evekhm/cms_iom_3000 huggingface dataset:
(Medicare Claims Processing Manual)

140.5-- Payment for Anesthesia Services Furnished by a Teaching CRNA  150 -  Clinical Social Worker (CSW) Services  160 -  Independent Psychologist Services  160.1 -  Payment  170 -  Clinical Psychologist Services  170.1 -  Payment  180 -  Care Plan Oversight Services  180.1 -  Care Plan Oversight Billing Requirements  190 -  Medicare Payment for Telehealth Services  190.1 -  Background  190.2 -  Eligibility Criteria  190.3 -  List of Medicare Telehealth Services  190.3.1 -  Telehealth Consultation Services, Emergency Department  or Initial Inpatient versus Inpatient Evaluation and Management (E/M) Visits  190.3.2 -  Telehealth Consultation Services, Emergency Department  or Initial Inpatient Defined  190.3.3 -  Follow -Up Inpatient Telehealth Consultations Defined  190.3.4  Payment for ESRD -Related Services as a Telehealth Service  190.3.5  Payment for Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services  190.3.6  Payment for Diabetes Self -Management Training (DSMT) as a Telehealth Service    190.3.7  Payment for Telehealth for Individuals with Acute Stroke  190.4 -  Conditions of Payment  190.5 -  Originating Site Facility Fee Payment Methodology  190.6 -  Payment Methodology for Physician/Practitioner at the Distant Site  190.6.1 -  Submission of Telehealth Claims for Distant Site Practitioners  190.6.2 -  Exception for Store and Forward (Non -Interactive) Telehealth  190.7 -  A/B MAC (B)  Editing of Telehealth Claims  200 -  Allergy Testing and Immunotherapy  210 -  Outpatient Mental Health Treatment Limitation  210.1 -  Application of the Limitation  220 Chiropractic Services  230 -  Primary Care Incentive Payment Program (PCIP)  230.1 -  Definition of Primary Care Practitioners and Primary Care Services  230.2 -  Coordination with Other Payments  230.3 -  Claims Processing and Payment  240 -  Marriage and Family Therapist (MFT) Services   250 -  Mental Health Counselor (MHC) Services                          10 - General  (Rev. 1, 10-01-03) B3-2020 This chapter provides claims processing instructions for physician and nonphysician practitioner services.  Most physician services are paid according to the Medicare Physician Fee Schedule.  Section 20
(Medicare Claims Processing Manual)

Revision to the Health Professional Shortage Area (HPSA) and Physician Scarcity Area (PSA) Payment Rules  10/03/2005  3822 R547CP  04/29/2005  Revision to the Health Professional Shortage Area (HPSA) and Physician Scarcity Area (PSA) Payment Rules  10/03/2005  3822 R524CP  04/15/2005  Clarification to the Health Professional Shortage Area Language in the Medicare Claims Processing Manual  05/16/2005  3736 R517CP  04/01/2005  List of Medicare Telehealth Services  05/02/2005  3747 R504CP  03/11/2005  Update to Pub 100-04, Chapter 12, Section 200 of the Internet Only Manual N/A 3732 R417CP  12/22/2004  Initial Preventive Physical Examination  01/03/2005  3638 R382CP  11/26/2004  Independent Laboratory Billing for the Technical Component (TC) of Physician Pathology Services to Hospital Patients 01/03/2005  3467 R302CP  09/24/2004  Nursing Facility Visits (Codes 99301 -99313)  10/25/2004  3096 R280CP  08/13/2004  Billing and Payment in a Health Professional Shortage Area 10/04/2004  3401 R277CP  08/13/2004  Instructions to Establish Carrier Web Pages for Health Professional Shortage Area and for Provider Education for the HPSA and Physician Scarcity Area Bonus Payment  09/13/2004  3388 Rev #  Issue Date  Subject  Impl Date  CR#  R218CP  06/25/2004  Implementation of the Analysis and Design Phases of The Revisions to the Health Professional Shortage Area Bonus Payment  10/04/2004  3317 R217CP  06/25/2004  Implementation of the Analysis and Design Phases of the Physician Scarcity Bonus 10/04/2004  3318 R203CP  06/10/2004  Billing Payment in a Health Professional Shortage Area 07/06/2004  3336 R178CP  05/14/2004  Evaluation and Management Service Codes N/A 2321 R168CP  05/07/2004  Chapter 12, Physician/Practitioner Billing0  N/A 1756 R157CP  04/30/2004  Implementation of the Analysis and Design Phase of the Physician Scarcity Bonus 10/04/2004  3223 R155CP  04/30/2004  Implementation of the Analysis and Design Phases of the Revision to the Health Professional Shortage Area Bonus Payment  10/04/2004  3215 R147CP  04/23/2004  Payment for Chemotherapy Administration Services, Nonchemotherapy Drug Infusion Services, and Drug Injection Services 05/24/2004  3192 R137CP  04/09/2004  Manualization of Section 4118 of the Medicare Carriers Manual, Part 3  N/A 3234 R078CP  02/06/2004  Medicare Incentive Payments for Physician Care  07/06/2004  3108 R001CP  10/01/2003  Initial Publication of Manual NA NA Back to top of Chapter
Article - Billing and Coding: Thermal Capsulorrhaphy (A53435)

CMS National Coverage PolicyN/AArticle TextThermal capsulorrhaphy, also known as thermal coagulation of joints, radiofrequency thermal shrinkage, electrothermal assisted capsulorrhaphy (ETAC) and laser-assisted capsular shrinkage (LACS) is proposed as a minimally invasive arthroscopic procedure to tighten the capsule and ligaments of joints.Due to the lack of clinical evidence to demonstrate improved health outcomes, Palmetto GBA has determined that this service as a treatment of joint instability, for the shoulder, knee, elbow, etc. is considered not medically necessary. Therefore, claims submitted for this service will be denied.To report this non-covered service, submit CPT code 29999 (unlisted procedure, arthroscopy).
Article - Billing and Coding: Amniotic Membrane Billing Guidelines for HCPCS Code V2790 (A53441)

CMS National Coverage PolicyN/AArticle TextHCPCS code V2790 (amniotic membrane for surgical reconstruction, per procedure) is included in the allowance for CPT Codes 65778 and 65779. In an inpatient facility reimbursement for HCPCS code V2790 is included in the Outpatient Prospective Payment System (OPPS) allowance. In an Ambulatory Surgical Center (ASC) reimbursement for V2790 is included in the facility allowance.HCPCS code V2790 (amniotic membrane for surgical reconstruction, per procedure) should not be billed to Part B separately except as noted below:HCPCS code V2790 can be reimbursed separately in an office setting when billed with CPT Code 65780. A copy of the invoice must be submitted when billing for V2790 and 65780 on the same claim.HCPCS code V2790 should not be billed with CPT Code 65775. However, if amniotic membrane application is required in the course of that procedure, then either CPT Codes 65778 or 65779, depending on the method of application of the membrane must be billed with 65775 when a membrane is applied. As indicated above, CPT Codes 65778 and 65779 both include payment for the membrane itself (V2790) and therefore V2790 should not be billed separately when those codes are billed.Documentation That Must Be Submitted with ClaimFor electronic claims, submit an invoice via fax.For paper claims, please submit the actual invoice with the claim.This instruction is effective for dates of service on or after September 4, 2012.
Article - Billing and Coding: Periodic Adjustment of Gastric Restrictive Device after the Global Period (A53444)

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. 100-03, Medicare National Coverage Determinations Manuel, Chapter 1, Part 2, 100.1 Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid ObesityArticle Text**Only payable in an office setting **The laparoscopic gastric band is an adjustable and reversible bariatric surgery procedure. The band is an inflatable doughnut-shaped ring. The diameter, which can be adjusted in the office setting by adding or removing saline via a port, is positioned beneath the skin. The number and frequency of adjustments to the band depends on individual consideration(s). Most patients have between 5 and 8 adjustments within the first year after surgery. Claims for an adjustment of a gastric restrictive device after the global period (90 days after surgery) may be reimbursable in the office setting.An adjustment of the gastric band (CPTcode 43999) and an evaluation and management service (E/M) service are not payable on the same day of service. An E/M and the adjustment of a gastric band (CPTcode 43999) will only be allowed on the same day if there was a significantly separate service provided. The CPTmodifier 25 should be appended to the E/M code to indicate the E/M service was a significantly separate service.To submit a claim for adjustment of Gastric Restrictive Device:Submit CPTCode 43999Narrative field put the words 'adjustment of lap-band'NOTE:Only reimbursable in the office setting.Imaging to locate the port would be included in the service of CPTcode 43999.
(Medicare National Coverage Determinations Manual)

Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions  04/07/2008  5818  R75NCD  09/11/2007  Lumbar Artificial Disc Replacement (LADR)  10/01/2007  5727  R70NCD  06/22/2007  Vagus Nerve Stimulation (VNS) for Resistant Depression  07/23/2007  5612  R69NCD  05/11/2007  Bone Mass Measurements (BMMs)  07/02/2007  5521  R67NCD  04/06/2007  Blood Brain Barrier Osmotic Disruption for Treatment of Brain Tumors  05/07/2007  5530  R66NCD  03/16/2007  Extracorporeal Photopheresis  04/02/2007  5464  R61NCD  11/24/2006  Cavernous Nerves Electrical Stimulation with Penile Plethysmography  01/08/2007  5294  R60NCD  06/23/2006  Lumbar Artificial Disc Replacement (LADR)  06/17/2006  5057  R55NCD  05/05/2006  Changes Conforming to CR 3648 Instructions for Therapy Services  10/02/2006  4014  R54NCD  04/28/2006  Bariatric Surgery for Treatment of Morbid Obesity  05/30/2006  5013  R48NCD  03/17/2006  Technical Corrections to the NCD Manual  06/19/2006  4278  R45NCD  12/06/2005  Stem Cell Transplantation  01/03/2006  4173  R43NCD  12/02/2005  Stem Cell Transplantation  01/03/2006  4173  R41NCD  06/24/2005  Osteogenic Stimulators  08/01/2005  3836  R40NCD  06/24/2005  Coverage of Aprepitant for Chemotherapy -Induced Emesis  07/05/2005  3831  R38NCD  06/17/2005  Coverage of Colorectal Anti -Cancer Drugs Included in Clinical Trials  04/18/2005  3742  R34NCD  04/25/2005  Abarelix for the Treatment of Abarelix for the Treatment of Prostate Cancer  05/25/2005  3775  R32NCD  04/15/2005  Autologous Stem Cell Transplantation (AuSCT)  05/16/2005  3797  R30NCD  03/29/2005  Coverage of Colorectal Anti -Cancer Drugs Included in Clinical Trials  04/18/2005  3742  R15NCD  06/18/2004  Sensory Nerve Conduction Threshold Tests  04/01/2004  3339  R14NCD  06/10/2004  Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee  07/11/2004  3281  R13NCD  05/28/2004  Removal of Coding from National Coverage Determination on Stem Cell Transplantation  07/06/2004  3265  R10NCD  04/06/2004  Re-release of NCD Manual  N/A N/A R08NCD  03/19/2004  Sensory Nerve Conduction Threshold (sNCT) Tests  04/01/2004  2988  R01NCD  10/01/2003  Initial Release of Manual  N/A N/A Back to top of Chapter
Article - Oral Surgery and Maxillofacial Surgery Specialty Codes (A53446)

CMS National Coverage PolicyN/AArticle TextPhysicians self-designate their Medicare physician specialty on the Medicare enrollment application (CMS-855I) or Internet-based Provider Enrollment, Chain and Ownership System when they enroll in the Medicare program. Dentists who practice general or specialized dentistry should be enrolled in Medicare as specialty 19 (oral surgery - dentists only) or specialty 85 (maxillofacial surgery). Dentists enrolled as specialty 19 might extract teeth, perform simple surgical biopsies or remove suspicious tumors or lesions in the oral cavity. Dentists enrolled as specialty 85 are trained and practice primarily maxillofacial surgery by doing major repairs of facial trauma, oral tumors or jaw reconstruction. Otolaryngologists should be enrolled in Medicare as specialty 04.It is important for physicians to select the most correct specialty code in order to promote the correct coding and processing of Medicare claims.
Article - Billing and Coding: MolDX: 4q25-AF Risk Genotype (A53457)

CMS National Coverage PolicyN/AArticle TextEffective for dates of services on and after 06/14/2012The 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:CPTcode 81479  Unlisted molecular pathology procedureAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierEnter 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 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 form
Article - Billing and Coding: MolDX: LPA-Aspirin Genotype (A53467)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) statutory exclusion covers diagnostic testing "except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member".Article TextThe MolDX Team has completed a review of the research on the LPA-Aspirin genotype test, developed to predict increased CVD risk and event reduction during aspirin therapy. To date, there is insufficient evidence to support the required clinical utility for the established Medicare benefit category. Therefore, the LPA-Aspirin genotype test is a statutorily excluded test.As reviewed, the developer described the indication to perform a LPA-Aspirin 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 LPA-Aspirin genotype test would continue to be a statutory excluded test.To receive a LPA-Aspirin service denial, please submit the following claim information:CPTcode 81479 Unlisted molecular pathology procedureAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierEnter 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 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 form
Article - Billing and Coding: MolDX: LPA-Intron 25 Genotype (A53468)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) statutory exclusion covers diagnostic testing "except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member".Article TextThe MolDX Team has completed a review of the research on the LPA-Intron 25 genotype test, developed to predict increased Coronary Heart Disease risk. To date, there is insufficient evidence to support the required clinical utility for the established Medicare benefit category. Therefore, the LPA-Intron 25 genotype test is a statutorily excluded service.As reviewed, the developer described the indication to perform a LPA-Intron 25 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 LPA-Intron 25 genotype test would continue to be a statutory excluded test.To receive a LPA-Intron 25 service denial, please submit the following claim information:CPTcode 81479 Unlisted molecular pathology procedureAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierEnter 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 DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/typesLine SV202-7 for 837I electronic claimBlock 80 for the UB04 claim form
Article - Billing and Coding: Pre/Postoperative Care: Date of Service (A53472)

CMS National Coverage PolicyTitle XVIII of the Social Security Act 1862(a)(1)(A)CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 40.2 - 40.4Article TextWhere physicians agree on the transfer of care during the global surgery period, the following modifiersare used:CPT modifier 54 - for surgical care only; orCPT modifier 55 - for postoperative management onlyThe claim for the surgical care and the claim(s) for the postoperative care must containthe same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier.AppropriateDateCPT Code/ModifierSurgeon/PhysicianMay 866982-54SurgeonMay 866982-55Post-op Care PhysicianInappropriateDateCPT Code/ModifierSurgeon/PhysicianMay 866982-54SurgeonMay 966982-55Post-op Care PhysicianThe surgeon and the physician(s) providing the postoperative care must collaborate to ensure the appropriate date of service and surgical code are submitted (with the appropriate CPT modifier).Claims are being monitored and will be rejected when submitted inappropriately.For more information regarding global surgery and transfer of care during the global surgery period, refer to the CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 40.2 - 40.4.
Article - Billing and Coding: MolDX: HTTLPR Gene Testing (A53480)

CMS National Coverage PolicyN/AArticle TextEffective for dates of service on and after June 26, 2013.Serotonin Transporter genotyping (HTTLPR) has been associated with response to selective serotonin reuptake inhibitors. However since the literature is conflicting and limited by small sample sizes, the MolDX Team has determined there is insufficient evidence to support coverage. Therefore, HTTLPR testing is a statutorily excluded service.To receive a HTTLPR analysis service denial, please submit the following claim information:CPTcode 81479An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierEnter 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 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 form
Article - Billing and Coding: MolDX: BluePrint® Test (A53484)

CMS National Coverage PolicyN/AArticle TextThe MolDX team has completed a technical assessment on BluePrint, a molecular subtyping assay. To date, there is insufficient evidence to support the required clinical utility for the established Medicare benefit category. Therefore, the BluePrint test is a statutorily excluded test.To receive a BluePrint service denial, please submit the following claim information:CPTcode 81479- Unlisted molecular pathology procedureAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierEnter 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 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 form
Article - Billing and Coding: Radiology Services: Multiple, Identical Services on Same Day (A53488)

CMS National Coverage PolicyCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, 100.1Article TextMultiple 'Serial' X-RaysMedicare Part B claims for multiple, identical services provided to an individual patient on the same day may be denied as duplicate services. To ensure correct claims processing:Submit multiple, identical services on the same claim,Use the days/units field when possible to identify multiple procedures,Indicate the time each service was performed in the appropriate documentation field for electronic claims or Item 19 of the CMS-1500 claim form,Use CPTmodifier 76 for multiple, identical services performed on the same date of service by the same physician.Example:Date of ServiceCPT Code/ModifierDays/Units1/1/137300011/1/1373000-762Multiple Interpretations, Same X-RayGenerally, Palmetto GBA may reimburse the first interpretation of an X-ray furnished to an emergency room patient. The 'interpretation and report' of an X-ray requires a complete, written report similar to the kind of report a specialist would prepare. Payment for a second interpretation of the same film is made only in unusual circumstances. Claims for the second interpretation of the same film must be submitted with CPTmodifier 77 when performed by a different physician and must provide documentation as to why a second interpretation is medically reasonable and necessary.Examples:A questionable finding for which the physician performing the initial interpretation believes that another physicians expertise is needed,A changed diagnosis resulting from a second interpretation of the results of the procedure.Palmetto GBA will not reimburse2 interpretations of the same X-ray without the additional required documentation. When an emergency room physician and a radiologist both perform interpretations of the same X-ray, both physicians should work together to determine who should submit the claim.Additional information and guidance on multiple interpretations of the same X-ray are available in theCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, 100.1.