evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
C. Subsequent Hospital Inpatient or Observation Visit and Discharge Management on Same Day  Pay only the hospital inpatient or observation discharge management code on the day of discharge (unless it is also the day of admission, in which case, refer to 30.6.9.1 C for the policy on Hospital Inpatient or Observation Care Services (Including Admis sion and Discharge Services CPT Codes 99234 -  99236).  A/B MACs (B) do not pay both a subsequent hospital inpatient or observation care visit in addition to hospital inpatient or observation discharge day management service on the same day by the same phys ician.  Instruct physicians that they may not bill for both a hospital inpatient or observation care visit and hospital inpatient or observation discharge management for the same date of service.   D. Hospital Inpatient or Observation Discharge Management (CPT Codes 99238 and 99239) and Nursing Facility Admission Code When Patient Is Discharged From Hospital and Admitted to Nursing Facility on Same Day   A/B MACs (B) pay the hospital inpatient or observation discharge code (codes 99238 or 99239) in addition to a nursing facility admission code when they are billed by the same physician with the same date of service.   If a surgeon is admitting the patient to the nursing facility due to a condition that is not as a result of the surgery during the postoperative period of a service with the global surgical period, he/she bills for the nursing facility admission and care w ith a modifier  -24 and provides documentation that the service is unrelated to the surgery (e.g., return of an elderly patient to the nursing facility in which he/she has resided for five years following discharge from the hospital for cholecystectomy).   A/B MACs (B) do not pay for a nursing facility admission by a surgeon in the postoperative period of a procedure with a global surgical period if the patients admission to the nursing facility is to receive post operative care related to the surgery (e.g., admission to a nursing facility to receive physical therapy following a hip replacement).  Payment for the nursing facility admission and subsequent nursing facility services are incl uded in the global fee and cannot be paid separately.   E. Hospital Inpatient or Observation Discharge Management and Death Pronouncement
(Medicare Claims Processing Manual)
E. Hospital Inpatient or Observation Discharge Management and Death Pronouncement   Only the physician who personally performs the pronouncement of death shall bill for the face -to-face Hospital Inpatient or Observation Discharge Day Management Service, CPT code 99238 or 99239.  The date of the pronouncement shall reflect the calendar date of service on the day it was performed even if the paperwork is delayed to a subsequent date.   30.6.10 - Consultation Services  (Rev.  2282, Issued: 08- 26-11, Effective: 01 -01-11, Implementation: 11- 28-11)  Consultation Services versus Other Evaluation and Management (E/M) Visits   Effective January 1, 2010, the consultation codes are no longer recognized for Medicare Part B payment.  Physicians shall code patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of  the visit performed.
(Medicare Claims Processing Manual)
Effective January 1, 2010, the consultation codes are no longer recognized for Medicare Part B payment.  Physicians shall code patient evaluation and management visits with E/M codes that represent where the visit occurs and that identify the complexity of  the visit performed.   In the inpatient hospital setting and the nursing facility setting, physicians (and qualified nonphysician practitioners where permitted) may bill the most appropriate initial hospital care code (99221 -99223), subsequent hospital care code (99231 and 99232), initial nursing facility care code (99304 -99306), or subsequent nursing facility care code (99307- 99310) that reflects the services the physician or practitioner furnished .  Subsequent hospital care codes could potentially meet the component work and me dical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252.  A/B MACs (B) shall not find fault in cases where the medical record appropriately demonstrates that the work and medical necess ity requirements are met for reporting a subsequent hospital care code (under the level selected), even though the reported code is for the provider's first E/M service to the inpatient during the hospital stay.  Unlisted evaluation and management service (code 99499) shall only be reported for consultation services when an E/M service that could be described by codes 99251 or 99252 is furnished, and there is no other specific E/M code payable by Medicare that describes that service.  Reporting code 99499 r equires submission of medical records and A/B MAC (B) manual medical review of the service prior to payment.  CMS expects reporting under these circumstances to be unusual.  The principal physician of record is identified in Medicare as the physician who oversees the patients care from other physicians who may be furnishing specialty care.  The principal physician of record shall append modifier  -AI (Principal Physician of Record), in addition to the E/M code. Follow -up visits in the facility setting sha ll be billed as subsequent hospital care visits and subsequent nursing facility care visits.   In the CAH setting, those CAHs that use method II shall bill the appropriate new or established visit code for those physician and non- physician practitioners who have reassigned their billing rights, depending on the relationship status between the physic ian and patient.
(Medicare Claims Processing Manual)
In the office or other outpatient setting where an evaluation is performed, physicians and qualified nonphysician practitioners shall use the CPT codes (99201 -  99215) depending on the complexity of the visit and whether the patient is a new or established patient to that physician.  All physicians and qualified nonphysician practitioners shall follow the E/M documentation guidelines for all E/M services.  These rules are applicable for Medicare secondary payer claims as well as for claims in which Medicare is the primary payer.   30.6.11 - Emergency Department Visits (Codes 99281 - 99288)  (Rev. 1875, Issued: 12- 14-09, Effective: 01 -01-10, Implementation: 01- 04-10)  A. Use of Emergency Department Codes by Physicians Not Assigned to Emergency Department   Any physician seeing a patient registered in the emergency department may use emergency department visit codes (for services matching the code description). It is not required that the physician be assigned to the emergency department.  B. Use of Emergency Department Codes In Office   Emergency department coding is not appropriate if the site of service is an office or outpatient setting or any sight of service other than an emergency department. The emergency department codes should only be used if the patient is seen in the emergency department and the services described by the HCPCS code definition are provided. The emergency department is defined as an organized hospital -based facility for the provision of unscheduled or episodic services to patients who present for immediate medical attention.  C. Use of Emergency Department Codes to Bill Nonemergency Services   Services in the emergency department may not be emergencies. However the codes (99281 - 99288) are payable if the described services are provided.  However, if the physician asks the patient to meet him or her in the emergency department as an alternative to the physicians office and the patient is not registered as a patient in the emergency department, the physician should bill the appropriate offi ce/outpatient visit codes. Normally a lower level emergency department code would be reported for a nonemergency condition.  D. Emergency Department or Office/Outpatient Visits on Same Day As Nursing Facility Admission
(Medicare Claims Processing Manual)
Emergency department visit provided on the same day as a comprehensive nursing facility assessment are not paid. Payment for evaluation and management services on the same date provided in sites other than the nursing facility are included in the payment f or initial nursing facility care when performed on the same date as the nursing facility admission.   E. Physician Billing for Emergency Department Services Provided to Patient by Both Patients Personal Physician and Emergency Department Physician   If a physician advises his/her own patient to go to an emergency department (ED) of a hospital for care and the physician subsequently is asked by the ED physician to come to the hospital to evaluate the patient and to advise the ED physician as to whether  the patient should be admitted to the hospital or be sent home, the physicians should bill as follows:    If the patient is admitted to the hospital by the patients personal physician, then the patients regular physician should bill only the appropriate level of the initial hospital care (codes 99221 -  99223) because all evaluation and management services pr ovided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.  The ED physician who saw the patient in the emergency department should bill the appropriate level of the ED codes.    If the ED physician, based on the advice of the patients personal physician who came to the emergency department to see the patient, sends the patient home, then the ED physician should bill the appropriate level of emergency department service.  The patients personal physician should also bill the level of emergency department code that describes the service he or she provided in the emergency department.  If the patients personal physician does not come to the hospital to see the patient, but only advises the emergency department physician by telephone, then the patients personal physician may not bill.  F. Emergency Department Physician Requests Another Physician to See the Patient in Emergency Department or Office/Outpatient Setting   If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code.  If the patient is admitted to the hospital by the second physician performing the evaluation, he or she should bill an initial hospital care code and not an emergency department visit code.
(Medicare Claims Processing Manual)
30.6.12 - Critical Care Visits and Neonatal Intensive Care (Codes 99291  - 99292)  (Rev. 11288; Issued:0 3- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  30.6.12.1  Definition  (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  For payment under the Medicare Physician Fee Schedule (PFS), Medicare adopts the definition of critical care services in the CPT Codebook, and the CPT listing of bundled services, unless otherwise specified.  This includes t he CPT prefatory language stating that critical care is the direct delivery by a physician(s) or other qualified healthcare professional (QHP) of medical care for a critically ill/injured patient in which there is acute impairment of one or more vital organ systems, such that there is a probability of imminent or life -threatening deterioration of the patients condition.  It involves high complexity decision- making to treat single or multiple vital organ system failure and/or to prevent further life -threatening deterioration of the patients condition.   Bundled services that are included by CPT in critical care services and therefore not separately payable include interpretation of cardiac output measurements, chest X rays, pulse oximetry, blood gases and collection and interpretation of physiologic data (for example, ECGs, blood pressures, hematologic data), gastric intubation, temporary transcutaneous pacing, ventilator management, and vascular access procedures.  As a result, these codes are not separately billable by a practitioner during the time -period when the practitioner is providing critical care for a given patient.  T ime spent performing separately reportable procedures or services should be reported separately and should not be included in the time reported as critical care time.   Because critical care services are delivered by a physician(s) or QHP(s), critical care may be reported by physicians and other practitioners who are qualified by education, training, licensure/regulation (when applicable), facility privileging (when applicable), and the applicable Medicare benefit category to perform critical care services and independently report them, referred to in this manual section as physicians and non- physician practitioners (NPPs).
(Medicare Claims Processing Manual)
As specified in CPT prefatory language, critical care may be furnished on multiple days, and is typically furnished in a critical care area, which can include an intensive care unit or emergency care facility.  Critical care requires the full attention of the physician or NPP and therefore, for any given time period spent providing critical care services, the practitioner cannot provide services to any other patient during the same period of time.    30.6.12.2 - Critical Care by a Single Physician or NPP  (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  For payment of critical care by a single physician or NPP, we are adopting CPTs reporting rules.  When a single physician or NPP furnishes 30 - 74 minutes of critical care services to a patient on a given date, the physician or NPP will report CPT code 99291. CPT code 99291 will be used only once per date even if the time spent by the practitioner is not continuous on that date.  Thereafter, the physician or NPP will report CPT code 99292 for additional 30 -minute time increments provided to the same patient.    CPT codes 99291 and 99292 will be used to report the total duration of time spent by the physician or NPP providing critical care services to a critically ill or critically injured patient, even if the time spent by the practitioner on that date is not continuous. Non- continuous time for medically necessary critical care services may be aggregated.    Regarding critical care services crossing midnight, CPT guidance defines how a service is to be billed when the service extends across calendar dates. For continuous services that extend beyond midnight, the physician or NPP will report the total units of time provided continuously. Any disruption in the service, however, creates a new initial service. We are adopting this rule for critical care being furnished by a single physician or NPP when the critical care crosses midnight.   30.6.12.3 - Critical Care Visits Furnished Concurrently by Different Specialties (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)
(Medicare Claims Processing Manual)
30.6.12.3 - Critical Care Visits Furnished Concurrently by Different Specialties (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  Concurrent care is when more than one physician renders services that are more extensive than consultative services during a period of time. The reasonable and necessary services of each physician furnishing concurrent care is covered when each plays an ac tive role in the patients treatment. In  the context of critical care services, a critically ill patient may have more than one medical condition requiring diverse , specialized medical services and requiring more than one practitioner , each having a differ ent specialt y, play ing an active role in the patients treatment.    Medicare policy allows critical care visits furnished as concurrent care (or concurrently) to the same patient on the same date by more than one practitioner in more than one specialty (for example, an internist and a surgeon, allergist and a cardiologist, neurosurgeon and NPP) , regardless of group affiliation, if the  service meet s the definition of critical care and is not duplicative of other services.  Additionally, these critical care visits need to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to im prove the functioning of a malformed body member.   30.6.12.4 - Critical Care Furnished Concurrently by Practitioners in the Same Specialty and Same Group (Follow-Up Care)  (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  Physician(s) or NPP (s) in the same specialty and in the same group may provide concurrent follow -up care, such as  a critical care visit subsequent to another practitioners critical care visit.  This  may be  as part of continuous staff coverage or follow -up care to critical care services furnished earlier in the day on the same calendar date.
(Medicare Claims Processing Manual)
In the situation where a practitioner furnishes the initial critical care service in its entirety and reports CPT code 99291, any additional practitioner(s) in the same specialty and the same group furnishing care concurrently to the same patient on the sa me date report their time using the code for subsequent time intervals (CPT code 99292). CPT code 99291 will not be reported more than once for the same patient on the same date by these practitioners. This policy recognizes that multiple practitioners in the same specialty and the same group can maintain continuity of care by providing follow -up care for the same patient on a single date.   When one practitioner begins furnishing the initial critical care service, but does not meet the time required to report CPT code 99291, another practitioner in the same specialty and group can continue to deliver critical care to the same patient on the s ame date. The total time spent by the practitioners is aggregated to meet the time requirement to bill CPT code 99291. Once the cumulative required critical care service time is met to report CPT code 99291, CPT code 99292 can only be reported by a practitioner in the same specialty and group when an additional 30 minutes of critical care services have been furnished to the same patient on the same date (74 minutes + 30 minutes = 104 total minutes).  The aggregated time spent on critical care visits must be medically necessary and each visit must meet the definition of critical care in order to add the times for purposes of meeting the time requirement to bill CPT code 99291.    For purposes of payment under the Physician Fee Schedule, Medicare classifies NPPs in a specialty that is not the same as a physician with whom the NPP is working, so the policies above would not apply to the situation where an NPP provides the follow -up care to a physician, or vice versa.  Instead, see the section below regarding split (or shared) critical care services.   30.6.12.5 - Split (or Shared) Critical Care Visits  (Rev.  11828; Issued: 02- 02-23; Effective: 01 -01-23; Implementation: 03 -03-23)
(Medicare Claims Processing Manual)
Critical care visits may be furnished as split (or shared) visits, defined in section 30.6.18. The rules described in section 30.6.18 for other types of split (or shared) visits apply (except for the listing of qualifying activities for determining the sub stantive portion, discussed below), and service time is counted for CPT code 99292 in the same way as for prolonged E/M services .  Specifically, the billing practitioner bills the initial service (CPT 99291) and any add- on codes(s) for additional time (CPT  99292). Also, the substantive portion for critical care services is defined as more than half of the total time spent by the physician and NPP beginning January 1, 2022.  In the context of critical care, split (or shared) visits occur when the total critical care service time furnished by a physician and NPP in the same group on a given calendar date to a patient is summed, and the practitioner who furnishes the substantive portion of the cumulative critical care time reports the critical care service(s).   As stated earlier, when critical care services are furnished as a split (or shared) visit, the substantive portion is defined as more than half the cumulative total time in qualifying activities that are included in CPT codes 99291 and 99292.  Since, unlike other types of E/M visits, critical care services can include additional activities that are bundled into the critical care visits code(s), there is a unique listing of qualifying activities for split (or shared) critical care.  These qualifying activiti es are described in the prefatory language for critical care services in the CPT Codebook.  To bill split (or shared) critical care services, the billing practitioner first reports CPT code 99291 and, if 104 or more cumulative total minutes are spent providing critical care, the billing practitioner reports one or more units of CPT code 99292. Modifier - FS (split or shared E/M visit) must be appended to the critical care CPT code(s) on the claim.   The same documentation rules apply for split (or shared) critical care visits as for other types of split (or shared) E/M visits. Consistent with all split (or shared) visits, when  two or more practitioners spend time jointly meeting with or discussing the patient as part of a critical care service, the time can be counted
(Medicare Claims Processing Manual)
other types of split (or shared) E/M visits. Consistent with all split (or shared) visits, when  two or more practitioners spend time jointly meeting with or discussing the patient as part of a critical care service, the time can be counted only once for purposes of reporting the split (or shared) critical care visit.
(Medicare Claims Processing Manual)
30.6.12.6 - Critical Care and Other Same -Day Evaluation and Management (E/M) Visits  (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)  Our general policy, as described in section 30.6.5, states that physicians in the same group who are in the same specialty must bill and be paid for services under the PFS as though they were a single physician. If more than one E/M visit is provided on the same date to the same patient by the same physician, or by more  than one physician in the same specialty in the same group, only one E/M service may be reported, unless the E/M services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. T his general policy is intended to ensure that multiple E/M visits for a patient on a single day are medically necessary and not duplicative.    However, in situations where a patient receives another E/M visit on the same calendar date as critical care services, both may be billed (regardless of practitioner specialty or group affiliation) as  long as the medical record documentation supports: 1) that the other E/M visit was provided prior to the critical care services at a time when the patient did not require critical care, 2) that the services were medically necessary, and 3) that the services were separate and distinct, with no duplicative eleme nts from the critical care services provided later in the day. Practitioners must use modifier - 25 (same -day significant, separately identifiable evaluation and management service) on the claim when reporting these critical care services.    30.6.12.7 - Critical Care Visits and Global Surgery    (Rev. 11288; Issued: 03- 04-22; Effective: 01 -01-22; Implementation: 02 -15-22)