Persius/hicric huggingface dataset:
Dropless Cataract Surgery Noridian Healthcare Solutions has become aware of a
relatively new technique where a retrozonular or intravitreal injection of
compounded antibiotics and or steroids are administered at the conclusion of
cataract surgery (CPT 66984 or 66982 or related codes) as a means of reducing
or eliminating the need for post-operative topical medications ("dropless"
cataract surgery).  
  
Noridian states that such injections are integral to the surgery being
performed and are bundled with the cataract surgery code for both the
physician and facility. Therefore, billing either Medicare or the patient for
these services separately is not appropriate. Furthermore, because they are
considered integral to and bundled with these codes, it is inappropriate to
include such services when performed as a separately itemized part of a
"package" related to the insertion of a premium intraocular lens.  
  
There may be rare cases where services represented by intravitreal injection
code (67028) and a drug code (J-series) need to be provided in the
contralateral eye. In such cases the surgical code and the injection and drug
codes should be appended with either a RT or a LT to reflect which eye the
cataract surgery was performed on and which eye received the injection. Do not
use modifier -59 in such cases as the claim will deny.
Dropless Cataract Surgery

Noridian Healthcare Solutions has become aware of a relatively new technique
where a retrozonular or intravitreal injection of compounded antibiotics and
or steroids are administered at the conclusion of cataract surgery (CPT 66984
or 66982 or related codes) as a means of reducing or eliminating the need for
post-operative topical medications ("dropless" cataract surgery).  
  
Noridian states that such injections are integral to the surgery being
performed and are bundled with the cataract surgery code for both the
physician and facility. Therefore, billing either Medicare or the patient for
these services separately is not appropriate. Furthermore, because they are
considered integral to and bundled with these codes, it is inappropriate to
include such services when performed as a separately itemized part of a
"package" related to the insertion of a premium intraocular lens.  
  
There may be rare cases where services represented by intravitreal injection
code (67028) and a drug code (J-series) need to be provided in the
contralateral eye. In such cases the surgical code and the injection and drug
codes should be appended with either a RT or a LT to reflect which eye the
cataract surgery was performed on and which eye received the injection. Do not
use modifier -59 in such cases as the claim will deny.
Fracture of Ribs with Internal Fixation

Most injuries to the chest wall do not result in long-term respiratory
dysfunction and operative indications for chest wall injuries are rare. Recent
studies have explored the option of internal fixation of rib fracture for
treatment of complex rib fractures, including flail chest, open fracture,
symptomatic nonunion, and thoracotomy for other indications. Flail chest is
diagnosed when multiple, consecutive ribs are fractured in two or more places,
creating an incompetent region of the chest wall.  
  
Internal Fixation is indicated to stabilize and provide fixation for
fractures, fusions, and osteotomies of the ribs. The Modular RibLoc System
consists of plates and screws for fractures, fusions, and osteotomies. The
plates are pre-contoured to minimize bending that is done intra-operatively.
Instrumentation is supplied with the implants to aid in the insertion of the
plates and screws. All plates and screws are manufactured from titanium or
titanium alloy.  
  
Palmetto GBA will cover CPT codes 21812 and 21813. CPT 21811 is not covered,
as in most instances fractures involving 1-3 ribs do not require internal
fixation.
Billing and Coding: Spinal Fusion Services: Documentation Requirements

Noridian Medical Review team and CERT contractor has identified multiple
errors regarding documentation to support the medical necessity of spinal
fusion procedures. This article clarifies medical necessity and documentation
requirements regarding spinal fusion procedures.  
  
**Medical Necessity**

  * History and Physical 
    * Duration/character/location/radiation of pain
    * Activity of daily living (ADL) limitations
    * Physical examination
  * Evidence/support of prior conservative treatment measure(s) attempted*
  * Imaging reports pertinent to performed procedure
  * Operative report(s)
  * Outpatient records before, during and after the procedure that support the medical necessity of performed procedures

  
*Note: physician statement that conservative treatment measures were completed is not supportive in and by itself; contractors do require the documentation of these measures.  
  
**Documentation Errors**  
  
The most common reason for denial of spinal fusion services is lack of
specific information regarding conservative treatment measures which were
attempted and failed prior to surgery. The statement "failed
conservative/outpatient treatment" is not sufficient evidence of medical
necessity for the procedure or inpatient admission. A detailed medical record
will help to support the reasonableness of the claim.  
  
Conservative treatment modalities include but are not limited to:

  * Physical Therapy
  * Occupational Therapy
  * Joint Injections/Epidural Injections
  * Anti-inflammatory/Analgesic medications
  * Assistive device use
  * Activity modification
  * Exercise

  
Situations arise where a fusion is approved without conservative treatment
being documented clearly when an emergent situation such as "cauda equina
syndrome" is present. Also if an imaging report showing severe cord
compression, osteophyte formation impinging on the spinal cord, loose pedicle
screws affecting stability, severe fibrosis or formation of scar tissue
compressing cord or nerves, and the patient's history and physical findings
correlate to the imaging the surgeon should clearly document these findings
and the reasons that such findings require imminent intervention.
Billing and Coding: Spinal Fusion Services: Documentation Requirements

Noridian Medical Review team and CERT contractor has identified multiple
errors regarding documentation to support the medical necessity of spinal
fusion procedures. This article clarifies medical necessity and documentation
requirements regarding spinal fusion procedures.  
  
**Medical Necessity**

  * History and Physical 
    * Duration/character/location/radiation of pain
    * Activity of daily living (ADL) limitations
    * Physical examination
  * Evidence/support of prior conservative treatment measure(s) attempted*
  * Imaging reports pertinent to performed procedure
  * Operative report(s)
  * Outpatient records before, during and after the procedure that support the medical necessity of performed procedures

*Note: physician statement that conservative treatment measures were completed is not supportive in and by itself; contractors do require the documentation of these measures.

  
**Documentation Errors**  
  
The most common reason for denial of spinal fusion services is lack of
specific information regarding conservative treatment measures which were
attempted and failed prior to surgery. The statement "failed
conservative/outpatient treatment" is not sufficient evidence of medical
necessity for the procedure or inpatient admission. A detailed medical record
will help to support the reasonableness of the claim.  
  
Conservative treatment modalities include but are not limited to:

  * Physical Therapy
  * Occupational Therapy
  * Joint Injections/Epidural Injections
  * Anti-inflammatory/Analgesic medications
  * Assistive device use
  * Activity modification
  * Exercise

  
Situations arise where a fusion is approved without conservative treatment
being documented clearly when an emergent situation such as "cauda equina
syndrome" is present. Also if an imaging report showing severe cord
compression, osteophyte formation impinging on the spinal cord, loose pedicle
screws affecting stability, severe fibrosis or formation of scar tissue
compressing cord or nerves, and the patient's history and physical findings
correlate to the imaging the surgeon should clearly document these findings
and the reasons that such findings require imminent intervention.
Billing and Coding: Percutaneous Ventricular Assist Device

Percutaneous insertion of an endovascular cardiac assist device will be
covered under limited conditions. Until the literature clearly demonstrates
the efficacy of the treatment approach, coverage may be made only in the
following three life-threatening situations and only when external
counterpulsation (intra-aortic balloon pump, IABP) is not expected to be
sufficient:

  * Cardiogenic shock ICD-10-CM code R57.0; or
  * Severe decompensated heart failure with threatening multi-organ failure, represented by one of the following ICD-10 codes: I50.21, I50.23, I50.41, I50.43, I97.110, I97.111, I97.130, I97.131; or
  * Complications/disturbances of the circulatory system intra-operatively or postoperatively: I97.790, I97.791, I97.88 and I97.89.

This service will only be covered when the FDA approval guidelines are
strictly adhered to.
Billing and Coding: Percutaneous Ventricular Assist Device

Percutaneous insertion of an endovascular cardiac assist device will be
covered under limited conditions. Until the literature clearly demonstrates
the efficacy of the treatment approach, coverage may be made only in the
following three life-threatening situations and only when external
counterpulsation (intraaortic balloon pump, IABP) is not expected to be
sufficient:

  * Cardiogenic shock ICD-10-CM code R57.0; or
  * Severe decompensated heart failure with threatening multi-organ failure, represented by one of the following ICD-10 codes: I50.21, I50.23, I50.41, I50.43, I97.110, I97.111, I97.130, I97.131; or
  * Complications/disturbances of the circulatory system intra-operatively or postoperatively: I97.790, I97.791, I97.88 and I97.89.

This service will only be covered when the FDA approval guidelines are
strictly adhered to.  
  
Part A Providers: ICD-10-PCS codes:

  * 5A02116 - Assistance with Cardiac Output using Other Pump, Intermittent
  * 5A0211D -Assistance with Cardiac Output using Impeller Pump, Intermittent
  * 5A02216 - Assistance with Cardiac Output using Other Pump, Continuous
  * 5A0221D - Assistance with Cardiac Output using Impeller Pump, Continuous

For Part A Services only, the provider should bill the appropriate procedure
code on the UB-04 as this is an inpatient only procedure.
Billing and Coding: MolDX: FDA-Approved BRAF Tests

Two tests have met the FDA criteria for BRAF genetic testing:  
  

    1. Effective 09/07/2012  
 **cobas  4800 BRAF V600** to detect the presence of a mutation in the BRAF
gene in melanoma cells and determine if a patient is eligible for Zelboraf
TM(vemurafenib), a treatment indicated for a melanoma that cannot be surgically
excised or has spread in the body.

    2. Effective 5/29/13   
**ThxID TM BRAF V600/K** to detect the BRAF V600E and V600K mutations in
selecting melanoma patients whose tumors carry the BRAF V600E mutation for
treatment with dabrafenib [Tafinlar] and as an aid in selecting melanoma
patients whose tumors carry the BRAF V600E or V600K mutation for treatment
with trametinib [MekinistTM].

  
To report an FDA approved or laboratory developed test (LDT) BRAF V600 test
kit service, please submit the following claim information:

  * CPT code 81210
  * 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 diagnosis.

  
NOTE: MolDX will apply NPI to ID editing on FDA approved BRAF kits. All labs
that submit claims for a BRAF V600 test kit **MUST** register the test and
confirm the **UNMODIFIED** use of the kit. Tests may be registered on the DEXTM
Diagnostics Exchange <https://app.dexzcodes.com/login>  
  
This article reflects the FDA-approved indications on article creation date.
MolDX will allow future FDA approved and amended indications for these tests.
Billing and Coding: MolDX: FDA-Approved EGFR Tests

 Two tests have met the FDA criteria for EGFR genetic testing:

1.  Effective 6/01/16

**cobas EGFR Mutation Test** is a real-time PCR test for the qualitative
detection of defined mutations of the epidermal growth factor receptor (EGFR)
gene in non-small cell lung cancer (NSCLC) patients. Defined EGFR mutations
are detected using DNA isolated from formalin-fixed paraffin-embedded tumor
tissue (FFPET) or circulating-free tumor DNA (cfDNA) from plasma derived from
EDTA anti-coagulated peripheral whole blood.

The test is indicated as a companion diagnostic to aid in selecting NSCLC
patients for treatment with the targeted therapies listed in the Table below
in accordance with the approved therapeutic product labeling:



Drug | FFPET | Plasma  
---|---|---  
TARCEVA (erlotinib)  | Exon 19 deletions and L858R | Exon 19 deletions and
L858R  
TAGRISSOTM (osimertinib)  | T790M |  
  


Patients with positive cobas EGFR Mutation Test v2 test results using plasma
specimens for the presence of EGFR exon 19 deletions or L858R mutations are
eligible for treatment with TARCEVA (erlotinib). Patients who are negative
for these mutations by this test should be reflexed to routine biopsy and
testing for EGFR mutations with the FFPET sample type.

2.  Effective  7/12/13

**therascreen EGFR RGQ** PCR kit for the detection of the epidermal growth
factor receptor (EGFR) gene for non-small cell lung cancer (NSCLC) tumor
tissue to help select patients with NSCLC for whom GILOTRIFTM (afatinib), an
EGFR tyrosine kinase inhibitor (TKI), is indicated.

  

To report an FDA approved or laboratory developed test (LDT) EGFR test kit
service, please submit the following claim information:

  * CPT code: 81235
  * 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
  * ICD-10-CM codes



**NOTE:** MolDX will apply NPI to ID editing on FDA approved EGFR kits. All
labs that submit claims for an EGFR kit **MUST** register the test and confirm
the **UNMODIFIED** use of the kit.



This article reflects the FDA-approved indications on article creation date.
MolDX will allow future FDA approved and amended indications for these tests.
Billing and Coding: MolDX: MMACHC Test

Methylmalonic aciduria (cobalamin deficiency) cblC type, with homocystinuria
(MMACHC) is associated with the most common error of vitamin B12 metabolism.
Although considered a disease of infancy or childhood, some individuals
develop symptoms in adulthood. However to date, the exact function of the
protein encoded by this gene is not known. Therefore, MMACHC testing does not
meet the clinical utility requirements for a Medicare Benefit and is
considered a statutorily excluded service. MolDX will also deny panels of
tests that include the MMACHC gene.  
  
To receive a MMACHC service denial, please submit the following claim
information:

  * CPT code 81404-MMACHC, fgs
  * 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
Billing and Coding: Infrared Coagulation (IRC) of Hemorrhoids

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Infrared
Coagulation (IRC) of Hemorrhoids L34422.

Payment for Infrared Coagulation of Hemorrhoids (IRC) will only be allowed
once per beneficiary per global period (90 days), regardless of how many IRC
treatment sessions occur or how many providers render the treatment within the
same global period. If, during the initial treatment episode (defined as the
90-day global period commencing with the initial IRC treatment) the IRC
treatment has not satisfactorily resolved symptoms, then another method of
treatment should be considered. Payment for such alternative hemorrhoid
treatments will not be made more than once per beneficiary during any
treatment episode in addition to the payment for the initial IRC treatment.
(For subsequent treatment, please see the next paragraph.)  
  
If the hemorrhoids recur subsequent to the initial treatment episode, payment
is subject to the same restrictions noted above.

Limitation of liability and refund requirements apply when denials are likely,
whether based on medical necessity or other coverage reasons. The
provider/supplier must notify the beneficiary in writing, prior to rendering
the service, if the provider/supplier is aware that the test, item or
procedure may not be covered by Medicare. The limitation of liability and
refund requirements do not apply when the test, item or procedure is a
statutory exclusion, has no Medicare benefit category or is rendered for
screening purposes.
Billing and Coding: Arthroscopic Lavage and Arthroscopic Debridement for
Osteoarthritic Knees

This article is being published to update the provider community on coverage
for Arthroscopic Lavage and Arthroscopic Debridement for Osteoarthritic Knees.  
  
National Coverage Determination (NCD) 150.9 issued in 2004 describes Medicare
coverage for Arthroscopic Lavage and Arthroscopic Debridement for
Osteoarthritic Knees. In this NCD, non-covered indications are:

    * Arthroscopic lavage used alone for the osteoarthritic knee

    * Arthroscopic debridement for osteoarthritic patients presenting with knee pain only; or,

    * Arthroscopic debridement and lavage with or without debridement for patients presenting with severe osteoarthritis

  
CPT 29871 - Arthroscopy, knee, surgical; for infection, lavage and drainage is
used to describe the service covered by NCD 150.9.  
  
All other indications for coverage of arthroscopic lavage remain at Contractor
discretion.  
  
**Resources:**  
[NCD 150.9 Arthroscopic Lavage and Arthroscopic Debridement for the
Osteoarthritic Knee](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/ncd103c1_Part2.pdf)  
[CMS Change Request 3281](https://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNMattersArticles/downloads/MM3281.pdf)
Billing and Coding: Speech Language Pathology (SLP) Services: Communication
Disorders

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L35070 Speech-Language Pathology (SLP) Services:
Communication Disorders. 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.  
  
When reporting services for speech generating devices the following Current
Procedural Terminology (CPT) codes should be utilized:

  * For selection and prescription report 92607
  * For adaptation and training report 92609

CPT does not define a specific re-evaluation code for speech language
pathology; the evaluation code should be used.

The group therapy CPT code 92508 should be reported when patients are not
receiving direct one-on-one contact, but are being supervised by the
therapist.

  
**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.
Response to Comments: Intravenous Immune Globulin (IVIG) L35893 The following
are comments received during the comment period for draft LCD DL35893
Intravenous Immune Globulin (IVIG). The policy has been released to its final
version with any updates made as indicated in the comment section.
Billing and Coding: MolDX: Afirma Assay by Veracyte Update

The MolDX Program contractor has completed the Afirma assessment and
determined that the test meets criteria for analytical and clinical validity,
and clinical utility as a reasonable and necessary Medicare benefit. Effective
10/01/2015, CGS Administrators and the MolDX Program contractor will reimburse
Afirma services for patients with the following conditions(patient must have 1
and 2):

1\. Patients with one or more thyroid nodules with a history or
characteristics suggesting malignancy such as:

  * Nodule growth over time
  * Family history of thyroid cancer
  * Hoarseness, difficulty swallowing or breathing
  * History of exposure to ionizing radiation
  * Hard nodule compared with rest of gland consistency
  * Presence of cervical adenopathy

2\. Have an indeterminate follicular pathology on fine needle aspiration

  
  
MolDX expects this test will be performed once per patient lifetime. Should
the unlikely situation of a second, unrelated thyroid nodule with
indeterminate pathology occur, coverage may be considered upon appeal with
support documentation.  
  
To report an Afirma service, please submit the following claim information:

  *     * Select the appropriate CPTcode
    * Select the appropriate ICD-10-CM diagnosis
    * Enter DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types: 
      * Loop 2400 or SV101-7 for the 5010A1 837P
      * Box 19 for paper claim
    * Enter DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types: 
      * Line SV202-7 for 837I electronic claim
      * Block 80 for the UB04 claim form
    *
Billing and Coding: MolDX: bioTheranostics Cancer TYPE ID

Effective November 19, 2012, Cancer TYPE ID, an RT-PCR 92-gene assay, has been
assigned a DEX Z-CodeTM identifier. To bill for Cancer TYPE ID, please provide
the following claim information:

  * CPT code: 81540- Oncology (tumor of unknown origin) mRNA gene expression of 92 genes
  * Enter "1" in the Days/Unit field
  * Enter "DEX Z-CodeTM Identifier" in the comment/narrative field for the following claim field/types:
    * Loop 2300 NTE01/SV202-7 for Part A or SV101-7 field for Part B
    * Submit "DEX Z-CodeTM Identifier" on an attachment to the claim form for paper claim (Form locator 80 for Part A or Box 19 for Part B
  *  Select the appropriate ICD-10-CM code:

Note: MolDX expects this test to ONLY be ordered by the treating physician.