evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
140.3.3 - Billing  Modifiers (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17) The following modifiers are used by qualified nonphysician anesthetists when billing for anesthesia  services:   QX  Qualified nonphysician anesthetist service: With medical direction by a  physician.  QZ  CRNA service: Without medical direction by a physician.   QS  Monitored anesthesia care services   NOTE:  The QS modifier can be used by a physician or a qualified nonphysician anesthetist and is for informational purposes.  Providers must report actual anesthesia time and one of the payment modifiers on the claim.  140.3.4 - General Billing Instructions  (Rev. 3747; Issued: 04- 14-17; Effective: 01 -01-17; Implementation: 05 -15-17) Claims for reimbursement for qualified nonphysician anesthetist services should be completed in accordance with existing billing instructions for anesthesiologists with the following  additions.  If an employer -physician furnishes  concurrent  medical  direction  for a procedure  involving CRNAs  and the medical  direction  service is unassigned, the physician should bill on an assigned  basis  on a separate claim  for the qualified  nonphysician anesthetist  service.  If the physician is  participating  or takes  assignment, both services  should be billed on one claim but as separate line items.    All claims  forms  must  have  the provider  billing  number  of the qualified nonphysician anesthetist and/or  the employer  of the qualified  nonphysician anesthetist  performing  the service in either  block 24.H  of the Form  CMS -1500 and/or block 31 as  applicable.  Verify  that the billing  number  is valid  before  making payment.   Payments should be calculated in accordance with Medicare payment rules in 140.3. The A/B MAC must institute all necessary payment edits to assure that duplicate payments are not made to physicians for qualified nonphysician anesthetist services or to a qualified nonphysician anesthetist directly for bills submitted on their behalf by qualified billers.  A CRNA is identified on the provider file by specialty code 43. An anesthesiologists assistant is identified on the provider file by specialty code  32.
(Medicare Claims Processing Manual)
 Recognize the full base units (assigned to the anesthesia code) where the teaching CRNA is present with the student nurse anesthetist throughout pre and post anesthesia care;  and   Recognize the actual time the teaching CRNA is personally present with the student nurse anesthetist.  Anesthesia time may be discontinuous. For example, a teaching CRNA is involved in two concurrent cases with student nurse anesthetists. Case 1 runs from 9:00 a.m. to 11:00 a.m. and case 2 runs from 9:45a.m. to 11:30 a.m. The teaching CRNA is present in case 1 from 9:00 a.m. to 9:30 a.m. and from 10:15 a.m. to 10:30 a.m. From 9:45 a.m. to 10:14 a.m. and from 10:31 a.m. to 11:30 a.m., the CRNA is present in case 2. The CRNA may report 45 minutes of anesthesia time for case 1 (i.e., 3 time units)  and 88 minutes (i.e., 5.9 units) of anesthesia time for case  2.  The teaching CRNA must document his/her involvement in cases with student nurse anesthetists. The documentation must be sufficient to support the payment of the fee and available for review upon request.   The teaching CRNA (not under the medical direction of a physician), can be paid for his or her involvement in each of two concurrent cases with student nurse anesthetists; allow payment at the regular fee schedule rate. The teaching CRNA reports the anesth esia service using the QZ  modifier.
(Medicare Claims Processing Manual)
To bill the anesthesia base units, the teaching CRNA must be present with the student nurse anesthetist during pre and post anesthesia care for each of the two  cases.  To bill anesthesia time for each case, the teaching CRNA must continue to devote his or her time to the two concurrent cases and not be involved in other activities. The teaching CRNA can decide how to allocate his or her time to optimize patient c are in the two cases based on the complexity of the anesthesia cases, the experience and skills of the student nurse anesthetists, and the patients health status and other  factors.  The teaching CRNA must document his or her involvement in the cases with the student nurse  anesthetists.   150 - Clinical Social Worker (CSW) Services (Rev. 2656, Issuance: 02- 07-13, Effective: 02- 19-13, Implementation: 02- 19-13)  See Medicare Benefit Policy Manual, Chapter 15, for coverage requirements.  Assignment of benefits is required.   Payment is at 75 percent of the physician fee schedule.  CSWs are identified on the provider file by specialty code 80 and provider type 56.  Medicare applies the outpatient mental health limitation to all covered therapeutic services furnished by qualified CSWs.  Refer to 210, below, for a discussion of the outpatient mental health limitation.   160 - Independent Psychologist Services  (Rev. 1, 10- 01-03) B3-2150, B3- 2070.2  See the Medicare Benefit Policy Manual, Chapter 15, for coverage requirements.  There are a number of types of psychologists.  Educational psychologists engage in identifying and treating education- related issues.  In contrast, counseling psychologists provide services that include a broader realm including phobias, familial issues, e tc.  Psychometrists are psychologists who have been trained to administer and interpret tests.  However, clinical psychologists are defined as a provider of diagnostic and therapeutic services.  Because of the differences in services provided, services pro vided by psychologists who do not provide clinical services are subject to different billing guidelines.  One service often provided by nonclinical psychologist is diagnostic testing.  NOTE: Diagnostic psychological testing services performed by persons who meet these requirements are covered as other diagnostic tests.  When, however, the psychologist is not practicing independently, but is on the staff of an institution, agency, or clinic, that entity bills for the diagnostic services.
(Medicare Claims Processing Manual)
Expenses for such testing are not subject to the payment limitation on treatment for mental, psychoneurotic, and personality disorders.  Independent psychologists are not required by law to accept assignment when performing psychological tests.  However, regardless of whether the psychologist accepts assignment, he or she must report on the claim form the name and address of the physician who ordered the test.   160.1 - Payment  (Rev. 1, 10- 01-03)  Diagnostic testing services are not subject to the outpatient mental health limitation.  Refer to 210, below, for a discussion of the outpatient mental health limitation. The diagnostic testing services performed by a psychologist (who is not a clinical psychologist) practicing independently of an institution, agency, or physicians office are covered as other diagnostic tests if a physician orders such testing.  Medicare c overs this type of testing as an outpatient service if furnished by any psychologist who is licensed or certified to practice psychology in the State or jurisdiction where he or she is furnishing services or, if the jurisdiction does not issue licenses, if  provided by any practicing psychologist.  (It is CMS understanding that all States, the District of Columbia, and Puerto Rico license psychologists, but that some trust territories do not.  Examples of psychologists, other than clinical psychologists, whose services are covered under this provision include, but are not limited to, educational psychologists and counseling psychologists.)
(Medicare Claims Processing Manual)
To determine whether the diagnostic psychological testing services of a particular independent psychologist are covered under Part B in States which have statutory licensure or certification, A/B MACs (B) must secure from the appropriate State agency a current listing of psychologists holding the required credentials.  In States or territories which lack statutory licensing and certification, A/B MACs (B) must check individual qualifications as claims are submitted.  Possible reference sources are the natio nal directory of membership of the American Psychological Association, which provides data about the educational background of individuals and indicates which members are board- certified, and records and directories of the State or territorial psychologica l association.  If qualification is dependent on a doctoral degree from a currently accredited program, A/B MACs (B) must verify the date of accreditation of the school involved, since such accreditation is not retroactive.  If the reference sources listed  above do not provide enough information (e.g., the psychologist is not a member of the association), A/B MACs (B) must contact the psychologist personally for the required information.  A/B MACs (B) may wish to maintain a continuing list of psychologists whose qualifications have been verified.   Medicare excludes expenses for diagnostic testing from the payment limitation on treatment for mental/psychoneurotic/personality disorders.   A/B MACs (B)  must identify the independent psychologists choice whether or not to accept assignment when performing psychological tests.  A/B MACs (B) must accept an independent psychologist claim only if the psychologist reports the name/UPIN of the physician who ordered a test.   A/B MACs (B) pay nonparticipating independent psychologists at 95 percent of the physician fee schedule allowed amount.  A/B MACs (B) pay participating independent psychologists at 100 percent of the physician fee schedule allowed amount.   Independent psychologists are identified on the provider file by specialty code 62 and provider type 35.   170 - Clinical Psychologist Services (Rev. 1, 10- 01-03) B3-2150  See Medicare Benefit Policy Manual, Chapter 15, for general coverage requirements.
(Medicare Claims Processing Manual)
170 - Clinical Psychologist Services (Rev. 1, 10- 01-03) B3-2150  See Medicare Benefit Policy Manual, Chapter 15, for general coverage requirements.   Direct payment may be made under Part B for professional services.  However, services furnished incident to the professional services of CPs to hospital patients remain bundled.  Therefore, payment must continue to be made to the hospital (by the A/B MAC ( A)) for such incident to services.  170.1 - Payment  (Rev. 2656, Issuance: 02- 07-13, Effective: 02- 19-13, Implementation: 02- 19-13)  All covered therapeutic services furnished by qualified CPs are subject to the outpatient mental health treatment limitation (the limitation).  Generally, the limitation does not apply to diagnostic services.  Refer to 210 below for a discussion of the outpatient mental health treatment limitation.   Payment for the services of CPs is made on the basis of a fee schedule or the actual charge, whichever is less, and only on the basis of assignment.  CPs are identified by specialty code 68 and provider type 27.
(Medicare Claims Processing Manual)
180 - Care Plan Oversight Services  (Rev. 999, Issued:  07- 14-06; Effective:  01 -01-05; Implementation:  10 -02-06) The Medicare Benefit Policy Manual, Chapter 15, contains requirements for coverage for medical and other health services including those of physicians and non- physician practitioners.  Care plan oversight (CPO) is the physician supervision of a patient receiving complex and/or multidisciplinary care as part of Medicare -covered services provided by a participating home health agency or Medicare approved hospice.  CPO services require complex or multidisciplinary care modalities involving:  Regular physician development and/or revision of care plans;   Review of subsequent reports of patient status;   Review of related laboratory and other studies;   Communication with other health professionals not employed in the same practice who are involved in the patients care;   Integration of new information into the medical treatment plan; and/or   Adjustment of medical therapy.  The CPO services require recurrent physician supervision of a patient involving 30 or more minutes of the physicians time per month.  Services not countable toward the 30 minutes threshold that must be provided in order to bill for CPO include, but are not limited to:   Time associated with discussions with the patient, his or her family or friends to adjust medication or treatment;  Time spent by staff getting or filing charts;   Travel time; and/or   Physicians time spent telephoning prescriptions into the pharmacist unless the telephone conversation involves discussions of pharmaceutical therapies.  Implicit in the concept of CPO is the expectation that the physician has coordinated an aspect of the patients care with the home health agency or hospice during the month for which CPO services were billed.  The physician who bills for CPO must be the sa me physician who signs the plan of care.  Nurse practitioners, physician assistants, and clinical nurse specialists, practicing within the scope of State law, may bill for care plan oversight.  These non- physician practitioners must have been providing ongoing care for the beneficiary through evaluation and management services.  These non -physician practitioners may not bill for CPO if they have been involved only with the delivery of the Medicare -covered home health or hospice service.  A. Home Health CPO  Non-physician practitioners can perform CPO only if the physician signing the plan of care provides regular ongoing care under the same plan of care as does the NPP billing for
(Medicare Claims Processing Manual)
the Medicare -covered home health or hospice service.  A. Home Health CPO  Non-physician practitioners can perform CPO only if the physician signing the plan of care provides regular ongoing care under the same plan of care as does the NPP billing for CPO and either:   The physician and NPP are part of the same group practice; or   If the NPP is a nurse practitioner or clinical nurse specialist, the physician signing the plan of care also has a collaborative agreement with the NPP; or   If the NPP is a physician assistant, the physician signing the plan of care is also the physician who provides general supervision of physician assistant services for the practice.  Billing may be made for care plan oversight services furnished by an NPP when:  The NPP providing the care plan oversight has seen and examined the patient;   The NPP providing care plan oversight is not functioning as a consultant whose participation is limited to a single medical condition rather than multidisciplinary coordination of care; and  The NPP providing care plan oversight integrates his or her care with that of the physician who signed the plan of care. NPPs may not certify the beneficiary for home health care.  B. Hospice CPO  The attending physician or nurse practitioner (who has been designated as the attending physician)  may bill for hospice CPO when they are acting as an attending physician.  An attending physician is one who has been identified by the individual, at the time he/she elects hospice coverage, as having the most significant role in the determination and delivery of their medical care.  They are not employed nor paid by the hospice . The care plan oversight services are billed using Form CMS -1500 or electronic  equivalent.  For additional information on hospice CPO, see Chapter 11, 40.1.3.1 of this manual .
(Medicare Claims Processing Manual)
180.1 - Care Plan Oversight Billing Requirements  (Rev. 999, Issued:  07- 14-06; Effective:  01 -01-05; Implementation:  10 -02-06)  A. Codes for Which Separate Payment May Be Made   Effective January 1, 1995, separate payment may be made for CPO oversight services for 30 minutes or more if the requirements specified in the Medicare Benefits Policy Manual, Chapter 15 are met.    Providers billing for CPO must submit the claim with no other services billed on that claim and may bill only after the end of the month in which the CPO services were rendered.  CPO services may not be billed across calendar months and should be submitted  (and paid) only for one unit of service.   Physicians may bill and be paid separately for CPO services only if all the criteria in the Medicare Benefit Policy Manual, Chapter 15 are met.   B. Physician Certification and Recertification of Home Health Plans of Care   Effective 2001, two new HCPCS codes for the certification and recertification  and development of plans of care for Medicare -covered home health services were created. See the Medicare General Information, Eligibility, and Entitlement Manual, Pub. 100- 01,  Chapter 4, Physician Certification and Recertification of Services , 10 -60, and the Medicare Benefit Policy Manual, Pub. 100- 02, Chapter 7, Home Health Services, 30.   The home health agency certification code can be billed only when the patient has not received Medicare -covered home health services for at least 60 days.  The home health agency recertification code is used after a patient has received services for at least 60 days (or one certification period) when the physician signs the certification after the initial certification period.  The home health agency recertification code will be reported only once every 60 days, except in the rare situation when the patient  starts a new episode before 60 days elapses and requires a new plan of care to start a new episode.
(Medicare Claims Processing Manual)
C. Provider Number of Home Health Agency (HHA) or Hospice For claims for CPO submitted on or after January 1, 1997, physicians must enter on the Medicare claim form the 6 -character Medicare provider number of the HHA or hospice providing Medicare -covered services to the beneficiary for the period during which CPO  services was furnished and for which the physician signed the plan of care.  Physicians are responsible for obtaining the HHA or hospice Medicare provider numbers.  Additionally, physicians should provide their UPIN to the HHA or hospice furnishing services to their patient.   NOTE:  There is currently no place on the HIPAA standard ASC X12N 837 professional format to specifically include the HHA or hospice provider number required for a care plan oversight claim.  For this reason, the requirement to include the HHA or hospice provider  number on a care plan oversight claim is temporarily waived until a new version of this electronic standard format is adopted under HIPAA and includes a place to provide the HHA and hospice provider numbers for care plan oversight claims.   190 - Medicare Payment for Telehealth Services  (Rev. 1, 10- 01-03) A3-3497, A3- 3660.2, B3 -4159, B3- 15516  190.1 - Background  (Rev. 1635, Issued: 11- 14-08, Effective: 01 -01-09, Implementation: 01- 05-09)  Section 223 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) -  Revision of Medicare Reimbursement for Telehealth Services amended 1834 (go to the link and then select the applicable title) of the Act to provide for an expansion of Medicare payment for telehealth services.
(Medicare Claims Processing Manual)
Effective October 1, 2001, coverage and payment for Medicare telehealth includes consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system.  Eligible geographic areas include rural health professional shortage areas (HPSA) and counties not classified as a metropolitan statistical area (MSA).  Additionally, Federal telemedicine demonstration projects a s of December 31, 2000, may serve as the originating site regardless of geographic location.  An interactive telecommunications system is required as a condition of payment; however, BIPA does allow the use of asynchronous store and forward technology in delivering these services when the originating site is a Federal telemedicine demonstration program in Alaska or Hawaii.  BIPA does not require that a practitioner present the patient for interactive telehealth services.   With regard to payment amount, BIPA specified that payment for the professional service performed by the distant site practitioner (i.e., where the expert physician or practitioner is physically located at time of telemedicine encounter) is equal to what w ould have been paid without the use of telemedicine.  Distant site practitioners include only a physician as described in 1861(r)  (go to the link and select the applicable title) of the Act and a medical practitioner as described in 1842(b)(18)(C)  (go to the link and select the applicable title) of the Act.  BIPA also expanded payment under Medicare to include a $20 originating site facility fee (location of beneficiary).   Previously, the Balanced Budget Act of 1997 (BBA) limited the scope of Medicare telehealth coverage to consultation services and the implementing regulation prohibited the use of an asynchronous, store and forward telecommunications system. BBA 1997 also required the professional fee to be shared between the referring and consulting practitioners, and prohibited Medicare payment for facility fees and line charges associated with the telemedicine encounter.   BIPA required that Medicare Part B (Supplementary Medical Insurance) pay for this expansion of telehealth services beginning with services furnished on October 1, 2001.
(Medicare Claims Processing Manual)
BIPA required that Medicare Part B (Supplementary Medical Insurance) pay for this expansion of telehealth services beginning with services furnished on October 1, 2001.   Section 149 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) amended 1834 of the Act to add certain entities as originating sites for payment of telehealth services.  Effective for services furnished on or after January 1, 2009, eligible originating sites include a hospital- based or critical access hospital -based renal dialysis center (including satellites); a skilled nursing facility (as defined in 1819(a) of the Act); and a community mental health center (as defined in 1861(f f)(3)(B) of the Act).  MIPPA also amended1888(e)(2)(A)(ii) of the Act to exclude telehealth services furnished under 1834(m)(4)(C)(ii)(VII) from the consolidated billing provisions of the skilled nursing facility prospective payment system (SNF PPS).   NOTE:  MIPPA did not add independent renal dialysis facilities as originating sites for payment of telehealth services.   The telehealth provisions authorized by 1834(m) of the Act are implemented in 42 CFR 410.78 and 414.65.  190.2 - Eligibility Criteria  (Rev. 2848, Issued 12- 30-13; Effective 01 -01-14; Implementation 01- 06-14)  1. Beneficiaries eligible for telehealth services   Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in either a rural health professional shortage area (HPSA) as defined by 332(a)(1) (A) of the Public Health Services Act or in a county outside of an MSA as defined by 1886(d)(2)(D)  (go to the link and select the applicable title) of the Act.   Effective January 1, 2014, rural HPSAs include HPSAs located outside of a county outside of an MSA as well as those located in rural census tracts as determined by the Office of Rural Health Policy.  Also effective January 1, 2014, geographic eligibility for an originating site is established for each calendar year based upon the status of the area as of December 31st of the prior calendar year.