Persius/hicric huggingface dataset:
Billing and Coding: MolDX: MammaPrint

_MammaPrint  is a diagnostic test that analyzes the gene expression profile
of FFPE breast cancer tissue samples to assess a patients' risk for distant
metastasis._

The test can be performed using either a FDA-cleared in vitro microarray assay
or a next generation sequencing (NGS)-based assay. Each assay has been
assigned a unique Z-code identifier in the DEX Registry.

MammaPrint was prospectively validated as a microarray assay in the 6,693
patient MINDACT trial in early stage breast cancer, <5cm up to 3 positive
lymph nodes and independent of receptor status. The Mammaprint NGS test has
demonstrated technically equivalent performance to the predicate microarray
test.

To bill for MammaPrint services, submit the following claim information:

  * Enter "1" in the Days/Unit field
  * For CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information. For dates of service on or after 1/1/2022, use CPT code 81523 for the test if performed by NGS.
    * 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

Only one test- NGS or microarray may be performed on a given date of service
for a given patient.

**Note:** MolDX expects this test may be performed upon occasion twice per
patient lifetime for bilateral disease. Should a patient experience an
additional occurrence, coverage may be considered with supporting
documentation through the appeal process.
Billing and Coding: MolDX: Oncotype DX Breast Cancer Assay

**NOTE:** The Oncotype DX Breast Cancer Assay and the Oncotype DX DCIS Score
are different tests and should NOT be submitted with the same Z-Code
Identifier. Because this article ONLY addresses Oncotype DX Breast, the
diagnosis codes for breast carcinoma in situ have been removed.  
  
Oncotype DX & reg Breast was developed for patients with the following
findings:

  * estrogen-receptor positive, node-negative carcinoma of the breast
  * estrogen-receptor positive micrometastases of carcinoma of the breast, and
  * estrogen-receptor positive breast carcinoma with 1-3 positive nodes

  
To bill an Oncotype Breast service, please provide the following claim
information:

  * CPT code 81519 - Oncology (breast)
  * Enter "1" in the Days/Unit field
  * Select the appropriate ICD-10-CM code.
  * Enter 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 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
MolDX: Oncotype DX Colon Cancer Assay Update The Oncotype DX Colon Cancer
Assay, developed to predict the recurrence risk for patients with Stage II
colon cancer, has been assigned a unique identifier. To bill an Oncotype DX
Colon service, please provide the following claim information:  
  

  * CPT code 81525-Oncology (colon), mRNA gene expression of 21 genes  
  

  * Enter 1 in the Days/Unit field  
  

  * For CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.  

    * 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: ResponseDX Tissue of Origin

Tissue of Origin, a microarray-based gene expression assay designed to
determine the similarity of unknown or unresolved tumors to cancers from 1 of
15 known tumors of origin, has been assigned a unique identifier. To bill for
Tissue of Origin services, please provide the following claim information:

  * CPT code 81504 - Oncology (tissue of origin)
  * Enter "1" in the Days/Unit field
  * Select the appropriate ICD-10-CM diagnosis.
  * Enter 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 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

Note: MolDX expects this test to ONLY be ordered by the treating physician.
Billing and Coding: Therapy Driving Evaluations

Medicare does not reimburse evaluations performed solely to assess a
beneficiary's ability to drive a vehicle. In order for a service to be
covered, the service must have a benefit category in the statute Title 18 of
the Social Security Act (SSA), it must not be excluded, and it must be
reasonable and necessary. There is no benefit category for driving
evaluations.  
  
In addition, both screening (except as specifically exempted by statute) and
routine physical examinations are excluded from coverage. 42 United States
Code (USC) 1395y (a) describes routine physical checkups as:  
  
1\. Examinations performed for a purpose other than treatment or diagnosis of
a specific illness, symptom, complaint, or injury.  
2\. Examinations required by insurance companies, business establishments,
government agencies or other third parties.  
  
For Medicare purposes, when services provided are related solely to driving,
they are not reasonable or necessary for the diagnosis or treatment of an
illness or injury and are excluded from coverage under the program by SSA
1862(a)(1).  
  
This is a statutory exclusion. The beneficiary is liable for the charges and
no Advance Beneficiary Notice of Noncoverage (ABN) is required. However,
providers are encouraged to provide a voluntary ABN. Append modifier GX
(Notice of Liability Issue, Voluntary under Payer Policy) to any billed line
item.  
  
 **Sources:**  
  
 CMS Internet Only Manual (IOM), Medicare Claims Processing Manual,
Publication 100-04, Chapter 1 Section 60  
 Social Security Act (SSA) Sections 1861 and 1862(a)(1)  
 42CFR 411.15(a)
Billing and Coding: Aflibercept (EYLEA)

Effective November 18, 2011, September 21, 2012, July 29, 2014, October 6,
2014, March 25, 2015, and May 13, 2019 respectively, Aflibercept (EYLEA) was
approved by the Food and Drug Administration (FDA) for the treatment of
patients with:  

  * Neovascular (Wet) Aged-related Macular Degeneration (AMD)   
  

  * Macular Edema following Retinal Vein Occlusion (RVO)   
  

  * Diabetic Macular Edema (DME)   
  

  * Diabetic Retinopathy (DR)

For AMD the recommended dose is 2 mg (0.05 mL) administered by intravitreal
injection every four weeks for the first 12 weeks (3 months), followed by 2 mg
(0.05 mL) once every 8 weeks (2 months) by intravitreal injection. Although
EYLEA may be dosed as frequently as 2 mg every 4 weeks (monthly), additional
efficacy was not demonstrated in most patients when EYLEA was dosed every 4
weeks compared to every 8 weeks. Some patients may need every 4 week (monthly)
dosing after the first 12 weeks (3 months).  
  
For Macular Edema following RVO the recommended dose is 2 mg (0.05 mL)
administered by intravitreal injection once every 4 weeks (monthly).  
  
For DME the recommended dose is 2 mg (0.05 mL) once every 4 weeks (monthly)
for the first 5 injections, and then 2 mg (0.05 mL) every 2 months (8 weeks)
by intravitreal injection. Although EYLEA may be dosed as frequently as 2 mg
every 4 weeks (monthly), additional efficacy was not demonstrated in most
patients when EYLEA was dosed every 4 weeks compared to every 8 weeks. Some
patients may need every 4 week (monthly) dosing after the first 20 weeks (5
months).

For Diabetic retinopathy (DR) the recommended dose is 2 mg (0.05 mL) once
every 4 weeks (monthly) for the first 5 injections, followed by 2 mg (0.05 mL)
once every 8 weeks (every 2 months). Although may be administered every 4
weeks, additional efficacy has not been demonstrated (compared with every 8
week administration); some patients may require every 4 week (monthly) dosing
after the first 20 weeks of therapy (5 months).

To bill aflibercept services, submit the following claim information on CMS
Form 1500:

 J0178 - Injection, aflibercept, 1 mg

 67028 - Intravitreal injection of a pharmacologic agent (separate procedure)

**Note:** It is not reasonable and necessary to inject more than one anti-
vascular endothelial growth factor (VEGF) medication (bevacizumab,
ranibizumab, aflibercept) in the same eye during the same treatment session.
It is not typical to inject one anti-VEGF medication in one eye and another in
the other eye. If different medications are injected into each eye during the
same DOS, the rationale for this therapy must be documented in the medical
record and the billing modifier (RT/LT) must be appended to the correct drug.

Intravitreal injection for the treatment of macular edema more frequently than
every 4 weeks regardless of which drug is used for any given injection i.e.
alternating drugs every 2 weeks will not be covered.
Videostroboscopy and Nasopharyngoscopy Procedures Performed by Speech-Language
Pathologists (SLPs)

Speech-language pathologists (SLPs) are trained in basic laryngeal examination
related to speech and dysfunctional swallowing conditions. Since an SLP does
not have the experience or knowledge to biopsy a neoplasm or an anatomical
pathologic condition, Palmetto PGA will reimburse a videostroboscopy and
nasopharyngoscopy service when an SLP performs the service under the direct
supervision of a physician credentialed by the hospital to perform the
services.
Anesthetic 'Caine Drugs' Anesthetic drugs such as Bupivacaine (Marcaine),
Bupivacaine (Sensorcaine), Chloroprocaine (Nesacaine), Lidocaine (Xylocaine),
Mepivacaine (Carbocaine), etc., when administered for chronic pain control are
not covered by Medicare.  
  
The CMS Internet-Only Manual, Pub. 100-04, Chapter 12, Section 50 specifies
that Palmetto GBA may not allow separate payment for the anesthesia service
performed by the physician who also furnishes the medical or surgical service.
In that case, payment for the anesthesia service is made through the payment
for the medical or surgical service.  
  
 For example, Palmetto GBA may not allow separate payment for the surgeon's
performance of a local or surgical anesthesia if the surgeon also performs the
surgical procedure.
Billing and Coding: Thermal Capsulorrhaphy Thermal capsulorrhaphy, also known
as thermal coagulation of joints, radiofrequency thermal shrinkage,
electrothermal assisted capsulorrhaphy (ETAC) and laser-assisted capsular
shrinkage (LACS) is proposed as a minimally invasive arthroscopic procedure to
tighten the capsule and ligaments of joints.  
  
Due to the lack of clinical evidence to demonstrate improved health outcomes,
Palmetto GBA has determined that this service as a treatment of joint
instability, for the shoulder, knee, elbow, etc. is considered not medically
necessary. Therefore, claims submitted for this service will be denied.  
  
To report this non-covered service, submit CPT code 29999 (unlisted procedure,
arthroscopy).
Billing and Coding: Amniotic Membrane Billing Guidelines for HCPCS Code V2790

HCPCS code V2790 (amniotic membrane for surgical reconstruction, per
procedure) is included in the allowance for CPT Codes 65778 and 65779. In an
inpatient facility reimbursement for HCPCS code V2790 is included in the
Outpatient Prospective Payment System (OPPS) allowance. In an Ambulatory
Surgical Center (ASC) reimbursement for V2790 is included in the facility
allowance.  
  
HCPCS code V2790 (amniotic membrane for surgical reconstruction, per
procedure) should not be billed to Part B separately except as noted below:  
  
HCPCS code V2790 can be reimbursed separately in an office setting when
billed with CPT Code 65780. A copy of the invoice must be submitted when
billing for V2790 and 65780 on the same claim.  
HCPCS code V2790 should not be billed with CPT Code 65775. However, if
amniotic membrane application is required in the course of that procedure,
then either CPT Codes 65778 or 65779, depending on the method of application
of the membrane must be billed with 65775 when a membrane is applied. As
indicated above, CPT Codes 65778 and 65779 both include payment for the
membrane itself (V2790) and therefore V2790 should not be billed separately
when those codes are billed.  
  
**Documentation That Must Be Submitted with Claim**  
  
For electronic claims, submit an invoice via fax.  
For paper claims, please submit the actual invoice with the claim.  
  
This instruction is effective for dates of service on or after September 4,
2012.
Billing and Coding: Periodic Adjustment of Gastric Restrictive Device after
the Global Period

****Only payable in an office setting ****  
  
The laparoscopic gastric band is an adjustable and reversible bariatric
surgery procedure. The band is an inflatable doughnut-shaped ring. The
diameter, which can be adjusted in the office setting by adding or removing
saline via a port, is positioned beneath the skin. The number and frequency of
adjustments to the band depends on individual consideration(s). Most patients
have between 5 and 8 adjustments within the first year after surgery. Claims
for an adjustment of a gastric restrictive device after the global period (90
days after surgery) may be reimbursable in the office setting.  
  
An adjustment of the gastric band (CPT code 43999) and an evaluation and
management service (E/M) service are not payable on the same day of service.
An E/M and the adjustment of a gastric band (CPT code 43999) will only be
allowed on the same day if there was a significantly separate service
provided. The CPT modifier 25 should be appended to the E/M code to indicate
the E/M service was a significantly separate service.  
  
To submit a claim for adjustment of Gastric Restrictive Device:

  * Submit CPT Code 43999

  * Narrative field put the words 'adjustment of lap-band'

  
**NOTE:**

Only reimbursable in the office setting.

Imaging to locate the port would be included in the service of CPT code
43999.
Oral Surgery and Maxillofacial Surgery Specialty Codes

Physicians self-designate their Medicare physician specialty on the Medicare
enrollment application (CMS-855I) or Internet-based Provider Enrollment, Chain
and Ownership System when they enroll in the Medicare program. Dentists who
practice general or specialized dentistry should be enrolled in Medicare as
specialty 19 (oral surgery - dentists only) or specialty 85 (maxillofacial
surgery). Dentists enrolled as specialty 19 might extract teeth, perform
simple surgical biopsies or remove suspicious tumors or lesions in the oral
cavity. Dentists enrolled as specialty 85 are trained and practice primarily
maxillofacial surgery by doing major repairs of facial trauma, oral tumors or
jaw reconstruction. Otolaryngologists should be enrolled in Medicare as
specialty 04.  
  
It is important for physicians to select the most correct specialty code in
order to promote the correct coding and processing of Medicare claims.
Billing and Coding: MolDX: 4q25-AF Risk Genotype

Effective for dates of services on and after 06/14/2012  
The 4q25-AF Risk Genotype Test was developed to help predict the risk of
atrial fibrillation and cardioembolic stroke. To date, there is insufficient
evidence to support the required clinical utility for the established Medicare
benefit category.  
  
As reviewed, the developer described the indication to perform a 4q25-AF Risk
Genotype Test as a risk assessment for developing a disease or condition. Risk
assessment for developing a disease or condition in the absence of signs and
symptoms of an illness or injury is also not defined as a Medicare benefit.
Therefore, the 4q25-AF Risk Genotype Test would continue to be a statutory
excluded service.  
  
To receive a 4q25-AF Risk genotype service denial, please submit the following
claim information:

  * CPT code 81479 - Unlisted molecular pathology procedure
  * 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
  * Enter 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 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: MolDX: LPA-Aspirin Genotype

The MolDX Team has completed a review of the research on the LPA-Aspirin
genotype test, developed to predict increased CVD risk and event reduction
during aspirin therapy. To date, there is insufficient evidence to support the
required clinical utility for the established Medicare benefit category.
Therefore, the LPA-Aspirin genotype test is a statutorily excluded test.  
  
As reviewed, the developer described the indication to perform a LPA-Aspirin
genotype test as a risk assessment for developing a disease or condition. Risk
assessment for developing a disease or condition in the absence of signs and
symptoms of an illness or injury is also not defined as a Medicare benefit.
Therefore, the LPA-Aspirin genotype test would continue to be a statutory
excluded test.  
  
To receive a LPA-Aspirin service denial, please submit the following claim
information:

  * CPT code 81479 -Unlisted molecular pathology procedure
  * 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
  * Enter 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 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: MolDX: LPA-Intron 25 Genotype

The MolDX Team has completed a review of the research on the LPA-Intron 25
genotype test, developed to predict increased Coronary Heart Disease risk. To
date, there is insufficient evidence to support the required clinical utility
for the established Medicare benefit category. Therefore, the LPA-Intron 25
genotype test is a statutorily excluded service.  
  
As reviewed, the developer described the indication to perform a LPA-Intron 25
genotype test as a risk assessment for developing a disease or condition. Risk
assessment for developing a disease or condition in the absence of signs and
symptoms of an illness or injury is also not defined as a Medicare benefit.
Therefore, the LPA-Intron 25 genotype test would continue to be a statutory
excluded test.  
  
To receive a LPA-Intron 25 service denial, please submit the following claim
information:

  * CPT code 81479 -Unlisted molecular pathology procedure
  * 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
  * Enter 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 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: Pre/Postoperative Care: Date of Service

_Where physicians agree on the transfer of care during the global surgery
period, the following modifiers  are used: _  
  
_ CPT modifier 54 - for surgical care only; or_  
  
 _ CPT modifier 55 - for postoperative management only_  
  
The claim for the surgical care and the claim(s) for the postoperative care
must contain _the same date of service and the same surgical procedure code,
with the services distinguished by the use of the appropriate modifier_.  
  
  
  
**Appropriate**

Date | CPT Code/Modifier | Surgeon/Physician  
---|---|---  
May 8 | 66982-54 | Surgeon  
May 8 | 66982-55 | Post-op Care Physician  
  
  
  
**Inappropriate**

Date | CPT Code/Modifier | Surgeon/Physician  
---|---|---  
May 8 | 66982-54 | Surgeon  
May 9 | 66982-55 | Post-op Care Physician  
  
  
  
The surgeon and the physician(s) providing the postoperative care must
collaborate to ensure the appropriate date of service and surgical code are
submitted (with the appropriate CPT modifier).  
  
Claims are being monitored and will be rejected when submitted
inappropriately.  
  
For more information regarding global surgery and transfer of care during the
global surgery period, refer to the CMS Internet-Only Manual, Pub 100-04,
Medicare Claims Processing Manual, Chapter 12, Sections 40.2 - 40.4.
Billing and Coding: MolDX: HTTLPR Gene Testing

Effective for dates of service on and after June 26, 2013.  
  
Serotonin Transporter genotyping (HTTLPR) has been associated with response to
selective serotonin reuptake inhibitors. However since the literature is
conflicting and limited by small sample sizes, the MolDX Team has determined
there is insufficient evidence to support coverage. Therefore, HTTLPR testing
is a statutorily excluded service.  
  
To receive a HTTLPR analysis service denial, please submit the following claim
information:

  * CPT code 81479
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.
    * For a voluntary issued ABN, append with GX modifier
    * To indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier
  * Enter 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 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