Persius/hicric huggingface dataset:
Billing and Coding: MolDX: Pharmacogenomics Testing

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for MolDX:
Pharmacogenomics Testing(DL38394).

To report a Pharmacogenomics Testing 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
  * Select the appropriate ICD-10-CM code
Billing and Coding: Transesophageal Echocardiogram

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L33756, Transesophageal Echocardiogram. Please
refer to the LCD for reasonable and necessary requirements.

**Coding Guidance**

If the service of the cardiologist is requested for a specific reason, his
professional services would be billed with CPT 93314 or 93317 with the 26
modifier.

**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. If the provider of transesophageal echocardiography studies is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician's order for the studies. When ordering transesophageal echocardiography studies, the ordering/referring physician must state the reason for the study in his order.
  5. An order from the treating physician/nonphysician practitioner as required by CFR, Title 42, Volume 2, Chapter IV, Part 410.32(a) Ordering diagnostic tests.
Billing and Coding: Allergy Testing

The following coding and billing guidance is to be used with its associated
Local coverage determination.

**Documentation Requirements**  
It is expected that supportive documentation evidencing the condition and
treatment will be documented in the medical record and be available to the
Contractor upon request.  
  
Documentation, such as ICD-10-CM codes, supporting the medical necessity of
the service must be submitted with each claim. Claims submitted without such
evidence will be denied as not medically reasonable and necessary.  
  
**Utilization Guidelines**  
The evaluation of an inhalant may require up to 90 prick-puncture tests
followed by up to 40 intracutaneous tests which are usually performed when
prick/puncture tests are negative. _Sometimes 60 intracutaneous tests
performed via multi test, in lieu of prick puncture, may be appropriate for
selected patients (for example young children, older adults and needle phobic
individuals.)_  
  
The number of percutaneous tests performed for the evaluation of food
sensitivity may require up to 40 tests.  
  
The total number of tests, i.e. prick or intracutaneous, should not exceed
generally accepted standards of testing set forth by professional
associations. Exceeding these parameters may be justified if preliminary
testing failed and immunotherapy failed to control symptoms.  
  
In California, for CPT code 95004, among patients treated by Allergists, over
half required fewer than 100 tests. The great majority required less than
120-130 tests, and only 5% required more than 200 tests. Some of the high-test
group includes repeat testing necessitated by unsatisfactory response to
clinical treatment and a clinical need for further investigation. For CPT code
95024, among patients treated by Allergists, over half required only 12 tests,
and only 5% required 70 or more tests. High-utilization testing may be
selected for medical review when inconsistent with clinical practice norms.
Billing and Coding: Cardiovascular Stress Testing, Including Exercise and/or
Pharmacological Stress and Stress Echocardiography

The following coding and billing guidance is to be used with its associated
Local coverage determination.

Supportive documentation evidencing the condition and treatment is expected to
be documented in the medical record and be available upon request.  
  
Documentation in the patient's medical record must substantiate the medical
necessity of the service, including the following:  
  
 A clinical diagnosis,  
  
 The specific reason for the study,  
  
 Reason for performing a stress echocardiogram as opposed to only an
electrical stress test,  
  
 The reason for using any pharmacological stress, and  
  
 The reason for a stress echocardiogram if a stress nuclear test is also
performed for the same patient for the same clinical condition.  
  
  
Document the referral order (written or verbal) in the patient's medical
record. For example, if a referring physician calls a cardiologist to order a
stress echocardiogram, the test report or office record must document the date
of the call, name of the referring physician, and reason for referral.  
  
Document the interpretation and report of all segments of the service (e.g.,
the electrical and echo results).  
  
Document the necessity for the test frequency, when applicable.  
  
Document (preferably on the test report) that any applicable physician
supervision requirement is met.  
  
For tests performed by leased employees, maintain the leasing contract on file
(e.g., in the office) and submit it to the contractor for review upon request.  
  
 **Utilization Guidelines:**  
Stress testing is covered only at a frequency appropriate for the patient's
condition, and when the results will potentially affect the patient's
treatment.  
  
A routine follow-up test after an MI, CABG, or PTCA, in the absence of
symptoms or clinical indications, outside of the reassessment period, is not
reasonable and necessary. Annual testing in the absence of individualized
clinical indications is not reasonable and necessary. For example, a patient
who has had a MI, CABG, PTCA, or other coronary revascularization procedure
may require an initial follow-up stress test several months later and a second
test one year after the first follow-up test. Thereafter, a patient who
initially presented with silent coronary disease (no reliable signs or
symptoms) may require testing as often as annually. However, a patient who
initially presented with reliable symptoms or signs of CAD (e.g., angina
pectoris) typically will not need annual testing. When the clinical
information is sufficient to reliably monitor the patient, an additional
follow-up test once every five years may be sufficient.
Billing and Coding: Cardiovascular Stress Testing, Including Exercise and/or
Pharmacological Stress and Stress Echocardiography

The following coding and billing guidance is to be used with its associated
Local coverage determination.

Supportive documentation evidencing the condition and treatment is expected to
be documented in the medical record and be available upon request.  
  
Documentation in the patient's medical record must substantiate the medical
necessity of the service, including the following:  
  
 A clinical diagnosis,  
  
 The specific reason for the study,  
  
 Reason for performing a stress echocardiogram as opposed to only an
electrical stress test,  
  
 The reason for using any pharmacological stress, and  
  
 The reason for a stress echocardiogram if a stress nuclear test is also
performed for the same patient for the same clinical condition.  
  
Document the referral order (written or verbal) in the patient's medical
record. For example, if a referring physician calls a cardiologist to order a
stress echocardiogram, the test report or office record must document the date
of the call, name of the referring physician, and reason for referral.  
  
Document the interpretation and report of all segments of the service (e.g.,
the electrical and echo results).  
  
Document the necessity for the test frequency, when applicable.  
  
Document (preferably on the test report) that any applicable physician
supervision requirement is met.  
  
For tests performed by leased employees, maintain the leasing contract on file
(e.g., in the office) and submit it to the contractor for review upon request.  
  
 **Utilization Guidelines:**

  
Stress testing is covered only at a frequency appropriate for the patient's
condition, and when the results will potentially affect the patient's
treatment.  
  
A routine follow-up test after an MI, CABG, or PTCA, in the absence of
symptoms or clinical indications, outside of the reassessment period, is not
reasonable and necessary. Annual testing in the absence of individualized
clinical indications is not reasonable and necessary. For example, a patient
who has had a MI, CABG, PTCA, or other coronary revascularization procedure
may require an initial follow-up stress test several months later and a second
test one year after the first follow-up test. Thereafter, a patient who
initially presented with silent coronary disease (no reliable signs or
symptoms) may require testing as often as annually. However, a patient who
initially presented with reliable symptoms or signs of CAD (e.g., angina
pectoris) typically will not need annual testing. When the clinical
information is sufficient to reliably monitor the patient, an additional
follow-up test once every five years may be sufficient.
Billing and Coding: Immune Globulin Intravenous (IVIg)

The following billing coding and guidance is to be used with its associated
Local Coverage Determination.

Medical record documentation maintained by the treating physician must clearly
document the medical necessity to initiate IVIg therapy and the continued need
thereof. Required documentation of medical necessity could include:  
 History and physical;  
 Office/progress note(s);  
 Test results with written interpretation; and An accurate weight in
kilograms should be documented prior to the infusion since the dosage is based
mg/kg/dosage.
Billing and Coding: Serum Magnesium

The following coding and billing guidance is to be used with its associated
Local Coverage Determination.

Documentation must be made available to Medicare upon request. Failure to do
so, may result in denial of claims.  
  
Documentation of the medical necessity of the test must be retained in the
ordering physician's patient medical record. Documentation should state the
signs/symptoms and/or diagnosis that caused the need of the test procedure.  
  
Laboratories must maintain the record of the physician's order for the test.  
  
Medical records must contain the lab test results.  
  
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 Medical Director's review.
Billing and Coding: Blepharoplasty, Eyelid Surgery, and Brow Lift

The following coding and billing guidance is to be used with its associated
Local coverage determination.

_**Other requirements**_  
The medical record documentation must support the medical necessity of the
services as directed in this policy.  
  
All documentation must be maintained in the patient's medical record and
available to the contractor upon request.  
  
Every page of the record must be legible and include appropriate patient
identification information (e.g., complete name, dates of service(s)).  
  
Documentation must support CMS 'signature requirements' as described in the
Medicare Program Integrity Manual (Pub. 100-08), Chapter 3.  
  
A pre-operative exam and operative report must be available.  
  
The submitted medical record must support the use of the selected ICD10-CM
code(s). The submitted CPT/HCPCS code must describe the service performed.
Billing and Coding: Immune Globulin Intravenous (IVIg)

The following billing and coding guidance is to be used with its associated
LCD.

Medical record documentation maintained by the treating physician must clearly
document the medical necessity to initiate IVIg therapy and the continued need
thereof. Required documentation of medical necessity could include:  
 History and physical;  
 Office/progress note(s);  
 Test results with written interpretation; and An accurate weight in
kilograms should be documented prior to the infusion since the dosage is based
mg/kg/dosage.
Billing and Coding: MRI and CT Scans of the Head and Neck

The following coding and billing guidance is to be used with its associated
Local Coverage Determination.

**Documentation Guidelines**

Diagnostic evaluation of the head and neck (head/neck scans) performed by
computerized tomography (CT) scanners is covered when the documentation
supports that the scan is reasonable and necessary. Accurate coding
information must be provided with claims to differentiate CT and/or MRI scans
from other radiology services and to make coverage determinations. Sufficient
documentation such as, history and physical notes, laboratory results, signs
and symptoms of the disease to warrant the diagnostic test and to support the
claim of reasonable and necessary must be included in the medical records.
This information must be available to Medicare upon request.

**Coding Guidelines**

The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits
in addition to guidance in this LCD. Please refer to the CCI for correct
coding guidelines and specific applicable code combinations prior to billing
Medicare. Whichever guidance is more restrictive should be adhered to.
Billing and Coding: Oximetry Services

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L35434, Oximetry Services. 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.  
  
Overnight oximetry should be reported with CPT code 94762.
Billing and Coding: Lumbar MRI

The following coding and billing guidance is to be used with its associated
Local coverage determination.

**Documentation Requirements**  
  
Supportive documentation evidencing the condition and treatment is expected to
be documented in the medical record and be available upon request.  
  
The patient's medical record must be legible and clearly indicate the
necessity and reasonableness of the service.  
  
The documentation must clearly support the ICD-10-CM code(s) reported on the
claim.  
  
An attending/treating physician's order is required for each test. The order
must be properly signed and dated.  
  
Lumbar MRI abnormalities alone do not validate the need for the test without
other supporting clinical rationale. Radiologists and/or ordering physicians
should include sufficient clinical information in the report to justify its
necessity.

The clinical findings and relevant prior treatment that support the need for
the MRI must be documented in the MRI report or clinical record and made
available to the contractor upon request.

The medical record of the referring physician must support a contemplated
diagnosis or treatment change derived from the MRI findings. The contractor
may request medical records from the referring physician if the radiologist's
documentation does not validate that the service is reasonable and necessary.  
  
According to national regulations, clinics which are (a) not physician owned
and which are (b) billing Medicare primarily for diagnostic tests may be
required to enroll as IDTFs. For example, a nonphysician owner who establishes
a Magnetic Resonance Imaging clinic by leasing office space, equipment, and
hiring technicians, and hires a retired ophthalmologist to provide off-site
(general) supervision of diagnostic testing without treatment would be more
appropriately enrolled as an IDTF rather than merely billing all services
through the physician's PIN.  
  
 **Utilization Guidelines**  
  
Normally only one lumbar MRI is sufficient to diagnose the patient's
condition. However, a second lumbar MRI, for the same patient, may be allowed
providing the documentation indicates that comparative test results were
needed to make a more definitive treatment decision.  
  
Payment will be allowed for multiple scans of different areas of the body
performed on the same day for the same patient when reasonable and necessary.
Billing and Coding: Plastic Surgery

The following coding and billing guidance is to be used with its associated
Local coverage determination.

Cosmetic surgery is performed to reshape normal structures of the body, for
the purpose of improving the patient's appearance and self-esteem. Per IOM
100-02 Chapter 16, cosmetic surgery and expenses incurred in connection with
such surgery are not covered. This exclusion does not apply to surgery in
connection with the treatment of severe burns, facial repair following auto
trauma, or similar surgeries for therapeutic purposes or reconstruction.

**For Reduction Mammoplasty:**  
1\. Physicians should document the severity of the symptoms of breast
hypertrophy and impact on health related quality of life as measured by an
accepted breast specific questionnaire.  
The beneficiary's medical record must contain the following information and be
made available to any authorized Medicare auditor upon request:

  * Height and weight
  * Clinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to reduction mammoplasty and the responses to these therapies.
  * The operative report with documentation of the weight of tissue removed from _each breast_ , obtained in the operating room.
  * The pathology report of the tissue removed from _each breast_.

2\. Reasons for denial include:

  1. Surgery is deemed or later determined to be cosmetic in nature. Breast surgery for uncomplicated macromastia, pendulous breasts, or to correct otherwise uncomplicated nipple inversions will be considered cosmetic and not reasonable and necessary.
  2. Failure to clearly document persistent signs and symptoms despite a reasonable trial of conservative therapy for a reasonable length of time.
  3. Services submitted without a listed diagnosis (ICD-10-CM) code supporting medical necessity.
  4. Use of any ICD-10-CM codes not listed in the ICD-10-CM Codes That Support Medical Necessity Section below.

**For all procedures noted within this policy:**  
The medical record must be made available to Medicare or a Medicare auditor
upon request.  
  
The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits.
This policy 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.

Services billed with a diagnosis code that is not listed in the ICD-10-CM
Codes That Support Medical Necessity section may be considered at
redetermination on a case-by-case basis.

When the documentation does not meet the criteria for the service rendered or
the documentation does not establish the medical necessity for the services,
such services may be denied as not reasonable and necessary.  
  
When requesting a written redetermination, providers must include all relevant
documentation with the request. Failure to include such items will likely
result in an unfavorable determination. While not required, high quality
photographs may be useful in determining medical necessity and may be
submitted when the provider feels it is appropriate to do so.
Billing and Coding: Plastic Surgery

The following coding and billing guidance is to be used with its associated
Local coverage determination.

Cosmetic surgery is performed to reshape normal structures of the body, for
the purpose of improving the patient's appearance and self-esteem. Per IOM
100-02 Chapter 16, cosmetic surgery and expenses incurred in connection with
such surgery are not covered. This exclusion does not apply to surgery in
connection with the treatment of severe burns, facial repair following auto
trauma, or similar surgeries for therapeutic purposes or reconstruction.

**For Reduction Mammoplasty:**  
1\. Physicians should document the severity of the symptoms of breast
hypertrophy and impact on health related quality of life as measured by an
accepted breast specific questionnaire.  
The beneficiary's medical record must contain the following information and be
made available to any authorized Medicare auditor upon request:

  * Height and weight
  * Clinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to reduction mammoplasty and the responses to these therapies.
  * The operative report with documentation of the weight of tissue removed from _each breast_ , obtained in the operating room.
  * The pathology report of the tissue removed from _each breast_.

2\. Reasons for denial include:

  1. Surgery is deemed or later determined to be cosmetic in nature. Breast surgery for uncomplicated macromastia, pendulous breasts, or to correct otherwise uncomplicated nipple inversions will be considered cosmetic and not reasonable and necessary
  2. Failure to clearly document persistent signs and symptoms despite a reasonable trial of conservative therapy for a reasonable length of time.
  3. Services submitted without a listed diagnosis (ICD-10-CM) code supporting medical necessity
  4. Use of any ICD-10-CM codes not listed in the ICD-10-CM Codes That Support Medical Necessity Section below.

**For all procedures noted within this policy:**  
The medical record must be made available to Medicare or a Medicare auditor
upon request.  
  
The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits.
This policy 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.

Services billed with a diagnosis code that is not listed in the ICD-10-CM
Codes That Support Medical Necessity section of this policy may be considered
at redetermination on a case-by-case basis.

When the documentation does not meet the criteria for the service rendered or
the documentation does not establish the medical necessity for the services,
such services may be denied as not reasonable and necessary.  
  
When requesting a written redetermination, providers must include all relevant
documentation with the request. Failure to include such items will likely
result in an unfavorable determination. While not required, high quality
photographs may be useful in determining medical necessity and may be
submitted when the provider feels it is appropriate to do so.