Persius/hicric huggingface dataset:
Billing and Coding: RAST Type Tests

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for RAST Type Tests.

**Coding Information:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the
referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to
the provider as an incomplete claim under Section 1833(e) of the Social
Security Act.

The diagnosis code(s) must best describe the patient's condition for which the
service was performed. For diagnostic tests, report the result of the test if
known; otherwise the symptoms prompting the performance of the test should be
reported.

**Documentation Requirements:**

The patient's medical record must contain documentation that fully supports
the medical necessity for services included within the related LCD. (See
"Indications and Limitations of Coverage.") This documentation includes, but
is not limited to, relevant medical history, physical examination, and results
of pertinent diagnostic tests or procedures.

Each claim must be submitted with ICD-10-CM codes that reflect the condition
of the patient, and indicate the reason(s) for which the service was
performed. Claims submitted without ICD-10-CM codes will be returned.

Documentation must be available to Medicare upon request.

**Utilization Guidelines:**  
  
It is expected that these services would be performed as indicated by current
medical literature and/or standards of practice. When services are performed
in excess of established parameters, they may be subject to review for medical
necessity.
Billing and Coding: Venous Angioplasty with or without Stent Placement for the
Treatment of Chronic Cerebrospinal Venous Insufficiency

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Venous Angioplasty with or without Stent
Placement for the Treatment of Chronic Cerebrospinal Venous Insufficiency.

**Coding Information:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the
referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to
the provider as an incomplete claim under Section 1833(e) of the Social
Security Act.

The diagnosis code(s) must best describe the patient's condition for which the
service was performed. For diagnostic tests, report the result of the test if
known; otherwise the symptoms prompting the performance of the test should be
reported.

**Documentation Requirements:**

The patient's medical record must contain documentation that fully supports
the medical necessity for services included within the related LCD. (See
"Indications and Limitations of Coverage.") This documentation includes, but
is not limited to, relevant medical history, physical examination, and results
of pertinent diagnostic tests or procedures.
Billing and Coding: Multiple Imaging in Oncology

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L35391, Multiple Imaging in Oncology. Please
refer to the LCD for reasonable and necessary requirements.  
  
 **Coding Guidance  
  
** **Notice:** It is not appropriate to bill Medicare for services that are
not covered (as described by the entire LCD) as if they are covered. When
billing for non-covered services, use the appropriate modifier.
Billing and Coding: MolDX: Percepta Bronchial Genomic Classifier

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for MolDX: Percepta
Bronchial Genomic Classifier L36854.

To report a Percepta Bronchial Genomic Classifier 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 837
    * 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: Laparoscopic Sleeve Gastrectomy for Severe Obesity

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Laparoscopic Sleeve
Gastrectomy for Severe Obesity L34576.
Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT)

The information in this article contains billing, coding, or other guidelines
that complement the Local Coverage Determination (LCD) for MolDX: Molecular
Diagnostic Tests (MDT) L35025.

To report a Molecular Diagnostic Test service, please submit the following
claim information:

  * Select appropriate CPT code 
  * Enter 1 unit of service (UOS)
  * Enter the appropriate DEX Z-Code 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-Code 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

**NOTE:** When entering the DEX Z-Code on the SV101-7 documentation field for
Part B claims please do not add additional characters and/or information on
the line.
Billing and Coding: MolDX: HLA-DQB1*06:02 Testing for Narcolepsy

The information in this article contains billing, coding, or other guidelines
that complement the Local Coverage Determination (LCD) for MolDX: HLA-
DQB1*06:02 Testing for Narcolepsy L36464.
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 L38294 LCD addresses limited coverage for gene-drug interactions.
  * CPT 81383 - The MolDX: HLA-DQB1*06:02 Testing for Narcolepsy L36464 LCD addresses non-coverage of HLA-DQB1*06:02 typing for the diagnosis or management of narcolepsy.
Billing and Coding: Select Minimally Invasive GERD Procedures

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Select Minimally Invasive GERD Procedures.

**Coding Information:**  
  
Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare.  
  
For services requiring a referring/ordering physician, the name and NPI of the
referring/ordering physician must be reported on the claim.  
  
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to
the provider as an incomplete claim under Section 1833(e) of the Social
Security Act.  
  
The diagnosis code(s) must best describe the patient's condition for which the
service was performed.

**Documentation Requirements:**  
  
The patient's medical record must contain documentation that fully supports
the medical necessity for services included within the LCD. (See "Indications
and Limitations of Coverage.") This documentation includes, but is not limited
to, relevant medical history, physical examination, and results of pertinent
diagnostic tests or procedures.
Billing and Coding: Outpatient Speech Language Pathology

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Outpatient Speech
Language Pathology L34429.

**Evaluation/Re-evaluation**

**Note:** Current Procedural Terminology (CPT) does not define a re-
evaluation code for Speech Language Pathology: use the evaluation code.

1\. **Treatment of speech, language, voice, communication, and/or auditory
processing disorder (CPT  code 92507); individual**

  * Regarding speech-generating devices (SGDs), use CPT code 92607 and 92608 for selection and prescription; use CPT code 92609 for programming and modification.

2\. **T **reatment of speech, language, voice, communication, and/or auditory
processing disorder; group, 2 or more individuals (CPT  code 92508)****

  * ****Note:**** Regardless of the therapy being performed, if the patient is not receiving direct 1-on-1 contact but is being supervised by the therapist, the group therapy code should be used.
Billing and Coding: Use of Laterality Modifiers

In order to facilitate claims processing and avoid denials for duplicate
claims, claims which contain CPT/HCPCS codes describing services performed on
anatomic structures that can be distinguished as left or right require
laterality modifiers. This article is not a comprehensive listing of all such
codes; however, all claims involving the CPT codes included in this article
will be rejected unless the appropriate laterality modifiers (-RT; -LT) for
unilateral procedures are reported. Bilateral procedures should be indicated
by the appropriate modifier for bilateral procedures. CPT codes that are
designated in their description as _" unilateral or bilateral" _do not require
additional laterality modifiers.

Claim lines for CPT/HCPCS codes requiring use of the RT and LT modifiers,
submitted without the RT and/or LT modifiers or with the RT/LT on a single
claim line will be rejected as incorrect coding.
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) L36912.

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: In Vitro Chemosensitivity & Chemoresistance Assays

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for In Vitro
Chemosensitivity & Chemoresistance Assays L34554.

To receive a CSRA denial, please submit the following claim information:

  * CPT code
  * 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
Billing and Coding: GlycoMark Testing for Glycemic Control

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for GlycoMark Testing
for Glycemic Control L36761.

To receive a GlycoMark test denial, please submit the following claim
information:

  * CPT code 84378 or 84999
  * 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
Billing and Coding: Stereotactic Radiation Therapy: Stereotactic Radiosurgery
(SRS) and Stereotactic Body Radiation Therapy (SBRT)

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Stereotactic Radiation and Therapy:
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy
(SBRT).

**Coding Information:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to
the provider as an incomplete claim under Section 1833(e) of the Social
Security Act.

The diagnosis code(s) must best describe the patient's condition for which the
service was performed.

SRS is typically performed in a single session. If more than one session is
required, SBRT codes must be used.

**Documentation Requirements:**

All documentation must be available upon request of the Medicare contractor.

The patient's record must support the necessity and frequency of treatment.
The medical record must clearly indicate the critical nature of the anatomy or
other circumstances necessitating the services, the patient's functional
status and a description of current performance status (Karnofsky Performance
Status).

Documentation should include the date and the current treatment dose.

Coverage may be considered at the Redetermination (Appeal) level on an
individual basis for lesions when documentation clearly supports the necessity
for high radiation dose per fraction and the necessity to avoid surrounding
tissue exposure. When requesting an individual consideration through the
written redetermination (formerly appeal) process, providers must include all
relevant medical records and literature that supports the request. At a
minimum two (2) Phase II studies (human feasibility studies suggesting
efficacy, pilots) or one (1) Phase III study (primary evidence of safety and
efficacy, pivotal) must be submitted for the Contractor Medical Director's
review.

Treatment devices, complex (CPT code 77334) is limited to one unit for each
collimator in a linear accelerator system or one for each helmet in a
cobalt-60 system. If the total number of units exceeds six (6) or the number
of isocenters plus three (3) when multiple isocenters are necessary, a
detailed explanation of medical necessity must be documented in the medical
record. Documentation must specify factors, such as, multiple isocenters,
irregularity of target volume(s), proximity of critical structures or other
reasons which justify the units of service for dosimetry or treatment devices.

**Utilization Guidelines:**

Codes 77373, G0339 and G0340 will pay _only once per day of treatment
regardless of the number of sessions or lesions. CPT code 77435 code will pay
only once per course of therapy_.
Billing and Coding: MolDX: Breast Cancer Index (BCI) Gene Expression Test

The information in this article contains billing, coding, or other guidelines
that complement the Local Coverage Determination (LCD) for MolDX: Breast
Cancer Index (BCI) Gene Expression Test L37794.

Effective 1/01/2019, MolDX will provide limited coverage for the BCI gene
expression test.

The BCI test is covered for postmenopausal women with invasive breast cancer
when the following criteria are met:

  * Pathology reveals invasive carcinoma of the breast that is ER+ and/or PR+ and HER2 -; and
  * Patient has early-stage disease (T1-3, pN0-N1, M0); and
  * Patient has no evidence of distant breast cancer metastasis (i.e., non-relapsed); and
  * Test results will be used in determining treatment management of the patient for chemotherapy and/or endocrine therapy.

MolDX expects this test will be performed once per patient lifetime on
formalin-fixed, paraffin-embedded (FFPE) tissue from the primary tumor
specimen obtained prior to adjuvant treatment.

To report a BCI service, please submit the following claim information:

  * Select CPT code 81518
  * 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 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: Spinal Cord Stimulators for Chronic Pain

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Spinal Cord
Stimulators for Chronic Pain L37632.

**Indications**

This A/B MAC will reimburse for placement of a maximum of 2 leads or 16
contacts, and for 2 spinal cord stimulator (SCS) trials per anatomic spinal
region per patient per lifetime (with exceptions allowed for technical
limitations for the initial trials or for use of different modalities of
stimulation, including new technology).  
  
If a trial fails, a repeat trial is not appropriate, unless there are
extenuating circumstances that lead to trial failure. Appropriate medical
documentation to support a repeat trial can be sent on appeal. Generally,
electronic analysis services (CPT codes 95970, 95971 and 95972) are not
considered medically necessary, when provided at a frequency more often than
once every 30 days. More frequent analysis may be necessary in the first month
after implantation.

CPT code 63650 - 2 temporary SCS trials per anatomic spinal region (2 per
date of service (DOS)) or (4 units) per patient per lifetime (with exceptions
allowed for technical limitations for the initial trials or for use of
different modalities of stimulation, including new technology), in place of
service office, ambulatory surgery center (ASC), outpatient hospital, or
hospital. Since permanent neurostimulator arrays can also be placed
percutaneously, code 63650 can be covered more often in place of service ASC,
outpatient hospital, or hospital.

CPT code 63655 - 1 permanent SCS per patient per lifetime and must be
performed in an ASC, outpatient hospital or hospital.

CPT codes 63661 and 63663 - Will not be reimbursed in the office setting
since they are included in 63650.

The CPT/HCPCS code(s) may be subject to Correct Coding Initiative (CCI)
edits. This article does not take precedence over CCI edits. Please refer to
the CCI for correct coding guidelines and specific applicable code
combinations prior to billing Medicare.
Billing and Coding: MolDX: HLA-DQB1*06:02 Testing for Narcolepsy

The information in this article contains billing, coding, or other guidelines
that complement the Local Coverage Determination (LCD) for MolDX: HLA-
DQB1*06:02 Testing for Narcolepsy L36485.
Billing and Coding: MolDX: Breast Cancer Index (BCI) Gene Expression Test

The information in this article contains billing, coding, or other guidelines
that complement the Local Coverage Determination (LCD) for MolDX: Breast
Cancer IndexTM (BCI) Gene Expression Test DL37832.

  
Effective 1/01/2019, MolDX will provide limited coverage for the BCI gene
expression test.

  
The BCI test is covered for postmenopausal women with invasive breast cancer
when the following criteria are met

  * Pathology reveals invasive carcinoma of the breast that is ER+ and/or PR+ and HER2 -; and
  * Patient has early-stage disease (T1-3, pN0-N1, M0); and
  * Patient is lymph node negative
  * Patient has no evidence of distant breast cancer metastasis (i.e., non-relapsed); and
  * Test results will be used in determining treatment management of the patient for chemotherapy and/or extension of endocrine therapy.

  
MolDX expects this test will be performed once per patient lifetime on FFPE
tissue from the primary tumor specimen obtained prior to adjuvant treatment.



To bill a BCI service, please provide the following claim information:

  * CPT code 81518
  * Enter "1" in the Days/Unit field
  * Select the appropriate ICD-10-CM diagnosis
  * Enter the assigned Z-codeTM in the comment/narrative field for the following claim field/types: 
    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper claim
  * Enter 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