Persius/hicric huggingface dataset:
Billing and Coding: MolDX: BluePrint Test

The MolDX team has completed a technical assessment on BluePrint, a molecular
subtyping assay. To date, there is insufficient evidence to support the
required clinical utility for the established Medicare benefit category.
Therefore, the BluePrint test is a statutorily excluded test.  
  
To receive a BluePrint service denial, please submit the following claim
information:

  * CPT code 81479- Unlisted molecular pathology procedure
  * 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
  * 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: Radiology Services: Multiple, Identical Services on Same
Day

**Multiple 'Serial' X-Rays**  
  
Medicare Part B claims for multiple, identical services provided to an
individual patient on the same day may be denied as duplicate services. To
ensure correct claims processing:

Submit multiple, identical services on the same claim,  
Use the days/units field when possible to identify multiple procedures,  
Indicate the time each service was performed in the appropriate documentation
field for electronic claims or Item 19 of the CMS-1500 claim form,  
Use CPT modifier 76 for multiple, identical services performed on the same
date of service by the same physician.

Example:

Date of Service | CPT Code/Modifier | Days/Units  
---|---|---  
1/1/13 | 73000 | 1  
1/1/13 | 73000-76 | 2  
  


**Multiple Interpretations, Same X-Ray**

Generally, Palmetto GBA may reimburse the first interpretation of an X-ray
furnished to an emergency room patient. The 'interpretation and report' of an
X-ray requires a complete, written report similar to the kind of report a
specialist would prepare. Payment for a second interpretation of the same film
is made only in unusual circumstances. Claims for the second interpretation of
the same film must be submitted with CPT modifier 77 when performed by a
different physician and must provide documentation as to why a second
interpretation is medically reasonable and necessary.  
  
Examples:

A questionable finding for which the physician performing the initial
interpretation believes that another physician's expertise is needed,  
A changed diagnosis resulting from a second interpretation of the results of
the procedure.  
  
Palmetto GBA will not reimburse 2 interpretations of the same X-ray without
the additional required documentation. When an emergency room physician and a
radiologist both perform interpretations of the same X-ray, both physicians
should work together to determine who should submit the claim.  
  
Additional information and guidance on multiple interpretations of the same
X-ray are available in the CMS Internet-Only Manual, Pub. 100-04, Medicare
Claims Processing Manual, Chapter 13, 100.1.
Billing and Coding: MolDX: HBB Gene Tests

Effective for dates of service on and after 05/03/2013  
  
HBB gene testing may be performed during the diagnosis of Sickle cell disease
(SCD). Since clinical symptoms and diagnosis usually occur prior to Medicare
eligibility and carrier testing is not a covered benefit, the MolDX Team has
determined HBB gene testing is a statutorily excluded service. MolDX will also
deny panels of tests that include the HBB gene.  
  
To receive a HBB gene sequencing service denial, please submit the following
claim information:

  * Select the appropriate CPT code based on gene test:
    * 81361 - HBB, common variants
    * 81362 - HBB, known familiar variants
    * 81363 - HBB, duplication/deletion
    * 81364 - HBB, full gene sequence
    * 81443 - Genetic testing for severe inherited conditions
  * 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
  * 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
Glaucoma Screening Medicare coverage of glaucoma screenings was implemented
with the Benefits Improvement and Protection Act of 2000 (BIPA).  
  
A glaucoma screening is defined to include:

  

  * A dilated eye examination with an intraocular pressure (IOP) measurement
  

  * A direct ophthalmoscopy examination or a slit-lamp biomicroscopic examination
  

  
Medicare covers glaucoma screening for the following persons considered to be
at high risk for developing this disease:

  

  * Individuals with diabetes mellitus
  

  * Individuals with a family history of glaucoma
  

  * African-Americans age 50 or over
  

  * Hispanics-Americans 65 or older
  

  
Glaucoma screening frequency limitations and payment information:

  

  * Medicare pays for this service annually (i.e., at least 11 full months must have passed following the month in which the last Medicare-covered glaucoma screening examination was performed)
  
Services rendered more frequently than allowed under this screening benefit
may require that the beneficiary be given an Advance Beneficiary Notice (ABN)  

  * The beneficiary will pay 20 percent as the co-payment or coinsurance after meeting the yearly Part B deductible
  

  
Medical record documentation requirements:

  

  * Medical record documentation to support that the beneficiary is a member of one of the high risk groups, as defined above
  

  * Documentation must support one of the screening defined:
  

    * A dilated eye examination with IOP measurement and direct ophthalmoscopic examination, or a slit-lamp biomicroscopic examination   
  
**Procedure and Diagnosis Code Information:**  
HCPCS Codes|  HCPCS Code Descriptors/Modifier|  Diagnosis Code  
---|---|---  
  
G0117|  Glaucoma screening for high risk patient furnished by an optometrist
or ophthalmologist|  Z13.5 (Encounter for Screening for Eye and Ear Disorders)  
  
G0118|  Glaucoma screening for high risk patient furnished under the direct
supervision of optometrist or ophthalmologist|  Z13.5 (Encounter for Screening
for Eye and Ear Disorders)
Billing and Coding: Oral Maxillofacial Prosthesis

Implants, which could be considered dental but are being inserted to secure,
attach, or support the maxillofacial prosthesis, will be covered when the
prosthesis is to be used secondary to maxillofacial surgery or repair of
traumatic injury. Use CPT code 21299 to bill the implants with an explanation
of the intended use. Please note dates of trauma or tumor biopsy/resection,
dates of radiation treatment and other pertinent medical history.  
  
 **E0485 to E0486: Oral Devices for Obstructive Sleep Apnea**  
  
HCPCS codes E0485 and E0486 describe oral devices or appliances used to reduce
upper airway collapsibility, adjustable or nonadjustable, prefabricated
(E0485) or custom fabricated (E0486). These devices are typically used to
treat obstructive sleep apnea (OSA). Both codes include all fitting and
adjustment. These codes are reimbursed as Durable Medical Equipment by the
Durable Medical Equipment Medicare Administrative Contractor (DME MAC). The
initial assessment and diagnostic services to determine whether an OSA
appliance should be used are billable to the Part B contractor up to the time
of the decision to order/provide the OSA appliance using the appropriate
Evaluation and Management (E&M) CPT code and other appropriate CPT codes for
diagnostic tests. At the time of the decision to order/provide the OSA
appliance, all fittings, adjustments, supplies, and services to provide the
appliance to the individual patient is inclusive. Medicare claims related to
the fitting, subsequent adjustments and repairs of an oral device should be
submitted to the appropriate DME MAC and not as E&M services to the A/B
Medicare Administrative Contractor (MAC). Additionally, any radiological or
other services performed in order to guide the adjustments of the oral device
should not be submitted separately to the A/B MAC, as the Medicare Program
payment associated with HCPCS Codes E0485 and E0486 already includes any
required adjustments to ensure a properly fitted device.
Billing and Coding: Implantable Miniature Telescope (IMT) for Macular
Degeneration

The Implantable Miniature Telescope (IMT) is a prosthetic device in the form
of a miniature telescope, implanted monocularly to enlarge the retinal image
of the central visual field and reduce the impact of untreatable, severe-to-
profound vision-impairing central scotomas associated with end stage age
related macular degeneration (ARMD).  
  
The implantable miniature telescope is considered medically reasonable and
necessary only for patients who meet ALL of the following criteria:  
  
 65 years of age or older; and  
 Diagnosis of stable, untreatable, severe-to-profound central vision
impairment caused by blind spots (bilateral central scotoma) associated with
end stage ARMD as determined by fluorescein angiography (findings of
geographic atrophy or disciform scar with foveal involvement); and  
 Evidence of a visually significant cataract (grade 2 or higher); and  
 Corrected distance Snellen visual acuity poorer than 20/160 but no worse
than 20/800; and  
 No active wet ARMD (no sign of active choroidal neovascularization in either
eye); and  
 Have no sign of eye disease other than well controlled glaucoma; and  
 Have not been treated for wet ARMD in the previous 6 months; and  
 Achieve at least a 5 letter improvement on the Early Treatment Diabetic
Retinopathy Study (ETDRS) visual acuity chart in the eye scheduled for surgery
using an external telescope; and  
 Agree to undergo 2 to 4 pre-surgical training sessions with a low vision
specialist (optometrist or occupational therapist); and  
 Agree to participate in postoperative visual rehabilitation with a low
vision specialist; and  
 Complete and agree to the 'Acceptance of Risk and Informed Consent
Agreement' provided in the device labeling documentation.  
  
**Note:** Palmetto GBA expects performing providers to obtain adequate
training prior to procedure performance. Medical records may be subject to
review and/or denial if criteria are not documented and IMT contraindications
are identified.
Billing and Coding: MolDX: BCR-ABL

Effective for dates of service on and after 4/15/13  
  
Breakpoint testing for BCR-ABL1 is commonly performed as a combination or
panel of tests (major, minor and other breakpoints). To report multiple tests
assigned a single ID, submit CPT code 81479. This guideline includes the
following CPT code combinations:

  * 81206 and 81207
  * 81206, 81207, and 81208

CPT codes 81206, 81207, and 81208 may only be reported when performed as a
single test.

To submit a claim for BCR-ABL translocation analysis by NGS, use CPT 81479
and one (1) UOS with the assigned DEX Z-code.

To report the FDA-approved MRDx BCR-ABL Test use the CPT code 0040U.

Refer to [Billing and Coding: MolDX: Testing of Multiple Genes A57503
](https://www.cms.gov/medicare-coverage-
database/view/article.aspx?articleid=57503&ver=10&bc=0)for additional
information regarding single-gene and panel testing of genes.
Billing and Coding: MolDX: ENG and ACVRL1 Gene Tests

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder
with variable clinical presentation. Most common manifestations are epistaxis,
recurrent gastrointestinal bleeding, iron deficiency anemia, and mucocutaneous
telangectasias. Arteriovenous malformations (AVMs), of various organs (lung,
liver, brain) are common.  
  
The two most prevalent forms of HHT, Type 1 and Type 2, are caused by
mutations in the endoglin (ENG) or the ACVRL1 gene respectively. Although
identification of these gene mutations can confirm the diagnosis of HHT, these
tests are not necessary in many cases. HHT is generally established using well
vetted consensus criteria (most often the International Curacao Criteria
(ICC)). The ICC uses the clinical characteristics of epistaxis, cutaneous or
mucosal telangectasias, visceral AVMs, and a first-degree relative with HHT to
judge likelihood of a given patient having HHT. A 'definite' diagnosis is
established when a patient has 3 or 4 of these criteria. Genetic testing for
ENG/ACVRL1 is not warranted. A patient with 0 to 1 criteria is 'unlikely' to
have HHT, and similarly would not be a candidate for genetic testing. Patients
with 2 or 3 Curacao criteria are defined as "suspected" of HHT and are
candidates for ENG/ACVRL1 testing.  
  
Since screening of patients without signs or symptoms of HHT, who have a
first-degree relative with HHT, is not a Medicare benefit, the MolDX Team has
determined ENG and/or ACVRL1 genetic testing and panels of tests that include
ENG/ACVRL1 are statutorily excluded services.  
  
**EXCEPTIONS:** For patients with "suspected" HHT in which diagnosis
confirmation would demonstrate an improved outcome, approval will be made on a
case-by-case basis through the appeal process.  
  
For tests that include ENG and ACVRL1 registered and assigned a single Z-CodeTM
Identifier, submit CPT code 81479.  
  
To receive an ENG and/or ACVRL1 gene test denial, please submit the following
claim information:

  * Select appropriate CPT code for test
    * 81405-ENG, Duplication/deletion
    * 81406-ENG, full gene sequence
    * 81479-ACVRL1
    * 81479-ACVRL1 and ENG
  * 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
  * For CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.
    * 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: SULT4A1 Genetic Testing

Sulfotransferase 4A1 (SULT4A1) is an enzyme found in the brain that interacts
with numerous neuroactive molecules, including some catecholamines and neural
steroids. Findings suggest the SULT4A1-1 haplotype of SULT4A1 is associated
with enhanced response to antipsychotic drug therapy. At present there is
insufficient evidence to support SULT4A1 genotyping to determine medical
management. Therefore, the MolDX Team has determined SULT4A1 genetic testing
is not a Medicare benefit and is a statutorily excluded service. In addition
to single gene testing, MolDX will also deny panels of tests that include the
SULT4A1 gene as a statutorily excluded service.  
  
To receive a SULT4A1 test denial, please submit the following claim
information:

  * CPT code 81479
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services
    * For a voluntary issued ABN, append with GX HCPCS modifier
    * To indicate a statutorily excluded service, append with a GY HCPCS modifier

For CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred)
or the NTE field to submit this required information.

  * 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: BLM Gene Analysis

Effective for dates of service on and after July 30, 2014  
  
The clinical diagnosis of Bloom (BLM syndrome, BSyn), characterized by severe
pre and postnatal growth deficiency, highly characteristic sparseness of
subcutaneous fat tissue in infants and children, is confirmed through
cytogenetic testing. Molecular genetic testing identifies BLM gene mutation
carriers at risk for conceiving offspring with the disease. Therefore, BLM
genetic testing is not a Medicare benefit and is a statutorily excluded
service. In addition to single gene testing, MolDX will also deny panels of
tests that include the BLM gene as a statutorily excluded service.  
  
To receive a BLM gene test service denial, please submit the following

  * CPT code 81209 or CPT code 81443
  * 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
  * 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: GBA Genetic Testing

Effective for dates of service on and after July 30, 2013.  
  
Mutations found in glucosidase, beta, acid (GBA) are associated with Gaucher
disease (GD), which encompasses a continuum of clinical findings. Since GBA
genetic testing is used to confirm the clinical findings to diagnose GD, the
MolDX Team has determined that GBA genetic testing is not a Medicare benefit
and is a statutorily excluded service. In addition to single gene testing,
MolDX will also deny panels of tests that include the GBA gene as a
statutorily excluded service.  
  
To receive a GBA test denial, please submit the following claim information:

  * CPT code 81251- GBA, common variants

  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services

    * For a voluntary issued ABN, append with GX HCPCS modifier

    * To indicate a statutorily excluded service, append with a GY HCPCS modifier

  * For CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.
    * 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: myPap

The myPAPTM DNA test, developed to complement a Papanicolaou (Pap) test,
confirms a Pap specimen belongs to the patient evaluated for treatment. The
MolDX Team agrees the healthcare community should define and follow strict
procedures regarding patient and patient specimen identification and handling.
Tests performed to measure the quality or control of a process and do not
provide information to diagnose or treat a patient illness or injury do not
meet the criteria for a Medicare benefit. Therefore, the myPAPTM test is a
statutorily excluded test. Although an Advance Beneficiary Notice (ABN) is not
required for a statutory exclusion, providers supplying this test (directly or
through a purchased service) should ensure patients understand the test is not
a covered benefit.  
  
Providers must register for a DEX Z-CodeTM identifier prior to claim
submission. To access the MolDX registry, go to the DEXTM Diagnostics Exchange
located at: https://app.dexzcodes.com/login. Once an ID has been obtained,
please submit the following claim information to receive a myPapTM Medicare
service denial:

    * CPT code 84999 - unlisted chemistry procedure
    * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded service 
      * For a voluntary issued ABN, append with GX modifier
      * To indicate a statutorily excluded service, append with a GY modifier
    * 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

If you believe your practice has submitted claims and received reimbursement
in error, you may take the following corrective actions:

  * Complete a Self-Audit 
    * Identify incorrect submissions
    * Contain further claim submission errors
  * Consider Self-Disclosure Protocol
  * Self-disclosure guidelines
Billing and Coding: MolDX: VEGFR2 Tests

Effective for dates of service on and after 05/03/2013.  
  
Vascular endothelial growth factor, subtype 2, (VEGFR2) receptor has been
found to be oncogenic. Current studies have targeted VEGFR2 as a potential
therapeutic option. However, at present there is insufficient evidence to
establish a clear association between VEGFR2 mutations and treatment response.
Therefore, the MolDX Team has determined VEGFR2 testing is a statutorily
excluded service. MolDX will also deny panels of tests that include the VEGFR2
receptor.  
  
To receive a VEGFR2 service denial, please submit the following claim
information:

  * CPT code 81479
  * 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