evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease (A58814)

CMS National Coverage PolicyN/AArticle TextThe information in this Article contains billing, coding, or other guidelines that complement the NGS LCD for Non-Invasive Fractional Flow Reserve for Ischemic Heart Disease.Procedure codes may be subject to National Correct Coding Initiative edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.As this service constitutes post-procedure analysis of a previously performed study (CCTA), the name and NPI of the referring/ordering physician that submitted imaging data for FFRct review must be reported on the claim.An Advance Beneficiary Notice of Non-coverage may be used for services that are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 30for complete instructions.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.The patients medical record must document all of the following:The clinical findings that led to the initial performance of the CCTA, and the CCTA must be fully reviewed before the performance of FFRct. (as evidenced by the submission of the Coronary Computed Tomographic Angiography Report)Description of symptoms consistent with stable ischemic heart disease.Body mass indexFractional Flow Reserve analysis report&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;panel&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;panel&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;Coding Information
Draft Article - Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound (DA58865)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) DL39116 Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound.
Article - Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound (A58865)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39116 Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound.
Draft Article - Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound (DA58867)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) DL39118 Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound.
Article - Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound (A58867)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39118 Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound.
Article - Billing and Coding: Tetanus Immunization (A58872)

CMS National Coverage PolicyInternet Only Manuals (IOMs)CMS IOM Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 50.4.4.2 ImmunizationsSocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextTetanus is a neurologic syndrome caused by a neurotoxin elaborated at the site of injury by Clostridium tetani. Nearly all cases of tetanus occur in nonimmunized or inadequately immunized individuals. In the absence of an injury or direct exposure to tetanus, preventative immunization is not covered.Coding GuidanceIf the provider knows the service is non-covered or is not a Medicare benefit, the GY modifier must be appended to the CPT/HCPCS code indicating the item or service is statutorily non-covered or does not meet the definition of any Medicare benefit.Documentation RequirementsAll documentation must be maintained in the patients medical record and made available to the contractor upon request.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.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.
Article - Billing and Coding: Tetanus Immunization (A58873)

CMS National Coverage PolicyInternet Only Manuals (IOMs)CMS IOM Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 50.4.4.2 ImmunizationsSocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextTetanus is a neurologic syndrome caused by a neurotoxin elaborated at the site of injury by Clostridium tetani. Nearly all cases of tetanus occur in nonimmunized or inadequately immunized individuals. In the absence of an injury or direct exposure to tetanus, preventative immunization is not covered.Coding GuidanceIf the provider knows the service is non-covered or is not a Medicare benefit, the GY modifier must be appended to the CPT/HCPCS code indicating the item or service is statutorily non-covered or does not meet the definition of any Medicare benefit.Documentation RequirementsAll documentation must be maintained in the patients medical record and made available to the contractor upon request.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.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.
Article - Billing and Coding: Treatment of Varicose Veins of the Lower Extremities (A58876)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet Only-Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 20.9 National Correct Coding Initiative (NCCI)CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code RequirementsArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) forTreatment of Varicose Veins of the Lower Extremities L39121.When billing for non-covered services, use the appropriate modifier.The sclerosant used in sclerotherapy procedures is included in the procedure code and is not separately reported.
Article - Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound (A58883)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior periodCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 30A Services Paid Under the Medicare Physicians Fee Schedule - Physicians ServicesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forAmniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-WoundL39128.
Draft Article - Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound (DA58893)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) DL39139 Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound.
Article - Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound (A58893)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39139 Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound.
Article - Billing and Coding: Mass Spectrometry (MS) Testing in Monoclonal Gammopathy (MG) (A58921)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) forMass Spectrometry (MS) Testing in Monoclonal Gammopathy (MG)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.Documentation Requirements:Documentation must be adequate to verify that coverage guidelines listed in the Local Coverage Determination (LCD) have been met. Thus, the medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed. The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition (ICD-10-CM code) that warrants the test(s).Examples of documentation requirements of the ordering physician/non-physician practitioner (NPP) include, but are not limited to, history and physical or exam findings that support the decision making, problems/diagnoses, relevant data (e.g., lab testing, imaging results).Documentation requirements of the performing laboratory (when requested) include, but are not limited to, lab accreditation, test requisition, test record/procedures, reports (preliminary and final), and quality control record.Documentation requirements for LDT(s)/protocols (when requested) include diagnostic test/assay, lab/manufacturer, names of comparable assays/services (if relevant), description of assay, analytical validity evidence, clinical validity evidence, and clinical utility.Specific Documentation RequirementsNote: Please specify in the comment/narrative field of the Part B claim whether serum OR urine testing was performed.The following are the appropriate field/types for Part B claims:Loop 2400 or SV101-7 for the 5010A1 837PBOX 19 for paper claimThe following are the appropriate field/types for Part A claims:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formUtilization Guidelines:Screening services such as pre-symptomatic tests and services used to detect an undiagnosed disease or disease predisposition are not a Medicare benefit and are not covered. Similarly, Medicare may not reimburse the costs of tests/examinations that assess the risk of a condition unless the risk assessment clearly and directly affects the management of the patient.Serum immunofixation electrophoresis (CPT code 86334) will be denied when submitted with PLA code 0077U.PLA code 0077U shall only be billed once per date of service.
Article - Billing and Coding: Multiplex Gastrointestinal Pathogen Panel (GPP) Tests for Acute Gastroenteritis (AGE) (A58963)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) forMultiplex Gastrointestinal Pathogen Panel (GPP) Tests for Acute Gastroenteritis (AGE).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.Specific Coding Information(Highly Multiplexed GPPs- Group 2 CPT Codes)Must be billed in POS 20, 21, 22, 23, or 81 (Urgent Care, Inpatient Hospital, Outpatient Hospital (observation), or Emergency Room), or in POS 81 (Independent Laboratory) in the case of a pre-transplant evaluation for an immune-compromised beneficiary.Outside of one of these POS, the test must be ordered by a clinician specialist in one of the following: Infectious Diseases (44), Gastroenterology (10), Oncology (83,90,91), or Transplant who is diagnosing and treating the beneficiary.*The specialist communication must be documented in the medical record.*An exception may be made in geographic locations where neither specialist can be reasonably reached by the beneficiary and the ordering provider is located closer to the beneficiarys place of residence than the nearest infectious disease specialist. We would generally expect that beneficiaries for whom the test is ordered under this exception to be living in rural locations, islands, or some other location where access to care is limited.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.
Article - Billing and Coding: MolDX: Plasma-Based Genomic Profiling in Solid Tumors (A58973)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claimCMS Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15,  80.1.2 A/B MAC (B) Contracts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Plasma-Based Genomic Profiling in Solid Tumors L39230.To report a Plasma-Based Genomic Profiling in Solid Tumors service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM codeNOTE:When entering the DEX Z- Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: MolDX: Plasma-Based Genomic Profiling in Solid Tumors (A58975)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claimCMS Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15,  80.1.2 A/B MAC (B) Contracts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Plasma-Based Genomic Profiling in Solid Tumors L39232.To report a Plasma-Based Genomic Profiling in Solid Tumors service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM codeNOTE:When entering the DEX Z- Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: Erythropoiesis Stimulating Agents (A58982)

Prophylactic Allogeneic Transfusion Reduction Intent in Presurgical AnemiaDarbepoetin alfa and epoetin beta are NOT indicated for this condition.Forepoetin alfa/epoetin alfa-epbx biosimilar in anemia ina presurgical setting:For HCPCS codes J0885 or Q5106: ICD-10-CM codes D63.8 and Z01.818 MUST be billed along with 1 of the osteoarthritis codes listed in ICD-10 Group 6. The EC modifier is also required.A JA or JB modifier is required; a JB modifier would be consistent with the FDA label indication.Inclusion of any other ICD-10 diagnoses on the claim which are non-covered with an EC modifier per NCD 110.21, will preclude payment for the ESA.Required Documentation Elements:A presurgical Hbgreater than 10 but less than 13 g/dL.A high risk for perioperative blood loss related to planned elective orthopedic hip or knee surgery with an expectation for more than 2 units of blood lossInability or unwillingness by the patient to donate autologous bloodA workup for anemia that suggests anemia of chronic diseaseIron supplementation ongoing during the entire course of the ESADeep vein thrombosis (DVT) prophylaxis ongoing during the entire course of the ESADosing: 300 u/kg/day SQ daily for 10 days prior to surgery, on the day of surgery and daily for 4 days following surgery. The other dosing option would be 600 units/kg SQ once weekly for 3 weeks prior to the surgery (21, 14 and 7 days before surgery) plus a 4thdose on the day of surgery.
Article - Billing and Coding: MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia (A59015)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia.To receive a denial, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code