evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
 Is licensed as an audiologist by the State in which the individual furnishes such services, or   In the case of an individual who furnishes services in a State which does not license audiologists has:  o Successfully completed 350 clock hours of supervised clinical practicum (or is in the process of accumulating such supervised clinical experience), and    Performed not less than 9 months of supervised full-time audiology services after obtaining a masters or doctoral degree in audiology or a related field, and   Successfully completed a national examination in audiology approved by the Secretary.  If it is necessary to determine whether a particular audiologist is qualified under the above definition, the A/B MAC (B) should check references.  A/B MACs (B) in States that have statutory licensure or certification should secure from the appropriate State agency a current listing of audiologists holding the required credentials.  Additional references for determining an audiologists professional qualifications are the national directory published annually by the American Speech-Language-Hearing Association and records and directories, which may be available from the State Licensing Authority.  80.4 - Coverage of Portable X -Ray Services Not Under the Direct Supervision of a Physician  (Rev. 1, 10-01-03) B3-2070.4  80.4.1 - Diagnostic X- Ray Tests  (Rev. 1, 10-01-03) B3-2070.4.A  Diagnostic x-ray services furnished by a portable x-ray supplier are covered under Part B when furnished in a place or residence used as the patients home and in nonparticipating institutions.  These services must be performed under the general supervision of a physician, the supplier must meet FDA certification requirements, and certain conditions relating to health and safety (as prescribed by the Secretary) must be met.  Diagnostic portable x-ray services are also covered under Part B when provided in participating SNFs and hospitals, under circumstances in which they cannot be covered under hospital insurance, i.e., the services are not furnished by the participating institution either directly or under arrangements that provide for the institution to bill for the services.  (See 250 for Part B services furnished to inpatients of participating and nonparticipating institutions.)  80.4.2 - Applicability of Health and Safety Standards  (Rev. 1, 10-01-03) B3-2070.4.B
(Medicare Benefit Policy Manual)
80.4.2 - Applicability of Health and Safety Standards  (Rev. 1, 10-01-03) B3-2070.4.B  The health and safety standards apply to all suppliers of portable x-ray services, except physicians who provide immediate personal supervision during the administration of diagnostic x -ray services.  Payment is made only for services of approved suppliers who have been found to meet the standards.  Notice of the coverage dates for services of approved suppliers are given to A/B MACs (B) by the RO.  When the services of a supplier of portable x-ray services no longer meet the conditions of coverage, physicians having an interest in the suppliers certification status must be notified.  The notification action regarding suppliers of portable x-ray equipment is the same as required for decertification of independent laboratories, and the procedures explained in 80.1.3 are followed.   80.4.3 - Scope of Portable X- Ray Benefit  (Rev. 71, Issued: 05-25-07, Effective: N/A; Implementation: July 2, 2007)  In order to avoid payment for services, which are inadequate or hazardous to the patient, the scope of the covered portable x -ray benefit is defined as:    Skeletal films involving the extremities, pelvis, vertebral column, or skull;   Chest films which do not involve the use of contrast media (except routine screening procedures and tests in connection with routine physical examinations);   Abdominal films which do not involve the use of contrast media; and   Diagnostic mammograms if the approved portable x-ray supplier, as defined in 42 CFR part 486, subpart C, meets the certification requirements of section 354 of the Public Health Services Act, as implemented by 21 CFR part 900, subpart B.  80.4.4 - Exclusions From Coverage as Portable X-Ray Services (Rev. 1, 10-01-03) B3-2070.4.D  Procedures and examinations which are not covered under the portable x-ray provision include the following:   Procedures involving fluoroscopy;   Procedures involving the use of contrast media;   Procedures requiring the administration of a substance to the patient or injection of a substance into the patient and/or special manipulation of the patient;
(Medicare Benefit Policy Manual)
 Procedures involving the use of contrast media;   Procedures requiring the administration of a substance to the patient or injection of a substance into the patient and/or special manipulation of the patient;   Procedures which require special medical skill or knowledge possessed by a doctor of medicine or doctor of osteopathy or which require that medical judgment be exercised;   Procedures requiring special technical competency and/or special equipment or materials;   Routine screening procedures; and   Procedures which are not of a diagnostic nature.  80.4.5 - Electrocardiograms  (Rev. 1, 10-01-03) B3-2070.4.F  The taking of an electrocardiogram tracing by an approved supplier of portable x- ray services may be covered as an other diagnostic test.  The health and safety standards referred to in 80.4.2 are applicable to such diagnostic EKG services, e.g., the technician must meet the personnel qualification requirements in the conditions for coverage of portable x- ray services.   80.5 - Bone Mass Measurements (BMMs)  (Rev.70, Issued: 05-11- 07, Effective: 01 -01-07, Implementation: 07-02-07)   80.5.1 - Background  (Rev. 70, Issued: 05-11- 07, Effective: 01 -01-07, Implementation: 07-02-07)   On June 24, 1998, CMS published an Interim Final Rule with Comment Period (IFC) in the Federal Register entitled "Medicare Coverage of and Payment for Bone Mass Measurements."  This IFC implemented section 4106 of the Balanced Budget Act of 1997 by establishing conditions for coverage and frequency standards thereby providing uniform coverage under Medicare Part B.  It was effective July1, 1998.  On December 1, 2006, CMS published the CY 2007 Physician Fee Schedule final rule.  This rule implemented several changes effective January 1, 2007, which are reflected below.   80.5.2 - Authority  (Rev. 70, Issued: 05-11- 07, Effective: 01 -01-07, Implementation: 07-02-07)
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80.5.2 - Authority  (Rev. 70, Issued: 05-11- 07, Effective: 01 -01-07, Implementation: 07-02-07)   Definitions can be found in sections 1861(s)(15) and (rr)(1) of the Social Security Act (the Act).  Conditions for coverage and frequency standards can be found in 42 CFR 410.31.  Denials as not reasonable and necessary can be found at 1862(a)(1)(A) of the Act, 42 CFR 410.31(e), and 42 CFR 411.15(k).  80.5.3 - Definition  (Rev. 70, Issued: 05-11- 07, Effective: 01 -01-07, Implementation: 07-02-07)   BMM means a radiologic, radioisotopic, or other procedure that meets all of the following conditions:   Is performed to identify bone mass, detect bone loss, or determine bone quality.   Is performed with either a bone densitometer (other than single-photon or dual-photon absorptiometry) or a bone sonometer system that has been cleared for marketing for BMM by the Food and Drug Administration (FDA) under 21 CFR part 807, or approved for marketing under 21 CFR part 814.   Includes a physicians interpretation of the results.  80.5.4 - Conditions for Coverage  (Rev. 70, Issued: 05-11- 07, Effective: 01 -01-07, Implementation: 07-02-07)   Medicare covers BMM under the following conditions:  1. Is ordered by the physician or qualified nonphysician practitioner who is treating the beneficiary following an evaluation of the need for a BMM and determination of the appropriate BMM to be used.  A physician or qualified nonphysician practitioner treating the beneficiary for purposes of this provision is one who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results in the management of the patient.  For the purposes of the BMM benefit, qualified nonphysician practitioners include physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives.   2. Is performed under the appropriate level of physician supervision as defined in 42 CFR 410.32(b).
(Medicare Benefit Policy Manual)
2. Is performed under the appropriate level of physician supervision as defined in 42 CFR 410.32(b).  3. Is reasonable and necessary for diagnosing and treating the condition of a beneficiary who meets the conditions described in 80.5.6.  4. In the case of an individual being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy, is performed with a dual-energy x-ray absorptiometry system (axial skeleton).  5. In the case of any individual who meets the conditions of 80.5.6 and who has a confirmatory BMM, is performed by a dual-energy x- ray absorptiometry system (axial skeleton) if the initial BMM was not performed by a dual-energy x-ray absorptiometry system (axial skeleton).  A confirmatory baseline BMM is not covered if the initial BMM was performed by a dual- energy x -ray absorptiometry system (axial skeleton).   80.5.5 - Frequency Standards  (Rev. 70, Issued: 05-11- 07, Effective: 01 -01-07, Implementation: 07-02-07)   Medicare pays for a screening BMM once every 2 years (at least 23 months have passed since the month the last covered BMM was performed).   When medically necessary, Medicare may pay for more frequent BMMs.  Examples include, but are not limited to, the following medical circumstances:    Monitoring beneficiaries on long-term glucocorticoid (steroid) therapy of more than 3 months.   Confirming baseline BMMs to permit monitoring of beneficiaries in the future.   80.5.6 - Beneficiaries Who May be Covered  (Rev. 70, Issued: 05- 11-07, Effective: 01 -01-07, Implementation: 07- 02-07)  To be covered, a beneficiary must meet at least one of the five conditions listed below:   1. A woman who has been determined by the physician or qualified nonphysician practitioner treating her to be estrogen- deficient and at clinical risk for osteoporosis, based on her medical history and other findings.
(Medicare Benefit Policy Manual)
1. A woman who has been determined by the physician or qualified nonphysician practitioner treating her to be estrogen- deficient and at clinical risk for osteoporosis, based on her medical history and other findings.  NOTE:  Since not every woman who has been prescribed estrogen replacement therapy (ERT) may be receiving an adequate dose of the therapy, the fact that a woman is receiving ERT should not preclude her treating physician or other qualified treating nonphysician practitioner from ordering a bone mass measurement for her.  If a BMM is ordered for a woman following a careful evaluation of her medical need, however, it is expected that the ordering treating physician (or other qualified treating nonphysician pr actitioner) will document in her medical record why he or she believes that the woman is estrogen -deficient and at clinical risk for osteoporosis.  2. An individual with vertebral abnormalities as demonstrated by an x- ray to be indicative of osteoporosis, osteopenia, or vertebral fracture.   3. An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3 months.  4. An individual with primary hyperparathyroidism.  5. An individual being monitored to assess the response to or efficacy of an FDA -approved osteoporosis drug therapy.   80.5.7 - Noncovered BMMs (Rev. 70, Issued: 05- 11-07, Effective: 01 -01-07, Implementation: 07- 02-07)  The following BMMs are noncovered under Medicare because they are not considered reasonable and necessary under section 1862(a)(1)(A) of the Act.   Single photon absorptiometry (effective January 1, 2007).  Dual photon absorptiometry (established in 1983).   80.5.8 - Claims Processing  (Rev. 70, Issued: 05- 11-07, Effective: 01 -01-07, Implementation: 07- 02-07)  For instructions concerning payment methodology, HCPCS coding, and Medicare summary notice and remittance advice messages, see chapter 13, section 140 of Pub. 100- 04, Medicare Claims Processing Manual.
(Medicare Benefit Policy Manual)
For instructions concerning payment methodology, HCPCS coding, and Medicare summary notice and remittance advice messages, see chapter 13, section 140 of Pub. 100- 04, Medicare Claims Processing Manual.   80.5.9 - National Coverage Determinations (NCDs)  (Rev. 70, Issued: 05- 11-07, Effective: 01 -01-07, Implementation: 07- 02-07)  In addition to these conditions for coverage, CMS may determine through the NCD process that additional BMM systems are reasonable and necessary under section 1862(a)(1) of the Act for monitoring and confirming baseline BMMs.  80.6 - Requirements for Ordering and Following Orders for Diagnostic Tests  (Rev. 80; Issued:  01- 11-08; Effective:  01 -01-03; Implementation:  11 -19-07)  The following sections provide instructions about ordering diagnostic tests and for complying with such orders for Medicare payment.   NOTE:  Unless specified, these sections are not applicable in a hospital setting.  80.6.1 - Definitions  (Rev. 94, Issued: 08- 29-08, Effective: 01- 01-03, Implementation: 09- 30-08)  Diagnostic Test   A diagnostic test includes all diagnostic x -ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary.   Treating Physician   A treating physician is a physician, as defined in 1861(r) of the Social Security Act (the Act), who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results of a diagnostic test in the management of the beneficiarys specific medical problem.   A radiologist performing a therapeutic interventional procedure is considered a treating physician.  A radiologist performing a diagnostic interventional or diagnostic procedure is not considered a treating physician.  Treating Practitioner   A treating practitioner is a nurse practitioner, clinical nurse specialist, or physician assistant, as defined in 1861(s)(2)(K) of the Act, who furnishes, pursuant to State law, a consultation or treats a beneficiary for a specific medical problem, and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem.   Testing Facility
(Medicare Benefit Policy Manual)
Testing Facility   A testing facility is a Medicare provider or supplier that furnishes diagnostic tests.  A testing facility may include a physician or a group of physicians (e.g., radiologist, pathologist), a laboratory, or an independent diagnostic testing facility (IDT F).  Order   An order is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary.  The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the in itial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y).  An order may be delivered via the following forms of communication:    A written document signed by the treating physician/practitioner, which is hand- delivered, mailed, or faxed to the testing facility; NOTE:   No signature is required on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services;    A telephone call by the treating physician/practitioner or his/her office to the testing facility; and    An electronic mail by the treating physician/practitioner or his/her office to the testing facility.   If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records.  While a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed.   80.6.2 - Interpreting Physician Determines a Different Diagnostic Test is Appropriate  (Rev. 80; Issued:  01- 11-08; Effective:  01 -01-03; Implementation:  11 -19-07)
(Medicare Benefit Policy Manual)
80.6.2 - Interpreting Physician Determines a Different Diagnostic Test is Appropriate  (Rev. 80; Issued:  01- 11-08; Effective:  01 -01-03; Implementation:  11 -19-07)  When an interpreting physician, e.g., radiologist, cardiologist, family practitioner, general internist, neurologist, obstetrician, gynecologist, ophthalmologist, thoracic surgeon, vascular surgeon, at a testing facility determines that an ordered diagnost ic radiology test is clinically inappropriate or suboptimal, and that a different diagnostic test should be performed (e.g., an MRI should be performed instead of a CT scan because of the clinical indication), the interpreting physician/testing facility ma y not perform the unordered test until a new order from the treating physician/practitioner has been received.  Similarly, if the result of an ordered diagnostic test is normal and the interpreting physician believes that another diagnostic test should be performed (e.g., a renal sonogram was normal and based on the clinical indication, the interpreting physician believes an MRI will reveal the diagnosis), an order from the treating physician must be received prior to performing the unordered diagnostic tes t.  80.6.3 - Rules for Testing Facility to Furnish Additional Tests  (Rev. 80; Issued:  01- 11-08; Effective:  01 -01-03; Implementation:  11 -19-07)  If the testing facility cannot reach the treating physician/practitioner to change the order or obtain a new order and documents this in the medical record, then the testing facility may furnish the additional diagnostic test if all of the following criter ia apply:    The testing center performs the diagnostic test ordered by the treating physician/practitioner;    The interpreting physician at the testing facility determines and documents that, because of the abnormal result of the diagnostic test performed, an additional diagnostic test is medically necessary;    Delaying the performance of the additional diagnostic test would have an adverse effect on the care of the beneficiary;    The result of the test is communicated to and is used by the treating physician/practitioner in the treatment of the beneficiary; and    The interpreting physician at the testing facility documents in his/her report why additional testing was done.   EXAMPLE:
(Medicare Benefit Policy Manual)
 The interpreting physician at the testing facility documents in his/her report why additional testing was done.   EXAMPLE:   The last cut of an abdominal CT scan with contrast shows a mass requiring a pelvic CT scan to further delineate the mass; (b) a bone scan reveals a lesion on the femur requiring plain films to make a diagnosis.  80.6.4 - Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests  (Rev. 80; Issued:  01- 11-08; Effective:  01 -01-03; Implementation:  11 -19-07)  The following applies to an interpreting physician of a testing facility who furnishes a diagnostic test to a beneficiary who is not a hospital inpatient or outpatient.  The interpreting physician must document accordingly in his/her report to the treating physician/practitioner.   Test Design   Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test (e.g., number of radiographic views obtained, thickness of tomographic sections acquired, use or non- use of contrast media).   Clear Error   The interpreting physician may modify, without notifying the treating physician/practitioner, an order with clear and obvious errors that would be apparent to a reasonable layperson, such as the patient receiving the test (e.g., x- ray of wrong foot ordered ).  Patient Condition   The interpreting physician may cancel, without notifying the treating physician/ practitioner, an order because the beneficiarys physical condition at the time of diagnostic testing will not permit performance of the test (e.g., a barium enema cannot be p erformed because of residual stool in colon on scout KUB; 170.5PA/LAT of the chest cannot be performed because the patient is unable to stand).  When an ordered diagnostic test is cancelled, any medically necessary preliminary or scout testing performed is  payable.   80.6.5 - Surgical/Cytopathology Exception  (Rev. 80; Issued:  01 -11-08; Effective:  01 -01-03; Implementation:  11 -19-07)
(Medicare Benefit Policy Manual)
80.6.5 - Surgical/Cytopathology Exception  (Rev. 80; Issued:  01 -11-08; Effective:  01 -01-03; Implementation:  11 -19-07)  This exception applies to an independent laboratorys pathologist or a hospital pathologist who furnishes a pathology service to a beneficiary who is not a hospital inpatient or outpatient, and where the treating physician/practitioner does not specificall y request additional tests the pathologist may need to perform.  When a surgical or cytopathology specimen is sent to the pathology laboratory, it typically comes in a labeled container with a requisition form that reveals the patient demographics, the nam e of the physician/practitioner, and a clinical impression and/or brief history.  There is no specific order from the surgeon or the treating physician/practitioner for a certain type of pathology service.  While the pathologist will generally perform some  type of examination or interpretation on the cells or tissue, there may be additional tests, such as special stains, that the pathologist may need to perform, even though they have not been specifically requested by the treating physician/practitioner.  T he pathologist may perform such additional tests under the following circumstances:    These services are medically necessary so that a complete and accurate diagnosis can be reported to the treating physician/practitioner;    The results of the tests are communicated to and are used by the treating physician/practitioner in the treatment of the beneficiary; and    The pathologist documents in his/her report why additional testing was done.  EXAMPLE:   A lung biopsy is sent by the surgeon to the pathology department, and the pathologist finds a granuloma which is suspicious for tuberculosis.  The pathologist cultures the granuloma, sends it to bacteriology, and requests smears for acid fast bacilli (tube rculosis).  The pathologist is expected to determine the need for these studies so that the surgical pathology examination and interpretation can be completed and the definitive diagnosis reported to the treating physician for use in treating the beneficia ry.  90 - X-Ray, Radium, and Radioactive Isotope Therapy  (Rev. 1, 10- 01-03) B3-2075  These services also include materials and services of technicians.