Persius/hicric huggingface dataset:
Billing and Coding: Home Health - Psychiatric Care

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Home Health -
Psychiatric Care L34561.

****Diagnostic Criteria****

A Patient must have a diagnosis as defined in the Diagnostic and Statistical
Manual of Mental Health Disorders, 5th Edition, DSM-5TM. This diagnosis must
match the diagnosis that the ordering physician is treating and/or for which
the patient was hospitalized. This diagnosis must be fully documented and
available in the medical record.  

The DSM-5TM has combined Axis III with Axes I and II. Clinicians should
continue to list medical conditions that are important to the understanding or
management of an individual's mental disorder as opposed to personality
disorders, mental retardation, general medical conditions, psychosocial and
environmental problems and global assessment of functioning.

**Billing When Separate Visits Were Made for Medical and Psychiatric Nursing
Care**  
  
Psychiatric nursing care is not separately billable from non-psychiatric
nursing care. Both of these services constitute skilled nursing care and may
be furnished by the psychiatric nurse, in the course of a single visit.
Therefore, visits will not be covered for 1 nurse to provide psychiatric
nursing care and another to provide non-psychiatric nursing care, unless the
non-psychiatric nursing care is of such a highly specialized and technical
nature, that the service could not be safely rendered by the psychiatric nurse
(e.g., infusion therapy).
Billing and Coding: Heavy Metal Testing

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Heavy Metal Testing.

**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.
Billing and Coding: Somatosensory Testing

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Somatosensory
Testing L34433.
Billing and Coding: Special Electroencephalography

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Special
Electroencephalography L33447.

Ambulatory electroencephalography (EEG) should always be preceded by a routine
EEG. A routine EEG is described by Current Procedural Terminology (CPT) codes
95812, 95813, 95816, 95819 or 95822 and refers to a routine EEG recording of
less than a 24-hour continuous duration.

A routine "resting" (EEG) (as described by CPT codes 95812, 95813, 95816,
95819 or 95822) must be performed prior to performing an ambulatory continuous
EEG. A claim for the routine EEG must have been submitted to Medicare with a
date of service (DOS) within 1 year of the DOS of the ambulatory EEG.

The CPT codes contained in this article are the codes that describe the
services covered per the LCD language. Claims billed with EEG services
represented by CPT codes not contained in this article require the submission
of documentation and will be reviewed on a claim-by-claim basis. Note that the
codes for these services now have separate coding for the professional and the
technical components. Providers should bill only the component of the service
which they have provided.
Billing and Coding: Virtual Colonoscopy (CT Colonography)

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Virtual Colonoscopy
(CT Colonography) L33452.

**Limitations**

CPT Code - 74263 Computed tomographic (CT) colonography (i.e., virtual
colonoscopy), screening, including image postprocessing is never covered.
Billing and Coding: Neurophysiology Evoked Potentials (NEPs)

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L34975 (Neurophysiology Evoked Potentials
[NEPs]). 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.  
  
CPT codes for **Somatosensory Evoked Potentials and Responses (SEPs/SERs):**
95925, 95926, 95927, 95928, 95929, 95938, 95939.  
  
CPT codes for **Brainstem Auditory Evoked Potentials and Responses
(BAEPs/BAERs):**   92651, 92652, 92653.  
  
CPT code for **Visual Evoked Potentials or Responses (VEPs/VERs):** 95930.
Billing and Coding: Ophthalmic Angiography (Fluorescein and Indocyanine Green)

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Ophthalmic
Angiography (Fluorescein and Indocyanine Green) L34426.
Billing and Coding: Magnetic Resonance Angiography

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Magnetic Resonance
Angiography L34424.
Billing and Coding: Total Joint Arthroplasty

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Total Joint
Arthroplasty L33456.
Response to Comments: Micro-Invasive Glaucoma Surgery (MIGS)

As an important part of Medicare Local Coverage Determination (LCD)
development, National Government Services solicits comments from the provider
community and from members of the public who may be affected by or interested
in our LCDs. The purpose of the advice and comment process is to gain the
expertise and experience of those commenting.

We would like to thank those who suggested changes to the Micro-Invasive
Glaucoma Surgery (MIGS) LCD. The official notice period for the final LCD
begins on October 10, 2019, and the final determination will become effective
on December 1, 2019.
Billing and Coding: Pulmonary Stress Testing

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Pulmonary Stress
Testing L33444.
Billing and Coding: Nonvascular Extremity Ultrasound

This article contains coding and other guidelines that compliment the LCD for
Nonvascular Extremity Ultrasound.

**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 LCD. 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.

A permanent record of the ultrasound and its interpretation should be kept on
file in the patient's record. The record should include all of the following:

  * Images of all appropriate areas, labeled with exam date, patient identification, and image orientation; and
  * documentation of the variations from normal, accompanied by measurements;
  * formal interpretation.

Results of all testing should be shared with the referring physician.
Documentation must be available to Medicare upon request.

**Utilization Guidelines:**

Services in excess of two tests per extremity in six months will be considered
not medically necessary.
Billing and Coding: YAG Capsulotomy

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for YAG Capsulotomy
L37644.
Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of
Hematolymphoid Diseases

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Genomic Sequence Analysis Panels in the
Treatment of Hematolymphoid Diseases.

**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.  
  

**Specific Coding Guidelines:**

Regarding Acute Myelogenous Leukemia (AML), Myelodysplastic Syndromes (MDS),
and Myeloproliferative Neoplasms (MPN), the following guidelines apply:

Targeted genomic sequence analysis panel, hematolymphoid neoplasm, DNA
analysis, and RNA analysis 5-50 genes (CPT 81450 or 81451) is a useful
representation of the aggregate of these gene tests, and may be used as long
as the panel contains, at a minimum, 5 or more gene tests for molecular
biomarkers determined to meet Medicare coverage criteria (for example, NCCN
Biomarkers Compendium Evidence Category I or 2A and associated clinical
utility). The specified coverage indications are in line with NCCN
recommendations. Evaluation of other genes or genomic sequences not addressed
by NCCN or other professional guidelines are not precluded, but their
inclusion in panels recognized by this code should not be interpreted as
endorsement of such testing by genomic sequencing procedures and laboratories
and users of such testing are advised to adhere to traditional regulatory and
institutional oversight mechanisms to assure their clinical validity and
utility.
Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee)

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L36007, Lower Extremity Major Joint Replacement
(Hip and Knee). 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.  
  
 **Documentation Requirements**

    1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
    2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
    3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
Billing and Coding: Fluid Jet System Treatment for LUTs/BPH

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Fluid Jet System Treatment for LUTS/BPH.

**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.
Billing and Coding: Magnetic Resonance Angiography (MRA)

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L34865, Magnetic Resonance Angiography (MRA).
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.

**Documentation Requirements**

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging
(SCODI)

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Scanning
Computerized Ophthalmic Diagnostic Imaging (SCODI) L34431.

SCODI (92133, 92134) and fundus photography (92250) are mutually exclusive
codes. However, there may be a limited number of clinical situations in which
it is necessary to perform both techniques in order to evaluate and treat the
patient. In these situations, both CPT codes may be reported appending
modifier 59 to indicate a distinct procedural service. Documentation
supportive of the need to perform both techniques should be clear in the
medical record.
Billing and Coding: B-type Natriuretic Peptide (BNP) Testing

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for B-type Natriuretic Peptide (BNP) Testing  

**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:**

Frequency of testing should be guided by the clinical circumstances and
evidence-based literature.
Billing and Coding: Proton Beam Therapy

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Proton Beam Therapy.



**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.

  
Documentation in the patient medical record must:  
  

  1. Support one or more medical necessity requirement(s) as provided under the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy.
  2. Include a treatment prescription that defines the goals of the treatment plan- including specific dose-volume parameters for the target and nearby critical structures- as well as pertinent details of beam delivery, such as method of beam modulation, field arrangement, and expected positional and range uncertainties.
  3. Include a treatment plan, signed by a physician, which meets the prescribed dose-volume parameters for the clinical target volume (CTV) and surrounding organs at risk (OARs) in the presence of expected uncertainties.
  4. Describe the target setup verification methodology, including patient positioning, immobilization and use of image guidance.
  5. Include verification of planned dose distribution via independent dose calculation or physical measurement.
Billing and Coding: Reduction Mammaplasty

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Reduction Mammaplasty.

**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.
Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical
Stains

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Lab: Special
Histochemical Stains and Immunohistochemical Stains L35922.

To report special histochemical stains and/or immunohistochemical stains
services, please submit the following claim information:

  * Select the appropriate CPT code
  * Enter 1 unit of service (UOS)
Billing and Coding: Vitamin D; 25 hydroxy, includes fraction(s), if performed

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L33771 Vitamin D; 25 hydroxy, includes
fraction(s), if performed. 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.

**Documentation Requirements**

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  4. The results of the Vitamin D testing and the resulting treatment regimen must be documented in the patient's medical record. This information includes, but is not limited to relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures usually found in hospital/office progress notes and written laboratory reports.