Persius/hicric huggingface dataset:
Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS)

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L38223, Micro-Invasive Glaucoma Surgery (MIGS).
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.  
  
 **Utilization Parameters  
  
** Medicare may cover only **1 unit per eye, per date of service of CPT code
66989 or 66991** for insertion of glaucoma drainage device(s) into the
trabecular meshwork (e.g., iStent, or iStent _inject_ ), performed in
conjunction with cataract surgery and when the medically reasonable and
necessary criteria as stated in the LCD are met. Although more than one
drainage device into the trabecular meshwork of a single eye on a single day
of service, may be performed using an insertion tool loaded with more than one
device, (e.g., iStent _inject_ ), once the insertion tool is deployed within
the eye, the work and clinical skill required to place additional device(s) is
equivalent to placement of other U.S. Food and Drug Administration (FDA)
cleared devices described by the same codes. Therefore, only one unit of 66989
or 66991 per eye per day may be billed, regardless of the number of devices
inserted into a single eye on the same date of service.  
  
Medicare may cover only **1 unit per eye, per date of service of CPT code
0449T** for insertion of glaucoma drainage device(s) into the subconjunctival
space (e.g., XEN45), when the medically reasonable and necessary criteria as
stated in the LCD are met.  
  
 **Note** : CPT Code 0450T for additional device insertion is not covered.  
  
 **Note** : CPT code 0671T does not need to be reported with any of the
following codes: 66982, 66983, 66984, 66987, and 66988.  
  
 **Documentation Requirements**  

  1. All documentation must be maintained in the patient's medical record and must support the medical necessity of the services as directed in this article and be 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: MolDX: DecisionDX-Melanoma (L38018)

The comments in this document reflect all the comments sent to all the MACs in
the MolDx project for the Draft Local Determination (LCD): MolDX: DecisionDX-
Melanoma.

Thank you for the comments.
Billing and Coding: MolDX: Melanoma Risk Stratification Molecular Testing

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for MolDX: Melanoma
Risk Stratification Molecular Testing DL38018.

To report a molecular diagnostic service, please submit the following claim
information:

  * Select the appropriate CPT code
  * Enter 1 unit of service (UOS)
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types: 
    * Loop 2400 or SV101-7 for the 5010A1 837P
    * Box 19 for paper claim
  * Enter the appropriate DEX Z-CodeTM identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types: 
    * Line SV202-7 for 837I electronic claim
    * Block 80 for the UB04 claim form
  * Select the appropriate ICD-10-CM code
Billing and Coding: Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex
Nucleic Acid Amplification Techniques (NAATs)

  
This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L38227 Gastrointestinal Pathogen (GIP) Panels
Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs). 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.  
  
A GIP test panel is a single service with a single unit of service (UOS=1). A
GIP test **panel must not be unbundled and billed as individual components**
regardless of the fact that the GIP test panel reports multiple individual
pathogens and/or targets.  
  
 **Utilization Parameters**  
  
Medicare will allow reporting only one GIP multiplex panel (CPT codes 0369U,
87505, 87506, and 87507) summing the testing for all targets per day per
beneficiary by the same or different provider consistent with the related LCD.  
  
Consistent with the LCD, repeat NAAT testing within seven days during the same
episode of diarrhea will be denied (any combination of CPT codes 0369U, 87505,
87506, and 87507).  
  
 **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.
Billing and Coding: Hospice Alzheimer's Disease & Related Disorders

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Hospice Alzheimer's
Disease & Related Disorders L34567.
Billing and Coding: Debridement of Mycotic Nails

Refer to the Novitas Local Coverage Determination (LCD) L35013, Debridement of
Mycotic Nails, for reasonable and necessary requirements and frequency
limitations.  
  
The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding
System (HCPCS) code(s) may be subject to National Correct Coding Initiative
(NCCI) edits. This information does not take precedence over NCCI edits.
Please refer to NCCI for correct coding guidelines and specific applicable
code combinations prior to billing Medicare.  
  
CPT codes 11720 and 11721 will not be reimbursed more often than once every 60
days.  
  
CPT codes 11720 and 11721 may be limited to 6 sessions per beneficiary, per 12
months. Refer to the Utilization Guidelines in the related LCD for information
related to this limitation.
Billing and Coding: Home Health Skilled Nursing Care-Teaching and Training:
Alzheimer's Disease and Behavioral Disturbances

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Home Health Skilled
Nursing Care-Teaching and Training: Alzheimer's Disease and Behavioral
Disturbances L34562.
Billing and Coding: Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex
Nucleic Acid Amplification Techniques (NAATs)

  
This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L38229 Gastrointestinal Pathogen (GIP) Panels
Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs). 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.  
  
A GIP test panel is a single service with a single unit of service (UOS=1). A
GIP test **panel must not be unbundled and billed as individual components**
regardless of the fact that the GIP test panel reports multiple individual
pathogens and/or targets.  
  
 **Utilization Parameters  
  
** Medicare will allow reporting only one GIP multiplex panel (CPT codes
0369U, 87505, 87506, and 87507) summing the testing for all targets per day
per beneficiary by the same or different provider consistent with the related
LCD.  
  
Consistent with the LCD, repeat NAAT testing within seven days during the same
episode of diarrhea will be denied (any combination of CPT codes 0369U, 87505,
87506, and 87507).  
  
 **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.
Billing and Coding: C-Reactive Protein High Sensitivity Testing (hsCRP)

Refer to the Novitas Local Coverage Determination (LCD) L34856, C-Reactive
Protein High Sensitivity Testing (hsCRP), for reasonable and necessary
requirements and frequency limitations.  
  
The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding
System (HCPCS) code(s) may be subject to National Correct Coding Initiative
(NCCI) edits. This information does not take precedence over NCCI edits.
Please refer to NCCI for correct coding guidelines and specific applicable
code combinations prior to billing Medicare.  
  
**Coding Guidance**  
  
CPT code 86140 is not to be used in place of CPT code 86141, which represents
high sensitivity C-reactive protein (hsCRP) testing.  
  
**Frequency Limitations**  
  
Consistent with the related LCD, no more than 3 services of CPT code 86141 may
be reported per patients lifetime.
Billing and Coding: Endovenous Stenting

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L38231 Endovenous Stenting. Please refer to the
LCD for reasonable and necessary requirements.

Medicare reimbursement for endovenous stenting is limited to the treatment of
severely symptomatic venous obstructions as outlined in the related LCD.

**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.

Claims must be submitted with an ICD-10-CM code that represents the reason the
procedure was done. The ICD-10-CM code must be billed to the highest level of
specificity for that code set. The ICD-10-CM code must be linked to the
appropriate procedure code.

**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.
  4. Medical record documentation should list type and length of conservative treatment as applicable per the LCD.
  5. Pre- and post-deployment intervention images should be obtained and made available upon request. Intermediate stages pertinent to the endovascular procedure may also be documented with images. Details should include the position of the device, and when appropriate, the nature of the obstruction (if a determination can be made regarding the etiology), and effect of the device on target or nontarget vessels.
  6. Medical record documentation should list guide catheter used, as well as stent type, diameter and length.
Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L35006, Controlled Substance Monitoring and Drugs
of Abuse Testing. Please refer to the LCD for reasonable and necessary
requirements and limitations.  
  
 **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.  
  
 **Utilization Parameters  
  
** Consistent with the related LCD:

  1. It is not appropriate to report more than twelve (12) presumptive UDT testing (CPT code 80305, 80306, or 80307) testing services per calendar year.   

    * As stated in the related LCD, an exception will be made for patients with documented diagnoses consistent with a substance abuse disorder (SUD). It is not appropriate to report more than three (3) presumptive UDT tests (80305, 80306, or 80307) in seven (7) days when billed with any of the ICD-10 codes noted in ICD-10 Group 1 Paragraph.
  2. It is not appropriate to report more than twelve (12) definitive UDT testing services (CPT/HCPCS code G0480, G0481, G0482, G0483, or G0659) per calendar year for chronic opioid therapy (COT), as noted in ICD-10 Group 2 Paragraph. Refer to the related LCD for more information.
  3. It is not appropriate to report more than one (1) presumptive test result per patient per date of service regardless of the number of billing providers.

**Documentation Requirements  
  
Note**: Refer to the LCD for documentation requirements, in the patient's
medical record, of medical necessity for testing ordered on an individual
patient basis by the clinician.

  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.
Billing and Coding: Chemodenervation

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Chemodenervation
L33458.
Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS)

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L38233, Micro-Invasive Glaucoma Surgery (MIGS).
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.  
  
 **Utilization Parameters  
  
** Medicare may cover only **1 unit per eye, per date of service of CPT code
66989 or 66991** for insertion of glaucoma drainage device(s) into the
trabecular meshwork (e.g., iStent, or iStent _inject_ ), performed in
conjunction with cataract surgery and when the medically reasonable and
necessary criteria as stated in the LCD are met. Although more than one
drainage device into the trabecular meshwork of a single eye on a single day
of service, may be performed using an insertion tool loaded with more than one
device, (e.g., iStent _inject_ ) once the insertion tool is deployed within
the eye, the work and clinical skill required to place additional device(s) is
equivalent to placement of other U.S. Food and Drug Administration (FDA)
cleared devices, described by the same codes. Therefore, only one unit of
66989 or 66991 per eye per day may be billed, regardless of the number of
devices inserted into a single eye on the same date of service.  
  
Medicare may cover only **1 unit per eye, per date of service of CPT code
0449T** for insertion of glaucoma drainage device(s) into the subconjunctival
space (e.g., XEN45), when the medically reasonable and necessary criteria as
stated in the LCD are met.  
  
 **Note:** CPT Code 0450T for additional device insertion is not covered.  
  
 **Note** : CPT code 0671T does not need to be reported with any of the
following codes: 66982, 66983, 66984, 66987, and 66988.  
  
 **Documentation Requirements**

  1. All documentation must be maintained in the patient's medical record and must support the medical necessity of the services as directed in this article and be 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.
Billing and Coding: Home Health-Surface Electrical Stimulation in the
Treatment of Dysphagia

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Home Health-Surface
Electrical Stimulation in the Treatment of Dysphagia L34565.
Billing and Coding: 4Kscore Test Algorithm

This article provides coding guidance for the Local Coverage Determination
(LCD) L37792 4Kscore Test Algorithm which will become effective on December
30, 2019. Refer to L37792 for reasonable and necessary guidelines.

The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding
System (HCPCS) code(s) may be subject to National Correct Coding Initiative
(NCCI) edits. This information does not take precedence over NCCI edits.
Please refer to NCCI for correct coding guidelines and specific applicable
code combinations prior to billing Medicare.

**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 should support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
  4. Documentation of shared decision making (SDM) concerning the 4Kscore testing, between the ordering provider and patient, must be present in the medical record and a copy of same shall be provided to the performing laboratory **prior** to the test being performed.
    * A simple notation that SDM occurred is insufficient for documentation. The actual process must be documented in the patient's record.
    * The document(s) shall be dated and include the ordering provider and patient's names and signatures legibly noted to attest that the SDM occurred.
Response to Comments: DL37943 Anorectal Manometry and Electromyography (EMG)
of the Urinary and Anal Sphincters

First Coast Service Options, Inc. (First Coast) received comments from
interested parties of the Medicare Administrative Contractor (MAC)
Jurisdiction N (JN) for Florida, Puerto Rico and the United States Virgin
Islands, representatives of the Florida Urological Society and the Florida
OB/GYN Society for the Draft Local Coverage Determination (LCD) DL37943,
Anorectal Manometry and Electromyography (EMG) of the Urinary and Anal
Sphincters. All comments were reviewed and incorporated into the final LCD
where applicable.
Billing and Coding: Cosmetic and Reconstructive Surgery

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) Cosmetic and
Reconstructive Surgery L33428.
Billing and Coding: Trastuzumab  Trastuzumab Biologics

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L34026 (Trastuzumab - Trastuzumab Biologics).
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.

**Utilization Guidelines**

In accordance with CMS Ruling 95-1 (V), utilization of these services should
be consistent with locally acceptable standards of practice.

Compliance with the provisions in LCD L34026 Trastuzumab - Trastuzumab
Biologics may be monitored and addressed through post payment data analysis
and subsequent medical review audits.

**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.

Medical record documentation maintained by the ordering/referring physician
must substantiate the medical need for the use of these chemotherapy drugs by
clearly indicating the condition for which these drugs are being used. This
might include the type of cancer, staging, if applicable, prior therapy and
the patient's response to that therapy. This documentation is usually found in
the history and physical or in the office/progress notes.

If the provider of the service is other than the ordering/referring physician,
that provider must maintain copies of the ordering/referring physician's order
for the chemotherapy drug. The physician must state the clinical
indication/medical need for using the chemotherapy drug in the order.

**Dosage and Administration**

For specific dosage and administration, please refer to the FDA approved drug
label for recommended dosages for specific FDA indications. This can be
accessed at <https://labels.fda.gov/>.
Billing and Coding: Hospice - Liver Disease

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Hospice - Liver
Disease L34544.
Billing and Coding: Nonobstetric Pelvic Ultrasound

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Nonobstetric Pelvic
Ultrasound L37636.

**Indications**

**76856** is a complete evaluation and must minimally include:

  1. Female: description and measurements of the uterus and adnexal structures, measurement of the endometrium and bladder, and a description of any pelvic pathology.
  2. Male: evaluation and measurement of the bladder, evaluation of the prostate and seminal vesicles and any pelvic pathology.

**76857** is a limited study and typically focuses on one or more elements
listed under 76856 and/or the reevaluation of one or more pelvic
abnormalities.

**Limitations**

  1. Post voiding residual bladder volume is not reimbursable by CPT codes 76856 and 76857. Measurement of post voiding residual should be billed using CPT code 51798.