evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: CPT® Modifier 59: Gastroenterology (A53399)
CMS National Coverage PolicyN/AArticle TextBackgroundUnder certain circumstances, a physician may need to indicate that a procedure or service was distinct or independent from other services and CPTmodifier 59 may be appropriate depending on the circumstances. CPTmodifier 59 is used to identify procedures/services that are not normally reported together and this includes the following procedures/services that are not ordinarily encountered or performed on the same day by the same physician:A differentSession or patient encounterProcedure or surgerySite or organ systemA separateIncision/excisionLesionInjury (or area of injury in extensive injuries)When another already established modifier is appropriate, it should be used rather than CPTmodifier 59. CPTmodifier 59 is an important National Correct Coding Initiative (NCCI) associated modifier that is often used incorrectly and it should only be used if no more descriptive modifier is available or when its use best explains the circumstances.For the NCCI, the primary purpose of CPTmodifier 59 is to indicate that two or more procedures are performed at different anatomic sites or during different patient encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes.NCCI edits define when two procedure HCPCS/CPTcodes may not be reported together except under special circumstances.If an edit allows use of NCCI-associated modifiers, the two procedure codes may be reported together if the two procedures are performed at:Different anatomic sitesDifferent patient encountersThe Part B MAC claim processing system utilizes NCCI-associated modifiers to allow payment of both codes of an edit.CPTmodifier 59 and other NCCI-associated modifiers should not be used to bypass an NCCI edit unless the proper criteria for use of the modifier is met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.
Article - Billing and Coding: CPT® Modifier 59: Gastroenterology (A53399)
One of the misuses of CPTmodifier 59 is related to the portion of the definition of CPTmodifier 59 allowing its use to describe 'different procedure or surgery.' The code descriptors of the two codes of a code pair edit usually represent different procedures or surgeries. The related NCCI edit indicates that the two procedures/surgeries cannot be reported together if performed at the same anatomic site and same patient encounter. The provider cannot use CPTmodifier 59 for such an edit based on the two codes being different procedures/surgeries. However, if the two procedures/surgeries are performed at separate anatomic sites or at separate patient encounters on the same date of service, CPTmodifier 59 may be appended to indicate that they are different procedures/surgeries on that date of service.Use of CPTmodifier 59 to indicate different procedures/surgeries does not require a different diagnosis for each HCPCS/CPTcoded procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of CPTmodifier 59. The HCPCS/CPTcodes remain bundled unless the procedures/surgeries are performed at different anatomic sites or separate patient encounters.From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. For example, treatment of the nail, nail bed and adjacent soft tissue constitutes a single anatomic site. Treatment of posterior segment structures in the eye constitutes a single anatomic site.Examples of CPTModifier 59 UsageThe following are some examples developed to help guide physicians and providers on the proper use of CPTmodifier 59:Example 1:Column 1 Code/Column 2 CPTCode 45385/45380CPTcode 45385 - Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare techniqueCPTcode 45380 - Colonoscopy, flexible; with biopsy, single or multiplePolicy: More extensive procedureCPTmodifier 59 is only appropriate if the two procedures are performed on separate lesions or at separate patient encounters.
Article - Billing and Coding: Repeat X-ray or EKG Interpretations by Same or Different Physician (A53423)
CMS National Coverage PolicyCMS-Internet Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 13, Section 100.1.Article TextCMS National Coverage Policy Language quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the article.A/B MACs (B) generally distinguish between an interpretation and report of an x-ray or an EKG procedure and a review of the procedure. A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service. This is because the review is already included in the emergency department evaluation and management (E/M) payment. For example, a notation in the medical records saying fx-tibia or EKG-normal would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M code. An interpretation and report should address the findings, relevant clinical issues, and comparative data (when available).Generally, A/B MACs (B) must pay for only one interpretation of an EKG or x-ray procedure furnished to an emergency room patient. They pay for a second interpretation (which may be identified through the use of modifier -77) only under unusual circumstances (for which documentation is provided) such as a questionable finding for which the physician performing the initial interpretation believes another physicians expertise is needed or a changed diagnosis resulting from a second interpretation of the results of the procedure.When only one claim for an interpretation is received, it must be presumed that the one service submitted was a service to the individual beneficiary rather than a quality control measure. The claim may be paid if it otherwise meets any applicable reasonable and necessary test.When multiple claims for the same interpretation are received, payment for the first claim received is generally made. Payment for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient is generally made.Consideration is not given to physician specialty as the primary factor in deciding which interpretation and report to pay regardless of when the service is performed.
Article - Billing and Coding: Repeat X-ray or EKG Interpretations by Same or Different Physician (A53423)
Consideration is not given to physician specialty as the primary factor in deciding which interpretation and report to pay regardless of when the service is performed. Consideration is not given to designation as the hospital's 'official interpretation' as a factor in determining which claim to pay. A/B MACs pay for the interpretationbilled by the cardiologist or radiologist if the interpretation of the procedure is performed at the same time as the diagnosis and treatment of the beneficiary. (This interpretation may be an oral report to the treating physician that will be written at a later time.)If the first claim received is from a radiologist, A/B MACs (B) generally pay the claim because they would not know in advance that a second claim would be forthcoming. When A/B MACs (B) receive the claim from the emergency room (ER) physician and can identify that the two claims are for the same interpretation, they must determine whether the claim from the ER physician was the interpretation that contributed to the diagnosis and treatment of the patient and, if so, they pay that claim. In such cases, A/B MACs (B) must determine that the radiologists claim was actually quality control and institute recovery action.The two parties should reach an accommodation about who should bill for these interpretations.Claim Submission InstructionsFor claims submitted electronically, the unusual circumstances must be submitted in the appropriate documentation record. Failure to use CPT modifier 77 and submit the necessary documentation will result in denial of the service. Limitations of liability and refund requirements apply.Repeat Procedures by Same PhysicianWhen the same physician interprets serial x-rays or EKGs performed on the same day, CPT modifier 76 must be submitted to indicate the service was repeated subsequent to the original procedure.These guidelines are available on the CMS-Internet Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 13, Section 100.1.
Article - Videostroboscopy and Nasopharyngoscopy Procedures Performed by Speech-Language Pathologists (SLPs) (A53430)
CMS National Coverage PolicyN/AArticle TextSpeech-language pathologists (SLPs) are trained in basic laryngeal examination related to speech and dysfunctional swallowing conditions. Since an SLP does not have the experience or knowledge to biopsy a neoplasm or an anatomical pathologic condition, Palmetto PGA will reimburse a videostroboscopy and nasopharyngoscopy service when an SLP performs the service under the direct supervision of a physician credentialed by the hospital to perform the services.
Article - Anesthetic 'Caine Drugs' (A53432)
CMS National Coverage PolicyN/AArticle TextAnesthetic drugs such as Bupivacaine (Marcaine), Bupivacaine (Sensorcaine), Chloroprocaine (Nesacaine), Lidocaine (Xylocaine), Mepivacaine (Carbocaine), etc., when administered for chronic pain control are not covered by Medicare.The CMS Internet-Only Manual, Pub. 100-04, Chapter 12, Section 50 specifies that Palmetto GBA may not allow separate payment for the anesthesia service performed by the physician who also furnishes the medical or surgical service. In that case, payment for the anesthesia service is made through the payment for the medical or surgical service. For example, Palmetto GBA may not allow separate payment for the surgeon's performance of a local or surgical anesthesia if the surgeon also performs the surgical procedure.
(Medicare Claims Processing Manual)
Medicare Claims Processing Manual  Chapter 12 - Physicians/Nonphysician Practitioners   Table of Contents  (Rev.  12461; Issued: 01-18-24)    Transmittals for Chapter 12
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10 - General  20 - Medicare Physicians Fee Schedule (MPFS)  20.1 - Method for Computing Fee Schedule Amount 20.2 - Relative Value Units (RVUs)  20.3 - Bundled Services/Supplies 20.4 - Summary of Adjustments to Fee Schedule Computations 20.4.1 - Participating Versus Nonparticipating Differential  20.4.2 - Site of Service Payment Differential  20.4.3 - Assistant at Surgery Services  20.4.4 - Supplies 20.4.5 - Allowable Adjustments  20.4.6 - Payment Due to Unusual Circumstances (Modifiers -22 and - 52) 20.4.7 -  Technical Component Payment Reduction for X-Rays and Other Imaging Services 20.5 - No Adjustments in Fee Schedule Amounts 20.6- Update Factor for Fee Schedule Services  20.7 - Comparability of Payment Provision of Delegation of Authority by CMS to Railroad Retirement Board  20.8 - Payment for Teleradiology Physician Services Purchased by Indian Health Services (IHS) Providers and Physicians 30 - Correct Coding Policy 30.1 - Digestive System (Codes 40000 - 49999) 30.2 - Urinary and Male Genital Systems (Codes 50010 - 55899) 30.3 - Audiology Sevices 30.4 - Cardiovascular System (Codes 92950-93799) 30.5 - Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions 30.6 - Evaluation and Management Service Codes - General (Codes 99202 - 99499) 30.6.1 - Selection of Level of Evaluation and Management Service  30.6.1.1 - Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV)  30.6.2 -  Billing for Medically Necessary Visit on Same Occasion as Preventive Medicine Service  30.6.3 -  Payment for Immunosuppressive Therapy Management  30.6.4 -  Evaluation and Management (E/M) Services Furnished Incident to Physicians Service by Nonphysician Practitioners  30.6.5 -  Physicians in Group Practice  30.6.6 -  Payment for Evaluation and Management Services Provided During Global Period of Surgery  30.6.7 -  Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99202 -  99215)  30.6.8 -  Payment for Hospital Observation Services and
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Provided During Global Period of Surgery  30.6.7 -  Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99202 -  99215)  30.6.8 -  Payment for Hospital Observation Services and Observation or Inpatient Care Services (Including Admission and Discharge Services)  30.6.9 -  Payment for Inpatient Hospital Visits -  General  30.6.9.1 -  Payment for Initial Hospital Inpatient or Observation  Care Services and  Hospital Inpatient or Observation or Inpatient Care Services (Including Admission and Discharge Services)  30.6.9.2 -  Subsequent Hospital Inpatient or Observation Care Visit and Hospital  Inpatient or Observation Discharge Day Management Services (Codes 99231 -  99239)  30.6.10 -  Consultation Services  30.6.11 -  Emergency Department Visits (Codes 99281 -  99288)  30.6.12 -  Critical Care Visits and Neonatal Intensive Care (Codes  99291 -  99292)
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30.6.12.1 -  Definition              30.6.12.2 -  Critical Care by a Single Physician or NPP  30.6.12.3 -  Critical Care Visits Furnished Concurrently by Different  Specialties  30.6.12.4 -  Critical Care Furnished Concurrently by Practitioners in the  Same Specialty and Same Group (Follow -Up Care)  30.6.12.5 -  Split (or Shared) Critical Care Visits  30.6.12.6 -  Critical Care and Other Same -Day Evaluation and  Management (E/M) Visits  30.6.12.7 -  Critical Care Visits and Global Surgery  30.6.12.8 -  Medical Record Documentation  30.6.13 -  Nursing Facility Services  30.6.14 -  Home or Residence Services (Codes 99341  99350)     30.6.14.1   Home or Residence Services (99341  99350) When     Performed in Place of Service 12 (Home)    30.6.15 -  Prolonged Services , Standby Services (Codes 99354 -  99360)  and                              Evaluation and Management service for Power Mobility Devices (PMDs) (G0372)  30.6.15.1 -  Prolonged Services  General Rules  30.6.15.2 -  Prolonged Office/Outpatient E/M Visits  30.6.15.3 -  Prolonged Other E/M Visits  30.6.15.4 - Power Mobility Devices (PMDs) (Code G0372)                          30.6.17  Physician Management Associated with Superficial Radiation                                      Treatment                30.6.18 -  Split (or Shared) Visits    30.6.19  Office/Outpatient Evaluation and Management  (O/O E/M) Complexity
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Add-on Payment (Code G2211)  40 - Surgeons and Global Surgery  40.1 -  Definition of a Global Surgical Package  40.2 -  Billing Requirements for Global Surgeries  40.3 -  Claims Review for Global Surgeries  40.4 -  Adjudication of Claims for Global Surgeries  40.5 -  Postpayment Issues  40.6 -  Claims for Multiple Surgeries  40.7 -  Claims for Bilateral Surgeries  40.8 -  Claims for Co -Surgeons and Team Surgeons  40.9 -  Procedures Billed With Two or More Surgical Modifiers  50 - Payment for Anesthesiology Services  60 - Payment for Pathology Services  70 - Payment Conditions for Radiology Services  80 - Services of Physicians Furnished in Providers or to Patients of Providers  80.1 -  Coverage of Physicians Services Provided in Comprehensive Outpatient Rehabilitation Facility  80.2 -  Rural Health Clinic and Federally Qualified Health Center Services  80.3 -  Unusual Travel (CPT Code 99082)  90 - Physicians Practicing in Special Settings  90.1 -  Physicians in Federal Hospitals  90.2 -  Physician Billing for End- Stage Renal Disease Services  90.2.1 -  Inpatient Hospital Visits With Dialysis Patients  90.3 -  Physicians Services Performed in Ambulatory Surgical Centers (ASC)  90.4 -  Billing and Payment in Health Professional Shortage Areas (HPSAs)  90.4.1 -  Provider Education 90.4.1.1 -  A/B MAC (B)  Web Pages  90.4.2 -  HPSA Designations  90.4.3 -  Claims Coding Requirements  90.4.4 -  Payment  90.4.5 -  Services Eligible for HPSA and Physician Scarcity Bonus Payments  90.4.6 -  Reserved for Future Use  90.4.7 -  Post -payment Review  90.4.8 -  Reporting 90.4.9 - HPSA Incentive Payments for Physician Services Rendered in a Critical Access Hospital  90.4.10 -  Administrative and Judicial Review  90.4.11 -  Health Professional Shortage Areas (HPSA) Surgical Incentive Payment Program (HSIP) for Surgical Services Rendered in HPSAs  90.4.11.1 -  Overview of the HSIP  90.4.11.2 -  HPSA Identification  90.4.11.3 -  Coordination with Other Payments  90.4.11.4 - General Surgeon and Surgical Procedure Identification for Professional Services Paid Under the Physician Fee Schedule (PFS)  90.4.11.5 -  Claims Processing and Payment  90.5 -  Billing and
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-  Coordination with Other Payments  90.4.11.4 - General Surgeon and Surgical Procedure Identification for Professional Services Paid Under the Physician Fee Schedule (PFS)  90.4.11.5 -  Claims Processing and Payment  90.5 -  Billing and Payment in a Physician Scarcity Area  90.5.1 -  Provider Education 90.5.2 -  Identifying Physician Scarcity Area Locations  90.5.3 -  Claims Coding Requirements  90.5.4 -  Payment  90.5.5 -  Services Eligible for the Physician Scarcity Bonus  90.5.5.1 -  Remittance Messages  90.5.6 -  Post -payment Review  90.5.7 -  Administrative and Judicial Review  90.6 -  Indian Health Services (IHS) Provider Payment to Non- IHS Physicians for Teleradiology Interpretations  90.7 -  Bundling of Payments for Services Provided in Wholly Owned and Wholly Operated Entities (including Physician Practices and Clinics): 3 -Day Payment Window  90.7.1 -  Payment Methodology: 3- Day Payment Window in Wholly Owned or Wholly Operated Entities (including Physician Practices and Clinics)  100 -  Teaching Physician Services  100.1 -  Payment for Physician Services in Teaching Settings Under the MPFS  100.1.1 -  Evaluation and Management (E/M) Services  100.1.2 -  Surgical Procedures  100.1.3 -  Psychiatry  100.1.4 -  Time -Based Codes  100.1.5 -  Other Complex or High- Risk Procedures  100.1.6 -  Miscellaneous  100.1.7 -  Assistants at Surgery in Teaching Hospitals  100.1.8 -  Physician Billing in the Teaching Setting 100.2 -  Interns and Residents  110 -  Physician Assistant (PA) Services Payment Methodology 110.1 -  Global Surgical Payments  110.2 -  Limitations for Assistant- at-Surgery Services Furnished by Physician Assistants  110.3 -  Outpatient Mental Health Treatment Limitation  110.4 -  PA Billing to the A/B MAC (B)  120 - Nurse Practitioner (NP) And Clinical Nurse Specialist (CNS) Services  Payment Methodology 120.1 -  Limitations for Assistant- at-Surgery Services Furnished by Nurse Practitioners and Clinical Nurse Specialists  120.2 -  Outpatient Mental Health Treatment Limitation  120.3 -  NP and CNS Billing to the A/B MAC (B)  130 -  Nurse -Midwife Services  130.1 -  Payment for Certified Nurse -Midwife Services  130.2 -  Global Allowances  140 -  Qualified Nonphysician Anesthetist Services  140.1
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to the A/B MAC (B)  130 -  Nurse -Midwife Services  130.1 -  Payment for Certified Nurse -Midwife Services  130.2 -  Global Allowances  140 -  Qualified Nonphysician Anesthetist Services  140.1 -  Qualified Nonphysician Anesthetists  140.2 -  Entity or Individual to Whom Fee Schedule is Payable for Qualified Nonphysician Anesthetists  140.3 -  Anesthesia Fee Schedule Payment for Qualified Nonphysician Anesthetists  140.3.1 -  Conversion Factors Used on or After January 1, 1997 for Qualified Nonphysician Anesthetists  140.3.2 -  Anesthesia Time and Calculation of Anesthesia Time Units  140.3.3 -  Billing Modifiers  140.3.4 -  General Billing Instructions  140.4 -  Qualified Nonphysician Anesthetist Special Billing and Payment Situations  140.4.1 -  An Anesthesiologist and Qualified Nonphysician Anesthetist Work Together  140.4.2 -  Qualified Nonphysician Anesthetist and an Anesthesiologist in a Single Anesthesia Procedure  140.4.3 -  Payment for Medical or Surgical Services Furnished by CRNAs
(Medicare Claims Processing Manual)
140.5-- Payment for Anesthesia Services Furnished by a Teaching CRNA  150 -  Clinical Social Worker (CSW) Services  160 -  Independent Psychologist Services  160.1 -  Payment  170 -  Clinical Psychologist Services  170.1 -  Payment  180 -  Care Plan Oversight Services  180.1 -  Care Plan Oversight Billing Requirements  190 -  Medicare Payment for Telehealth Services  190.1 -  Background  190.2 -  Eligibility Criteria  190.3 -  List of Medicare Telehealth Services  190.3.1 -  Telehealth Consultation Services, Emergency Department  or Initial Inpatient versus Inpatient Evaluation and Management (E/M) Visits  190.3.2 -  Telehealth Consultation Services, Emergency Department  or Initial Inpatient Defined  190.3.3 -  Follow -Up Inpatient Telehealth Consultations Defined  190.3.4  Payment for ESRD -Related Services as a Telehealth Service  190.3.5  Payment for Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services  190.3.6  Payment for Diabetes Self -Management Training (DSMT) as a Telehealth Service    190.3.7  Payment for Telehealth for Individuals with Acute Stroke  190.4 -  Conditions of Payment  190.5 -  Originating Site Facility Fee Payment Methodology  190.6 -  Payment Methodology for Physician/Practitioner at the Distant Site  190.6.1 -  Submission of Telehealth Claims for Distant Site Practitioners  190.6.2 -  Exception for Store and Forward (Non -Interactive) Telehealth  190.7 -  A/B MAC (B)  Editing of Telehealth Claims  200 -  Allergy Testing and Immunotherapy  210 -  Outpatient Mental Health Treatment Limitation  210.1 -  Application of the Limitation  220 Chiropractic Services  230 -  Primary Care Incentive Payment Program (PCIP)  230.1 -  Definition of Primary Care Practitioners and Primary Care Services  230.2 -  Coordination with Other Payments  230.3 -  Claims Processing and Payment  240 -  Marriage and Family Therapist (MFT) Services   250 -  Mental Health Counselor (MHC) Services                          10 - General  (Rev. 1, 10-01-03) B3-2020 This chapter provides claims processing instructions for physician and nonphysician practitioner services.  Most physician services are paid according to the Medicare Physician Fee Schedule.  Section 20