evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
80.4  RHC Productivity Standards  (Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Productivity standards are used to help determine the average cost per patient for Medicare reimbursement in RHCs.  The current productivity standards require 4,200 visits per full- time equivalent physician and 2,100 visits per full-time equivalent non- physician practitioner (NP, PA, or CNM).  Physician and non-physician practitioner productivity may be combined.  The FTE on the cost report for providers is the time spent seeing patients or scheduled to see patients and does not inc lude administrative time.  The A/B MAC has the discretion to make an exception to the productivity standards based on individual circumstances.  All visits (Medicare, Medicaid, Managed Care, etc.) are included in determining the productivity standards for the cost report. At the end of the cost reporting year, the A/B MAC re- calculates the AIR by dividing the total allowable costs across all patient types (i.e., the numerator) by the number of visits (as defined in section 40) for all patient types (i.e., the denominator).  If fewer than expected visits based on the productivity standards have been furnished, the A/B MAC substitutes the expected number of visits for the denominator and uses that instead of the actual number of visits.  The total allowable cos ts (numerator) would be divided by the higher, expected number of visits (denominator).  In this example, this would have the effect of lowering the AIR. Physician services that are provided on a short term or irregular basis under agreements are not subject to the productivity standards.  Instead of the productivity limitation, purchased physician services are subject to a limitation on what Medicare would otherwise pay for the services under the Physician Fee Schedule (PFS), in accordance with 42 CFR 405.2468(d)(2)(v) .  Practitioners working on a regular, ongoing basis are subject to the productivity standards, regardless of whether they are paid as an employee or independent contractor.  FQHCs are not subject to the productivity standards.
(Medicare Benefit Policy Manual)
90 - RHC and FQHC Charges, Coinsurance, Deductible, and Waivers  (Rev. 252, Issued: 12-07-18, Effective: 01-01-19, Implem entation: 01 - 02-19) Except for certain preventive services for which the coinsurance is statutorily waived, the beneficiary in an RHC must pay the deductible and coinsurance amount, and the beneficiary in an FQHC must pay the coinsurance amount (there is no Part B deductible in FQHCs for FQHC -covered services).  For RHCs, the coinsurance is 20 percent of the total charges.  For FQHCs, the coinsurance is 20 percent of the lesser of the FQHCs charge for the specific payment code or the PPS rate.  For claims  with a mix of waived and non- waived services, applicable coinsurance and deductibles are assessed only on the non-waived services.  For both RHCs and FQHCs, coinsurance for care management and virtual communication services is 20 percent of the lesser of submitted charges or the payment rate.   90.1 - Charges and Waivers  (Rev. 220, Issued: 01-15-16, Effective: 02-01-16, Implementation: 02-01-16)   Charges for services furnished to Medicare beneficiaries must be the same as the charges for non-Medicare beneficiaries.  FQHCs may waive collection of all or part of the copayment, depending on the beneficiarys ability to pay.  RHCs may waive the copayment and deductible after a good faith determination has been made that the patient is in financial need, provided the waivers are not routine and not advertised.  (See 42 U.S.C. 1320a- 7a(6)(A))
(Medicare Benefit Policy Manual)
90.2 - Sliding Fee Scale  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  RHCs may establish a sliding fee scale if it is uniformly applied to all patients.  An RHC that chooses to offer a sliding fee scale must post the policy so that all patients are aware of the policy.  If the payment policy is based on an individuals income, the RHC must document that income information from the patient was obtained in order to determine that the patient qualified.  Copies of their wage statement or income tax return are not required, and self -attestations are acceptable.  FQHCs that are approved by HRSA are required to establish a sliding fee scale in accordance with statutory and HRSA requirements.   100  Commingling  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Commingling refers to the sharing of RHC or FQHC space, staff (employed or contracted), supplies, equipment, and/or other resources with an onsite Medicare Part B or Medi caid fee-for-service practice operated by the same RHC or FQHC physician(s) and/or non- physician(s) practitioners.  Commingling is prohibited in order to prevent:    Duplicate Medicare or Medicaid reimbursement (including situations where the RHC or FQHC is  unable to distinguish its actual costs from those that are reimbursed on a fee-for-service basis), or    Selectively choosing a higher or lower reimbursement rate for the services.
(Medicare Benefit Policy Manual)
 Selectively choosing a higher or lower reimbursement rate for the services.  RHC and FQHC practitioners may not furnish or separately bill for RHC or F QHC -covered professional services as a Part B provider in the RHC or FQHC, or in an area outside of the certified RHC or FQHC space such as a treatment room adjacent to the RHC or FQHC, during RHC or FQHC hours of operation.  If an RHC or FQHC practitioner furnishes an RHC or FQHC service at the RHC or FQHC during RHC or FQHC hours, the service must be billed as an RHC or FQHC service.  The service cannot be carved out of the cost report and billed to Part B. If an RHC or FQHC is located in the same building  with another entity such as an unaffiliated medical practice, x -ray and lab facility, dental clinic, emergency room, etc., the RHC or FQHC space must be clearly defined.  If the RHC or FQHC leases space to another entity, all costs associated with the lea sed space must be carved out of the cost report.
(Medicare Benefit Policy Manual)
RHCs and FQHCs that share resources (e.g., waiting room, telephones, receptionist, etc.) with another entity must maintain accurate records to assure that all costs claimed for Medicare reimbursement are on ly for the RHC or FQHC staff, space, or other resources.  Any shared staff, space, or other resources must be allocated appropriately between RHC or FQHC and non-RHC or non- FQHC usage to avoid duplicate reimbursement.  This commingling policy does not prohi bit a provider -based RHC from sharing its health care practitioners with the hospital emergency department in an emergency, or prohibit an RHC practitioner from providing on- call services for an emergency room, as long as the RHC would continue to meet the  RHC conditions for coverage even if the practitioner were absent from the facility.  The RHC must be able to allocate appropriately the practitioner's salary between RHC and non- RHC time.  It is expected that the sharing of the practitioner with the hospital emergency department would not be a common occurrence.  The A/B MAC has the authority to determine acceptable accounting methods for allocation of costs between the RHC or FQHC and another entity.  In some situations, the practitioners employment agree ment will provide a useful tool to help determine appropriate accounting.
(Medicare Benefit Policy Manual)
110 - Physician Services (Rev. 252, Issued: 12- 07-18, Effective: 01- 01-19, Implementation: 01-  02-19) The term physician includes a doctor of medicine, osteopathy, dental surgery, dental medicine, podiatry, optometry, or chiropractic who is licensed and practicing within the licensees scope of practice, and meets other requirements as specified.   Physi cian services are professional services furnished by a physician to an RHC or FQHC patient and include diagnosis, therapy, surgery, and consultation.  The physician must either examine the patient in person or be able to visualize directly some aspect of t he 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 c onstitute 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).
(Medicare Benefit Policy Manual)
110.1 - Dental, Podiatry, Optometry, and Chiropractic Services  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Dentists, podiatrists, optometrists, and chiropractors are defined as physicians in Medicare  statute, and qualified services furnished by physicians are billable visits in an RHC or FQHC.  These practitioners can provide RHC or FQHC services that are within their scope of practice and not excluded from coverage (e.g., Medicare coverage of chiropr actic services is limited to manual manipulation of the spine for a demonstrated subluxation).  An RHC or FQHC can bill for a face -to-face, medically necessary visit furnished by a dentist, podiatrist, optometrist, or chiropractor if the service furnished i s a qualifying visit for RHCs or FQHCs and all other requirements are met.  All services furnished must be within the state scope of practice for the practitioner, and all HCPCS codes must reflect the actual services that were furnished.  RHCs and FQHCs are  required to primarily provide primary health care.  Since dentists, podiatrists, optometrists, and chiropractors are not considered primary care physicians, they do not meet the requirements to be either i) a physician medical director or ii) the physicia n or non-physician  practitioner (NP, PA, or CNM) that must be available at all times the clinic is open.  Therefore, a dentist, podiatrist, optometrist, or chiropractor can provide a medically necessary, face- to-face visit with an RHC or FQHC patient only when the statutory and regulatory staffing requirements are otherwise met.  For additional information on these services, see Pub. 100-02, Medicare Benefit Policy Manual, chapter 15 on Covered Medical and Other Health Service at http://www.cms.gov/Regulations -and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf .
(Medicare Benefit Policy Manual)
110.2 - Treatment Plans or Home Care Plans  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Except for comprehensive care plans that are a component of authorized care management services (see section 230), treatment plans and home care oversight provided by RHC or FQHC physicians to RHC or FQHC patients are considered part of the RHC or FQHC visit and are not a separately billable service.   110.3 - Graduate Medical Education  (Rev. 263, Issued: Effective: 01-01-20, Implementation: 01-23-20)  Freestanding RHCs and FQHCs may receive direct graduate medical education (GME) payment for residents if the RHC or FQHC incurs the salaries and fringe benefits (including travel and lodging expenses where applicable) of residents training at the RHC or FQHC.  Allowable costs incurred by the RHC or FQHC for GME are paid on a reasonabl e cost basis and are not subject to the payment limit.  RHCs and FQHCs may claim allowable costs only while residents are on their RHC or FQHC rotation.  RHCs and FQHCs that are receiving GME payment may not separately bill for an RHC or FQHC visit provided by a resident, as the cost of these practitioners is included in the GME payment.  A medically -necessary medical, or a qualifying preventive health, face -to-face encounter with a teaching physician who is an RHC or FQHC practitioner may be a billable visit if applicable teaching physician supervision and documentation requirements are met.    Under Pub. 100-04, Chapter 12, section 100.1.1.C., the Primary Care Exception (PCE) only applies in an outpatient department or an ambulatory setting where a hospita l is claiming on the cost report the residents for indirect medical education and direct GME purposes.  Therefore, in the instance where the RHC or FQHC is incurring the cost of the resident(s), the PCE would not apply.  For additional information see 42 CFR 405.2468 (f)  and 42 CFR 413.75(b).
(Medicare Benefit Policy Manual)
120 - Services and Supplies Furnished Incident to Physicians Services  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Incident to refers to s ervices and supplies that are an integral, though incidental, part of the physicians professional service and are:   Commonly rendered without charge and included in the RHC or FQHC payment;     Commonly furnished in an outpatient clinic setting;    Furnished under the physicians direct supervision; except for authorized care management services which may be furnished under general supervision; and   Furnished by RHC or FQHC auxiliary personnel.   Incident to services and supplies include:    Drugs and biologicals  that are not usually self -administered, and Medicare -covered preventive injectable drugs (e.g., influenza, pneumococcal);    Venipuncture;    Bandages, gauze, oxygen, and other supplies; or    Services furnished by auxiliary personnel such as a nurse, medical a ssistant, or other clinical personnel acting under the supervision of the physician.  Supplies and drugs that must be billed to the DME MAC or to Part D are not included. NOTE:   Payment for Medicare -covered Part B drugs that are not usually self -administered and are furnished by an RHC or FQHC practitioner to a Medicare patient are included in the RHC AIR or the FQHCs PPS per diem payment.  However, Section 1861(s)(2)(G) of the  Act provides an exception for RHCs when a physician prepares a specific formulation of an antigen for a patient if the antigen is forwarded to another qualified person (including a rural health clinic) for administration to such patient, by or under the  supervision of another such physician.  An RHC practitioner (physician, NP, PA, or CNM) acting within their scope of practice may administer the drug and the cost of the administration may be included on the RHC's cost report as an allowable expense.  Th e cost of the antigen prepared by a physician outside of the RHC is not included in the RHC AIR.  Physicians who prepare an antigen that is forwarded to an RHC should submit a claim for the antigen in accordance with instructions from the contractor that p rocesses their Part B claims and applicable CMS requirements.
(Medicare Benefit Policy Manual)
120.1 - Provision of Incident to Services and Supplies  (Rev. 263, Issued: Effective: 01- 01-20, Implementation: 01- 23-20)  Incident to services and supplies can be furnished by auxiliary personnel.  All services and supplies provided incident to a physicians visit must result from the patients encounter with the physician and be furnished in a medically appropriate timeframe.  More than one incident to service or supply can be provided as a res ult of a single physician visit.    Incident to services and supplies must be provided by someone who has an employment agreement or a direct contract with the RHC or FQHC to provide services.  Services or supplies provided by individuals who are not emplo yed by or under direct contract with the RHC or FQHC, even if provided on the physicians order or included in the RHC or FQHCs bill, are not covered as incident to a physicians service.  Services that are not considered incident to include the services of an independently practicing therapist who forwards his/her bill to the RHC or FQHC for inclusion in the entitys statement of services, services provided by an independent laboratory or a hospital outpatient department, services furnished by a nurse, medical assistant, or other auxiliary personnel who is not an employee of or working under contract to the RHC or FQHC, including services provided by a third party under contract, etc.    Services and supplies furnished incident to physicians services are limited to situations in which there is direct physician supervision of the person performing the service, except for authorized care management services (as described in section 230) which may be furnished under general supervision.  Direct supervision does not require the physician to be present in the same room.  However, the physician must be in the RHC or FQHC and immediately available to provide assistance and direction throughout the time the incident to service or supply is being furnished.    When services and supplies are furnished incident to an RHC or FQHC visit, payment for the services are included in the RHC AIR or the FQHC PPS rate.  An encounter that includes only an incident to service(s) is not a stand- alone billable visit for RHCs or FQHC s.
(Medicare Benefit Policy Manual)
120.2 - Incident to Services and Supplies Furnished in the Patients Home or Location Other than the RHC or FQHC  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Except for authorized care management services, services furnished incident to a physicians visit by RHC or FQHC auxiliary personnel in the patients home or location other than the RHC or FQHC must have direct supervision by the physician.  For example, if an RHC or FQHC nurse accompanies the physician to a pa tients home and administers an injection, the nurses services would be considered incident to the physicians visit.  If the same nurse makes the call alone and administers an injection, the services are not incident to services since the physician is not providing direct supervision.  The availability of the physician by telephone and the presence of the physician somewhere in the building does not constitute direct supervision.  (This rule applies only to the incident to provision.  It does not apply to visiting nursing services described in section 190.)  For additional information on supervision requirements for Part B services incident to physician services see Pub. 100 -02, Medicare Benefit Policy Manual, chapter 15, section 60.1. 120.3 - Payment for Incident to Services and Supplies  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Services that are covered by Medicare but do not meet the requirements for a medically necessary or qualified preventive health visit with an RHC or  FQHC practitioner (e.g., blood pressure checks, allergy injections, prescriptions, nursing services, etc.) are considered incident to services.  The cost of providing these services may be included on the cost report, but the provision of these services does not generate a billable visit.  Incident to services provided on a different day as the billable visit may be included in the charges for the visit if furnished in a medically appropriate timeframe.  Incidental services or supplies must represent an exp ense incurred by the RHC or FQHC.  For example, if a patient purchases a drug and the physician administers it, the cost of the drug is not covered and cannot be included on the cost report. If a Medicare- covered Part B drug is furnished by an RHC or FQHC
(Medicare Benefit Policy Manual)
example, if a patient purchases a drug and the physician administers it, the cost of the drug is not covered and cannot be included on the cost report. If a Medicare- covered Part B drug is furnished by an RHC or FQHC practitioner to a Medicare patient as part of a billable visit, the cost of the drug and its administration is included in the RHCs AIR or the FQHCs PPS payment.  RHCs and FQHCs cannot bill separately for Part B drugs or other incident to services or supplies.
(Medicare Benefit Policy Manual)
130 - Nurse Practitioner, Physician Assistant, and Certified Nurse Midwife Services  (Rev. 252, Issued: 12-  07-18, Effective: 01- 01-19, Implementation: 01-  02-19)  Professional services furnished by an NP, PA, or CNM to an RHC or FQHC patient are services that would be considered covered physician services under Medicare (see section 110), and which are permitted by state laws and RHC or FQHC policies.  Services may include diagnosis, treatment, and consultation.  The NP, PA, or CNM must directly exa mine the patient, or directly review the patients medical information such as X -rays, EKGs and electroencephalograms, tissue samples, etc.  Except for services that meet the criteria for authorized care management or virtual communication services, telephone or electronic communication between an NP, PA, or CNM and a patient, or between such practitioner and someone on behalf of a patient, are considered NP, PA, or CNM services, and are included in an otherwise billable visit.  They do not constitute a separately billable visit.   130.1 - NP, PA, and CNM Requirements  (Rev. 220, Issued: 01- 15-16, Effective: 02- 01-16, Implementation: 02- 01-16)  Services performed by NPs, PAs, and CNMs must be:    Furnished under the general (or direct, if required by state law) medical supervision of a physician;    Furnished in accordance with RHC or FQHC policies and any physician medical orders for the care and treatment of a patient;    A type of service which the NP, PA, or CNM who furnished the service is legally permitted to f urnish by the state in which the service is rendered;    Furnished in accordance with state restrictions as to setting and supervision;    Furnished in accordance with written RHC or FQHC policies that specify what services these practitioners may furnish to patients; and    A type of service which would be covered under Medicare if furnished by a physician.   130.2 - Physician Supervision  (Rev . 220, Issued: 01- 15-16, Effective: 02- 01-16, Implementation: 02- 01-16)
(Medicare Benefit Policy Manual)
130.2 - Physician Supervision  (Rev . 220, Issued: 01- 15-16, Effective: 02- 01-16, Implementation: 02- 01-16)  RHCs and FQHCs which are not physician -directed must have an arrangement with a physician that provides for the supervision and guidance of NPs, PAs, and CNMs.  The arrangement must b e consistent with state law.    130.3 - Payment to Physician Assistants  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Section 1842(b)(6)(C) of the Act prohibits PAs from enrolling in and being paid directly for Part B services.  The only exception to this is found in Section 4205(d)(3)(B) of the Balanced Budget Act (BBA), which amended Section 1842(b)(6)(C) of the Act to allow Medicare to directly pay a PA when the PA was the owner of an RHC for a continuous period beginning befor e the date of the enactment of the BBA, and ending on the date the Secretary determines the RHC no longer meets the requirements of Section 1861(aa)(2) of the Act.  140 - Services and Supplies Furnished Incident to NP, PA, and CNM Services  (Rev. 239, Issue d: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Services and supplies that are integral, though incident to an NP, PA, or CNM service are:   Commonly rendered without charge or included in the RHC or FQHC payment    Commonly furnished in an outpatient clinic setting;    Furnished under the direct supervision of an NP, PA, or CNM, except for authorized care management services which may be furnished under general supervision; and