evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
(1) More Than Half of the Total Time   Beginning January 1, 2024, substantive portion means more than half of the total time spent by the physician and NPP performing the split (or shared) visit.   During the transitional year from January 1, 2023 through December 31, 2023, except for critical care visits, the substantive portion can be one of the three key E/M visit components (a medically appropriate history or exam, or medical decision- making (MDM )), or more than half of the total time spent by the physician and NPP performing the split (or shared) visit.  In other words, for calendar year 2023, the practitioner who spends more than half of the total time, or performs the medically appropriate hist ory or exam described in the code descriptor, or MDM can be considered to have performed the substantive portion and can bill for the split (or shared) E/M visit.  When one of the three key components is used as the substantive portion in 2023, the practit ioner who bills the visit must perform that component in its entirety in order to bill.  For example, if history is used as the substantive portion, the billing practitioner must perform the history as described in the code descriptor in order to bill.  If  physical exam is used as the substantive portion, the billing practitioner must perform the exam as described in the code descriptor in order to bill.  If MDM is used as the substantive portion, each practitioner could perform certain aspects of MDM, but the billing practitioner must perform all portions or aspects of MDM that are required to select the visit level billed.   For critical care visits, starting for services furnished in CY 2022, the substantive portion will be more than half of the total time.  A unique listing of qualifying activities for purposes of determining the substantive portion of critical care visits a pplies (see below).   We summarize these policies in the following table.   Definition of Substantive Portion for E/M Visit Code Families
(Medicare Claims Processing Manual)
Definition of Substantive Portion for E/M Visit Code Families   E/M Visit Code Family  2022 -2023 Definition of Substantive Portion  2024 Definition of Substantive Portion  Other Outpatient*  History, or exam, or MDM, or more than half of total time  More than half of total time  Inpatient/Observation/Hospital/SNF*  History, or exam, or MDM, or more than half of total time  More than half of total time  Emergency Department  History, or exam, or MDM, or more than half of total time  More than half of total time  Critical Care  More than half of total time  More than half of total time  Acronyms: E/M (Evaluation and Management), MDM (medical decision- making), SNF (Skilled Nursing Facility)  *Office visits and Nursing Facility visits are not billable as split (or shared) services.   (2) Distinct Time   In accordance with the CPT E/M Guidelines, only distinct time can be counted.  When the practitioners jointly meet with or discuss the patient, only the time of one of the practitioners can be counted.   Example: I f the NPP first spent 10 minutes with the patient and the physician then spent another 15 minutes, their individual time spent would be summed to equal a total of 25 minutes. The physician would bill for this visit, since they spent more than half of the t otal time (15 of 25 total minutes).  If, in the same situation, the physician and NPP met together for five additional minutes (beyond the 25 minutes) to discuss the patients treatment plan, that overlapping time could only be counted once for purposes of  establishing total time and who provided the substantive portion of the visit.  The total time would be 30 minutes, and the physician would bill for the visit, since they spent more than half of the total time (20 of 30 total minutes).    (3) Qualifying Time   Drawing on the  CPT E/M Guidelines, except for critical care visits, the following listing of activities can be counted toward total time for purposes of determining the substantive portion, when performed and whether or not the activities involve direct patient contact:
(Medicare Claims Processing Manual)
C. New and Established Patients, and Initial and Subsequent Visits   Split (or shared) visits may be billed for new and established patients , as well as for initial and subsequent visits, that otherwise meet the requirements for split (or shared) visit payment.  D. Settings of Care   Split (or shared) visits are furnished only in the facility setting, meaning institutional settings in which payment for services and supplies furnished incident to a physician or practitioners professional services is prohibited under our regulations at 42 CFR  410.26.    Accordingly, split (or shared) visits are billable for E/M visits furnished in hospital and skilled nursing facility (SNF) settings. Visits in these settings that are required by our regulations to be performed in their entirety by a physician are not bill able as split (or shared) services. For example, our Conditions of Participation require certain SNF visits to be performed directly and solely by a physician; accordingly, those SNF visits cannot be billed as a split (or shared) visit (see Section 30.6.13).   E.  Medical Record Documentation   Documentation in the medical record must identify the physician and NPP who performed the visit.  The individual who performed the substantive portion of the visit (and therefore bills for the visit) must sign and date the medical record.   F. Claim Identification   Modifier - FS (Split or Shared E/M Visit) must be reported on claims for split (or shared) visits, to identify that the service was a split (or shared) visit.    The modifier identified by CPT for purposes of reporting partial services (modifier - 52 (reduced services)) cannot be used to report partial E/M visits, including any partial services furnished as split (or shared) visits. Medicare does not pay for partial  E/M visits.     30.6.19  Office/Outpatient Evaluation and Management  (O/O E/M) Complexity Add- on Paymen t (Code G2211)  (Rev. 12370; Issued: 11- 21-23; Effective: 01 -01-24; Implementation: 01 -02-24)
(Medicare Claims Processing Manual)
40 - Surgeons and Global Surgery  (Rev. 1, 10- 01-03) B3-4820  A national definition of a global surgical package has been established to ensure that payment is made consistently for the same services across all A/B MAC (B) jurisdictions, thus preventing Medicare payments for services that are more or less comprehensive than intended.  The national global surgery policy became effective for surgeries performed on and after January 1, 1992.  The instructions that follow describe the components of a global surgical package and payment rules for minor surgeries, endoscopies and global surgical packages that are split between two or more physicians.  In addition, billing, mandatory edits, claims review, adjudication, and postpayment instructions are included.  In addition to the global policy, uniform payment policies and claims processing requirements have been established for other surgical issues, including bilateral and multiple surgeries, co-surgeons, and team surgeries. 40.1 - Definition of a Global Surgical Package  (Rev . 11287; Issued:03- 02-22; Effective:01 -01-22; Implementation: 02 -22-22)  B3-4821, B3- 15900.2  Field 16 of the Medicare Fee Schedule Data Base (MFSDB) provides the postoperative periods that apply to each surgical procedure.  The payment rules for surgical procedures apply to codes with entries of 000, 010, 090, and, sometimes, YYY.  Codes with 090 in Field 16 are major surgeries.  Codes with 000 or 010 are either minor surgical procedures or endoscopies. Codes with YYY are A/B MAC (B) -priced codes, for which A/B MACs (B) determine the global period (the global period for these codes will be 0, 10, or 90 days).  Note that not all A/B MAC (B) -priced codes have a YYY global surgical indicator; sometimes t he global period is specified.  While codes with ZZZ are surgical codes, they are add -on codes that are always billed with another service.  There is no postoperative work included in the fee schedule payment for the ZZZ codes.  Payment is made for both the primary and the add- on cod es, and the global period assigned is applied to the primary code.
(Medicare Claims Processing Manual)
B. Services Not Included in the Global Surgical Package  A/B MACs (B) do not include the services listed below in the payment amount for a procedure with the appropriate indicator in Field 16 of the MFSDB.  These services may be paid for separately.   The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery.  Please note that this policy only applies to major surgical procedures.  The initial evaluation is always included in the allowance for a minor surgical procedure;   Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care.  This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;   Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;   Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery;   Diagnostic tests and procedures, including diagnostic radiological procedures;   Clearly distinct surgical procedures during the postoperative period which are not re -operations or treatment for complications.  (A new postoperative period begins with the subsequent procedure.)  This includes procedures done in two or more parts for whi ch the decision to stage the procedure is made prospectively or at the time of the first procedure.  Examples of this are procedures to diagnose and treat epilepsy (codes 61533, 61534- 61536, 61539, 61541, and 61543) which may be performed in succession within  90 days of each other;   Treatment for postoperative complications which requires a return trip to the operating room (OR).  An OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures.  The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite.  It does not include a patients room, a minor treatment room, a recovery room, or an intensive care unit (unless the patients condition was so critical there would be insufficient time for transportation to an OR);   If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately;   For certain services performed in a physicians office, separate payment can no longer be made for a surgical tray (code A4550).  This code
(Medicare Claims Processing Manual)
fails, and a more extensive procedure is required, the second procedure is payable separately;   For certain services performed in a physicians office, separate payment can no longer be made for a surgical tray (code A4550).  This code is now a Status B and is no longer a separately payable service on or after January 1, 2002.  However, splints and c asting supplies are payable separately under the reasonable charge payment methodology;   Immunosuppressive therapy for organ transplants; and  Critical care services (CPT codes 99291 and 99292) unrelated to the surgery, for example, where a seriously injured or burned patient is critically ill and requires constant attendance of the physician. See section 30.6.12.7 of this chapter for further discussion of critical care visits unrelated to the procedure with a global surgical period.
(Medicare Claims Processing Manual)
C. Minor Surgeries and Endoscopies   Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.  For example, a visit on the same day could be properly bil led in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma.  Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status.  A postoperative period of 10 days applies to some minor surgeries.  The postoperative period for these procedures is indicated in Field 16 of the MFSDB.  If the Field 16 entry is 010, A/B MACs (B) do not allow separate payment for postoperative visits or s ervices within 10 days of the surgery that are related to recovery from the procedure.  If a diagnostic biopsy with a 10-day global period precedes a major surgery on the same day or in the 10- day period, the major surgery is payable separately.  Services by other physicians are not included in the global fee for a minor procedures except as otherwise excluded.  If the Field 16 entry is 000, postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery.  Separat e payment is made in this instance.  See section 30.6.12.7 of this chapter for further discussion of critical care visits unrelated to the procedure with a global surgical period.   D. Physicians Furnishing Less Than the Full Global Package  B3-4820- 4831  There are occasions when more than one physician provides services included in the global surgical package.  It may be the case that the physician who performs the surgical procedure does not furnish the follow -up care.  Payment for the postoperative, post -discharge care is split between two or more physicians where the physicians agree on the transfer of care.
(Medicare Claims Processing Manual)
2. Physicians in Group Practice   When different physicians in a group practice participate in the care of the patient, the group bills for the entire global package if the physicians reassign benefits to the group.  The physician who performs the surgery is shown as the performing physici an.  (For dates of service prior to January 1, 1994, however, where a new physician furnishes the entire postoperative care, the group billed for the surgical care and the postoperative care as separate line items with the appropriate modifiers.)   3. Physicians Who Furnish Part of a Global Surgical Package   Where physicians agree on the transfer of care during the global period, the following modifiers are used:   -54 for surgical care only; or   -55 for postoperative management only.   Both the bill for the surgical care only and the bill for the postoperative care only, will contain the same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier.   Providers need not specify on the claim that care has been transferred.  However, the date on which care was relinquished or assumed, as applicable, must be shown on the claim.  This should be indicated in the remarks field/free text segment on the claim form/format.  Both the surgeon and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiarys medical record.   Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service.  Once the physician has seen the patient, that physician may bill for the period beginning with the date on which he/she assumes care of the patient.   EXCEPTIONS:    Where a transfer of care does not occur, occasional post -discharge services of a physician other than the surgeon are reported by the appropriate evaluation and management code.  No modifiers are necessary on the claim.    If the transfer of care occurs immediately after surgery, the physician other than the surgeon who provides the in- hospital postoperative care bills using subsequent hospital care codes for the inpatient hospital care and the surgical code with the - 55 m odifier for the post -discharge care.  The surgeon bills the surgery code with the  -54 modifier.
(Medicare Claims Processing Manual)
 Physicians who provide follow -up services for minor procedures performed in emergency departments bill the appropriate level of office visit code.  The physician who performs the emergency room service bills for the surgical procedure without a modifier.    If the services of a physician other than the surgeon are required during a postoperative period for an underlying condition or medical complication, the other physician reports the appropriate evaluation and management code.  No modifiers are necessary on the claim.  An example is a cardiologist who manages underlying cardiovascular conditions of a patient.   4. Evaluation and Management Service Resulting in the Initial Decision to Perform Surgery   Evaluation and management services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery and, therefore, may be billed and paid separately.   In addition to the CPT evaluation and management code, modifier  -57 (decision for surgery) is used to identify a visit which results in the initial decision to perform surgery.  (Modifier  -QI was used for dates of service prior to January 1, 1994.)   If evaluation and management services occur on the day of surgery, the physician bills using modifier  -57, not -25.  The  -57 modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery.  Moreover, where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.  5. Return Trips to the Operating Room During the Postoperative Period   When treatment for complications requires a return trip to the operating room, physicians must bill the CPT code that describes the procedure(s) performed during the return trip.  If no such code exists, use the unspecified procedure code in the correct series, i.e., 47999 or 64999.  The procedure code for the original surgery is not used except when the identical procedure is repeated.   In addition to the CPT code, physicians use CPT modifier  -78 for these return trips (return to the operating room for a related procedure during a postoperative period.)
(Medicare Claims Processing Manual)
Services submitted with the  -24 modifier must be sufficiently documented to establish that the visit was unrelated to the surgery.  A diagnosis code that clearly indicates that the reason for the encounter was unrelated to the surgery is acceptable docum entation.  A physician who is responsible for postoperative care and has reported and been paid using modifier  -55 also uses modifier  -24 to report any unrelated visits.   For critical care visits that are unrelated to the surgical procedure and performed postoperatively, report modifier FT as discussed in section 30.6.12.7 of this chapter.   8. Significant Evaluation and Management on the Day of a Procedure   Modifier  -25 is used to facilitate billing of evaluation and management services on the day of a procedure for which separate payment may be made.   It is used to report a significant, separately identifiable evaluation and management service by same physician on the day of a procedure.  The physician may need to indicate that on the day a procedure or service that is identified with a CPT code was performed, the patients condition required a significant, separately identifiable evaluation and management service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed.  This circumstance may be report ed by adding the modifier  -25 to the appropriate level of evaluation and management service.   Claims containing evaluation and management codes with modifier  -25 are not subject to prepayment review except in the following situations:    Effective January 1, 1995, all evaluation and management services provided on the same day as inpatient dialysis are denied without review with the exception of CPT Codes 99221- 9223, 99251- 99255, and 99238.  These codes may be billed with modifier -25 an d reviewed for possible allowance if the evaluation and management service is unrelated to the treatment of ESRD and was not, and could not, have been provided during the dialysis treatment;   When preoperative critical care codes are being billed within a global surgical period; and
(Medicare Claims Processing Manual)
 Preoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure; or    Same day or postoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure or endoscopy;   and -   Services that were furnished within the prescribed global period of the surgical procedure;    Services that are billed without modifier  -78,  -79,  -24, 25, or  -57 or are billed with modifier  -24 but without the required documentation; and    Services that are billed with the same provider or group number as the surgical procedure or endoscopy.  Also, edit for any visits billed separately during the postoperative period without modifier  -24 by a physician who billed for the postoperative care  only with modifier  -55.  A/B MACs (B) use the following evaluation and management codes in establishing edits for visits included in the global package.  CPT codes 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99271, 99272, 99273, 99274, and 99275 have been transferred from the excluded category and are now included in the global surgery edits.   Evaluation and Management Codes for A/B MAC (B) Edits   92012  92014  99211  99212  99213  99214  99215  99217  99218  99219  99220  99221  99222  99223  99231  99232  99233  99234  99235  99236  99238  99239  99241  99242  99243  99244  99245  99251  99252  99253  99254  99255  99261  99262  99263  99271  99272  99273  99274  99275  99291  99292  99301  99302  99303  99311  99312  99313  99315  99316  99331  99332  99333  99347  99348  99349  99350     99374  99375  99377  99378
(Medicare Claims Processing Manual)
NOTE:   In order for the services of CPT codes 99291 or 99292 to be paid during the preoperative or postoperative period, the critical care service must be unrelated to the procedure. In these situations, the physician must append the modifier -FT ((unrelated evaluation and management (E/M) visit on the same day as another E/M visit or during a global procedure (preoperative, postoperative period, or on the same day as the procedure, as applicable). (Report when an E/M visit is furnished within the global period but is unrelated, or when one or more additional  E/M visits furnished on the same day are unrelated.))  See section 30.6.12.7 of this chapter for further discussion of critical care visits unrelated to the procedure with a global surgical period.   If a surgeon is admitting a patient to a nursing facility for a condition not related to the global surgical procedure, the physician should bill for the nursing facility admission and care with a -24 modifier and appropriate documentation.  If a surgeon is admitting a patient to a nursing facility and the patients admission to that facility relates to the global surgical procedure, the nursing facility admission and any services related to the global surgical procedure are included in the global surgery fee.   C. Exclusions from Prepayment Edits   A/B MACs (B) exclude the following services from the prepayment audit process and allow separate payment if all usual requirements are met:   Services listed in 40.1.B ; and  Services billed with the modifier  -25,   -57,   -58,   -78, or  -79.  Exceptions   See 40.2.A.8, 40.2.A.9 , and 40.4.A  for instances where prepayment review is required for modifier  -25.  In addition, prepayment review is necessary for CPT codes 90935, 90937, 90945, and 90947 when a visit and modifier  -25 are billed with these services.   Exclude the following codes from the prepayment edits required in 40.3.B .