Persius/hicric huggingface dataset:
Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS)

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Micro-Invasive Glaucoma Surgery (MIGS).

**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 Guideline:**

Effective for services rendered on or after 1/1/2022, codes 0191T and 0376T
are being replaced by CPT codes 66989, 66991.

**Documentation Requirements:** The patient's medical record must contain
documentation that fully supports the medical necessity for services. included
in 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.
The medical record and/or test results documenting medical necessity should be
maintained and made available on request. iStent, iStent inject, and Hydrus
must be performed in conjunction with cataract surgery on the same date of
service and documented in the medical record.
Billing and Coding: Water Vapor Thermal Therapy for LUTS/BPH

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Water Vapor Thermal Therapy 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: Blood Glucose Monitoring in a Skilled Nursing Facility
(SNF)

Refer to the Novitas Local Coverage Determination (LCD) L34834, Blood Glucose
Monitoring in a Skilled Nursing Facility (SNF), for reasonable and necessary
requirements.

  
The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding
System (HCPCS) code(s) may be subject to National Correct Coding Initiative
(NCCI) edits. This information does not take precedence over NCCI edits.
Please refer to NCCI for correct coding guidelines and specific applicable
code combinations prior to billing Medicare.

**  
Coding Information**

  
The material for examination may be from any source unless otherwise specified
in the code descriptor. When an analyte is measured in multiple specimens from
different sources or in specimens that are obtained at different times, the
analyte is reported separately for each source and for each specimen.
Billing and Coding: Foodborne Gastrointestinal Panels Identified by Multiplex
Nucleic Acid Amplification (NAATs)

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Foodborne
Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification
(NAATs) (L37364).

This contractor will provide limited coverage for Gastrointestinal Pathogen
(GIP) molecular assays identified by multiplex nucleic acid amplification
tests (NAATs). In immune competent beneficiaries, coverage is limited to no
more than 5 bacterial targets (when not testing for clostridium difficile).
Testing for 6-11 pathogens is covered when there is a clinical concern for
clostridium difficile colitis, and clostridium difficile is one of the
pathogens being tested.

Testing for 12 or more organisms will only be covered in critically ill or
immunosuppressed patients. This contractor expects that critically ill
patients will be tested and managed in the appropriate inpatient facility. As
such, for critically ill patients, only Part A claims should be submitted.

ICD-10-CM diagnosis codes supporting medical necessity must be submitted with
each claim. Claims submitted without such evidence will be denied as not
medically necessary.

Any diagnosis submitted must have documentation in the patient's record to
support coverage and medical necessity.

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 Information:**

To bill for GIP molecular assays identified by multiplex NAATs, please provide
the following claim information:

  * If the panel being used does not have its own proprietary CPT code, use CPT code 87505, 87506 or 87507
  * For dates of service on or after 7/1/2019, laboratories billing for services using the BioFire FilmArray Gastrointestinal (GI) Panel (BioFire Diagnostics) should report 0097U
  * Enter 1 unit of service (UOS)
  * Enter the appropriate 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 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
  * ICD-10-CM diagnosis code(s) as set forth below.
Billing and Coding: Cardiac Rhythm Device Evaluation

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L34833, Cardiac Rhythm Device Evaluation. 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 code 93292 should be reported when billing Medicare Part B for the
analysis of a Wearable Defibrillator System.  
  
CPT Codes 93260, 93261, 93279-93292 are reported per procedure.  
  
 **Utilization Parameters  
  
** CPT Codes 93293, 93294, 93295 and 93296 are reported no more than once
every 90 days.  
  
Do not report CPT codes 93293, 93294, 93295 and 93296, if the monitoring
period is less than 30 days.  
  
 **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: B-type Natriuretic Peptide (BNP) Testing

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for B-type Natriuretic
Peptide (BNP) Testing L34410.
Billing and Coding: Cardiac Event Detection

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Cardiac Event
Detection L34573.
Billing and Coding: Continuous Peripheral Nerve Blocks (CPNB)

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Continuous
Peripheral Nerve Blocks (CPNB) L37641.

**Limitations**

Reimbursement for the control or management of pain in the immediate
postoperative period is bundled into the payment for the procedure, surgical
or anesthetic - regardless of the method by which the care provider, including
the anesthesiologist, decides to manage pain.
Billing and Coding: Biomarker Testing for Prostate Cancer Diagnosis

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Biomarker Testing for Prostate Cancer
Diagnosis.

**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: Hospice Cardiopulmonary Conditions

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Hospice
Cardiopulmonary Conditions L34548.
Billing and Coding: Corneal Pachymetry

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Corneal Pachymetry
L34512.
Billing and Coding: CT of the Head

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for CT of the Head
L34417.

1\. The ICD-10 codes R51.9 (Headache, unspecified) and G44.1 (Vascular
headache, not elsewhere classified) will only be covered in the following
situations:

a. The patient is suffering from headaches and a head injury. Head computed
tomography (CT) is performed to rule out the possibility of an intracranial
bleed.  
  
b. The patient is suffering from headaches unusual in duration (greater than 2
weeks) not responding to medical therapy. Head CT is performed to rule out the
possibility of a tumor.  
  
c. The patient is suffering from new onset headache (less than 2 weeks)
suggestive of intracranial bleeding as evidenced by signs (e.g., weakness or
paralysis), symptoms (e.g., blurred vision, nausea and vomiting), or clinical
history.

2\. Any claim billed with ICD-10 code R51.9 (Headache, unspecified) or G44.1
(Vascular headache, not elsewhere classified) may be subject to manual review.

3\. Claims billed with ICD-10 codes S09.19XA (Other specified injury of muscle
and tendon of head, initial encounter), S09.19XD (Other specified injury of
muscle and tendon of head, subsequent encounter) , S09.19XS (Other specified
injury of muscle and tendon of head, sequela), S09.8XXA (Other specified
injuries of head, initial encounter), S09.8XXD (Other specified injuries of
head, subsequent encounter), S09.8XXS (Other specified injuries of head,
sequela), S09.90XA (Unspecified injury of head, initial encounter), S09.90XD
(Unspecified injury of head, subsequent encounter), or S09.90XS (Unspecified
injury of head, sequela) should have documented associated signs and symptoms
to support the need for CT scan of the head and may be subject to manual
review.
Billing and Coding: Cataract Surgery

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Cataract Surgery
L34413.

When billing ICD-10 codes H26.231, H26.232, H26.233, H26.221, H26.222,
H26.211, H26.212, H26.213, H26.221, H26.222, H26.223, E08.36, E09.36, E10.36,
E11.36, E13.36 or H28 note that coding guidelines require that the ICD-10 code
for the underlying condition must appear and be coded first on the claim. For
ICD-10 codes H26.31, H26.32, H26.33 and H26.8, coding guidelines require that
the causative agent be identified on the claim.
Billing and Coding: Psychiatric Inpatient Hospitalization

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Psychiatric
Inpatient Hospitalization L34570.

**Limitations:**

Listing an ICD-10-CM code in the mental disorders category (F01.50-F99) does
not assure coverage of the specific service.
Billing and Coding: Cataract Extraction (including Complex Cataract Surgery)

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L35091, Cataract Extraction (including Complex
Cataract Surgery). 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.  
  
The primary diagnosis submitted by the physician performing the preoperative
ophthalmologic evaluation must be cataract (ICD-10-CM codes listed in the
"ICD-10 Codes that Support Medical Necessity" section of this article).  
  
The diagnoses submitted by the physician performing the evaluation and
management component of the preoperative workup, when it is medically
necessary, should indicate cataract (ICD-10-CM codes listed in the "ICD-10
Codes that Support Medical Necessity" section of this article) as the primary
or secondary diagnosis.  
  
Complex cataract extraction should require devices or techniques not generally
used in routine cataract surgery.  
  
 **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. When complex cataract procedures are reported the medical record must support that devices or techniques not generally used in routine cataract surgery were used, for example:

    * Insertion of iris retractors through additional incisions
    * Mechanical expansion of the pupil using iris hooks
    * Creation of a sector iridectomy with subsequent suture repair of iris sphincter
    * Use of intraoperative iris expansion device to maintain pupil dilation (i.e., Malyugin ring) iris sphincterotomies created with scissors
    * The need to support the lens implant with permanent intraocular sutures
    * Placement of a capsular support ring is necessary to allow secure placement of an intraocular lens
Billing and Coding: Chiropractic Services

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Chiropractic
Services L37387.

**Limitations:**

Coverage of chiropractic service is specifically limited to treatment by means
of manual manipulation, i.e., by use of the hands. Additionally, manual
devices (i.e., those that are hand-held with the thrust of the force of the
device being controlled manually) may be used by chiropractors in performing
manual manipulation of the spine. However, no additional payment is available
for use of the device nor does Medicare recognize an extra charge for the
device itself.

No other diagnostic or therapeutic service furnished by a chiropractor or
under the chiropractor's order is covered. This means that if a chiropractor
orders, takes or interprets an x-ray or any other diagnostic test, the x-ray
or other diagnostic test can be used for claims processing purposes but
Medicare coverage and payment are not available for those services. This
prohibition does not affect the coverage of x-rays or other diagnostic tests
furnished by other practitioners under the program. For example, an x-ray or
any diagnostic test taken for the purpose of determining or demonstrating the
existence of a subluxation of the spine is a diagnostic x-ray test covered
under 1861(s)(3) of the Social Security Act if ordered, taken and interpreted
by a physician who is a doctor of medicine or osteopathy.

The precise level(s) of the subluxation(s) must be specified by the
chiropractor to substantiate a claim for manipulation of each spinal
region(s).

Medicare does not cover chiropractic treatments to extraspinal regions.

For Medicare purposes, a chiropractor **must** place an AT modifier on a claim
when providing active/corrective treatment to treat acute or chronic
subluxation. However, the presence of the AT modifier may not in all instances
indicate that the service is reasonable and necessary. As always, contractors
may deny if appropriate after medical review. Modifier AT must only be used
when the chiropractic manipulation is "reasonable and necessary" as defined by
national policy and the Chiropractic Services L37387 LCD. Modifier AT must not
be used when maintenance therapy has been performed. The need for a prolonged
course of treatment should be appropriate to the reported procedure code(s).

The precise level of subluxation must be specified by the chiropractor to
substantiate a claim for manipulation of the spine. A statement on a claim
that there is "pain" is insufficient.

Only 1 chiropractic manipulation service for a beneficiary can be reimbursed
per day.
Billing and Coding: Swallowing Studies for Dysphagia

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Swallowing Studies
for Dysphagia L33449.

**_Utilization Guidelines_**

CPT codes 70370, 70371 and 74230 describe the complete procedure and should
not be billed more than 1 time per patient on the same date of service.

Only 1 of the above codes should be billed per patient on the same date of
service.
Billing and Coding: Echocardiography

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Echocardiography
L37379.

**Follow-up Studies or Limited Studies**

When a less than complete examination is performed for the purpose of
evaluation of 1 specific cardiac problem, or region of the heart, the service
is described by CPT codes 93308 and 93321, follow-up or limited studies. When
a limited service is performed, or the patient's condition requires only a
limited examination, these codes must be used to indicate the appropriate
service.

Examples of appropriate use of CPT code 93308:

  * a follow-up study of a patient with pericardial effusion following heart surgery, to evaluate progression or resolution of the effusion; or
  * a serial evaluation of left ventricular (LV) function during antineoplastic chemotherapy

Examples of appropriate use of CPT code 93321:

  * recording tricuspid regurgitant velocity in order to estimate pulmonary artery systolic pressure; or 
  * sequential evaluation of the transmitral velocity profile in a patient with mitral stenosis, in order to evaluate for a change in gradient or valve area

**Doppler Color Flow Velocity Mapping**

When the test is performed without a specific indication, it is considered
routine screening, and must be billed with a screening ICD-10 code to indicate
the reason for the test.

**Limitations**

When ultrasound (US) contrast enhancement is used for visualizing the
ventricular chambers and endocardial border, the supply is considered separate
from the procedure for reimbursement from Medicare.

**Noncovered**

When a screening test is performed, use the appropriate screening ICD-10 code
to indicate the test is being done for screening purposes. When the result of
the test is abnormal, subsequent services may be billed with the test-result
diagnosis; however, the initial screening test must be listed as screening,
even though the result of the screening test may be a covered condition.

Diagnostic injection services are an integral part of a contrast procedure and
are not separately payable.

**Transesophageal Echocardiography (TEE)**

Use of intraoperative TEE for monitoring purposes (CPT code 93318) performed
by the anesthesiologist during cardiopulmonary surgery (e.g., cardiopulmonary
bypass and valvular surgery) is included in the reimbursement for the
anesthesia service and not separately reportable.

**Note:** When 2 (or more) imaging studies are routinely billed (i.e., without
a supporting clinical indication), only 1 of the services will be allowed and
the other(s) will be denied as not medically necessary.
Billing and Coding: Thoracic Aortography and Carotid, Vertebral, and
Subclavian Angiography

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L35035, Thoracic Aortography and Carotid,
Vertebral, and Subclavian Angiography. Please refer to the LCD for reasonable
and necessary requirements.  
  
The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding
System (HCPCS) code(s) may be subject to National Correct Coding Initiative
(NCCI) edits. This information does not take precedence over NCCI edits.
Please refer to NCCI Coding Policy Manual for Medicare Services, Chapters V
and IX, for information on proper coding for these services.  
  
**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.

Do not report CPT Codes 36222, 36223, or 36224 together for ipsilateral
angiography. Instead, select the code that represents the most comprehensive
service.

Do not report CPT Codes 36225 and 36226 together for ipsilateral angiography.
Select the code that represents the more comprehensive service.

CPT codes 75600 and 75605 typically should not be reported with CPT codes
36221 - 36227. Refer to the related LCD for full information on reporting
these services together.
Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for
Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy L34454.

**Covered Indications:**

For surveillance of colonic neoplasia (when the patient has a history of
colorectal cancer or polyps and is being followed for this indication, use the
appropriate CPT/HCPCS code with the appropriate ICD-10-CM code and 1 of the
following ICD-10-CM codes as the secondary diagnosis: Z85.038, Z85.048 or
Z86.010):

  * For follow-up 1 year after surgery for treatment of colorectal cancer when the patient is identified as being at high-risk for colon cancer and is eligible for continued screenings at 24-month intervals (HCPCS code G0105 should be reported).

**Limitations:**

**Marking of a neoplasm for localization (tattooing) is covered, but is not
separately payable. **  
**

Infectious colitis is an acceptable indication in its general form.
Specificity in ICD-10 coding is not needed but should be maintained in the
patient's chart.