Persius/hicric huggingface dataset:
Billing and Coding: Patients Supplied Donated or Free-of-Charge Drug

The Medicare Program provides limited benefits for outpatient drugs. The
program covers drugs that are furnished "incident to" a physician's service,
provided that the drugs are not usually self-administered by the patients who
take them, and is reasonable and necessary for the diagnosis or treatment of
the illness or injury according to accepted standards of medical practice.  
  
In order to meet all the general requirements for coverage under the "incident
to" provision an FDA approved drug or biological must be furnished by a
physician and administered by the physician or by auxiliary personnel employed
by the physician and under the physician's personal supervision.  
  
The charge, if any, for the drug or biological must be included in the
physician's bill and the cost of the drug or biological must represent an
expense to the physician.  
  

  * Pharmacies cannot bill Medicare Part B for drugs furnished to a physician for administration to a Medicare beneficiary.
  * Pharmacies, suppliers and providers cannot bill Medicare Part B for drugs dispensed directly to a beneficiary for administration "incident to" a physician service, such as refilling an implanted drug pump.
  * Providers can bill Medicare only when such drugs are purchased by the physician, from the pharmacy, and administered in the physician's office.

  
**Donated or Free-of-Charge Drug**  
  
To avoid a chemotherapy or other drug administration code denial, a drug code
must be present on the same or prior claim. Enter the below information in the
appropriate Part A or Part B electronic claim or the equivalent Part A UB04 or
Part B CMS-1500 claim form.

  * Part A 
    * Loop 2400 Segment SV202-7 or Box 80 
      * Enter "Drug Donated"
      * Enter code description, strength and dosage - if billing a Not Otherwise Classified (NOC) HCPCS code
    * Loop 2400 Segment SV202-2 or Box 44 
      * Enter drug (HCPCS) code
    * Loop 2300 Segment CLM02 or Box 47 and 48 
      * Enter $0.01 for the billed amount

  * Part B 
    * Loop 2400 Segment SV101-7 for the 5010A1 837P or Item 19 
      * Enter "Drug Donated"
      * Enter code description, strength and dosage - if billing a Not Otherwise Classified (NOC) HCPCS code
    * Loop 2400 Segment SV101-2 or Item 24D 
      * Enter drug (HCPCS) code
    * Loop 2300 CLM02 or Item 28 
      * Enter $0.01 for the billed amount

This will allow the claim processing system to register the drug claim as
being allowed which should allow the administration.  
  
 **NOTE:** Per the "incident to" guidelines explained above and in the CMS
Internet-Only Manual (IOM) Publication 100-02, Chapter 15, Sections 50 and
50.3 [(MBPM)](http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/bp102c15.pdf). Providers are **NOT**
allowed to instruct their patients to purchase the drug themselves and then
bring them to the provider's office for administration. If the drug is not
supplied as a donation or free of charge, then the provider must provide the
drug under incident to guidelines.
Response to Comments: MolDX: NRAS Genetic Testing Noridians Response to
Provider Recommendations (for comment period ending 12/7/2015).
Response to Comments: Treatment of Males with Low Testosterone The number of
comments were few, partly because several clinical societies were given early
drafts of this policy and the policy was adopted to include their suggestions.
Response to Comments: Treatment of Males with Low Testosterone The number of
comments were few, partly because several clinical societies were given early
drafts of this policy and the policy was adopted to include their suggestions
Billing and Coding: Testopel Coverage Injectable testosterone pellets (brand
name Testopel) may be covered, by Medicare, for the FDA approved indication,
if the service meets all Medicare coverage requirements quoted below verbatim
in the Internet Only Manual (IOM) _Medicare Benefit Policy Manual_ (MBPM)
Chapter 15, Section 50.4.3.2 [MBPM](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/bp102c15.pdf)  
  
 **Injection Method Not Indicated**  
  
Medication given by injection (parenterally) is not covered if standard
medical practice indicates that the administration of the medication by mouth
(orally) is effective and is an accepted or preferred method of
administration. For example, the accepted standard of medical practice for the
treatment of certain diseases is to initiate therapy with parenteral
penicillin and to complete therapy with oral penicillin. Carriers exclude the
entire charge for penicillin injections given after the initiation of therapy
if oral penicillin is indicated unless there are special medical circumstances
that justify additional injections."  
  
The Noridian Contractor Medical Directors (CMDs) believe that the use of this
product should be rare since the "accepted method of medical practice" is to
administer testosterone transdermally, but there may be reasons that require
this injectable medication. Compliance with Medicare requirements is subject
to review by the Recovery Auditors.  
  
A submitted claim form must contain the below information.

  

  * In Item 19 of CMS-1500 paper claim form or Loop 2400/SV101-7 for electronic claims
  

  * Enter word "Testopel"
  

  * Enter drug dosage given (include milligrams delivered only)
  

  *  **NOTE:** Medicare may only cover the number of pellets actually implanted in the patient (maximum of six pellets); wastage is not covered. Use of additional pellets may be paid on appeal if the documentation supports medical necessity as determined by the FDA approved drug label and the service complies with all Medicare requirements as indicated above.
  

  * Item 24D or electronic equivalent
  

  * Enter J3490
Waiver of Face-to-Face Visit for Home Dialysis Patients Physician management
services for patients on dialysis are usually paid for a full month of
management services. For in-center dialysis patients, this is billed and paid
based on the number of face-to-face visits made during the month and the age
bracket of the patient. For home dialysis patients there is a single fee based
on the age bracket of the patient. Medicare requires that physicians billing
this service must provide certain minimal services including at least one
face-to-face visit each month to assess the condition of the vascular access.  
  
Since 2011, CMS has allowed payment of the ESRD Monthly Capitation (MCP) for
certain home dialysis patients even when the physician has not actually had a
face-to-face visit; this requires an individual waiver at contractor
discretion (IOM 100-04, Chapter 8, Section 140.1.1). Starting July 7, 2016,
physicians may request this waiver by appending the -52 modifier (reduced
services) to the appropriate monthly capitation CPT code (90963  90966).  
  
Place the words, No Face-to-Face in Item 19 (or electronic equivalent).
Noridian may request medical records to assess whether the notes support that
the **physician actively and adequately managed the care of the home dialysis
patient throughout the month**. Noridian expects that requests for these
waivers will be unusual.  
  
 **References:** Internet Only Manual (IOM), Publication 100-04, _Medicare
Claims Processing Manual,_ Chapter 8, Section 140.1.1 at
[MCPM](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/clm104c08.pdf)
Waiver of Face-to-Face Visit for Home Dialysis Patients Physician management
services for patients on dialysis are usually paid for a full month of
management services. For in-center dialysis patients, this is billed and paid
based on the number of face-to-face visits made during the month and the age
bracket of the patient. For home dialysis patients there is a single fee based
on the age bracket of the patient. Medicare requires that physicians billing
this service must provide certain minimal services including at least one
face-to-face visit each month to assess the condition of the vascular access.  
  
Since 2011, CMS has allowed payment of the ESRD Monthly Capitation (MCP) for
certain home dialysis patients even when the physician has not actually had a
face-to-face visit; this requires an individual waiver at contractor
discretion (IOM 100-04, Chapter 8, Section 140.1.1). Starting July 7, 2016,
physicians may request this waiver by appending the -52 modifier (reduced
services) to the appropriate monthly capitation CPT code (90963  90966).  
  
Place the words, No Face-to-Face in Item 19 (or electronic equivalent).
Noridian may request medical records to assess whether the notes support that
the **physician actively and adequately managed the care of the home dialysis
patient throughout the month**. Noridian expects that requests for these
waivers will be unusual.  
  
  
 **References:** Internet Only Manual (IOM), Publication 100-04, _Medicare
Claims Processing Manual,_ Chapter 8, Section 140.1.1 at
[MCPM](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/clm104c08.pdf)
Billing and Coding: IUD (Hormone-Eluting) for Endometrial Hyperplasia - CPT
58999

Providers are aware that Medicare does not allow payment for contraceptive
devices or medication. For this reason the service, 58300, insertion of
intrauterine device (IUD) has an "N" status in the Medicare Physician Fee
Schedule, which means the service cannot be covered when billed to Medicare.  
  
Noridian is aware that insertion of a progestin-containing intrauterine device
(IUD) is an alternative method of managing endometrial hyperplasia in patients
who are not reasonable surgical candidates or who wish to preserve fertility.
Noridian has determined that the use of a progestin containing IUD may be
approved for use in the Medicare beneficiary who presents with endometrial
hyperplasia without atypia.  
  
Since the CPT code for IUD insertion will be auto-denied, providers should
bill this service using CPT 58999 and an appropriate diagnosis for endometrial
hyperplasia, including the product description "hormone IUD for endometrial
hyperplasia" in Item 19 of the CMS-1500 form or the electronic equivalent.  
  
 **Acceptable CPT Code for Billing IUD Insertion**  
  
 **CPT** **DESCRIPTION**  
58999 UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NON-OBSTETRICAL)  
  
 **Acceptable ICD-10-CM Codes for Billing IUD Insertion**  
  
 **ICD-10-CM Codes** **Description**  
N85.00 ENDOMETRIAL HYPERPLASIA, unspecified  
N85.01 SIMPLE ENDOMETRIAL HYPERPLASIA WITHOUT ATYPIA  
  
The medical record must clearly document the specific clinical circumstances
evidencing this medical necessity.  
  
 **Effective Immediately**
Billing and Coding: IUD (Hormone-Eluting) for Endometrial Hyperplasia - CPT
58999

Providers are aware that Medicare does not allow payment for contraceptive
devices or medication. For this reason the service, 58300, insertion of
intrauterine device (IUD) has an "N" status in the Medicare Physician Fee
Schedule, which means the service cannot be covered when billed to Medicare.  
  
Noridian is aware that insertion of a progestin-containing intrauterine device
(IUD) is an alternative method of managing endometrial hyperplasia in patients
who are not reasonable surgical candidates or who wish to preserve fertility.
Noridian has determined that the use of a progestin containing IUD may be
approved for use in the Medicare beneficiary who presents with endometrial
hyperplasia without atypia.  
  
Since the CPT code for IUD insertion will be auto-denied, providers should
bill this service using CPT 58999 and an appropriate diagnosis for endometrial
hyperplasia, including the product description "hormone IUD for endometrial
hyperplasia" in Item 19 of the CMS-1500 form or the electronic equivalent.  
  
 **Acceptable CPT Code for Billing IUD Insertion**  
  
 **CPT** **DESCRIPTION**  
58999 UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NON-OBSTETRICAL)  
  
Acceptable ICD-10-CM Codes for Billing IUD Insertion  
  
 **ICD-10-CM Codes** **Description**  
N85.00 ENDOMETRIAL HYPERPLASIA, unspecified  
N85.01 SIMPLE ENDOMETRIAL HYPERPLASIA WITHOUT ATYPIA  
  
The medical record must clearly document the specific clinical circumstances
evidencing this medical necessity.  
  
 **Effective Immediately**
Billing and Coding: Screening Colonoscopy Converted to a Diagnostic and/or
Therapeutic Colonoscopy

If during a colonoscopy a pathology is encountered that necessitates an
intervention which converts the screening colonoscopy to a
diagnostic/therapeutic colonoscopy, the appropriate CPT code which includes
the -PT modifier for the diagnostic/therapeutic colonoscopy must be submitted
with an appropriate diagnosis to justify the procedure such as Z80.0-Family
history of malignant neoplasm of digestive organs.  
  
1) Choose the correct CPT code which describes the procedure that was
attempted.

2) Append the -PT modifier to the CPT code. The -PT modifier indicates a
screening colonoscopy has been converted to a diagnostic test or other
procedure.  
  
3) Use an appropriate ICD-10 diagnosis code to indicate the procedure was a
screening procedure. The diagnosis Z80.0- Family history of malignant neoplasm
of digestive organs is an example of a diagnosis that can be used to indicate
screening of beneficiaries at high risk.
Billing and Coding: Once in a Lifetime Abdominal Aortic Aneurysm (AAA)
Screening Article

Once in a lifetime abdominal aortic aneurysm (AAA) screening is only covered
under certain specified conditions.  
  
When billing for AAA screenings, the following ICD-10 codes should be billed:  
  
* Z13.6 for the encounter for screening for cardiovascular disorders **_and either_**  
  
** The most appropriate code for tobacco usage: Z87.891, F17.210, F17.211,
F17.213, F17.218 and F17.219 **_OR_**  
  
* Z84.89 for family history of other specified conditions  
  
 **Note:** CPT code 76706 is the only ultrasound service that is payable for
AAA screening under Medicare services. No other CPT/HCPCS codes are covered.  
  
Per the CMS Internet-Only Manual, Publication 100-04, Medicare Claims
Processing Manual, Chapter 18, Section 110.2 and 110.3.2,  
  
 _Payment may be made for a one-time ultrasound screening for AAA for
beneficiaries who meet the following criteria:  
(i) receives a referral for such an ultrasound screening from the
beneficiary's attending physician, physician assistant, nurse practitioner or
clinical nurse specialist;  
(ii) receives such ultrasound screening from a provider or supplier who is
authorized to provide covered ultrasound diagnostic services;  
(iii) has not been previously furnished such an ultrasound screening under the
Medicare Program; and  
(iv) is included in at least one of the following risk categories-  
  
(I) has a family history of abdominal aortic aneurysm;  
(II) is a man age 65 to 75 who has smoked at least 100 cigarettes in his
lifetime; or  
(III) is a beneficiary who manifests other risk factors in a beneficiary
category recommended for screening by the United States Preventive Services
Task Force regarding AAA, as specified by the Secretary of Health and Human
Services, through the national coverage determination process.***_  
  
*For risk category (I) note that Z84.89 is an "other specified" code and requires that the condition be reflected in the medical record, therefore family history of abdominal aortic aneurysm must be documented in the medical record.  
**For risk category (II)  
***For risk category (III) USPST does not currently have any additional
screening recommendations at B or above grade at this time.  
  
 _Effective for services furnished on or after January 1, 2017, the following
code_ , modifiers, and type of service (TOS) _are used for AAA screening
services:_  
  
_CPT  code 76706: Ultrasound, abdominal aorta, real time with image
documentation, screening study for abdominal aortic aneurysm (AAA)_  
 _Short Descriptor: Us abdl aorta screen AAA_

__Modifiers: TC, 26_  
TOS: 4  
Bill Types: 12x, 13x, 22x, 23x, 71x, 73x, 85x_
Response to Comments: Total Hip Arthroplasty Noridian's Response to Provider
Recommendations (for comment period ending 04/10/2016):
Response to Comments: Total Hip Arthroplasty Noridian's Response to Provider
Recommendations (for comment period ending 4/10/16):
Response to Comments: Total Knee Arthroplasty Noridian's Response to Provider
Recommendations (for comment period ending 4/10/16):
Billing and Coding: MolDX: CHD7 Gene Analysis

_CHD7_  gene testing may be performed during the diagnosis of CHARGE Syndrome.
Since clinical symptoms and diagnosis usually occur prior to Medicare
eligibility and carrier testing is not a covered benefit, the MolDX Contractor
has determined  _CHD7_  gene testing is a statutorily excluded service. MolDX
will also deny tests that include one or more of  _CHD7_  tests reported with
CPT code 81479 as statutorily excluded services.  
  
To receive a  _CHD7_  analysis service denial, please submit the following
claim information:

  * Select appropriate CPT code
    * 81407  _CHD7_ , full gene sequencing
    * 81479 all other  _CHD7_  testing
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.
    * For a voluntary issued ABN, append with GX modifier
    * To indicate a known 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
    * Item19 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: CHD7 Gene Analysis

CHD7 gene testing may be performed during the diagnosis of CHARGE Syndrome.
Since clinical symptoms and diagnosis usually occur prior to Medicare
eligibility and carrier testing is not a covered benefit, the MolDX Contractor
has determined CHD7 gene testing is a statutorily excluded service. MolDX will
also deny tests that include one or more of CHD7 tests reported with CPT code
81479 as statutorily excluded services.  
  
To receive a CHD7 analysis service denial, please submit the following claim
information:

  * Select appropriate CPT code
    * 81407 CHD7, full gene sequencing
    * 81479 all other CHD7 testing
  * An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.
    * For a voluntary issued ABN, append with GX modifier
    * To indicate a known 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
    * Item 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: Aspartoacyclase 2 Deficiency (ASPA) Testing

Asparoacyclase 2 Deficiency (ASPA) Testing, also known as Canavan Disease, is
an autosomal recessive degenerative disorder that causes progressive nerve
damage to nerve cells in the brain. Genetic testing identifies parents that
may be at risk for conceiving a child with the disease and offspring suspected
to have or diagnosed with the disease. Therefore, the MolDX Contractor has
determined that testing for the ASPA is not a Medicare benefit and is a
statutorily excluded test. MolDX will also deny panels that include ASPA
testing.  
  
To receive an ASPA service denial, please submit the following claim
information:

  * Select the appropriate CPT codes for the performed service 
    * 81200 - ASPA, common variant
    * 81412 - Ashkenazi Jewish associated disorders
    * 81443 - Genetic testing for severe inherited conditions
    * 81479 - Unlisted molecular pathology procedures
  * 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 the DEX Z-CodeTM identifier adjacent to each code in the stack 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 each code in the stack in the comment/narrative field for the following Part A claim field/types: 
    * Line SV202-7 for 837-I electronic claim
    * Block 80 for the UB04 claim form
Billing and Coding: MolDX: Aspartoacyclase 2 Deficiency (ASPA) Testing

Asparoacyclase 2 Deficiency (ASPA) Testing, also known as Canavan Disease, is
an autosomal recessive degenerative disorder that causes progressive nerve
damage to nerve cells in the brain. Genetic testing identifies parents that
may be at risk for conceiving a child with the disease and offspring suspected
to have or diagnosed with the disease. Therefore, the MolDX Contractor has
determined that testing for the ASPA is not a Medicare benefit and is a
statutorily excluded test. MolDX will also deny panels that include ASPA
testing.  
  
To receive an ASPA service denial, please submit the following claim
information:

  * Select the appropriate CPT codes for the performed service 
    * 81200 - ASPA, common variant
    * 81412 - Ashkenazi Jewish associated disorders
    * 81443 - Genetic testing for severe inherited conditions
    * 81479 - Unlisted molecular pathology procedures
  * 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 the DEX Z-CodeTM identifier adjacent to each code in the stack 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 each code in the stack in the comment/narrative field for the following Part A claim field/types: 
    * Line SV202-7 for 837-I electronic claim
    * Block 80 for the UB04 claim form
Billing and Coding: MolDX: 4q25-AF Risk Genotype

The 4q25-AF Risk Genotype Test was developed to help predict the risk of
atrial fibrillation and cardioembolic stroke. To date, there is insufficient
evidence to support the required clinical utility for the established Medicare
benefit category.

As reviewed, the developer described the indication to perform a 4q25-AF Risk
Genotype Test as a risk assessment for developing a disease or condition. Risk
assessment for developing a disease or condition in the absence of signs and
symptoms of an illness or injury is also not defined as a Medicare benefit.
Therefore, the 4q25-AF Risk Genotype Test would continue to be a statutory
excluded service.  
  
To receive a 4q25-AF Risk genotype 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 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
      * Item 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