evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Erythropoiesis Stimulating Agents (ESAs) (A56795)
All documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.For any ESA, the medical record must reflect that ESA therapy for the individualized patient is reasonable and necessary. The medical record must document the most recent blood pressure and demonstrate reasonable control not in significant excess of a baseline range for a given patient, weight in kilograms, date and results of HCT or Hb level prior to the administration of ESA therapy, evidence of assessment ruling out other causative factors of anemia or, if causative factors are present, that they have been managed and that it is still necessary to initiate ESA The dosage and route of administration must be documented.
(Medicare Benefit Policy Manual)
Medicare Benefit Policy Manual  Chapter 13 - Rural Health Clinic (RHC) and  Federally Qualified Health Center (FQHC) Services   Table of Contents (Rev. 11803, 01-26-23)  Transmittals for Chapter 13   Index of Acronyms  10 - RHC and FQHC  General Information  10.1 - RHC General Information  10.2 - FQHC General Information  20 - RHC and FQHC Location Requirements  20.1 - Non -Urbanized Area Requirement for RHCs  20.2 - Designated Shortage Area Requirement  for RHCs  30 - RHC and FQHC Staffing Requirements  30.1 - RHC Staffing Requirements  30.2 - RHC Temporary Staffing Waivers  30.3 - FQHC Staffing R equirements  40 - RHC and FQHC Visits  40.1 - Location  40.2 - Hours of Operation  40.3 - Multiple Visits on Same Day  40.4 - Global Billing  40.5 - 3 Day Payment Window  50 - RHC and FQHC Services  50.1 - RHC Services  50.2 - FQHC Services  50.3 - Emergency Services  60 - Non RHC/FQHC Services  60.1 - Description of Non RHC/FQHC Services  70 - RHC  and FQHC  Payment Rate
(Medicare Benefit Policy Manual)
70.1 - RHCs Billing Under the AIR  70.2 - RHC Payment Limit and Exceptions  70.2.1 -  Payment Limits Applicable to Independent RHCs, and Provider -Based RHCs in a Hospital with 50 or More Beds, and New RHCs  70.2.2  Payment Limits Applicable to Provider -Based RHCs in a Hospital with Less than 50 Beds  70.2.2.1 -  Determining Payment Limits for Specified (that is, Grandfathered) Provider -Based RHCs with an AIR Established for RHC Services Fu rnished in 2020 70.2.2.2 -  Determining Payment Limits for Specified (that is, Grandfathered) Provider -Based RHCs that did not have an AIR Established for RHC Services Furnished in 2020  70.3 -  FQHC PPS  Payment Rate and Adjustments  70.4 -  FQHC  Payment Codes  80 - RHC and FQHC Cost Reports  80.1 -  RHC and FQHC Cost Report Requirements  80.2 -  RHC and FQHC Co nsolidated Cost Reports  80.3 -  RHC and FQHC Cost Report Forms  80.4  RHC Productivity Standards  90 - RHC and FQHC Charges, Coinsurance, Deductible, and Waivers  90.1 -  Charges and Waivers  90.2 -  Sliding Fee Scale  100 -  Commingling  110 -  Physician Services  110.1 -  Dental, Podiatry, Optometry, and Chiropractic Services  110.2 -  Treatment Plans or Home Care Plans  110.3 -  Graduate Medical Education  120 -  Services and Supplies Furnished Incident to Physicians Services  120.1 -  Provision of Incident to Services and Supplies  120.2 -  Incident to Services and Supplies Furnished in the Patients Home or Location Other than the RHC or FQHC  120.3 -  Payment for Incident to Services and Supplies  130 -  Nurse Practitioner, Physician Assistant, and Certified Nurse Midwife Services  130.1 -  NP, PA, and CNM Requirements  130.2 -  Physician Supervision  130.3 -  Payment to Physician Assistants  140 -  Services and Supplies Furnished Incident to NP, PA, and CNM Services  150 -  Clinical Psychologist a nd Clinical Social Worker Services  160 -  Services and Supplies Incide nt to CP Services  170 -  Mental Health Visits  180 -  Physical Therapy, Occupational Therapy, and Speech Language P athology Services  190 -  Visiting Nursing Services  190.1 -  Description of Visiting Nursing Services
(Medicare Benefit Policy Manual)
Clinical Social Worker Services  160 -  Services and Supplies Incide nt to CP Services  170 -  Mental Health Visits  180 -  Physical Therapy, Occupational Therapy, and Speech Language P athology Services  190 -  Visiting Nursing Services  190.1 -  Description of Visiting Nursing Services  190.2 -  Requirements for Furnishing Visiting Nursing Services  190.3 -  Home Health Agency Shortage Area  190.4  Authorization for Visiting Nursing Services  190.5  Treatment Plans  for Visiting Nursing Services  200 -  Telehealth Services  210 -  Hospice  Services  210.1 -  Hospice Attending  Physician Services Payment  210.2 -  Provision of Services to Hospice Patients in a n RHC or FQHC  220 -  Preventive Health Services  220.1 -  Preventive Health Services in RHCs  220.2 -  Copayment and Deductible for RHC Preventive Health Services  220.3-  Preventive Health Services in FQHCs  220.4 -  Copayment for FQHC Preventive Health Services  230  Care Management Services
(Medicare Benefit Policy Manual)
230.1 -  Transitional Care Management Services  230.2 -  General Care Management  Services  Chronic Care Management, Principal Care Management, and General Behavioral Health Integration Services  230.2.1  Chronic Care Management (CCM) Services  230.2.2  Principal Care Management (PCM) Services  230.2.3  Chronic Pain Management (CPM) Services  230.2.4  General Behavioral Health Integration (BHI) Services  230.2.5  Payment for General C are Management Services   230.3 -  Psychiatric Collaborative Care Model Services   240  Virtual Communication Services   Index of Acronyms (Rev. 10729, 04- 26-21)  AIR  all inclusive rate  AWV  annual welln ess visit  BHI  behavioral health integration  CCM  chronic care management  CCN  CMS certification number  CNM  certified nurse midwife  CoCM  collaborative care model  CP  clinical psychologist  CSW  clinical social worker  DSMT  diabetes self -management training  EKG  electrocardiogram  E/M  evaluation and management  FQHC  Federally qualified health center  FTE  full time equivalent GAF  geographic adjustment factor  GME  graduate medical education  HCPCS  Healthcare Common Procedure Cod ing System  HHA  home health agency  HHS  Health and Human Services  HPSA  Health Professional Shortage Area  HRSA  Health Resources and Services Administration IPPE  initial preventive physical exam LDTC  low dose computed tomography  LPN  licensed practical nurse  MAC  Medicare Administrative Contractor  MEI  Medicare Economic Index  MNT  medical nutrition therapy  MSA  metropolitan statistical area  MUA  Medically -Underserved Area  MUP  Medically -Underserved Population NCD  national coverage determina tion NECMA  New England County Metropolitan Area  NP  nurse practitioner  OBRA -  Omnibus Budget Reconciliation Act  PA  physician assistant  PCE -  Primary Care Exception  PCM  Principal Care Management  PFS  physician fee schedule PPS  prospective payment system  PHS  Public Health Service  RHC  rural health clinic  RN  registered nurse  RO  regional office  RUCA  Rural Urban Commuting Area  SLP  speech language therapy  TCM  transitional care management  UA  urbanized area  USPSTF  U.S. Preventive Services  Task Force 10 - RHC and FQHC General Information  (Rev. 239, Issued: 01 -09-18, Effective: 1 -22-18, Implementation: 1-22-18)
(Medicare Benefit Policy Manual)
10.1 - RHC General Information  (Rev. 11803; Issued: 01- 26-23; Effective: 01 -01-23; Implementation: 02- 27-23)  Rural  Health  Clinics  (RHCs)  were established  by the Rural  Health  Clinic  Service Act of 1977 to address an inadequate supply of physicians serving Medicare beneficiaries in underserved rural areas, and to increase the utilization of nurse practitioners (NP) and physician assistants (PA) in these areas.  RHCs have been eligible to participate in the  Medicare program since March 1, 1978, and are paid an all -inclusive rate (AIR) for  medically -necessary primary health services, and qualified preventive health services,  furnishe d by an RHC practitioner.  RHCs are defined in section 1861(aa)(2) of the Social Security Act (the Act) as facilities  that are engaged primarily in providing services that are typically furnished in an  outpatient  clinic.  RHC services  are defined  as:    Physician  services;    Services  and supplies  furnished incident  to a physicians  services;    NP, PA, certified  nurse  midwife  (CNM),  clinical  psychologist  (CP),  and clinical  social worker  (CSW) services; and    Services and supplies furnished incident to an NP, PA, CNM, or CP  services.  RHC services may also include nursing visits to patients confined to the home that are  furnished by a registered professional  nurse  (RN) or a licensed  professional  nurse  (LPN)  when  certain conditions are  met.  (See section 190 of  this manual)   To be eligible for certification as an RHC, a clinic must be located in a non -urbanized area, as determined by the U.S. Census Bureau, and in an area designated or certified  within the previous 4 years by the Secretary, Health and Human Services ( HHS), in any  one of the four types of shortage area designations that are accepted for RHC  certification.  (See section 20 of  this manual)   In addition to  the location  requirements,  an RHC  must:     Employ  an NP or  PA;  Have an  NP, PA, or CNM  working  at the clinic  at least  50 percent  of the time the clinic  is operating  as an  RHC;    Directly  furnish  routine  diagnostic  and laboratory  services;    Have arrangements with one or more hospitals to furnish medically necessary  services  that are not available  at the  RHC;
(Medicare Benefit Policy Manual)
 Directly  furnish  routine  diagnostic  and laboratory  services;    Have arrangements with one or more hospitals to furnish medically necessary  services  that are not available  at the  RHC;    Have available drugs  and biologicals  necessary  for the  treatment  of emergencies;    Meet  all health  and safety  requirements;    Not be a rehabilitation agency  or a facility  that is primarily  for mental health  treatment;   Furnish onsite  all of the following  six laboratory  tests:    Chemical  examination of  urine  by stick  or tablet  method or  both;   Hemoglobin or  hematocrit;   Blood sugar;   Examination  of stool  specimens  for occult  blood;   Pregnancy  tests; and   Primary  culturing  for transmittal to  a certified  laboratory.    Not be concurrently  approved as  an FQHC,  and   Meet  other  applicable State  and Federal  requirements. RHCs can be either independent or provider -based. Independent RHCs are stand- alone  or freestanding clinics and submit claims to a Medicare Administrative Contractor (A/B  MAC).  They are assigned a CMS Certification Number (CCN) in the range 3800- 3974 or 8900- 8999. Provider -based RHCs are an integral and subordinate part of a hospital  (including a critical access hospital (CAH)), skilled nursin g facility (SNF), or a home  health agency (HHA).  They are assigned a CCN in the range 3400 -3499, 3975- 3999, or  8500- 8899. ( NOTE: A provider -based CCN is not an indication that the RHC has met the qualifications for the special payment rules applicable  to payment limit s discussed in section 70.2 of this chapter .) The statutory  requirements for  RHCs are  found in  section  1861(aa) of the Act. Many  of the regulations pertaining to RHCs can be found at 42 CFR 405.2400 Subpart X   and following, and 42 CFR 491 Subpart A   and following.  For inform ation on claims processing, see Pub. 100- 04, Medicare Claims Processing  Manual, chapter 9, http://www.cms.gov/Regulations -and- Guidance/Guidance/Manuals/downloads/clm104c09.pdf
(Medicare Benefit Policy Manual)
For information on certification requirements, see Pub. 100-07, State Operations Manual, Chapter 2, and Appendix G, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107c02.pdf    10.2 - FQHC General Information  (Rev. 239, Issued: 01 -09-18 , Effective: 1-22-18, Implementation: 1-22-18)  Federally Qualified Health Centers (FQHCs) were established in 1990 by section 4161 of the Omnibus Budget Reconciliation Act (OBRA) of 1990 and were effective beginning on October 1, 1991.  As with RHCs, they are also faci lities that are primarily engaged in providing services that are typically furnished in an outpatient clinic.  FQHCs were paid an AIR for primary health services and qualified preventive health services until October 1, 2014, when they began to transition to the FQHC prospective payment system (PPS).  Beginning on January 1, 2016, all FQHC are paid under the provisions of the FQHC PPS, as required by Section 10501(i)(3)(B) of the Affordable Care Act. FQHC services are defined as:    Physician services;    Services and supplies furnished incident to a physicians services;   NP, PA, certified nurse midwife (CNM), clinical psychologist (CP), and clinical social worker (CSW) services;    Services and supplies furnished incident to an NP, PA, CNM, or CP services; and
(Medicare Benefit Policy Manual)
 NP, PA, certified nurse midwife (CNM), clinical psychologist (CP), and clinical social worker (CSW) services;    Services and supplies furnished incident to an NP, PA, CNM, or CP services; and   Outpatient diabetes self -management training (DSMT) and medical nutrition therapy (MNT) for beneficiaries with diabetes or renal disease.  The statutory requirements that FQHCs must meet to qualify for the Medicare benefit are in section 1861(aa)(4) of the Act.  No Part B deductible is applied to expenses for services that are payable under the FQHC benefit.  An entity that qualifies as an FQHC is assigned a CCN in the range 1800-1989 and 1000-1199. FQHC services also include certain preventive primary health services.  The law defines Medicare- covered preventive services provided by an FQHC as the preventive primary health services that an FQHC is required to provide under section 330 of the Public Health Service (PHS) Act.  Medicare may not cover some of the preventive services that FQHCs provide, such as dental services, which are specifically excluded under Medicare law.  There are 3 types of organizations that are eligible to enroll in Medicare as FQHCs:    Health Center Program Grantees: Organizations receiving grants under section 330 of the PHS Act, including Community Health Centers, Migrant Health Centers, Health Care for the Homeless Health Centers, and Public Housing Primary Care Centers;    Health Center Program Look -Alikes: Organizations  that hav e been identified by HRSA as meeting the definition of Health Center under section 330 of the PHS Act, but not receiving grant funding under section 330; and    Outpatient health programs/facilities operated by a tribe or tribal organization (under the In dian Self -Determination Act) or by an urban Indian organization (under Title V of the Indian Health Care Improvement Act).   NOTE:   Information in this chapter applies to FQHCs that are Health Center Program Grantees and Health Center Program Look- Alikes.  It does not necessarily apply to tribal or urban Indian FQHCs or grandfathered tribal FQHCs. An FQHC must:    Provide comprehensive  services and have an ongoing quality assurance program;    Meet other health and safety requirements;    Not be concurrently approved as an RHC; and
(Medicare Benefit Policy Manual)
 Provide comprehensive  services and have an ongoing quality assurance program;    Meet other health and safety requirements;    Not be concurrently approved as an RHC; and    Meet all requirements contained in section 330 of the Public Health Service Act, including:   o Serve a designat ed Medically -Underserved Area (MUA) or Medically -Underserved Population (MUP);   o Offer a sliding fee scale to persons with incomes below 200 percent of the federal poverty level; and   o Be governed by a board of directors, of whom a majority of the members receive their care at the FQHC.  Additional information on these and other section 330 requirements can be found at http://bphc.hrsa.gov/ . Per 42 CFR 413.65(n) , only FQHCs that were operating as provider-based clinics prior to 1995 and either a) received funds under section 330 of the PHS Act or b) were determined by CMS to meet the criteria to be a look -alike clinic, are eligible to be certified as provider -based FQHCs.  Clinics that do not already have provider- based status as an FQHC are no longer permitted to receive the designation.  For information on claims processing, see to Pub. 100- 04, Medicare Claims Processing Manual, chapter 9, http://www.cms.gov/Regulations -and-Guidance/Guidance/Manuals/downloads/clm104c09.pdf , and P ub. 100-07, State Operations Manual chapter 2, sections 2825 and 2826, http://www.cms.gov/Regulations -an d-Guidance/Guidance/Manuals/downloads/som107c02.pdf .
(Medicare Benefit Policy Manual)
20 - RHC and FQHC Location Requirements  (Rev. 239, Issued: 01 -09-18 , Effective: 1-22-18, Implementation: 1-22-18)  To be eligible for certification as an RHC, a clinic must be located in 1) a non -urbanized area, as determined by the U.S. Census Bureau, and 2) an area designated or certified within the previous 4 years by the Secretary, HHS, in any one of the four types of shortage area designations that are accepted for RHC certification as listed in section 20.2. A clinic applying to become a Medicare- certified RHC must meet both the rural and underserved location requirements.  Mobile clinics must have a fixed schedule that specifies the date and location for services, and each location must meet the location requirements. Existing RHCs are not current ly required to continue to meet the location requirements.  RHCs that plan to relocate or expand should contact their Regional Office (RO) to determine their location requirements.  FQHCs may be located in rural or urban areas.  FQHCs that are Health Center Program Grantees or Look -Alikes must be located in or serve people from a HRSA-designated MUA or MUP.   20.1 - Non -Urbanized Area Requirement for RHCs  (Rev. 220, Issued: 01-15-16, Effective: 02-01-16, Implementation: 02-01-16)   The U.S. Census Bureau dete rmines if an area is an urbanized area (UA).  Any area that is not in a UA is considered a non-urbanized area.  A clinic located in an area that is not a UA would meet the RHC requirement for being in a non-urbanized area.  Information on whether an area is in an urbanized area can be found at http://factfinder.census.gov; or http://www.raconline.org ; or by contacting the appropriate CMS RO at http://www.cms.gov/RegionalOffices/ .  20.2 - Designated Shortage Area Requirement for RHCs  (Rev. 220, Issued: 01-15-16, Effective: 02-01-16, Implementation: 02-01-16)
(Medicare Benefit Policy Manual)
20.2 - Designated Shortage Area Requirement for RHCs  (Rev. 220, Issued: 01-15-16, Effective: 02-01-16, Implementation: 02-01-16)   The HRSA designates areas as MUAs/MUPs and/or Health Professional  Shortage Areas (HPSAs).  To be eligible for RHC certification, a clinic must be located in an area that has one of the following types of shortage area designations:   Geographic Primary Care HPSA;    Population- group Primary Care HPSA;    MUA (this does not include the population group MUP designation); or   Governor- Designated and Secretary -Certified Shortage Area (this does not include a Governors Medically Underserved Population designation).  No other type of shortage area designation is accepted for purposes of RHC certification.  The designation cannot be more than 4 years old in order to meet the requirement of being in a currently designated area.  For RHC purposes, the age of the designation is calculated as the last day of the year 4 years from the d ate of the original designation, or the date the area was last designated.  For example, a clinic that is located in an area that was most recently designated or updated on June 1, 2010, would be considered as meeting this location requirement through December 31, 2014.  Areas that are listed as proposed for withdrawal are considered designated.  The designation date is the date that the area was last updated, not when the area was proposed for withdrawal.  To determine the designation date of an area that is listed as proposed for withdrawal, contact HRSAs Shortage Designation Branch at sdb@hrsa.gov or call 1 -888-275-4772.  30 - RHC and FQHC Staffing Requirements  (Rev. 166, Issued: 01-31-13, Effective: 03-01-13, Implementation: 03 -01-13)   30.1 - RHC Staffing Requirements  (Rev. 239, Issued: 01 -09-18 , Effective: 1-22-18, Implementation: 1-22-18)  In addition to the location requirements, an RHC must:  Employ an NP or PA; and
(Medicare Benefit Policy Manual)
 Have an NP, PA, or CNM working at the clinic at least 50 percent of the time the clinic is operating as an RHC.  The employment may be full or part time, and is evidenced by a W- 2 form from the RHC.  If another entity such as a hospital has 100 percent ownership of the RHC, the W- 2 form can be from that entity as long as all the non -physician practitioners employed in the RHC receive their W -2 from this owner. The following are examples of situations that would NOT satisfy the employment requirement:   An NP or PA who is employed by a hospital that has an ownership interest in the RHC but is not physically present and working in the RHC;   A CNM who is employed by the RHC;    An Advanced Practice Registered Nurse who is not an NP or PA; or    An NP or PA who is working as a substitute in an arrangement  similar to a locum tenens physician.  An RHC practitioner is a physician, NP, PA, CNM, CP, or CSW.  At least one of these practitioners must be present in the RHC and available to furnish patient care at all times the RHC is in operation.  A clinic that is  open solely to address administrative matters or to provide shelter from inclement weather is not considered to be in operation during this period and is not subject to the staffing requirements.  An NP, PA, or CNM must be available to furnish patient care  at least 50 percent of the time that the RHC is open to provide patient care.  This requirement can be fulfilled through any combination of NPs, PAs, or CNMs as long as the total is at least 50 percent of the time the RHC is open to provide patient care.  Only the time that an NP, PA, or CNM spends in the RHC, or the time spent directly furnishing patient care in another location as an RHC practitioner, is counted towards the 50 percent time.  It does not include travel time to another location, or time sp ent not furnishing patient care when in another location outside the RHC (e.g. home, SNF, etc.).
(Medicare Benefit Policy Manual)
A clinic located on an island that otherwise meets the requirements for RHC certification is not required to employ an NP or PA, although it is still required to have an NP or PA at least 50 percent of the time that the RHC is in operation (OBRA 89, Sec 4024).  An island is a body of land completely surrounded by water, regardless of size and accessibility (e.g., bridges).  As of July 1, 2014, RHCs may contract  with non- physician practitioners (PAs, NPs, CNM, CPs or CSWs) if at least one NP or PA is employed by the RHC (subject to the waiver provision for existing RHCs set forth at section 1861(aa)(7) of the Act).  It is the responsibility of the RHC to assure th at all staffing requirements are met and that RHC practitioners provide services in accordance with state and federal laws and regulations.  See section 80.4 of this chapter for information on productivity standards for RHCs. 30.2 - RHC Temporary Staffing Waivers  (Rev. 239, Issued: 01 -09-18, Effective: 1-22- 18, Implementation: 1-22-18)  An existing RHC may request a temporary staffing waiver if the RHC met the staffing requirements before seeking the waiver, and either or both of the following occur:    An NP or PA is not currently employed by the RHC.