Persius/hicric huggingface dataset:
Billing and Coding: Short Tandem Repeat (STR) Markers and Chimerism (CPT
codes 81265-81268)

Please note that CPT codes 81265 and 81266 describe services performed for
recipient/donor testing and twin zygosity. Laboratories are encouraged to
register tests based on the use of the test. Through the MolDX identification
process, tests registered for recipient/donor testing will be considered for
payment and tests for twin zygosity will be denied as a statutorily excluded
service. The following instructions outline the correct reporting of
recipient/donor testing for transplant services.  
  
Chimerism analysis to identify appropriate donors and monitor engraftment
success or disease reoccurrence is a covered Medicare service.

  * Code 81265 should be reported with one unit of service (UOS). Except in rare cases, this service would only be performed once per lifetime.   
  

  * Code 81266, when used in bone marrow transplants to report an additional double-cord blood sample, is a covered service.   
  

  * Code 81267 should be used post transplantation to confirm successful engraftment or disease reoccurrence. Although the original donor specimen may be referenced, an additional 81265 should NOT be submitted in addition to the 81267 service. For labs that hold the pre-transplant specimen (81265 and/or 81266) until after the transplant occurs, use 81267 plus 81265 and 81266 if necessary.

  
  
Note: Code 81267 should be reported for the findings of the pre and post-
transplant comparison.  
  

  * Code 81268 should be used to report chimerism using a buccal or other germline tissue specimen from the recipient post-transplantation. For labs that hold the pre-transplant specimen (81265 and/or 81266) until after the transplant occurs, use 81267 plus 81265 and 81266 if necessary.

  
  
MolDX would not expect to see a claim for 81265 pre-transplant and an
additional 81265 and 81267 post-transplant or a claim for 81265 pre-transplant
and an additional claim for 81268.  
  
**EXCEPTIONS:** Although the initial chimerism testing, code 81265, for
engraftment is usually limited to once in a lifetime, MolDX recognizes special
circumstances may require an additional service and will consider approval on
a case-by-case basis through the appeal process.
Billing and Coding: Short Tandem Repeat (STR) Markers and Chimerism (CPT
codes 81265-81268)

Please note that CPT codes 81265 and 81266 describe services performed for
recipient/donor testing _and_ twin zygosity. Tests indicated for
recipient/donor testing will be considered for payment and tests for twin
zygosity will be denied as a statutorily excluded service. The following
instructions outline the correct reporting of recipient/donor testing for
transplant services.  
  
Chimerism analysis to identify appropriate donors and monitor engraftment
success or disease reoccurrence is a covered Medicare service.  
  

    * Code 81265 should be reported with one unit of service (UOS). Except in rare cases, this service would only be performed once per lifetime.



    * Code 81266, when used in bone marrow transplants to report an additional double-cord blood sample, is a covered service.



    * Code 81267 should be used post transplantation to confirm successful engraftment or disease reoccurrence. Although the original donor specimen may be referenced, an additional 81265 should NOT be submitted in addition to the 81267 service. For labs that hold the pre-transplant specimen (81265 and/or 81266) until after the transplant occurs, use 81267 plus 81265 and 81266 if necessary.

  
**Note:**

Code 81267 should be reported for the findings of the pre and post-transplant
comparison.

  
  

  * Code 81268 should be used to report chimerism using a buccal or other germline tissue specimen from the recipient post-transplantation. For labs that hold the pre-transplant specimen (81265 and/or 81266) until after the transplant occurs, use 81267 plus 81265 and 81266 if necessary.

  
  
MolDX would not expect to see a claim for 81265 pre-transplant and an
additional 81265 and 81267 post-transplant or a claim for 81265 pre-transplant
and an additional claim for 81268.  
  
 **EXCEPTIONS:** Although the initial chimerism testing, code 81265, for
engraftment is usually limited to once in a lifetime, MolDX recognizes special
circumstances may require an additional service and will consider approval on
a case-by-case basis through the appeal process.

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

  * Select appropriate CPT code
  * Enter 1 unit of service (UOS)
  * Enter the appropriate DEX Z-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
Billing and Coding: MolDX: CDH1 Genetic Testing

CDH1 testing is utilized in patients with specified cancers as an adjunctive
test. CDH1 testing has also been recommended as a screening test for other
cancers. However, screening for individuals at risk for cancer is not a
Medicare benefit and is statutorily excluded.  
  
To receive a CDH1 test denial, please submit the following claim information:  

  * CPT 81406 - CDH1, full gene sequence  
  

  * 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 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

  
In rare cases in which HDGC is suspected in a Medicare beneficiary, MolDX will
review the documentation on a case-by-case basis.
Response to Comments: Allergy Immunotherapy (L36408) WPS did not receive any
comments for Draft Local Coverage Determination (LCD) Allergy Immunotherapy
(L36408). Thank you for reviewing this draft policy.
Response to Comments: Allergy Testing (L36402) This article summarizes the
comments WPS received for Draft Local Coverage Determinations (LCD) Allergy
Testing (L36402). Thank you for the reviewing this draft policy and the
comments.
Billing and Coding: MolDX: CDH1 Genetic Testing

CDH1 testing is utilized in patients with specified cancers as an adjunctive
test.  CDH1 testing has also been recommended as a screening test for other
cancers. However, screening for individuals at risk for cancer is not a
Medicare benefit and is statutorily excluded.  
  
To receive a CDH1 test denial, please submit the following claim information:

  * CPT 81406 - CDH1, full gene sequence
  * 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 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 8371 electronic claim
    * Block 80 for paper claim

  
In rare cases in which HDGC is suspected in a Medicare beneficiary, MolDX will
review the documentation on a case-by-case basis.
Response to Comments: MolDX: HLA-B*15:02 Genetic Testing The following comment
was received by Noridian Healthcare Solutions for DL36145 and DL36149
policies.
Response to Comments: MolDX: Genetic Testing for Hypercoagulability /
Thrombophilia Noridians Response to Provider Recommendations (for comment
period ending 08/10/2015).
Response to Comments: MolDX: MGMT Promoter Methylation Analysis Noridian's
response to provider recommendations for comment period ending 08/10/2015:
Response to Comments: MolDX Biomarkers in Cardiovascular Risk Assessment
Response to Comments received by Noridian on Biomarkers in CV Risk Assessment
(JE-DL36358; JF-DL36360).  
  
CV risk assessment biomarker **panels, except the basic lipid panel,** are
non-covered per this policy. Under preventative services, Medicare Part B
covers cardiovascular disease screening, consisting of tests for cholesterol,
lipid and triglyceride levels, every 5 years when ordered by a doctor. NCD
190.23 covers basic lipid panel testing for evaluating atherosclerotic CV
disease, to monitor the progress of patients on anti-lipid dietary management
and pharmacologic therapy for various lipid disorders. Routine screening and
prophylactic testing for lipid disorders are not covered by Medicare. Lipid
testing in asymptomatic individuals is considered to be screening regardless
of the presence of other risk factors such as family history, tobacco use,
etc.  
  
This policy denies coverage for **all CV risk assessment panels** , except the
basic lipid panel. Additionally, the policy defines the medical necessity for
individual **lipid** biomarkers for CV risk assessment, each of which must be
specifically ordered and the reason for the test order documented in the
patients medical record. The policy denies coverage (not reasonable and
necessary) for **non-lipid** biomarkers including biochemical, hematologic,
immunologic, and genetic biomarkers for CV risk assessment.  
  
A lipid biomarker may be covered to characterize a given lipid abnormality or
disease, to determine a treatment plan or to assist with intensification of
therapy. These markers include hs-CRP, Lp(a), Lp-PLA2, LDL particles, and Apo
B. For each of these biomarkers, professional association recommendations and
evidence from the scientific literature guide the limited use of these
biomarkers. Wholesale use for every patient at every patient visit is not
supported in the literature and is not anticipated per this policy.
Response to Comments: MolDX: Genetic Testing for BCR-ABL Negative
Myeloproliferative Disease Noridians Response to Provider Recommendations
(for comment period ending 08/10/2015).
Response to Comments: Genetic Testing for Hypercoagulability /Thrombophilia
(Factor V Leiden, Factor II Prothrombin, and MTHFR) L36400 (A54920) This
article summarizes the comments WPS received for Draft Local Coverage
Determinations (LCD) Genetic Testing for Hypercoagulability /Thrombophilia
(Factor V Leiden, Factor II Prothrombin, and MTHFR) (L36400).
Billing and Coding: Bariatric Surgery for Treatment of Co-Morbidities
Conditions Related to Morbid Obesity

_Italicized font_ represents CMS national language/wording copied directly
from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing
national NCD language/wording.  
  
Bariatric Surgery for Treatment of Morbid Obesity is a payable Medicare
service when billed in accordance with instructions outlined in:  
  
CMS Pub 100-03 _Medicare National Coverage Determinations (NCD) Manual_ ,  
Chapter 1 - Coverage Determinations, Part 2 (Sections 90-160.2), Section 100.1
- Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid
Obesity (Effective September 24, 2013).  
  
CMS Pub 100-04 _Medicare Claims Processing Manual_ ,  
Chapter 32 - Billing Requirements for Special Services, Section 150- Billing
Requirements for Bariatric Surgery for Morbid Obesity.  
  
 **This local coverage Article lists the additional diagnoses that are covered
for bariatric surgery for treatment of co-morbid conditions related to morbid
obesity** for the procedure codes for Part A providers found in CMS Pub 100-04
_Medicare Claims Processing Manual_ , Chapter 32 - Billing requirements for
Special Services, Section 150- Billing Requirements for Bariatric Surgery for
Morbid Obesity; and the listed CPT codes in the article. The diagnoses codes
listed in section _150.5.1 -_ ICD Codes for Type II Diabetes Mellitus
Complication are not included in this article but are covered based on the
IOM.
Response to Comments: MolDX: Genetic Testing for Lynch Syndrome Noridians
Response to Provider Recommendations (for comment period ending 12/7/2015):
Billing and Coding: MolDX: Arrhythmogenic Right Ventricular
Dysplasia/Cardiomyopathy (ARVD/C) Testing

ARVD/C, characterized by fatty replacement of heart cells predominantly in the
right ventricle of the heart, is most often inherited as an autosomal dominant
disease that may be associated with testing in at least seven genes (RYR2,
TMEM43, DSP, PKP2, DSG2, DSC2 and JUP). Genetic testing may be performed in
panels of 5-7 of these genes and disease-causing mutation is expected to be
identified in 42-55% of cases. Testing would be performed to confirm an
established diagnosis or on individuals already diagnosed with ARVD/C to
identify family members at risk. Therefore, MolDX has determined that testing
for ARVD/C is a statutorily excluded test.  
  
To receive an ARVD/C panel test denial, please submit the following claim
information:

  * 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
  * Select the appropriate diagnosis for the patient
  * Enter the 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
    * Item 19 for paper claim 
  * Enter the 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
Response to Comments: MolDX: Biomarkers in Cardiovascular Risk Assessment
Noridian's Response to Provider Recommendations (for comment period ending
12/07/2015):  
  
CV risk assessment biomarker **panels, except the basic lipid panel,** are
non-covered per this policy. Under preventative services, Medicare Part B
covers cardiovascular disease screening, consisting of tests for cholesterol,
lipid and triglyceride levels, every 5 years when ordered by a doctor. NCD
190.23 covers basic lipid panel testing for evaluating atherosclerotic CV
disease, to monitor the progress of patients on anti-lipid dietary management
and pharmacologic therapy for various lipid disorders. Routine screening and
prophylactic testing for lipid disorders are not covered by Medicare. Lipid
testing in asymptomatic individuals is considered to be screening regardless
of the presence of other risk factors such as family history, tobacco use,
etc.  
  
This policy denies coverage for **all CV risk assessment panels** , except the
basic lipid panel. Additionally, the policy defines the medical necessity for
individual **lipid** biomarkers for CV risk assessment, each of which must be
specifically ordered and the reason for the test order documented in the
patients medical record. The policy denies coverage (not reasonable and
necessary) for **non-lipid** biomarkers including biochemical, hematologic,
immunologic, and genetic biomarkers for CV risk assessment.  
  
A lipid biomarker may be covered to characterize a given lipid abnormality or
disease, to determine a treatment plan or to assist with intensification of
therapy. These markers include hs-CRP, Lp(a), Lp-PLA2, LDL particles, and Apo
B. For each of these biomarkers, professional association recommendations and
evidence from the scientific literature guide the limited use of these
biomarkers. Wholesale use for every patient at every patient visit is not
supported in the literature and is not anticipated per this policy.
Response to Comments: Spinal Cord Stimulators for Chronic Pain Noridian's
Response to Provider Recommendations (for comment period ending 08/10/2015):
Response to Comments: MolDX-CDD: Genomic Health Oncotype DX Prostate Cancer
Assay The following Response to Comments address comments received by
Noridian Administative Services (NAS) on draft policy DL36364.
Response to Comments: Nerve Conduction Studies and Electromyography Noridian's
response to provider recommendations for comment period ending 12/02/2013.  
  
Note: Comments and responses are those received for both JEA DL34113 and JEB
DL34109. Both draft LCDs were retired and finalized under L36524.
Response to Comments: Nerve Conduction Studies and Electromyography Noridian's
response to provider recommendations for comment period ending 11/26/2013.  
  
Note: Comments and responses are those received for both JFA DL34111 and JFB
DL33984. Both draft LCDs were retired and finalized under L36526.
Response to Comments: Controlled Substance Monitoring and Drugs of Abuse
Testing Comment Period Ending 05/02/2014. Article for Response to comments for
Controlled Substance Monitoring and Drugs of Abuse Testing Comment Period
Ending 05/02/2014.
Billing and Coding: Urine Drug Testing

This article contains coding that complements the Local Coverage Determination
(LCD) for Urine Drug Testing.

**Coding Guidelines:  **

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.
Response to Comments: MolDX: Biomarkers in Cardiovascular Risk Assessment
(L36523) This article summarizes the comments WPS received for draft Local
Coverage Determination (LCD) MolDx: Biomarkers in Cardiovascular Risk
Assessment. Thank you for the comments.
Billing and Coding: Lab: Bladder/Urothelial Tumor Markers

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Lab:
Bladder/Urothelial Tumor Markers (L36678).

Noridian will only cover bladder tumor marker fluorescence in situ
hybridization (FISH) testing services when performed using validated assays.
To date, UroVysionTM Bladder Cancer Kit is the only Federal Drug Administration
(FDA) approved assay that is designed to detect aneuploidy for chromosomes 3,
7, 17 and loss of the 9p21 locus via FISH. The assay is performed on urine
specimens from persons with hematuria suspected of having bladder cancer as an
aid for initial diagnosis of bladder carcinoma and subsequent monitoring for
tumor recurrence in patient previously diagnosed with bladder cancer.
UroVysionTM Bladder Kit services may only be billed by a CLIA certified lab.

To bill UroVysionTM Bladder Kit services, submit the following claim
information:

  * Select CPT code 88120 or 88121 as appropriate.

Laboratories reporting only the technical component for a UroVysionTM service
should append the appropriate code 88120 or 88121 with the TC modifier.

  * Select CPT code 88120 or 88121 as appropriate.

**Note:** Physicians may NOT submit claims for a code 88120 and 88121
professional components when the interpretive information is provided by a lab
technician or scientist. Per Chapter 10 in the NCCI Policy Manual for Medicare
Services, Version 16.3, the physician work component requires a physician to
read, quantitate and interpret the tissues/cells stained with the probes(s).
Physicians who knowingly report and interpretation based on the documented
results of another professional may be subject to additional corrective action
including Recovery Audit Contractor (RAC) or fraud referrals.

To report a Bladder/Urothelial Tumor Marker service, please submit the
following claim information:

  * Select the appropriate CPT code.
  * Enter 1 unit of service (UOS)
  * Select the appropriate ICD-10 code.
Billing and Coding: Lab: Bladder/Urothelial Tumor Markers

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Lab:
Bladder/Urothelial Tumor Markers (L36680).

Noridian will only cover bladder tumor marker fluorescence in situ
hybridization (FISH) testing services when performed using validated assays.
To date, UroVysionTM Bladder Cancer Kit is the only Federal Drug Administration
(FDA) approved assay that is designed to detect aneuploidy for chromosomes 3,
7, 17 and loss of the 9p21 locus via FISH. The assay is performed on urine
specimens from persons with hematuria suspected of having bladder cancer as an
aid for initial diagnosis of bladder carcinoma and subsequent monitoring for
tumor recurrence in patient previously diagnosed with bladder cancer.
UroVysionTM Bladder Kit services may only be billed by a CLIA certified lab.

To bill UroVysionTM Bladder Kit services, submit the following claim
information:

  * Select CPT code 88120 or 88121 as appropriate.

Laboratories reporting only the technical component for a UroVysionTM service
should append the appropriate code 88120 or 88121 with the TC modifier.  
  
All other services that meet the code 88120 or 88121 definition performed by
any provider type MUST bill the following claim information.

  * Select CPT code 88120 or 88121 as appropriate.

**Note:** Physicians may NOT submit claims for a code 88120 and 88121
professional components when the interpretive information is provided by a lab
technician or scientist. Per Chapter 10 in the NCCI Policy Manual for Medicare
Services, Version 16.3, the physician work component requires a physician to
read, quantitate and interpret the tissues/cells stained with the probes(s).
Physicians who knowingly report and interpretation based on the documented
results of another professional may be subject to additional corrective action
including Recovery Audit Contractor (RAC) or fraud referrals.

To report a Bladder/Urothelial Tumor Marker service, please submit the
following claim information:

  * Select the appropriate CPT code.
  * Enter 1 unit of service (UOS)
  * Select the appropriate ICD-10 code.
Billing and Coding: Urine Drug Testing

This article contains coding that complements the Local Coverage Determination
(LCD) for Urine Drug Testing.

**Coding Guidelines:  **

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 results of the test if
known; otherwise the symptoms prompting the performance of the test should be
reported.
Response to Comments: MolDX-CDD: Genomic Health Oncotype DX Prostate Cancer
Assay Noridians Response to Provider Recommendations (for comment period
ending 12/7/2015):