TL;DR
Chapter 12 of the Medicare Claims Processing Manual (Pub. 100-04) is the claims rulebook for physicians and nonphysician practitioners billing Part B. It explains how a Physician Fee Schedule amount is built and adjusted, how evaluation and management visits, split or shared visits and critical care are billed, what the global surgical package contains, and how assistant, co-surgeon, bilateral, teaching-physician and telehealth claims are paid.
Chapter 12 at a glance
- Current revision
- Rev. 13316
- Issued July 24, 2025
- Effective
- January 1, 2025
- Implemented August 25, 2025
- Sections
- 180
- 25 top-level sections
- Transmittals in history
- 126
- Listed at the end of the chapter
- Monthly searches
- 260
- Google Ads, US, October 2026
What chapter 12 governs for billing
Most of what a professional Medicare claim looks like is settled in this chapter. Section 20 explains the Medicare Physician Fee Schedule: relative value units for work, practice expense and malpractice are each adjusted by a geographic practice cost index and multiplied by the conversion factor (20.1 and 20.2), and the result is then adjusted for the site of service, for participating versus nonparticipating status and for assistant-at-surgery services (20.4). Section 30 sets correct coding policy for particular code families, from chemotherapy administration and nonchemotherapy injections and infusions (30.5) to the long run of evaluation and management rules in 30.6.
Section 30.6 is the part most billing teams keep open. It covers choosing a visit level, billing a problem-oriented visit on the same day as a preventive visit (30.6.2), office and outpatient visits including when the complexity add-on G2211 is payable next to a visit billed with modifier 25 and a listed preventive service (30.6.7), hospital inpatient and observation care (30.6.8 and 30.6.9), critical care including split or shared critical care (30.6.12), prolonged services (30.6.15) and split or shared visits paid to the practitioner who performs the substantive portion (30.6.18). Section 30.6.19 describes G2211 itself.
Section 40 defines the global surgical package. Preoperative visits from the day before a major procedure (the day of a minor one), intra-operative work, complications that do not need a return to the operating room and related postoperative visits are all inside the surgical payment, and 40.6 to 40.9 set the payment rules for multiple, bilateral, co-surgeon and team surgery claims. Later sections handle anesthesia (50), teaching physicians (100), physician assistants, nurse practitioners and clinical nurse specialists, who are paid at 85 percent of the fee schedule (110 and 120), telehealth (190), and the newer marriage and family therapist and mental health counselor benefits (240 and 250).
Sections billing teams use most
Section numbers and headings are CMS's; the notes are ours. Each section number opens the official chapter 12 PDF at the page where that section starts.
| Section | CMS heading | Why it matters |
|---|---|---|
| 20.4.3 | Assistant at Surgery Services | Assistant-at-surgery payment: the fee schedule pays 16 percent of the global surgical amount, and a nonphysician assistant is paid 85 percent of that. |
| 30.6.7 | Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99202 - 99215) | Office and outpatient visits, including the payment criteria for G2211 when the visit carries modifier 25 and a listed preventive service is billed the same day. |
| 30.6.12 | Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292) | Critical care definitions, concurrent care by different specialties, split or shared critical care and critical care during a global period. |
| 30.6.18 | Split (or Shared) Visits | Split or shared visits: which practitioner bills, and how the substantive portion is decided. |
| 40.1 | Definition of a Global Surgical Package | What the global surgical package includes, and the visits and services that fall outside it. |
| 40.6 | Claims for Multiple Surgeries | Multiple surgeries on the same day: ranking procedures and the reduced payment for the second and later ones. |
| 40.8 | Claims for Co-Surgeons and Team Surgeons | Co-surgeons with modifier 62 are each paid 62.5 percent of the global amount; team surgery under modifier 66 is priced by report. |
| 100.1 | Payment for Physician Services in Teaching Settings Under the MPFS | Teaching physician presence and documentation rules for services furnished with residents. |
| 190.6 | Payment Methodology for Physician/Practitioner at the Distant Site | How the distant-site practitioner is paid for telehealth, including place of service and modifier reporting. |
How chapter 12 shows up on claims and denials
Chapter 12 problems usually surface as bundling and modifier denials. A visit billed inside a global period without modifier 24, 25 or 57 is folded into the surgery and comes back with claim adjustment reason code 97, often with remark M144 saying pre- and post-operative care is included in the surgical allowance. A modifier that does not fit the code, such as a bilateral modifier on a code that is already bilateral, returns reason code 4. Multiple-procedure reductions post as reason code 59, which is a payment adjustment, not a denial, so it should not be appealed unless the ranking is wrong.
Before appealing, check the fee schedule indicators for the code: the global days, the multiple-procedure, bilateral, assistant, co-surgeon and team-surgery indicators decide most of these outcomes, and the NCCI edits decide the rest. A co-surgeon claim also needs the operative notes from both surgeons, and a split or shared visit needs documentation showing who performed the substantive portion.
Codes you are likely to see on the remittance when a claim runs into this chapter's rules. The code pages explain each code's meaning, root causes and the usual fix.
| Code | Type | When it appears |
|---|---|---|
| 97 | Claim adjustment reason code | Visit or service bundled into a global surgical package or another paid service. |
| M144 | Remark code | Pre- and post-operative care is included in the surgical allowance. |
| 4 | Claim adjustment reason code | Procedure code inconsistent with the modifier billed. |
| 59 | Claim adjustment reason code | Payment reduced under multiple or concurrent procedure rules. |
| 54 | Claim adjustment reason code | Assistant or multiple surgeons not payable for this procedure. |
Current revision and recent transmittals
The chapter PDF posted on cms.gov is current through Rev. 13316, issued July 24, 2025, effective January 1, 2025, implemented August 25, 2025 (change request 14047). That revision changed section 30.6.7 (Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99202 - 99215)). Its subject line reads: “Update to Publication 100-04, Chapter 12, Section 30.6.7 to Establish Payment Criteria for Healthcare Common Procedure Coding System (HCPCS) Add-on Code G2211 Billed on the Same Day as Identified Preventive Services”.
The newest rows of the transmittal history printed at the end of the chapter (126 revisions in all). Rows whose subject could not be read reliably from the PDF table are left out; the PDF has the complete list.
| Revision | Issued | Subject | CR |
|---|---|---|---|
| R13316CP | July 24, 2025 | Update to Publication 100-04, Chapter 12, Section 30.6.7 to Establish Payment Criteria for Healthcare Common Procedure Coding System (HCPCS) Add-on Code G2211 Billed on the Same Day as Identified Preventive Services | 14047 |
| R13012CP | December 19, 2024 | Internet Only Manual (IOM) Update to 100-04 Chapter 12, Section 30.5 - Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions | 13904 |
| R12961CP | November 14, 2024 | Updates to the Publication 100-04 Claims Processing Manual in the Internet Only Manual (IOM) to Remove Obsolete Language Related to Medicare Fee-for-Service (FFS) Systems Claims Edits | 13854 |
| R12823CP | September 5, 2024 | Update to Internet-Only Manual Publication (Pub.) 100-04, Chapters 12 and 23, to Update Place of Service (POS) Code Descriptions to Match the POS Descriptions Found in Pub. 100-04, Chapter 26 | 13744 |
| R12671CP | June 6, 2024 | Billing and Payment for Telehealth Services with Place of Service (POS) 10 | 13582 |
| R12604CP | May 3, 2024 | Internet-Only Manual (IOM) Updates for Split (or Shared) Evaluation and Management Visits | 13592 |
Sections ordered by the date in the revision note printed under each heading.
| Section | Heading | Revision |
|---|---|---|
| 30.6.7 | Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99202 - 99215) | Rev. 13316, July 24, 2025; effective January 1, 2025 |
| 30.5 | Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions | Rev. 13012, December 19, 2024; effective January 1, 2025 |
| 30 | Correct Coding Policy | Rev. 12961, November 14, 2024; effective October 1, 2024 |
| 20.4.2 | Site of Service Payment Differential | Rev. 12823, September 5, 2024; effective October 8, 2024 |
| 190.6 | Payment Methodology for Physician/Practitioner at the Distant Site | Rev. 12671, June 6, 2024; effective January 1, 2024 |
| 190.6.1 | Submission of Telehealth Claims for Distant Site Practitioners | Rev. 12671, June 6, 2024; effective January 1, 2024 |
| 190.7 | A/B MAC (B) Editing of Telehealth Claims | Rev. 12671, June 6, 2024; effective January 1, 2024 |
| 30.6.18 | Split (or Shared) Visits | Rev. 12604, May 3, 2024; effective January 1, 2024 |
Section index
Every section in the chapter's table of contents, grouped under its top-level heading, with the PDF page where it starts. Open a heading to see its subsections.
10 General · p. 8
20 Medicare Physicians Fee Schedule (MPFS) · p. 8 · 15 subsections
- Open section 20 in the PDF
- 20.1 Method for Computing Fee Schedule Amount · p. 9
- 20.2 Relative Value Units (RVUs) · p. 11
- 20.3 Bundled Services/Supplies · p. 12
- 20.4 Summary of Adjustments to Fee Schedule Computations · p. 13
- 20.4.1 Participating Versus Nonparticipating Differential · p. 14
- 20.4.2 Site of Service Payment Differential · p. 14
- 20.4.3 Assistant at Surgery Services · p. 17
- 20.4.4 Supplies · p. 18
- 20.4.5 Allowable Adjustments · p. 18
- 20.4.6 Payment Due to Unusual Circumstances (Modifiers "-22" and "-52") · p. 19
- 20.4.7 Technical Component Payment Reduction for X-Rays and Other Imaging Services · p. 19
- 20.5 No Adjustments in Fee Schedule Amounts · p. 19
- 20.6 Update Factor for Fee Schedule Services · p. 20
- 20.7 Comparability of Payment Provision of Delegation of Authority by CMS to Railroad Retirement Board · p. 20
- 20.8 Payment for Teleradiology Physician Services Purchased by Indian Health Services (IHS) Providers and Physicians · p. 20
30 Correct Coding Policy · p. 21 · 40 subsections
- Open section 30 in the PDF
- 30.1 Digestive System (Codes 40000 - 49999) · p. 24
- 30.2 Urinary and Male Genital Systems (Codes 50010 - 55899) · p. 24
- 30.3 Audiology Sevices · p. 25
- 30.4 Cardiovascular System (Codes 92950-93799) · p. 31
- 30.5 Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions · p. 32
- 30.6 Evaluation and Management Service Codes - General (Codes 99202 - 99499) · p. 36
- 30.6.1 Selection of Level of Evaluation and Management Service · p. 36
- 30.6.1.1 Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) · p. 37
- 30.6.2 Billing for Medically Necessary Visit on Same Occasion as Preventive Medicine Service · p. 38
- 30.6.3 Payment for Immunosuppressive Therapy Management
- 30.6.4 Evaluation and Management (E/M) Services Furnished Incident to Physician's Service by Nonphysician Practitioners · p. 39
- 30.6.5 Physicians in Group Practice · p. 39
- 30.6.6 Payment for Evaluation and Management Services Provided During Global Period of Surgery · p. 39
- 30.6.7 Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99202 - 99215) · p. 41
- 30.6.8 Payment for Hospital Observation Services and Observation or Inpatient Care Services (Including Admission and Discharge Services) · p. 44
- 30.6.9 Payment for Inpatient Hospital Visits - General · p. 48
- 30.6.9.1 Payment for Initial Hospital Inpatient or Observation Care Services and Hospital Inpatient or Observation or Inpatient Care Services (Including Admission and Discharge Services) · p. 50
- 30.6.9.2 Subsequent Hospital Inpatient or Observation Care Visit and Hospital Inpatient or Observation Discharge Day Management Services (Codes 99231 - 99239) · p. 54
- 30.6.10 Consultation Services · p. 55
- 30.6.11 Emergency Department Visits (Codes 99281 - 99288) · p. 56
- 30.6.12 Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292) · p. 58
- 30.6.12.1 Definition · p. 58
- 30.6.12.2 Critical Care by a Single Physician or NPP · p. 59
- 30.6.12.3 Critical Care Visits Furnished Concurrently by Different Specialties · p. 59
- 30.6.12.4 Critical Care Furnished Concurrently by Practitioners in the Same Specialty and Same Group (Follow-Up Care) · p. 59
- 30.6.12.5 Split (or Shared) Critical Care Visits · p. 60
- 30.6.12.6 Critical Care and Other Same-Day Evaluation and Management (E/M) Visits · p. 61
- 30.6.12.7 Critical Care Visits and Global Surgery · p. 61
- 30.6.12.8 Medical Record Documentation · p. 62
- 30.6.13 Nursing Facility Services · p. 63
- 30.6.14 Home or Residence Services (Codes 99341 – 99350) · p. 68
- 30.6.14.1 Home or Residence Services (99341 – 99350) When Performed in Place of Service 12 (Home) · p. 70
- 30.6.15 Prolonged Services, Standby Services (Codes 99354 - 99360) and Evaluation and Management service for Power Mobility Devices (PMDs) (G0372) · p. 70
- 30.6.15.1 Prolonged Services – General Rules · p. 70
- 30.6.15.2 Prolonged Office/Outpatient E/M Visits · p. 70
- 30.6.15.3 Prolonged Other E/M Visits · p. 71
- 30.6.15.4 Power Mobility Devices (PMDs) (Code G0372) · p. 72
- 30.6.17 Physician Management Associated with Superficial Radiation Treatment · p. 73
- 30.6.18 Split (or Shared) Visits · p. 73
- 30.6.19 Office/Outpatient Evaluation and Management (O/O E/M) Complexity Add-on Payment (Code G2211) · p. 78
40 Surgeons and Global Surgery · p. 78 · 9 subsections
- Open section 40 in the PDF
- 40.1 Definition of a Global Surgical Package · p. 79
- 40.2 Billing Requirements for Global Surgeries · p. 82
- 40.3 Claims Review for Global Surgeries · p. 88
- 40.4 Adjudication of Claims for Global Surgeries · p. 90
- 40.5 Postpayment Issues · p. 95
- 40.6 Claims for Multiple Surgeries · p. 96
- 40.7 Claims for Bilateral Surgeries · p. 100
- 40.8 Claims for Co-Surgeons and Team Surgeons · p. 101
- 40.9 Procedures Billed With Two or More Surgical Modifiers · p. 104
50 Payment for Anesthesiology Services · p. 105
60 Payment for Pathology Services · p. 111
70 Payment Conditions for Radiology Services · p. 116
80 Services of Physicians Furnished in Providers or to Patients of Providers · p. 116 · 3 subsections
- Open section 80 in the PDF
- 80.1 Coverage of Physicians' Services Provided in Comprehensive Outpatient Rehabilitation Facility · p. 117
- 80.2 Rural Health Clinic and Federally Qualified Health Center Services · p. 118
- 80.3 Unusual Travel (CPT Code 99082) · p. 119
90 Physicians Practicing in Special Settings · p. 119 · 34 subsections
- Open section 90 in the PDF
- 90.1 Physicians in Federal Hospitals · p. 119
- 90.2 Physician Billing for End-Stage Renal Disease Services · p. 119
- 90.2.1 Inpatient Hospital Visits With Dialysis Patients · p. 120
- 90.3 Physicians' Services Performed in Ambulatory Surgical Centers (ASC) · p. 120
- 90.4 Billing and Payment in Health Professional Shortage Areas (HPSAs) · p. 120
- 90.4.1 Provider Education · p. 122
- 90.4.1.1 A/B MAC (B) Web Pages · p. 122
- 90.4.2 HPSA Designations · p. 122
- 90.4.3 Claims Coding Requirements · p. 123
- 90.4.4 Payment · p. 124
- 90.4.5 Services Eligible for HPSA and Physician Scarcity Bonus Payments · p. 124
- 90.4.6 Reserved for Future Use · p. 127
- 90.4.7 Post-payment Review · p. 127
- 90.4.8 Reporting · p. 128
- 90.4.9 HPSA Incentive Payments for Physician Services Rendered in a Critical Access Hospital · p. 129
- 90.4.10 Administrative and Judicial Review · p. 129
- 90.4.11 Health Professional Shortage Areas (HPSA) Surgical Incentive Payment Program (HSIP) for Surgical Services Rendered in HPSAs · p. 129
- 90.4.11.1 Overview of the HSIP
- 90.4.11.2 HPSA Identification · p. 130
- 90.4.11.3 Coordination with Other Payments · p. 130
- 90.4.11.4 General Surgeon and Surgical Procedure Identification for Professional Services Paid Under the Physician Fee Schedule (PFS) · p. 131
- 90.4.11.5 Claims Processing and Payment · p. 131
- 90.5 Billing and Payment in a Physician Scarcity Area · p. 133
- 90.5.1 Provider Education · p. 133
- 90.5.2 Identifying Physician Scarcity Area Locations · p. 133
- 90.5.3 Claims Coding Requirements · p. 134
- 90.5.4 Payment · p. 134
- 90.5.5 Services Eligible for the Physician Scarcity Bonus · p. 135
- 90.5.5.1 Remittance Messages · p. 135
- 90.5.6 Post-payment Review · p. 135
- 90.5.7 Administrative and Judicial Review · p. 135
- 90.6 Indian Health Services (IHS) Provider Payment to Non-IHS Physicians for Teleradiology Interpretations · p. 136
- 90.7 Bundling of Payments for Services Provided in Wholly Owned and Wholly Operated Entities (including Physician Practices and Clinics): 3-Day Payment Window · p. 136
- 90.7.1 Payment Methodology: 3-Day Payment Window in Wholly Owned or Wholly Operated Entities (including Physician Practices and Clinics) · p. 137
100 Teaching Physician Services · p. 138 · 10 subsections
- Open section 100 in the PDF
- 100.1 Payment for Physician Services in Teaching Settings Under the MPFS · p. 140
- 100.1.1 Evaluation and Management (E/M) Services · p. 140
- 100.1.2 Surgical Procedures · p. 143
- 100.1.3 Psychiatry · p. 145
- 100.1.4 Time-Based Codes · p. 146
- 100.1.5 Other Complex or High-Risk Procedures · p. 146
- 100.1.6 Miscellaneous · p. 146
- 100.1.7 Assistants at Surgery in Teaching Hospitals · p. 147
- 100.1.8 Physician Billing in the Teaching Setting · p. 149
- 100.2 Interns and Residents · p. 150
110 Physician Assistant (PA) Services Payment Methodology · p. 150 · 4 subsections
- Open section 110 in the PDF
- 110.1 Global Surgical Payments · p. 150
- 110.2 Limitations for Assistant-at-Surgery Services Furnished by Physician Assistants · p. 151
- 110.3 Outpatient Mental Health Treatment Limitation · p. 151
- 110.4 PA Billing to the A/B MAC (B) · p. 151
120 Nurse Practitioner (NP) And Clinical Nurse Specialist (CNS) Services Payment Methodology · p. 152 · 3 subsections
- Open section 120 in the PDF
- 120.1 Limitations for Assistant-at-Surgery Services Furnished by Nurse Practitioners and Clinical Nurse Specialists · p. 152
- 120.2 Outpatient Mental Health Treatment Limitation · p. 153
- 120.3 NP and CNS Billing to the A/B MAC (B) · p. 153
130 Nurse-Midwife Services · p. 153 · 2 subsections
- Open section 130 in the PDF
- 130.1 Payment for Certified Nurse-Midwife Services · p. 153
- 130.2 Global Allowances · p. 154
140 Qualified Nonphysician Anesthetist Services · p. 155 · 12 subsections
- Open section 140 in the PDF
- 140.1 Qualified Nonphysician Anesthetists · p. 155
- 140.2 Entity or Individual to Whom Fee Schedule is Payable for Qualified Nonphysician Anesthetists · p. 156
- 140.3 Anesthesia Fee Schedule Payment for Qualified Nonphysician Anesthetists · p. 157
- 140.3.1 Conversion Factors Used on or After January 1, 1997 for Qualified Nonphysician Anesthetists · p. 157
- 140.3.2 Anesthesia Time and Calculation of Anesthesia Time Units · p. 157
- 140.3.3 Billing Modifiers · p. 158
- 140.3.4 General Billing Instructions · p. 158
- 140.4 Qualified Nonphysician Anesthetist Special Billing and Payment Situations · p. 159
- 140.4.1 An Anesthesiologist and Qualified Nonphysician Anesthetist Work Together · p. 159
- 140.4.2 Qualified Nonphysician Anesthetist and an Anesthesiologist in a Single Anesthesia Procedure · p. 159
- 140.4.3 Payment for Medical or Surgical Services Furnished by CRNAs · p. 160
- 140.5 Payment for Anesthesia Services Furnished by a Teaching CRNA · p. 160
150 Clinical Social Worker (CSW) Services · p. 161
160 Independent Psychologist Services · p. 161 · 1 subsections
- Open section 160 in the PDF
- 160.1 Payment · p. 162
170 Clinical Psychologist Services · p. 163 · 1 subsections
- Open section 170 in the PDF
- 170.1 Payment · p. 163
180 Care Plan Oversight Services · p. 163 · 1 subsections
- Open section 180 in the PDF
- 180.1 Care Plan Oversight Billing Requirements · p. 165
190 Medicare Payment for Telehealth Services · p. 166 · 16 subsections
- Open section 190 in the PDF
- 190.1 Background · p. 166
- 190.2 Eligibility Criteria · p. 168
- 190.3 List of Medicare Telehealth Services · p. 169
- 190.3.1 Telehealth Consultation Services, Emergency Department or Initial Inpatient versus Inpatient Evaluation and Management (E/M) Visits · p. 169
- 190.3.2 Telehealth Consultation Services, Emergency Department or Initial Inpatient Defined · p. 170
- 190.3.3 Follow-Up Inpatient Telehealth Consultations Defined · p. 171
- 190.3.4 Payment for ESRD-Related Services as a Telehealth Service · p. 172
- 190.3.5 Payment for Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services · p. 173
- 190.3.6 Payment for Diabetes Self-Management Training (DSMT) as a Telehealth Service · p. 174
- 190.3.7 Payment for Telehealth for Individuals with Acute Stroke · p. 175
- 190.4 Conditions of Payment · p. 175
- 190.5 Originating Site Facility Fee Payment Methodology · p. 176
- 190.6 Payment Methodology for Physician/Practitioner at the Distant Site · p. 180
- 190.6.1 Submission of Telehealth Claims for Distant Site Practitioners · p. 181
- 190.6.2 Exception for Store and Forward (Non-Interactive) Telehealth · p. 182
- 190.7 A/B MAC (B) Editing of Telehealth Claims · p. 182
200 Allergy Testing and Immunotherapy · p. 183
210 Outpatient Mental Health Treatment Limitation · p. 187 · 1 subsections
- Open section 210 in the PDF
- 210.1 Application of the Limitation · p. 188
220 Chiropractic Services · p. 194
230 Primary Care Incentive Payment Program (PCIP) · p. 197 · 3 subsections
- Open section 230 in the PDF
- 230.1 Definition of Primary Care Practitioners and Primary Care Services · p. 197
- 230.2 Coordination with Other Payments · p. 199
- 230.3 Claims Processing and Payment · p. 199
240 Marriage and Family Therapist (MFT) Services · p. 200
250 Mental Health Counselor (MHC) Services · p. 201
Using this chapter in a denial or appeal
Start with the remittance. The claim adjustment reason code says what happened to the line, the remark code narrows it, and the group code says who is liable. Match that to the section of the chapter that sets the rule, then read the section in the official PDF rather than a summary: the wording that matters, such as a time limit, a modifier requirement or a documentation element, is usually a single sentence. Check the revision note under the section heading, because a rule that changed after the date of service may not apply to the claim, and an effective date earlier than the issue date can make a new rule reach back.
When the chapter supports the claim, cite it precisely in the redetermination request: the publication number, chapter, section and revision. When it does not, the fix is usually a corrected claim or better documentation rather than an appeal, and a coding or format rejection is corrected and resubmitted because it carries no appeal rights. Manual instructions bind the Medicare Administrative Contractor, so they settle most first-level disputes; at the hearing level, administrative law judges give them substantial deference without being bound by them. If the issue turns on whether a service is covered at all, read the matching Benefit Policy Manual chapter and any national coverage determination or local coverage determination as well, because coverage and billing rules are written in different places.
How QuickIntell works with Claims Processing Manual chapter 12
QuickRCM covers eligibility, claim readiness, denials, posting and A/R with configurable automation and human review, which is where the billing rules in this chapter are checked before a claim goes out. QuickCode supports qualified coder review of the coding and modifier questions the chapter answers.
Frequently asked questions: chapter 12
Which chapter of the Medicare Claims Processing Manual covers physician billing?
Chapter 12 of Pub. 100-04, titled Physicians/Nonphysician Practitioners. It holds the Physician Fee Schedule payment rules, E/M visit policy, global surgery, anesthesia, teaching physician, nonphysician practitioner and telehealth billing instructions.
Where are the global surgery rules in Pub. 100-04?
Section 40 of chapter 12. Section 40.1 defines the global surgical package, 40.2 sets the billing requirements, including modifiers 24, 25, 57, 58, 78 and 79 and the split-care modifiers 54 and 55, and 40.4 explains how contractors adjudicate the claims.
Is incident-to billing in chapter 12?
Chapter 12 section 30.6.4 covers E/M services furnished incident to a physician's service by nonphysician practitioners, but the coverage rules for incident-to services, including direct supervision, live in chapter 15 section 60 of the Medicare Benefit Policy Manual (Pub. 100-02).
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-10. Verify against the primary file before billing or contracting decisions. The reference methodology explains how each figure is computed from these files.
- Medicare Claims Processing Manual, Chapter 12: Physicians/Nonphysician PractitionersVersion Rev. 13316, issued 2025-07-24 · effective 2025-01-01 · file clm104c12.pdfSHA-256 ca5ded3c8c676a23…
- Medicare Claims Processing Manual (Pub. 100-04)Version 39 chapter PDFs; newest revision Rev. 13836 (chapter 14), issued 2026-06-24 · effective 2026-09-27 · file 100-04-claims-processing-manual/*.pdf (39 chapters; SHA-256 of their sha256sum listing)SHA-256 f87bc3bcd9d1570d…
Disclaimer
This guide summarizes a CMS manual chapter in our own words for billing teams; section headings and transmittal subjects are quoted from the chapter PDF. The chapter itself is the authority, and it changes by transmittal. Not legal, clinical or billing advice.
Found a figure that does not match the CMS file? Report a data correction with the CMS file and the value you expected; the request reaches the editorial team through the contact form.