using film must include modifier FX, which will result in the applicable payment reduction.   20.2.5.1 - Remittance Advice Remark Codes (RARCs), Claim Adjustment Reason Codes (CARCs), and Medicare Summary Notice (MSN)  (Rev. 3820, Issued: 11- 21-17, Effective: 01 -01-18, Implementation; 01- 02-18)  Contractors shall use the following messages when adjusting x- ray radiograph claim lines that have been reported with the FX modifier:  CARC 237  Legislated/Regulatory Penalty. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)   RARC N775 - Payment adjusted based on x -ray radiograph on film.   MSN 30.1 -  The approved amount is based on a special payment method.
(Medicare Claims Processing Manual)
RARC N775 - Payment adjusted based on x -ray radiograph on film.   MSN 30.1 -  The approved amount is based on a special payment method.   20.2.6 - Special Rule to Incentivize Transition from X-rays taken using Computed Radiography to Digital Radiography (Rev.  3820, Issued: 11- 21-17, Effective: 01 -01-18, Implementation; 01- 02-18)  1848 (b)(9) of the Social Security Act provides that payments for imaging services that are X -rays taken using computed radiography (including the X -ray component of a packaged service) furnished during CY 2018, 2019, 2020, 2021, or 2022, that would  other wise be made under the PFS (without application of subparagraph (B)(i)  and before application of any other adjustment), be reduced by 7 percent, and similarly, if such X -ray services are furnished during CY 2023 or a subsequent year, by 10 percent.   Computed radiography technology is defined for purposes of this paragraph as cassette -based imaging which utilizes an imaging plate to create the image involved.   Modifier FY was created to implement this provision.   Beginning January 1, 2018, claims for  computed radiography must include modifier FY, which will result in the applicable payment reduction.   20.3  Anti -Markup Payment Limitation  (Rev. 1931, Issued: 03- 12-10, Effective: 06 -14-10, Implementation: 06- 14-10)
(Medicare Claims Processing Manual)
20.3  Anti -Markup Payment Limitation  (Rev. 1931, Issued: 03- 12-10, Effective: 06 -14-10, Implementation: 06- 14-10)  Section 1842(n) (1) of the Social Security Act (the Act) establishes payment rules for certain diagnostic tests (other than clinical diagnostic laboratory tests) where the physician performing or supervising the test does not share a practice with the billing physician or  other supplier.  Examples of tests covered under this rule include, but are not limited to: x- rays, EKGs, EEGs, cardiac monitoring, and ultrasound services furnished on or after January 1, 1994.  (Note that screening mammography services are covered under  another provision of the Act and are not subject to the anti -markup payment limitation.)  The anti -markup payment limitation applies to the technical component or TC of certain diagnostic tests that are payable on the Medicare Physician Fee Schedule (MP FS).  Effective January 1, 2009, the anti -markup payment limitation also applies to the professional component or (PC) of diagnostic tests (other than clinical diagnostic tests). The anti- markup payment limitation only applies when a physician (or other supplier) orders and bills for a diagnostic test in which the TC or PC is performed by a physician who does not share a practice with the ordering/billing physician (or other supplier).  For more information on the anti -markup payment limitation, see cha pter 1, 30.2.9.  20.3.1  A/B MAC (B) Payment Rules (Rev. 1931, Issued: 03- 12-10, Effective: 06 -14-10, Implementation: 06- 14-10)  If a diagnostic test (other than a clinical diagnostic laboratory test) is personally performed or is supervised by a physician, such physician may bill under the normal physician fee schedule rules.  This includes situations in which the test is performed or supervised by another physician with whom the billing physician shares a practice (see Pub. 100- 04, chapter 1, 30.2.9).  Section 80, chapter 15, of Pub. 100-02, Medicare Benefit Policy, sets forth the various levels of physician supervision required f or diagnostic tests.  The supervision requirement for physician billing is not  met when the test is administered by supplier personnel regardless of whether the test is performed at the physician's office or at another location.
(Medicare Claims Processing Manual)
If a physician bills for a diagnostic test that is subject to the anti- markup payment limitation, the fee schedule amount for the acquired service equals the lower of:    The performing physician or other suppliers net charge to the billing physician or other supplier for performing the service;    The billing physician or other suppliers actual charge; or    The fee schedule amount allowed for the jurisdiction where the service was performed.   The lowest figure is the fee schedule amount for purposes of the limiting charge.  (See chapter 1, 30.3.12.1 of this publication)  The billing entity must identify the performing physician or other supplier (including the performing providers NPI) and the amount the performing physician or other supplier charged the billing entity (net of any discounts).  A physician who accepts assignment is permitted to bill and collect from the beneficiary only the applicable deductible and coinsurance for the acquired  test.  A physician who does not accept assignment is permitted to bill and collect from the beneficiary only the fee schedule amount (as defined above) for the acquired test.  The limiting charge provision is not applicable.  If the physician does not identify who performed the test and provide the other required information, no payment is allowed.  The physician may not bill the beneficiary any amount for the test.   20.3.2 - Billing for Services  (Rev. 1931, Issued: 03- 12-10, Effective: 06 -14-10, Implementation: 06- 14-10)
(Medicare Claims Processing Manual)
20.3.2 - Billing for Services  (Rev. 1931, Issued: 03- 12-10, Effective: 06 -14-10, Implementation: 06- 14-10)  A physician or other supplier may bill and receive Part B payment for the technical component (TC) or professional component (PC) of diagnostic tests which the physician or other supplier contracts a physician, medical group, or other supplier to perform.  (This claim and payment procedure does not extend to clinical diagnostic laboratory tests.)  The anti -markup rule will apply to the TC or PC of diagnostic tests that have been ordered by the billing physician or other supplier (or by a party financially r elated to the billing physician or other supplier through common ownership or control) if the performing physician or other supplier does not meet the criteria for sharing a practice with the ordering/billing entity.  An example is when the attending physician orders radiology tests from a radiologist and the radiologist purchases the tests from an imaging center with whom the radiologist does not meet the criteria for sharing a practice.  Under the anti -markup payment limitation, the billing physician or other supplier may not mark up the charge for a test from the acquisition price and must accept as full payment for the test (even if assignment is not accepted) the lowest of: the fee schedule amount as if the performing physician or other supplier had billed directly, the billing entitys actual charge, or the performing physician or other suppliers net charge to the billing entity. The billing physician or other supplier must be financially related to the physician or group that ordered the tests through common ownership or control.  If the performing physician or other supplier meets the criteria for sharing a practice with the billing physician or other supplier, then the anti -markup payment limitation will not apply and the lower of the physician fee schedule amount or the billed amount will be paid.  The physician or other supplier that performed the component that is subject to the anti -markup rule must be enrolled in the Medicare program.  No formal reassignment is necessary; however, reassigned services are also subject to the anti -markup payment li mitation.   A.  Radiology Services   Contractors shall apply the anti -markup payment limitation to the TC and PC of radiology diagnostic testing services other than screening mammography procedures.  See Publication 100- 04, chapter 1, 30.2.9 for more information on the anti -markup payment limitation.
(Medicare Claims Processing Manual)
B.  Payment to a Physician or Other  Supplier of Diagnostic Tests for Services Subject to the Anti -Markup Payment Limitation   A physician or other supplier that provides diagnostic tests may bill and receive the Part B payment for the TC or PC of diagnostic tests which that physician or other supplier acquires from another physician, medical group, or other supplier.  If the perf orming physician does not meet the requirements for sharing a practice with the ordering/billing physician or other supplier, then the anti -markup payment limitation rules will apply. (See section 30.2.9 of this chapter for more information.)  If the performing physician is deemed to share a practice with the physician or other supplier that ordered the test, then the physician fee schedule amount may be billed and the anti -markup payment limitation will not apply.  In either case, the performing physician or other supplier must be enrolled in the Medicare program.  No formal reassignment is necessary; however, the anti -markup payment limitation will apply to reassigned services.   If the anti -markup rules apply, payment may not exceed the lowest of the following amounts:    The performing physician or other suppliers net charge to the billing physician or other supplier;*   The billing physician or other suppliers actual charges; or    The fee schedule amount allowed for the test if the performing physician or other supplier billed directly.   *The net charge must be determined without regard to any charge that is intended to reflect the cost of equipment or space leased to the performing physician or supplier by or through the billing entity.  For more information, see Pub. 100- 04, chapter 1, 30.2.9.  The billing physician or other supplier must keep on file the name, address, and NPI of the physician or other supplier who performed the anti -markup service.   C.  Sanctions   Physicians who knowingly and willfully, in repeated cases, bill Medicare beneficiaries amounts beyond those outlined in this chapter are subject to the penalties contained under 1842(j)(2)  of the Act.  Penalties are assigned after post -pay review depending on the severity.   D.  Questionable Business Arrangements
(Medicare Claims Processing Manual)
D.  Questionable Business Arrangements   No special charge or payment constraints are imposed on tests performed by a physician or a technician under the physicians supervision.  There are two requirements for all diagnostic tests under 1861(s)(3) of the Act, as implemented by 42 CFR 410.32 and section 10 of chapter13 of this publication and section 80, chapter 15 of Pub. 100- 02BP.  Namely, the test must be ordered by the treating practitioner, and the test must be supervised by a physician.  However, attempts may be made by the medical diagnos tic community to adjust or establish arrangements which continue to allow physicians to profit from other's work or by creating the appearance that the physician has performed or supervised his/her technicians who are employed, contracted, or leased.  Some  of these arrangements may involve cardiac scanning services and mobile ultrasound companies leasing their equipment to physicians for the day the equipment is used, and hiring out their staff to the physicians to meet the supervision requirement.  The bona fides of such arrangements may be suspect and could be an attempt to circumvent the anti -markup payment limitation.  If you have any doubt that a particular arrangement is a valid relationship where the physician is performing or supervising the s ervices, this should be investigated.  The Office of the Inspector General (OIG) has responsibility for investigating violations of 1842(n)  of the Act.   Another arrangement to circumvent the anti -markup payment limitation is for the ordering physician to reassign his/her payment for the interpretation of the test to the supplier.  The supplier, in turn, bills for both the test and the interpretation and pa ys the ordering physician a fee for the interpretation.  This arrangement violates 1842(b)(6) of the Act, which prohibits Medicare from paying benefits due the person that furnished the service to any other person, subject to limited exceptions discussed in Pub. 100-04, chapter 1, 30.2.2.  Also, this arrangement could constitute a violation of 1128 B (b) of the Act, which prohibits remuneration for referrals (i.e., kickbacks).