Persius/hicric huggingface dataset:
Billing and Coding: Electroretinography (ERG)

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L37371, Electroretinography (ERG). Please refer
to the LCD for reasonable and necessary requirements.

**Coding Guidance**

**Notice:** It is not appropriate to bill Medicare for services that are not
covered (as described by the entire LCD) as if they are covered. When billing
for non-covered services, use the appropriate modifier.

When reporting ICD-10 code Z79.899, the medical record must reflect the
medication administered as well as the underlying condition for which it was
given.

**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: Outpatient Observation Bed/Room Services

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Outpatient
Observation Bed/Room Services L34552.
Billing and Coding: Home Health Plans of Care: Monitoring Glucose Control in
the Medicare Home Health Population with Type II Diabetes Mellitus

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Home Health Plans
of Care: Monitoring Glucose Control in the Medicare Home Health Population
with Type II Diabetes Mellitus L35132.
Billing and Coding: Homocysteine Level, Serum

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Homocysteine Level,
Serum L34419.

**Limitations:**

Serum homocysteine levels will not be covered other than for suspected
B12/folate deficiency, or for risk stratification for the conditions noted in
the  _ **ICD-10-CM Codes that Support Medical Necessity**_ section of this
article. It is covered only once in a lifetime for the initial determination
for risk stratification. Subsequent determinations will be covered only if
appropriate treatment does not correct the anemia or symptoms.
Billing and Coding: Hospice  HIV Disease

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Hospice - HIV
Disease L34566.
Billing and Coding: Hospice The Adult Failure To Thrive Syndrome

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Hospice The Adult
Failure To Thrive Syndrome L34558.

Hospices may not report diagnosis codes that cannot be used as the principal
diagnosis according to ICD-10-CM Coding Guidelines or require further
compliance with various ICD-10-CM coding conventions, such as those that have
principal diagnosis code sequencing guidelines. Hospices may not report
debility, failure to thrive, or dementia codes classified as unspecified as
principal hospice diagnoses on the hospice claim.
Billing and Coding: Diagnostic Abdominal Aortography and Renal Angiography

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L35092, Diagnostic Abdominal Aortography and
Renal Angiography. 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.

CMS issued HCPCS code G0278 for femoral or iliac angiography when done at the
time of coronary angiography.

**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: Intraoperative Radiation Therapy

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Intraoperative
Radiation Therapy L37779.

ICD-10-CM diagnosis codes supporting medical necessity must be submitted with
each claim. Claims submitted without such evidence will be denied as not
medically necessary.
Billing and Coding: Partial Hospitalization Programs

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Partial
Hospitalization Programs L37633.

**_Limitations_**

**Noncovered-Reasonable and Necessary Denials**

  1. CPT codes 90875 and 90876
Billing and Coding: HbA1c

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for HbA1c L33431.
Response to Comments: Tumor Treatment Field Therapy (TTFT) - DL34823

During the 45-day comment period the DME MACs received a total of 301
comments. Two hundred and nine (209) from Optune users and/or caregivers, 80
from treating practitioners/researchers, 9 comments from 5 advocacy groups, 1
from a clinical society, 1 from the manufacturer and 1 from a consultant.

Introduction to Responses

The DME MACs appreciate the comments received from stakeholders during the
open comment period on the proposed Tumor Treatment Field Therapy (TTFT) Local
Coverage Determination (LCD).

Pursuant to the CMS Program Integrity Manual (CMS Pub. 100-08) Chapter 13:

_In conducting a review, MACs shall use the available evidence of general
acceptance by the medical community, such as published original research in
peer-reviewed medical journals, systematic reviews and meta-analyses,
evidence-based consensus statements and clinical guidelines._

Accordingly, the final policy and our response to comments are based on the
best currently available published clinical evidence, in order to afford the
most optimal opportunity for success in Medicare-eligible beneficiaries with
newly diagnosed Glioblastoma Multiforme (GBM).
Billing and Coding: Magnetic Resonance Image Guided High Intensity Focused
Ultrasound (MRgFUS) for Essential Tremor

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Magnetic Resonance
Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor
L37761.
Billing and Coding: Cardiac Computed Tomography & Angiography (CCTA)

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Cardiac Computed
Tomography & Angiography (CCTA) L33423.

Refer to the Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic
Heart Disease L38278 LCD and related billing and coding article A58406 for
more information regarding the use of add-on analysis of CCTA.
Billing and Coding: Stretta Procedure

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Stretta Procedure
L34553.
Billing and Coding: Respiratory Therapy (Respiratory Care)

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Respiratory Therapy
(Respiratory Care) L34430.

Therapeutic procedures whose principle aim is to treat a respiratory
impairment should be identified using the G0237-G0239 series of HCPCS codes.
CPT codes 97000 to 97799 are not to be billed by professionals involved in
treating respiratory conditions, unless these services are delivered by
physical or occupational therapists and meet the other requirements for
physical and occupational therapy services.
Billing and Coding: Intravenous Immunoglobulin (IVIG)

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Intravenous
Immunoglobulin (IVIG) L34580.

**Note:** With respect to HCPCS codes J2792 Injection, Rho D immune globulin
(human), solvent detergent (WINRho) and J2791 Injection immune globulin
(human), (Rhophylac), this article only addresses their use intravenously.
Billing and Coding: Intraoperative Neurophysiological Testing

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L35003, Intraoperative Neurophysiological
Testing. 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.

CPT Code 95940 is reported per 15 minutes of service. CPT Code 95940 requires
reporting only the portion of time the monitoring professional was physically
present in the operating room providing one-on-one patient monitoring, and no
other cases may be monitored at the same time. Time spent in the operating
room is cumulative. To determine units of service of 95940, use the total
minutes monitoring in the operating room one-on-one. Monitoring may begin
prior to incision (e.g., when positioning on the table is a time of risk).
Report continuous intraoperative neurophysiologic monitoring in the operating
room (95940) in addition to the services related to monitoring from outside
the operating room (G0453), and interpret the baseline studies, and to remove
electrodes at the end of the procedure.

When services support the covered indications in the related LCD,
reimbursement may be made for the following places of service (POS):

  * Off Campus-Outpatient Hospital (POS 19)
  * Inpatient Hospital (POS 21)
  * On Campus-Outpatient Hospital (POS 22)
  * Ambulatory Surgical Center (POS 24)
Billing and Coding: Wireless Gastrointestinal Motility Monitoring Systems

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Wireless
Gastrointestinal Motility Monitoring Systems L33455.
Billing and Coding: Intensity Modulated Radiation Therapy (IMRT)

This Billing and Coding Article provides billing and coding guidance for Local
Coverage Determination (LCD) L36711, Intensity Modulated Radiation Therapy
(IMRT). 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.
Billing and Coding: Wireless Capsule Endoscopy

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Wireless Capsule
Endoscopy L36427.
Billing and Coding: Magnetic Resonance Imaging of the Orbit, Face, and/or Neck

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Magnetic Resonance
Imaging of the Orbit, Face, and/or Neck L34425.
Billing and Coding: Respiratory Therapy and Oximetry Services

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Respiratory Therapy
and Oximetry Services L33446.

CPT code 31720 is payable only if it is personally performed by the physician
(or qualified Non-Physician Practitioner (NPP)).

**Note:**

CPT codes 94760, 94761 and 94762 are bundled by the Correct Coding Initiative
(CCI) with critical care services. Therefore, CPT codes 94760, 94761 and
94762 cannot be paid separately when billed with critical care CPT codes
(99291 and 99292).

CPT code **94762** is considered medically necessary when performed for any
of the following reasons:

  * The patient has a condition for which intermittent arterial blood gas sampling is likely to miss important variations.
  * The patient has a condition resulting in hypoxemia and there is a need to assess supplemental oxygen requirements and/or a therapeutic regimen.

Payment can be allowed for CPT code 31720 only if supporting documentation
demonstrates the service was personally performed by the physician or NPP when
this service falls within his scope of practice.

Payment for CPT code 31720 may be allowed, on an individual consideration
basis, for respiratory treatments for 3 consecutive days or 3 identical
services within a 30-day time frame. Additional payment may be allowed for
respiratory therapy treatments exceeding these parameters only if medical
necessity can be established by medical documentation. In the case of
consecutive days of care, the medical record should indicate why the patient
was not transferred to a higher level of care.
Billing and Coding: Nerve Blocks and Electrostimulation for Peripheral
Neuropathy

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Nerve Blocks and
Electrostimulation for Peripheral Neuropathy L37642.

Use of Physical Medicine and Rehabilitation CPT/HCPCS Codes (97032, 97139,
G0282, G0283) for these treatments is inappropriate.
Billing and Coding: Mohs Micrographic Surgery (MMS)

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Mohs Micrographic
Surgery (MMS) L33436.

To allow separate payment for a biopsy and pathology on the same day as MMS,
the 59 modifier is appropriate. Modifier 59 is also appropriate when a
separate skin lesion, other than the lesion for which Mohs surgery is
performed, is biopsied on the same day that the Mohs surgery is performed.

If the 59 modifier is used with a skin biopsy/pathology code on the same day
the MMS was performed, physician documentation should clearly indicate:

  * That the biopsy was performed on a lesion other than the lesion on which the MMS was performed;
  * That if the biopsy is of the same lesion on which the MMS was performed, a biopsy of that lesion had not been done within the previous 60 days; or
  * If a recent (within 60 days) biopsy of the same lesion that MMS was performed or had been done, the results of that biopsy were unobtainable by the Mohs surgeon using reasonable effort.

At this time, all laboratory tests covered under CLIA are edited at the CLIA
certificate level. The previously mentioned Mohs micrographic surgery HCPCS
codes would require either a CLIA certificate of registration (certificate
type code 9), a CLIA certificate of compliance (certificate type code 1), or a
CLIA certificate of accreditation (certificate type code 3). A facility
without a valid current CLIA certificate, with a current CLIA certificate of
waiver (certificate type code 2), or with a current CLIA certificate for
provider-performed microscopy procedures (certificate type code 4) must not be
permitted to bill for these tests.
Response to Comments: Water Vapor Thermal Therapy for LUTS/BPH

As an important part of Medicare Local Coverage Determination (LCD)
development, National Government Services solicits comments from the provider
community and from members of the public who may be affected by or interested
in our LCDs. The purpose of the advice and comment process is to gain the
expertise and experience of those commenting.

We would like to thank those who suggested changes to the LCD for Water Vapor
Thermal Therapy for LUTS/BPH. The official notice period for the final LCD
begins on October 10, 2019 and the final determination will become effective
for services rendered on or after December 1, 2019.
Billing and Coding: Cardiac Computed Tomography (CCT) and Coronary Computed
Tomography Angiography (CCTA)

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Cardiac Computed Tomography (CCT) and
Coronary Computed Tomography Angiography (CCTA).

**Coding Information:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the
referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to
the provider as an incomplete claim under Section 1833(e) of the Social
Security Act.

The diagnosis code(s) must best describe the patient's condition for which the
service was performed. For diagnostic tests, report the result of the test if
known; otherwise the symptoms prompting the performance of the test should be
reported.  
  

**Documentation Requirements:**

The patient's medical record must contain documentation that fully supports
the medical necessity for services included within the attached LCD. (See
"Indications and Limitations of Coverage.") This documentation includes, but
is not limited to, relevant medical history, physical examination, and results
of pertinent diagnostic tests or procedures.

Each claim must be submitted with ICD-10-CM codes that reflect the condition
of the patient, and indicate the reason(s) for which the service was
performed.

The documentation of the study requires a formal written report, with clear
identifying demographics, the name of the interpreting provider, the reason
for the tests, an interpretive report and copies of images. The computerized
image reconstruction data should also be maintained.

Documentation must be available to Medicare upon request.
Response to Comments: Biomarker Testing (Prior to Initial Biopsy) for Prostate
Cancer Diagnosis

As an important part of Medicare Local Coverage Determination (LCD)
development, National Government Services solicits comments from the provider
community and from members of the public who may be affected by or interested
in our LCDs. The purpose of the advice and comment process is to gain the
expertise and experience of those commenting.

We would like to thank those who suggested changes to the Biomarker Testing
(Prior to Initial Biopsy) for Prostate Cancer Diagnosis LCD. The official
notice period for the final LCD begins on October 10, 2019, and the final
determination will become effective on December 1, 2019.
Billing and Coding: Cardiovascular Nuclear Medicine

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Cardiovascular Nuclear Medicine.

**Coding Information:**

Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the
referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to
the provider as an incomplete claim under Section 1833(e) of the Social
Security Act.

The diagnosis code(s) must best describe the patient's condition for which the
service was performed. For diagnostic tests, report the result of the test if
known; otherwise the symptoms prompting the performance of the test should be
reported.

**Documentation Requirements:**

The patient's medical record must contain documentation that fully supports
the medical necessity for services included within this LCD. (See "Indications
and Limitations of Coverage.") This documentation includes, but is not limited
to, relevant medical history, physical examination, and results of pertinent
diagnostic tests or procedures.

Medical records must substantiate the medical necessity of the services,
including a clinical diagnosis and the specific reason for the study.

All segments of the service must have a formal interpretation and report.

The referral order must include the medical indication for the study, and be
kept on file in the patient's medical record.

When CPT code 78472 and add-on code 78496 are submitted with perfusion codes
78451-78454, the formal reports must document that simultaneous cardiac
function studies using the first pass technique were performed and that the
laboratories are equipped to perform such studies.

When a blood pool scan is performed to assess ejection fraction prior to
implantation of defibrillator or biventricular pacemaker, the record must
document the intended plan for insertion and the result of the test.

When billing for the purchase of radiopharmaceutical(s), a copy of the bill
indicating the dosage administered, unit price per dose, name and total charge
of the radiopharmaceutical must be on file in the patient's medical record and
available on request.

**Utilization Guidelines:**

Risk assessment or re-evaluation of disease in patients who are asymptomatic
or have stable symptoms, with known atherosclerotic heart disease on
catheterization or SPECT perfusion imaging, who have not had a
revascularization procedure within the past two years would be reimbursable;
otherwise tests repeated in the absence of changes in cardiac signs or
symptoms will be considered not medically necessary.
Billing and Coding: Trigger Point Injections

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for Trigger Point
Injections L37635.

More than four (4) trigger point injections in a year's time will not be
covered.

If a patient requires more than four (4) procedures of either CPT codes 20552
or 20553 during one year, a report stating the unusual circumstances and
medical necessity for giving the additional injections must be documented in
the patient's medical record and made available to the A/B MAC upon request.
Billing and Coding: White Cell Colony Stimulating Factors

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for White Cell Colony
Stimulating Factors L37176.
Billing and Coding: Intravesical Instillation of Bacillus Calmette-Guerin
(BCG)

Due to the current shortage of Bacillus Calmette-Guerin (BCG) for intravesical
instillation it may be necessary to maintain ongoing treatment for bladder
cancer with this product at less than the Food and Drug Administration (FDA)
label dose of 81 mg (1 vial) per instillation. In response to this situation,
Centers for Medicare and Medicaid Services (CMS) has created a new HCPCS code
by which to report BCG which will allow for reporting of doses less than 1
vial per instillation. HCPCS code J9030 _BCG live intravesical instillation, 1
mg_ becomes effective 7/1/2019 and replaces HCPCS code J9031 _BCG intravesical
per instillation_. HCPCS code J9031 _BCG intravesical per instillation_ will
no longer be payable by Medicare as of 7/1/2019. HCPCS code J9030 should be
reported with the number of units corresponding to the units being equal to
the number of milligrams actually instilled per treatment, as the unit equals
1 mg for the new code.

For updates on the current shortage of BCG live intravesical:

<https://www.ashp.org/Drug-Shortages/Current-Shortages>