Persius/hicric huggingface dataset:
Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility

Medicare covers the following solid organ transplants: kidney, heart, lung,
heart/lung, liver, pancreas, pancreas/kidney, and intestinal/multi-visceral.
Medicare also covers stem cell transplants for certain conditions.

Claims for CPT codes used to describe Human Leukocyte Antigen (HLA) testing
used for transplant histocompatibility testing will be denied. See below for
further explanation on correct billing for these services. This does not refer
to HLA testing for non-transplant services.

HLA testing for histocompatibility testing as part of transplantation are part
of solid organ acquisition services.

Services for organ transplants must be billed as described in the Centers for
Medicare and Medicaid Services (CMS) Internet-Only Manual, Pub 100-04,
Medicare Claims Processing Manual, Inpatient Hospital Billing, Chapter 3
Section 90 and as described in the Electronic Code of Federal Regulations,
Title 42, Public Health, Part 412 Prospective Payment Systems for Inpatient
Hospital Services. The acquisition costs of hearts, kidneys, livers, lungs,
pancreas, and intestines (or multivisceral organs) incurred by approved
transplantation centers are paid on a reasonable cost basis by approved
transplant centers; they are not billed as stand-alone laboratory services.

HLA typing is a component of the acquisition services for an allogeneic stem
cell transplant as well. Payment for these acquisition services is included in
the MS-DRG payment for the allogeneic stem cell transplant when the transplant
occurs in the inpatient setting and in the OPPS APC payment for the allogeneic
stem cell transplant when the transplant occurs in the outpatient setting. The
Medicare contractor does not make separate payment for these acquisition
services, because hospitals may bill and receive payment only for services
provided to the Medicare beneficiary who is the recipient of the stem cell
transplant and whose illness is being treated with the stem cell transplant.
Unlike the acquisition costs of solid organs for transplant (e.g., hearts and
kidneys), which are paid on a reasonable cost basis, acquisition costs for
allogeneic stem cells are included in prospective payment.

Acquisition charges do not apply to autologous transplants.

HLA CPT codes **_unrelated to transplant testing_ **have coverage as outlined
in the following Local Coverage Determinations (LCDs):

  * CPT 81381 - The MolDX: Pharmacogenomics Testing L38394 LCD addresses limited coverage for gene-drug interactions.
  * CPT 81383 - The MolDX: HLA-DQB1*06:02 Testing for Narcolepsy L36485 LCD addresses non-coverage of HLA-DQB1*06:02 typing for the diagnosis or management of narcolepsy.
Billing and Coding: MolDX: Oncotype DX Breast Cancer for DCIS (Genomic
Health)

The information in this article contains billing, coding, or other guidelines
that complement the Local Coverage Determination (LCD) for MolDX: Oncotype DX
Breast Cancer for DCIS (Genomic HealthTM) L36951.

To report an Oncotype DX Breast Cancer for DCIS service, please submit the
following claim information:

  * Select PLA code 0045U
  * Enter 1 unit of service (UOS)
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types: 
    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper claim
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types: 
    * Line SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form
  * Select the appropriate ICD-10-CM code
Billing and Coding: Loss-of-Heterozygosity Based Topographic Genotyping with
Pathfinder TG

Refer to the Novitas Local Coverage Determination (LCD) L34864 Loss-of
-Heterozygosity Based Topographic Genotyping with PathfinderTG, for
reasonable and necessary requirements.  
  
The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding
System (HCPCS) code(s) may be subject to National Correct Coding Initiative
(NCCI) edits. This information does not take precedence over NCCI edits.
Please refer to NCCI for correct coding guidelines and specific applicable
code combinations prior to billing Medicare.
Billing and Coding: MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis
Diagnostic Test

The information in this article contains billing, coding, or other guidelines
that complement the Local Coverage Determination (LCD) for MolDX: EnvisiaTM,
VeracyteTM, Idiopathic Pulmonary Fibrosis Diagnostic Test L37857.

To report an EnvisiaTM Genomic Classifier service, please submit the following
claim information:

  * Select CPT code
  * Enter 1 unit of service (UOS)
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types: 
    *  Loop 2400 or SV101-7 for the 5010A1 837P
    *  Box 19 for paper claim
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types: 
    * Line SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form
  * Select the appropriate ICD-10-CM code
Billing and Coding: MolDX: Genetic Testing for
Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and
MTHFR)

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for MolDX: Genetic
Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II
Prothrombin, and MTHFR) L36089.

To report a Genetic Testing for Hypercoagulability/Thrombophilia service,
please submit the following claim information:

  * Select appropriate CPT code
  * Enter 1 unit of service (UOS)
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types: 
    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper claim
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types: 
    * Line SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form
Billing and Coding: Immunizations

The billing and coding information in this article is dependent on the
coverage indications, limitations and/or medical necessity described in the
associated LCD L34596 Immunizations.
Billing and Coding: Polysomnography and Other Sleep Studies

The billing and coding information in this article is dependent on the
coverage indications, limitations and/or medical necessity, and documentation
requirements described in the associated LCD L36839 Polysomnography and Other
Sleep Studies.

  * Diagnostic testing will be considered for coverage if the patient has the symptoms or complaints of one of the conditions listed in L36839.
  * Patients who undergo the diagnostic testing are not considered inpatients, although they may come to the facility in the evening for testing and then leave after testing is over. The overnight stay is considered an integral part of these tests. Documentation must support indications if the patient is admitted.
  * Ordinarily, a single polysomnogram and electroencephalogram (EEG) can diagnose sleep apnea. If more than one such testing session is claimed, the carrier will require persuasive medical evidence justifying the medical necessity for the additional test ( _CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70_ ).
  * Ordinarily, a diagnosis of narcolepsy can be confirmed by three sleep naps. If more than three sleep naps are claimed; the A/B MAC (B) will require persuasive medical evidence justifying the medical necessity for the additional test(s). ( _CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70_.)
  * More than one HST per year interval would not be expected. If more than one HST session is performed for suspected OSA, persuasive medical evidence justifying the medical necessity for the additional tests will be required. Similarly, more than two PSG per year interval would not be expected. If more than two PSG sessions are performed for the diagnosis or adjustment of treatment of sleep, pervasive medical evidence justifying the medical necessity for the additional tests will be required upon request. When services are performed in excess of established parameters, they may be subject to review for medical necessity.
  * The routine use of more than one PSG to titrate CPAP therapy would not be considered reasonable and necessary. If more than one CPAP titration PSG is claimed, persuasive medical evidence justifying the medical necessity for the additional tests may be requested.
  * 95805 MSLT- includes all the naps done in a single day. Only one (1) unit of service should be submitted.

**Coding Guidance**

  1. WatchPat must be billed as CPT code 95800 or 95801.
  2. If a sleep study is performed for less than 6 hours, it should be billed with modifier 52. Providers should report the service provided with the appropriate reduced original charge.
Billing and Coding: Surgical Treatment of Obstructive Sleep Apnea (OSA)

The billing and coding information in this article is dependent on the
coverage indications, limitations and/or medical necessity described in the
associated LCD L34526.

Sleep-Disordered Breathing, often referred to as Obstructive Sleep Apnea
(OSA), is characterized by frequent episodes of hypopnea or apnea during
sleep. Multiple detrimental physiologic changes may result from these
hypopneic and apneic episodes. Non-surgical and surgical approaches to
obstructive apnea and hypopnea have been developed.

The following procedures are not covered at this time.

  1. Laser-assisted uvulopalatoplasty (LAUP) is not covered at this time since it is not considered effective for OSA. LAUP **must not** be billed as 42145, Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty). This code is not appropriate for this procedure. If LAUP is billed for denial purposes, it should be coded as 42299, (unlisted procedure, palate, uvula) with "LAUP" in the electronic narrative 2400/SV101-7 equivalent to line 19 of the CMS 1500 form. The claim will be denied as not proven effective.
  2. SomnoplastyTM is a trade name for palate reduction with the SomnoplastyTM System of Somnus Medical Systems. This is not a term recognized by this Contractor as a covered procedure under Medicare Part B. Therefore SomnoplastyTM must not be billed as 42145. This code is not appropriate for this procedure. If SomnoplastyTM is billed for denial purposes, it should be coded as 42299, (unlisted procedure, palate, uvula) with "SomnoplastyTM" in the electronic narrative 2400/SV101-7 equivalent to line 19 of the CMS 1500 form. This claim will be denied as not proven effective.
  3. The Pillar ProcedureTM is a trade name for palatal implants. Palatal implants have not been shown effective for the treatment of obstructive sleep apnea and are not covered. This procedure should be billed by the physician as 42299 (unlisted procedure, palate, uvula) with "Pillar ProcedureTM" or "palatal implant" in the electronic narrative 2400/SV101-7 equivalent to line 19 of the CMS 1500 form. This claim will then be denied as not proven effective. Hospital outpatient departments would use code C9727.
  4. Submucosal ablation of the tongue base, radiofrequency, one or more sites, per session. (41530) will be denied as investigational and experimental.
Billing and Coding: MolDX: DecisionDx-UM (Uveal Melanoma)

The information in this article contains billing, coding, or other guidelines
that complement the Local Coverage Determination (LCD) MolDX: DecisionDx-UM
(Uveal Melanoma) L37033.

To report a DecisionDx-UM (Uveal Melanoma) service, please submit the
following claim information:

  * Select CPT code 81552 
  * Enter 1 unit of service (UOS)
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types: 
    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper claim
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types: 
    * Line SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form
  * Select the appropriate ICD-10-CM code
Billing and Coding: Bisphosphonate Drug Therapy

The billing and coding information in this article is dependent on the
coverage indications, limitations, and/or medical necessity described in the
related LCD, L34648 Bisphosphonate Drug Therapy.

**Documentation Requirements**  
 **Note:** If bone metastasis (C79.51 or C79.52) is the condition being
treated, the diagnosis of a primary malignant neoplasm must be present in the
patient's medical record and available if requested.

Information in the medical record including diagnostic information and lab
results should support the medical necessity of this service. Based on the
indications listed, the specific signs and symptoms must be documented to
substantiate the FDA labeled or the FDA off labeled reasons for drug usage. An
indication that the patient has been advised to take adequate calcium and
vitamin D supplementation should be in the medical record. The medical record
must be available on request. Diagnosis codes supporting medical necessity
should be submitted on the claim.

Evidence in the medical record should clearly support the need for the
intravenous administration of bisphosphonates for the treatment of
osteoporosis including description of treatment failure of oral or self-
administered drugs for osteoporosis and heterotrophic ossification. Lab work
should include serum creatinine measured prior to the administration of the
drug.

**Utilization Guidelines**  
It is expected that these services would be performed as indicated by current
literature and/or standards of practice and should follow the guidelines for
administration and safety found in the FDA approved labels for these drugs
along with the indications found in the Coverage Indications, Limitations,
and/or Medical Necessity section of this policy. When services are performed
in excess of established parameters, it may result in medical review to
determine if the services were medical necessity.

Preventive services other than those payable by statute are excluded from
Medicare coverage.

Per the Summary and Analysis of Evidence contained in the associated LCD, the
breast cancer diagnosis codes included in this Billing and Coding Article will
reflect the current NCCN recommendations. It will continue to be required to
bill the appropriate breast cancer diagnosis code, along with a bone loss
diagnosis code, and a diagnosis code to reflect that the patient is currently
receiving adjuvant selective estrogen receptor modulators OR aromatase
inhibitor therapy for breast cancer.
Billing and Coding: Trigger Points, Local Injections

The billing and coding information in this article is dependent on the
coverage indications, limitations and/or medical necessity described in the
associated Local Coverage Determination (LCD) L34588 Trigger Points, Local
Injections.

Myofascial trigger points are self-sustaining hyper-irritative foci that may
occur in any skeletal muscle in response to strain produced by acute or
chronic overload.
Billing and Coding: Corneal Hysteresis

CPT code 92145 is considered not medically necessary and will be automatically
denied as a non-covered procedure.
Billing and Coding: MDS FISH

The information in this article contains billing, coding, or other guidelines
that complement the Local Coverage Determination (LCD) for MDS FISH L37602.

**Coding for FISH Testing**

There are 2 sets of codes that describe in situ hybridization (ISH). Although
the laboratory methods are similar, 1 distinguishes between the 2 sets of
codes based on whether the ISH test is an adjunct to a surgical or
cytopathology case, versus whether it is part of a clinical, chromosomal
analysis. Specifically, the CPT codes 88271-88291 should be used when the
laboratory performs ISH as an ancillary analysis to cytogenetic studies for
oncologic or inherited disorders.

When a pathologist performs ISH techniques as an adjunct to a surgical
pathology or cytopathology case, CPT codes 88365-88377 should be used to
distinguish qualitative versus quantitative analysis (computer assisted versus
manual). These codes must never be used by a pathologist when ISH is performed
as an ancillary analysis to cytogenetic studies.

To report an MDS FISH service, please submit the following claim information:

  * Select the appropriate CPT code 
  * Enter 1 unit of service (UOS)
  * Select the appropriate ICD-10-CM code

 A DEX Z-CodeTM identifier is not required for FISH testing.
Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging
(SCODI)

The billing and coding information in this article is dependent on the
coverage indications, limitations and/or medical necessity described in the
associated LCD L34760 Scanning Computerized Ophthalmic Diagnostic Imaging
(SCODI).

Medicare will consider SCODI medically reasonable and necessary in evaluating
retinal disorders, glaucoma, and anterior segment disorders as documented in
L34760.

**Coding Guidelines:**  
 **For claims submitted to the Part B MAC:**  
All services/procedures performed on the same day for the same beneficiary by
the physician/provider should be billed on the same claim.

Claims for SCODI services (CPT codes 92133 and 92134) are payable under
Medicare Part B in the following places of service:

  * The global service is payable in the office (11), nursing facility (32- for Medicare patient not in a Part A stay) and independent clinic (49).
  * The technical component (modifier TC) is payable in the office (11), nursing facility (32- for Medicare patient not in a Part A stay), independent clinic (49), federally qualified health center (50), and rural health clinic (72).
  * The professional component (modifier 26) is payable in the office (11), inpatient hospital (21), Off campus-outpatient hospital (19), On campus- outpatient hospital (22), skilled nursing facility (31), nursing facility (32- for Medicare patient not in a Part A stay), and independent clinic (49).

Please review 100-04 _Medicare Claims Processing Manual_ , Chapter 32 -
Billing Requirements for Special Services, Section 300.2 for Claims Processing
Requirements for OPT with Verteporfin Services on Professional Claims and
Outpatient Facility Claims.
Response to Comments: Corneal Hysteresis L38211

This article summarizes the comments WPS received for Draft Local Coverage
Determinations (LCD) Corneal Hysteresis DL38211. Thank you for the comments.
Billing and Coding: Outpatient Sleep Studies

Refer to the Novitas Local Coverage Determination (LCD) L35050, Outpatient
Sleep Studies, for reasonable and necessary requirements.  
  
The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding
System (HCPCS) code(s) may be subject to National Correct Coding Initiative
(NCCI) edits. This information does not take precedence over NCCI edits.
Please refer to NCCI for correct coding guidelines and specific applicable
code combinations prior to billing Medicare.  
  
 **Coding Guidance  
  
** WatchPAT must be billed as CPT code 95800 or 95801.  
  
While actigraphy coverage is not included in the related LCD, this service may
be reported with CPT code 95803 for documentation of coverage of CPAP by NCD
but consistent with the related LCD the coverage of interpretation will not be
paid separately. CPT code 95803 may also be reported for follow-up CPAP
administration if allowed through the DME contractors as an acceptable test.
Billing and Coding: MolDX: Inivata, InVisionFirst, Liquid Biopsy for
Patients with Lung Cancer

The information in this article contains billing, coding, or other guidelines
that complement the Local Coverage Determination (LCD) for MolDX: InivataTM,
InVisionFirst, Liquid Biopsy for Patients with Lung Cancer L37870.

To report an InvisionFirst - Lung service, please submit the following claim
information:

  * Select CPT code 81479
  * Enter 1 unit of service (UOS)
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types: 
    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper claim
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types: 
    * Line SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form
  * Select the appropriate ICD-10-CM code
Billing and Coding: MDS FISH

The information in this article contains billing, coding, or other guidelines
that complement the Local Coverage Determination (LCD) for MDS FISH L37608.

**Coding for FISH Testing**

There are 2 sets of codes that describe in situ hybridization (ISH). Although
the laboratory methods are similar, one distinguishes between the 2 sets of
codes based on whether the ISH test is an adjunct to a surgical or
cytopathology case, versus whether it is part of a clinical, chromosomal
analysis. Specifically, the CPT codes 88271-88291 should be used when the
laboratory performs ISH as an ancillary analysis to cytogenetic studies for
oncologic or inherited disorders.  

When a pathologist performs ISH techniques as an adjunct to a surgical
pathology or cytopathology case, CPT codes 88365-88377 should be used to
distinguish qualitative versus quantitative analysis (computer assisted versus
manual). These codes must never be used by a pathologist when ISH is performed
as an ancillary analysis to cytogenetic studies.

To report an MDS FISH service, please submit the following claim information:

  * Select the appropriate CPT code 
  * Enter 1 unit of service (UOS)
  * Select the appropriate ICD-10-CM code

 A DEX Z-CodeTM identifier is not required for FISH testing. If submitting a
DEX Z-CodeTM identifier, please submit following the below instructions:

  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types: 
    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper claim 
  *  Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types: 
    *  Line SV202-7 for 837I electronic claim
    *  Block 80 for the UB04 claim form
Billing and Coding: BDX-XL2

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for BDX-XL2 L37031.
Billing and Coding: 4Kscore Assay

The information in this article contains billing, coding, or other guidelines
that complement the Local Coverage Determination (LCD) for 4Kscore Assay
L36763.
Billing and Coding: MolDX: Prometheus IBD sgi Diagnostic Policy

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for MolDX: Prometheus
IBD sgi Diagnostic Policy L37260.

To receive a Prometheus IBD sgi Diagnostic denial, please submit the
following claim information:

  * Select the applicable CPT code
  * Enter 1 unit of service (UOS)
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services
    * For a voluntary issued ABN, append with GX modifier
    * To indicate a statutorily excluded service, append with a GY modifier
  * If submitting a DEX Z-CodeTM identifier, enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types: 
    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper claim
  * If submitting a DEX Z-CodeTM identifier, enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types: 
    * Line SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form