evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
To furnish covered PA services, the PA must meet the conditions as follows:   1.  Have graduated from a physician assistant educational program that is accredited by the Accreditation Review Commission on Education for the Physician Assistant (its predecessor agencies, the Commission on Accreditation of Allied Health Education Progr ams (CAAHEP) and the Committee on Allied Health Education and Accreditation (CAHEA); or   2.  Have passed the national certification examination that is administered by the National Commission on Certification of Physician Assistants (NCCPA); and   3.  Be licensed by the State to practice as a physician assistant.   B.  Covered Services   Coverage is limited to the services a PA is legally authorized to perform in accordance with State law (or State regulatory mechanism provided by State law).   1.  General   The services of a PA may be covered under Part B, if all of the following requirements are met:    They are the type that are considered physicians services if furnished by a doctor of medicine or osteopathy (MD/DO);   They are performed by a person who meets all the PA qualifications,   They are performed under the general supervision of an MD/DO;   The PA is legally authorized to perform the services in the state in which they are performed; and    They are not otherwise precluded from coverage because of one of the statutory exclusions.  2.  Incident To   If covered PA services are furnished, services and supplies furnished incident to the PAs services may also be covered if they would have been covered when furnished incident to the services of an MD/DO, as described in 60.  3. Medical Record Documentation for Part B Services    This medical record documentation requirement applies to Part B professional services that are paid under the Medicare physician fee schedule.   Accordingly, for Part B physician assistant covered services, the physician assistant may review and verify (sign and date), rather than re -document notes in a patients medical record made by physicians, residents, nurses, medical; physician assistant; nurse practitioner; clinical nurse specialist; certified nurse -midwife; and certified registered nurse anesthetist  students or other members of the medical team, including as applicable, notes documenting the physician assistants presence and participation in the service.    For documentation requirements specific to E/M services furnished by physicians and certain nonphysician practitioners, see Chapter 12, section 30.6 of the Medicare Claims Processing Manual, publication 100-04.
(Medicare Benefit Policy Manual)
4.  Types of PA Services That May Be Covered  State law or regulation governing a PAs scope of practice in the State in which the services are performed applies.  A/B MACs (B) should consider developing lists of covered services.  Also, if authorized under the scope of their State license, PAs may furnish services billed under all levels of CPT evaluation and management codes, and diagnostic tests if furnished under the general supervision of a physician.  Examples of the types of services that PAs may provide include services that traditionally have been reserved to physicians, such as physical examinations, minor surgery, setting casts for simple fractures, interpreting x -rays, and other activities that involve an independent evaluation or treatment of the patients condition.  See 60.2 for coverage of services performed by PAs incident to the services of physicians.  5.  Services Otherwise Excluded From Coverage  The PA services may not be covered if they are otherwise excluded from coverage even though a PA may be authorized by State law to perform them.  For example, the Medicare law excludes from coverage routine foot care, routine physical checkups, and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.  Therefore, these services are precluded from coverage even though they may be within a PAs scope of practice under State law.   C.  Physician Supervision  The physician supervision requirement under Medicare law is met under the circumstances as follows:
(Medicare Benefit Policy Manual)
C.  Physician Supervision  The physician supervision requirement under Medicare law is met under the circumstances as follows:   Medicare Part B covers a PAs services only if the PA performs the services in accordance with state law and state scope of practice rules for PAs in the state in which the PAs professional services are furnished. Any state laws and scope of practice rules that describe the required practice relationship between physicians and PAs, including explicit supervisory or collaborative practice requirements, describe a form of supervision for purposes of the PA benefit category under section 1861(s)(2)(K)(i) of the Act. For states with no explicit state law and scope of practice rules regarding physician supervision of PAs services, physician supervision is a process in which a PA has a working relationship with one or more physicians to supervise the delivery of their health care services. Such physician supervision is evidenced by documenting at the practice level the PAs scope of practice and the working relationships the PA has with the supervising physician/s when furnishing professional services.  D.  Direct Billing and Payment  Effective January 1, 2022, direct billing and payment for PA services may be made to the PA.  E.  Assignment Assignment for PA services is mandatory.  200 - Nurse Practitioner (NP) Services  (Rev. 11771 ; Issued:12 -30-22 ; Effective:01 -01-23 ; Implementation:01-01-23 )  Effective for services rendered after January 1, 1998, any individual who is participating under the Medicare program as a nurse practitioner (NP) for the first time ever, may have his or her professional services covered if he or she meets the qualifications listed below, and he or she is legally authorized to furnish NP services in the State where the services are performed.  NPs who were issued billing provider numbers prior to January 1, 1998, may continue to furnish services under the NP benefit.  Payment for NP services is effective on the date of service, that is, on or after January 1, 1998, and payment is made on an assignment -related basis only.  A.  Qualifications for NPs   In order to furnish covered NP services, an NP must meet the conditions as follows:    Be a registered professional nurse who is authorized by the State in which the services are furnished to practice as a nurse practitioner in accordance with State law; and be certified as a nurse practitioner by a recognized national certifying body that has established standards for nurse practitioners; or
(Medicare Benefit Policy Manual)
 Be a registered professional nurse who is authorized by the State in which the services are furnished to practice as a nurse practitioner by December 31, 2000.  The following organizations are recognized national certifying bodies for NPs at the advanced practice level:    American Academy of Nurse Practitioners;   American Nurses Credentialing Center;   National Certification Corporation for Obstetric, Gynecologic and Neonatal Nursing Specialties;  Pediatric Nursing Certification Board (previously named the National Certification Board of Pediatric Nurse Practitioners and Nurses);   Oncology Nurses Certification Corporation;   AACN Certification Corporation;    National Board on Certification of Hospice and Palliative Nurses; and,   Nurse Portfolio Credentialing Commission.   The NPs applying for a Medicare billing number for the first time on or after January 1, 2001, must meet the requirements as follows:    Be a registered professional nurse who is authorized by the State in which the services are furnished to practice as a nurse practitioner in accordance with State law; and    Be certified as a nurse practitioner by a recognized national certifying body that has established standards for nurse practitioners.  The NPs ap plying for a Medicare billing number for the first time on or after January 1, 2003, must meet the requirements as follows:   Be a registered professional nurse who is authorized by the State in which the services are furnished to practice as a nurse practitioner in accordance with State law;    Be certified as a nurse practitioner by a recognized national certifying body that has established standards for nurse practitioners; and    Possess a masters degree in nursing or a doctor of nursing practice (DNP) doctoral degree.   B.  Covered Services   Coverage is limited to the services an NP is legally authorized to perform in accordance with State law (or State regulatory mechanism established by State law).   1.  General   The services of an NP may be covered under Part B if all of the following conditions are met:  They are the type that are considered physicians services if furnished by a doctor of medicine or osteopathy (MD/DO);   They are performed by a person who meets the definition of an NP (see subsection A);   The NP is legally authorized to perform the services in the State in which they are performed;    They are performed in collaboration with an MD/DO (see subsection D); and
(Medicare Benefit Policy Manual)
 The NP is legally authorized to perform the services in the State in which they are performed;    They are performed in collaboration with an MD/DO (see subsection D); and   They are not otherwise precluded from coverage because of one of the statutory exclusions. (See subsection C.2.)  2.  Incident To   If covered NP services are furnished, services and supplies furnished incident to the services of the NP may also be covered if they would have been covered when furnished incident to the services of an MD/DO as described in 60.  3. Medical Record Documentation for Part B Services   This medical record documentation requirement applies to Part B professional services that are paid under the Medicare physician fee schedule.   Accordingly, for Part B nurse practitioner covered services, the nurse practitioner may review and verify (sign and date), rather than re-document notes in a patients medical record made by physicians, residents, nurses, medical; physician assistant; nurse practitioner; clinical nurse specialist; certified nurse- midwife; and certified registered nurse anesthetist s tudents or other members of the medical team, including as applicable, notes documenting the nurse practitioners presence and participation in the service.     For documentation requirements specific to E/M services furnished by physicians and certain nonphysician practitioners, see Chapter 12, section 30.6 of the Medicare Claims Processing Manual, publication 100-04.   C.  Application of Coverage Rules  1.  Types of NP Services That May Be Covered  State law or regulation governing an NPs scope of practice in the State in which the services are performed applies.  Consider developing a list of covered services based on the State scope of practice.  Examples of the types of services that NPs may fur nish include services that traditionally have been reserved to physicians, such as physical examinations, minor surgery, setting casts for simple fractures, interpreting x-rays, and other activities that involve an independent evaluation or treatment of the patients condition.  Also, if authorized under the scope of their State license, NPs may furnish services billed under all levels of evaluation and management codes and diagnostic tests if furnished in collaboration with a physician.  See 60.2 for coverage of services performed by NPs incident to the services of physicians.
(Medicare Benefit Policy Manual)
for coverage of services performed by NPs incident to the services of physicians.  2.  Services Otherwise Excluded From Coverage  The NP services may not be covered if they are otherwise excluded from coverage even though an NP may be authorized by State law to perform them.  For example, the Medicare law excludes from coverage routine foot care, routine physical checkups, and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.  Therefore, these services are precluded from coverage even though they may be within an NPs scope of practice under State law.   D.  Collaboration  Collaboration is a process in which an NP works with one or more physicians (MD/DO) to deliver health care services, with medical direction and appropriate supervision as required by the law of the State in which the services are furnished.  In the absence of State law governing collaboration, collaboration is to be evidenced by NPs documenting their scope of practice and indicating the relationships that they have with physicians to deal with issues outside their scope of practice.   The collaborating physician does not need to be present with the NP when the services are furnished or to make an independent evaluation of each patient who is seen by the NP.  E.  Direct Billing and Payment   Direct billing and payment for NP services may be made to the NP.   F.  Assignment   Assignment is mandatory.  210 - Clinical Nurse Specialist (CNS) Services  (Rev. 11771 ; Issued:12 -30-22 ; Effective:01 -01-23 ; Implementation:01 -01-23 )  Effective for services rendered after January 1, 1998, any individual who is participating under the Medicare program as a clinical nurse specialist (CNS) for the first time ever, may have his or her professional services covered if he or she meets the qualifications listed below and he or she is legally authorized to furnish CNS s ervices in the State where the services are performed.  CNSs who were issued billing provider numbers prior to January 1, 1998, may continue to furnish services under the CNS benefit.  Payment for CNS services is effective on the date of service, that is, on or after January 1, 1998, and payment is made on an assignment -related basis only.  A.  Qualifications for CNSs   In order to furnish covered CNS services, a CNS must meet the conditions as follows:
(Medicare Benefit Policy Manual)
A.  Qualifications for CNSs   In order to furnish covered CNS services, a CNS must meet the conditions as follows:   1. Be a registered nurse who is currently licensed to practice in the State where he or she practices and be authorized to furnish the services of a clinical nurse specialist in accordance with State law;   2. Have a masters degree in a defined clinical area of nursing from an accredited educational institution or a doctor of nursing practice (DNP) doctoral degree; and   3. Be certified as a clinical nurse specialist by a recognized national certifying body that has established standards for CNSs.   The following organizations are recognized national certifying bodies for CNSs at the advanced practice level:    American Academy of Nurse Practitioners;   American Nurses Credentialing Center;   National Certification Corporation for Obstetric, Gynecologic and Neonatal Nursing Specialties;  Pediatric Nursing Certification Board (previously named the National Certification Board of Pediatric Nurse Practitioners and Nurses);   Oncology Nurses Certification Corporation;   AACN Certification Corporation;   National Board on Certification of Hospice and Palliative Nurses; and,   Nurse Portfolio Credentialing Commission.   B.  Covered Services   Coverage is limited to the services a CNS is legally authorized to perform in accordance with State law (or State regulatory mechanism provided by State law).   1.  General   The services of a CNS may be covered under Part B if all of the following conditions are met:   They are the types of services that are considered as physicians services if furnished by an MD/DO;    They are furnished by a person who meets the CNS qualifications (see subsection A);    The CNS is legally authorized to furnish the services in the State in which they are performed;    They are furnished in collaboration with an MD/DO as required by State law (see subsection C); and   They are not otherwise excluded from coverage because of one of the statutory exclusions. (See subsection C.)   2.  Types of CNS Services that May be Covered   State law or regulations governing a CNS scope of practice in the State in which the services are furnished applies.  A/B MACs (B) must develop a list of covered services based on the State scope of practice.
(Medicare Benefit Policy Manual)
State law or regulations governing a CNS scope of practice in the State in which the services are furnished applies.  A/B MACs (B) must develop a list of covered services based on the State scope of practice.   Examples of the types of services that a CNS may furnish include services that traditionally have been reserved for physicians, such as physical examinations, minor surgery, setting casts for simple fractures, interpreting x- rays, and other activities that  involve an independent evaluation or treatment of the patients condition.  Also, if authorized under the scope of his or her State license, a CNS may furnish services billed under all levels of evaluation and management codes and diagnostic tests if furnished in collaboration with a physician.  3.  Incident To   If covered CNS services are furnished, services and supplies furnished incident to the services of the CNS may also be covered if they would have been covered when furnished incident to the services of an MD/DO as described in 60.  4. Medical Record Documentation for Part B Services   This medical record documentation requirement applies to Part B professional services that are paid under the Medicare physician fee schedule.  Accordingly, for Part B Clinical Nurse Specialist (CNS) covered services, the CNS may review and verify (sign and date), rather than re-document notes in a patients medical record made by physicians, residents, nurses, medical; physician assistant; nurse practitioner; clinical nurse specialist; certified nurse- midwife; and certified registered nurse anesthetist stu dents or other members of the medical team, including as applicable, notes documenting the CNSs presence and participation in the service.
(Medicare Benefit Policy Manual)
For documentation requirements specific to E/M services furnished by physicians and certain nonphysician practitioners, see Chapter 12, section 30.6 of the Medicare Claims Processing Manual, publication 100-04.  C.  Application of Coverage Rules  1.  Types of CNS Services  Examples of the types of services that CNS may provide are services that traditionally have been reserved for physicians, such as physical examinations, minor surgery, setting casts for simple fractures, interpreting x -rays, and other activities that invol ve an independent evaluation or treatment of the patients condition.  State law or regulation governing a CNS scope of practice for his or her service area applies.  2.  Services Otherwise Excluded From Coverage  A CNS services are not covered if they are otherwise excluded from coverage even though a CNS may be authorized by State law to perform them.  For example, the Medicare law excludes from coverage routine foot care and routine physical checkups and services that are not reasonable and necessary for diagnosis or treatment of an illness or injury or to improve the function of a malformed body member.  Therefore, these services are precluded from coverage even though they may be within a CNS scope of practice under State law.   See 60.2  for coverage of services performed by a CNS incident to the services of physicians.  D.  Collaboration  Collaboration is a process in which a CNS works with one or more physicians (MD/DO) to deliver health care services within the scope of the CNS professional expertise with medical direction and appropriate supervision as required by the law of the State in which the services are furnished.  In the absence of State law governing collaboration, collaboration is to be evidenced by the CNS documenting his or her scope of practice and indicating the relationships that the CNS has with physicians to deal with is sues outside the CNS scope of practice.   The collaborating physician does not need to be present with the CNS when the services are furnished or to make an independent evaluation of each patient who is seen by the CNS.   E.  Direct Billing and Payment  A CNS may bill directly and receive direct payment for their services.   F.  Assignment Requirement   Assignment is required for the service to be covered.  220 - Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech -Language Pathology Services) Under Medical Insurance  (Rev. 12425; Issued: 12-21- 23: Effective: 01 -01-24; Implementation: 01-02-24)
(Medicare Benefit Policy Manual)
A comprehensive knowledge of the policies that apply to therapy services cannot be obtained through manuals alone.  The most definitive policies are Local Coverage Determinations found at the Medicare Coverage Database www.cms.hhs.gov/mcd.  A list of Medicare contractors is found at the CMS Web site.  Specific questions about all Medicare policies should be addressed to the contractors through the contact information supplied on their Web sites.  General Medicare questions may be addressed to the Medicare regional offices http://www.cms.hhs.gov/RegionalOffices/ .    A.  Definitions    The following defines terms used in this section and 230:    ACTIVE PARTICIPATION of the clinician in treatment means that the clinician personally furnishes in its entirety at least 1 billable service on at least 1 day of treatment.    ASSESSMENT is separate from evaluation, and is included in services or procedures, (it is not separately payable).  The term assessment as used in Medicare manuals related to therapy services is distinguished from language in Current Procedural Terminology (CPT) codes that specify assessment, e.g., 97755, Assistive Technology Assessment, which may be payable).  Assessments shall be provided only by clinicians, because assessment requires professional skill to gather data by observation and patient inquiry a nd may include limited objective testing and measurement to make clinical judgments regarding the patient's condition(s).  Assessment determines, e.g., changes in the patient's status since the last visit/treatment day and whether the planned procedure or service should be modified.  Based on these assessment data, the professional may make judgments about progress toward goals and/or determine that a more complete evaluation or re- evaluation (see definitions below) is indicated.  Routine weekly assessments  of expected progression in accordance with the plan are not payable as re- evaluations.    CERTIFICATION is the physicians/nonphysician practitioners (NPP) approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.