Persius/hicric huggingface dataset:
Billing and Coding: Routine Foot Care

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L35138 (Routine Foot Care). Please refer to the
LCD for reasonable and necessary requirements.  
  
 **Coverage 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.  
  
It is not appropriate to report procedure codes 11305-11308 for the removal of
corns and calluses of the feet. Removal of these lesions is considered to be
routine foot care and must be reported with procedure codes 11055-11057,
paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus).
Services must be reported using the procedure code that most accurately
describes the procedure performed.  
  
When reporting routine foot care services that needs to meet one of the
exclusions, one of the following applicable Q modifiers identifying the class
findings must be included on the claim.

  * Q7 - 1 Class A finding
  * Q8 - 2 Class B findings
  * Q9 - 1 Class B and 2 Class C findings

  
For all claims for foot-care services, report a foot/toe location modifier
(when appropriate). The following are valid HCPCS modifiers:

  * Left foot - LT
  * First toe, left foot - TA
  * Second toe, left foot - T1
  * Third toe, left foot - T2
  * Fourth toe, left foot - T3
  * Fifth toe, left foot - T4
  * Right foot - RT
  * First toe, right foot - T5
  * Second toe, right foot - T6
  * Third toe, right foot - T7
  * Fourth toe, right foot - T8
  * Fifth toe, right foot - T9

  
If a significant separately identified evaluation and management service is
provided on the same day as routine foot care, the -25 modifier should be
appended.  
  
Report only one of CPT codes 11055-11057 for each date of service. Total the
number of keratotic lesions debrided and select the most appropriate CPT code.
Example: if one lesion is debrided on the right foot and two lesions are
debrided on the left foot, code 11056 (two to four lesions) would be the most
appropriate CPT code.  
  
When reporting one of the ICD-10-CM codes that fall under the "active care
requirement", the date that the beneficiary was last seen by the M.D., D.O.,
or qualified NPP, responsible for treating the underlying condition must be
reported in line 19 of the CMS-1500 claim form or the electronic equivalent.
Billing and Coding: Hemorrhoid Artery Ligation

Effective 08/11/2011, Palmetto GBA will reimburse services for doppler-guided
hemorrhoid artery ligation with or without retroanal repair for Grade II or
III hemorrhoids that have failed rubber band ligation or conservative
treatment, such as behavior modification, high fiber diets to control
constipation, and hydrocortisone cream/suppositories.  
  
To submit claims for this service, submit code 46948.  
  
According to CPT coding references, it is not appropriate to submit the
following codes with a 46948 service: 46020, 46221, 46250, 46255, 46257,
46258, 46260, 46261, 46262, 46600, 46945, 46946, 76872, 76942, and 76998.
Self-Administered Drug Exclusion List: Medical Policy Article

Coverage for self-administered drugs for both Part A and Part B is determined
by the MAC Contractor in each jurisdiction. HCPCS codes used under Outpatient
Prospective Payment System (OPPS) are included, in addition to the codes used
for Part B claims, when appropriate.  
  
The table below lists drugs that are not covered by Medicare, the effective
date of non-coverage, and the rationale. (Please see "Process for Determining
Self-Administered Drug Exclusions - Medical Policy Article"). The column,
"Brand Names," provides one or more examples but may not include all brand
names.  
  
Information about drugs not separately reimbursed or not covered for reasons
other than "usually self-administered," is detailed in Part A and Part B MAC
publications and postings available elsewhere.

**Route of Administration Modifier**

The use of the JA and JB modifiers is required for drugs which have one HCPCS
Level II (J or Q) code but multiple routes of administration. Drugs that fall
under this category will be marked with an asterisk (*) and must be billed
with the JA modifier for the intravenous infusion of the drug or billed with
the JB modifier for the subcutaneous injection form of administration.
Subcutaneously administered drugs listed on the Usually Self-Administered list
will be denied as a benefit exclusion. Claims for drugs marked with an
asterisk (*) billed without either a JA or JB modifier will also be denied.
Billing and Coding: Endometrial Hyperplasia Treatment

Treatment of endometrial hyperplasia with the insertion of a hormone-
containing intrauterine device (IUD) is an accepted method to manage
endometrial hyperplasia for patients with abnormal uterine bleeding and who
are unable to tolerate oral megestrol or are at high risk for complications of
oral megestrol.  
  
Effective for dates of service on and after 02/01/12, Palmetto GBA will
reimburse IUD insertion services for patients who meet these criteria.  
Since IUD insertion services auto-deny, submit the following claim
information:

  * CPT code 58999
  * ICD-10 codes N84.0 or N85.00-N85.02
  * Enter "hormone IUD" in the comment/narrative field of the CMS-1500 claim form or the equivalent electronic claim field
Billing and Coding: CPT Code 97755 - Assistive Technology Assessment

CPT code 97755, assistive technology assessment (for example, to restore,
augment or compensate for an existing function, optimize functional tasks
and/or maximize environmental accessibility), direct 1-on-1 contact with
written report, each 15 minutes, is related to the following local coverage
determinations (LCDs):

* Outpatient Physical Therapy (L34428)  
* Outpatient Occupational Therapy (L34427)  
* Home Health-Occupational Therapy (L34560)  
* Home Health-Physical Therapy (L34564)

This is an assessment code, per each 15 minutes, and must be accompanied by a
written report explaining the nature and complexity of the assistive
technology needed by the patient. This can include: testing multiple
components/systems to determine optimal interface between client and
technology applications and determining the appropriateness of commercial (off
the shelf) components/systems. If the service provided by a physical or
occupational therapist is more clearly defined by another CPT code (for
example, 97535 self-care/home management training), it should be used instead.  
  
It would be inappropriate to use the CPT code 97755 for services other than
for those who have lost the use of their limbs and who can benefit from new
technology advancements. CPT 97755 should only be billed by occupational and
physical therapists that have the additional knowledge and expertise of the
assistive technology that is required for these individuals.  
  
For rationale, clinical example and description of CPT 97755, please refer to
CPT 2004 Changes: An Insider's View, American Medical Association (2003(C)).
Home-Based Fall Evaluations and Interventions

The goal of this article is to provide a framework for the communication of
information that both clinicians and Medicare need to make patient-centered
decisions.

Services provided by HHAs under the 32x bill type are reimbursed under the
Home Health Prospective Payment System (HH PPS), while those delivered under
the 34x bill type are reimbursed as Part B Outpatient Rehabilitation Services.
Part B Outpatient Rehabilitation Services (with the exception of those
furnished by or under arrangements with a hospital) are subject to the
financial limitations described in the CMS Internet-Only Manual, Pub. 100-04,
Medicare Claims Processing Manual, Chapter 5, Section 10.2.  
  
This article underscores the importance of a comprehensive evaluation of the
circumstances surrounding the documented fall event(s). It is important that a
comprehensive examination and evaluation including a detailed history as well
as neurological/sensory, musculoskeletal, and vascular/cardiopulmonary systems
reviews be documented. Palmetto GBA is addressing this need through an
approach called Going Beyond Diagnosis (GBD). GBD promotes use of the
International Classification of Functioning Disability and Health (ICF) to
capture and organize the information necessary to support the clinical and
administrative needs of HHAs performing home-based fall evaluations and
interventions.
Hospice: Documenting Weight Loss for Beneficiaries with Non-Neoplastic
Conditions

Weight has long been used as a measure of nutritional status. Both absolute
body weight and changes in body weight have prognostic significance. The
documentation of absolute body weight provides information at a specified
point in time, while changes in body weight allow clinicians to gauge a given
patient's response to treatment over time.  
  
If hospice organizations record "percent weight loss" as an indicator of
nutritional status, this A/B HHH MAC expects to see supporting documentation
of the absolute weights used to calculate the percent decrease. The reporting
of absolute weights strengthens documentation of percent change in weight over
time (e.g., > 10% weight loss over the last 6 months with weight decreasing
from 110 pounds to 95 pounds). This A/B HHH MAC encourages hospice providers
to include absolute weights in their responses to additional documentation
requests (ADRs).  
  
Unsupported percent weight loss in the medical record may result in a denial
if other documentation does not lend support to impaired nutritional status.
Billing and Coding: Home Health Physical Therapy

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Home Health
Physical Therapy L34564.

**Coding Guidelines**  
  
1\. For CPT codes 97010 (Hot or Cold Packs), 97018 (Paraffin Bath), 97022
(Whirlpool), and 97026 (Infrared Application), documentation must reflect
medical necessity and be made available to the Medicare Administrative
Contractor (MAC) upon request.  
  
2\. When both a modality/procedure and an evaluation service are billed on the
same day, the evaluation may be reimbursed only if the medical necessity for
the evaluation is clearly documented.  
  
3\. CPT codes 95851 (range of motion measurements and report), 95852 (Range
of motion measurements hand, with or without comparison with normal side) and
97750 (Physical performance test or measurement [e.g., musculoskeletal,
functional capacity], with written report, each 15 minutes) should not be
billed with an initial evaluation.  
  
4\. CPT code 97140 (Manual therapy techniques) excludes manipulation
performed in the home setting.  
  
5\. When billing a "z" code as a diagnosis code, documentation should include
the name of the orthotic/prosthetic device, date the patient received the
device, and the date training/teaching began.  
  
6\. Associated with several procedure codes are guidelines on the number of
visits generally needed to accomplish the task. If more visits are needed the
documentation should support the necessity of the additional visits.  
  
7\. As of July 1999, Physical Therapy must report time spent with the patient
in 15-minute increments. The following code should be used by Physical
Therapy:

  * G0151 Physical therapy

8\. The related LCD is based on impairments of structure/function and
functional limitations. While the pathophysiology is an important factor, the
purpose of the related LCD is to show the specific functional limitation of
the patient.  
  
9\. "Clinical note means a notation of a contact with a patient that is
written and dated by a member of the health team, and that describes signs and
symptoms, treatment and drugs administered and the patient's reaction, and any
changes in physical or emotional condition." (42 CFR 484.2)  
  
10\. "Progress note means a written notation, dated and signed by a member of
the health team, that summarizes facts about care furnished and the patient's
response during a given period of time." (42 CFR 484.2)

**Therapeutic Exercises (CPT  code 97110)**

A physical therapist may use this code when addressing impairments of exercise
tolerance due to cardiopulmonary impairments.

**Self-Care/Home Management Training (CPT  code 97535)**

This code should not be used globally for all home instructions. When
instructing the patient in a self-management program, use the code that best
describes the focus of the self-management activity.

**Wheelchair Management Training (CPT  code 97542)**

When billing 97542 for wheelchair propulsion training, documentation must
relate the training to expected functional goals that are attainable by the
patient and/or caregiver.
Billing and Coding: Ophthalmology: Extended Ophthalmoscopy and Fundus
Photography

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for the Ophthalmology:
Extended Ophthalmoscopy and Fundus Photography L33467.

General ophthalmoscopy and biomicroscopy are part of an ophthalmologic
examination. These codes are included in and are not separately payable when
an extended ophthalmoscopy code is billed, but these should still be
documented in the patient's medical record.  
  
If extended ophthalmoscopy is done without a drawing or does not meet
indicated standards, the service is not separately payable and will be
considered part of a general ophthalmologic exam or E&M service.  
  
 ** _PART B_**  
  
Fundus photography is a bilateral service on the Medicare Physician Fee
Schedule Data Base. Services performed unilaterally are subject to a reduction
in fee. [Use -52 modifier to indicate unilateral service; -RT and -LT are not
required in this circumstance.] CPT codes 92201 and 92202 should not be
billed if fundus photography is performed.  
  
Extended ophthalmoscopy (CPT codes 92201, 92202) performed during the global
surgery period of an ophthalmologic surgery procedure, by the same provider
performing the surgery, will not be separately payable unless unrelated to the
condition for which the surgery was performed. This circumstance can be
indicated by reporting a modifier -76 or -79 depending on the date of service.

CPT code 92227 is not for routine screening, but is covered for evaluation of
asymptomatic patients at risk with known disease (e.g., diabetes mellitus)
that is likely to cause retinal disease when the test is ordered by the
treating physician (or other treating practitioner acting within the scope of
his or her license and Medicare requirements).

CPT code 92228 is a covered service when ordered by the treating physician
(or other treating practitioner acting within the scope of his or her license
and Medicare requirements).
Billing and Coding: Sclerosing of Varicose Veins

Important Coding Alert  
  
Noridian is revising this article to further clarify that CPT 37241 is not an
acceptable choice of procedure codes for treatment of symptoms of varicose
veins of the lower extremity regardless of the method used.  
  
Noridian's Local Coverage Determination, Treatment of Varicose Veins of the
Lower Extremities; L34209 (JEA and JEB)/L34010 (JFA and JFB) provides coverage
criteria for the treatment of varicose veins and the CPT codes that are
expected to be utilized for billing this service.  
  
As previously noted, a product for the treatment of varicose veins has
appeared on the market for which the product's information states that it
utilizes both a sclerosing agent and a rotating wire which allegedly mixes the
agent and possibly macerates any clots in the area.  
  
Noridian has been informed that some providers may have been recommended to
use CPT 37241 when using this device for the treatment of varicose veins.
This advice is incorrect. CPT37241 must not be used to bill for the treatment
of varicose veins of the lower extremities with this or similar devices.  
  
When using the ClariVein device in the treatment of varicose veins before
January 1, 2017, Noridian recommends billing with CPT code 36299. The
sclerosing agent is bundled into the procedure code and is not separately
reimbursable. ClariVein must be entered in Item 19 of the CMS-1500 form or the
electronic notepad equivalent. For dates of service on and after January 1,
2017 providers should use CPT 36473 for first vein (Endovenous ablation
therapy of incompetent vein, extremity, inclusive of all imaging guidance and
monitoring, percutaneous, mechanochemical; first vein treated) and 36474
(Endovenous ablation therapy of incompetent vein, extremity, inclusive of all
imaging guidance and monitoring, percutaneous, mechanochemical; subsequent
vein(s) treated in a single extremity, each through separate access sites
(List separately in addition to code for primary procedure) If billing for
both extremities it is appropriate to append modifier RT or LT to the
respective claim line.  
  
Based on the intensity of service for CPT code 37241, Noridian no longer
allows payment for claims using this CPT in Place of Service 11 - Office
effective June 6, 2016.
Billing and Coding: Sclerosing of Varicose Veins

Important Coding Alert  
  
Noridian is revising this article to further clarify that CPT 37241 is not an
acceptable choice of procedure codes for treatment of symptoms of varicose
veins of the lower extremity regardless of the method used.  
  
Noridian's Local Coverage Determination, Treatment of Varicose Veins of the
Lower Extremities; L34209 (JEA and JEB)/L34010 (JFA and JFB) provides coverage
criteria for the treatment of varicose veins and the CPT codes that are
expected to be utilized for billing this service.  
  
As previously noted, a product for the treatment of varicose veins has
appeared on the market for which the product's information states that it
utilizes both a sclerosing agent and a rotating wire which allegedly mixes the
agent and possibly macerates any clots in the area.  
  
Noridian has been informed that some providers may have been recommended to
use CPT 37241 when using this device for the treatment of varicose veins.
This advice is incorrect. CPT 37241 must not be used to bill for the
treatment of varicose veins of the lower extremities with this or similar
devices.  
  
When using the ClariVein device in the treatment of varicose veins before
January 1, 2017, Noridian recommends billing with CPT code 36299. The
sclerosing agent is bundled into the procedure code and is not separately
reimbursable. ClariVein must be entered in Item 19 of the CMS-1500 form or the
electronic notepad equivalent. For dates of service on and after January 1,
2017 providers should use CPT 36473 for first vein (Endovenous ablation
therapy of incompetent vein, extremity, inclusive of all imaging guidance and
monitoring, percutaneous, mechanochemical; first vein treated) and 36474
(Endovenous ablation therapy of incompetent vein, extremity, inclusive of all
imaging guidance and monitoring, percutaneous, mechanochemical; subsequent
vein(s) treated in a single extremity, each through separate access sites
(List separately in addition to code for primary procedure) If billing for
both extremities it is appropriate to append modifier RT or LT to the
respective claim line.  
  
Based on the intensity of service for CPT code 37241, Noridian no longer
allows payment for claims using this CPT in place of Service 11 - Office,
effective June 6, 2016.
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 L33420.

This A/B MAC 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 patients 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 component 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 provide 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: MolDX: Afirma Assay by Veracyte Update

The MolDX Team 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, MolDX
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 CPT code
  * 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 Update

Effective November 19, 2012, Cancer TYPE ID, an RT-PCR 92-gene assay, has been
assigned a DEX Z-Code 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-Code 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-Code 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.

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