evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Treatment of Varicose Veins of the Lower Extremities (A57706)

CMS National Coverage PolicyLanguage quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review a NCD. See 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act, 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Manual System, Pub 100-08,Medicare Program Integrity Manual,Chapter 13, 13.5.1 indicates services will be considered medically reasonable and necessary only if ordered and furnished by appropriately trained personnel.This training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty or must reflect extensive continued medical education activities. If these skills have been acquired by way of continued medical education, the courses must be comprehensive, offered or sponsored or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States, and designated by the American Medical Association (AMA) as Category 1 Credit.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.1. Each claim must be submitted with an ICD-10-CM code(s) that reflects the condition of the patient and indicates the reason(s) for which the service was performed.2. The patient's medical record must contain a history and physical examination supporting the diagnosis of symptomatic varicose veins, and the failure of an adequate (at least 3 months) trial of conservative management.3. The medical record must document the performance of appropriate tests, if medically necessary, to confirm the pathology of the vascular anatomy.4. This documentation must be made available to Medicare upon request.5. The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.6. When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.
Article - Billing and Coding: Treatment of Varicose Veins of the Lower Extremities (A57707)

CMS National Coverage PolicyLanguage quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review a NCD. See 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act, 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Manual System, Pub 100-08,Medicare Program Integrity Manual,Chapter 13, 13.5.1 indicates services will be considered medically reasonable and necessary only if ordered and furnished by appropriately trained personnel.This training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty or must reflect extensive continued medical education activities. If these skills have been acquired by way of continued medical education, the courses must be comprehensive, offered or sponsored or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States, and designated by the American Medical Association (AMA) as Category 1 Credit.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.1. Each claim must be submitted with an ICD-10-CM code(s) that reflects the condition of the patient and indicates the reason(s) for which the service was performed.2. The patient's medical record must contain a history and physical examination supporting the diagnosis of symptomatic varicose veins, and the failure of an adequate (at least 3 months) trial of conservative management.3. The medical record must document the performance of appropriate tests, if medically necessary, to confirm the pathology of the vascular anatomy.4. This documentation must be made available to Medicare upon request.5. The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.6. When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.
Article - Billing and Coding: Vitamin D Assay Testing (A57718)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.42CFR410.32(a) requires a clinical diagnostic test be ordered by the physician who is treating the patient for a specific medical problem and uses the results in the management of the beneficiarys specific problem.MBPM Internet Only Manual(IOM 100-02), chap. 6, 20.4.3 applies 42CFR410.32 to hospitals.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation must clearly indicate the necessity for the test(s), any and all repeat testing and frequency of testing.The medical record must be made available to Medicare upon request.The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.
Article - Billing and Coding: Vitamin D Assay Testing (A57719)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.42CFR410.32(a) requires a clinical diagnostic test be ordered by the physician who is treating the patient for a specific medical problem and uses the results in the management of the beneficiarys specific problem.MBPM Internet Only Manual(IOM 100-02), chap. 6, 20.4.3 applies 42CFR410.32 to hospitals.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation must clearly indicate the necessity for the test(s), any and all repeat testing and frequency of testing.The medical record must be made available to Medicare upon request.The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.
Article - Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains (A57733)

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 claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS Internet-Only Manual, Pub. 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 Lab: Special Histochemical Stains and Immunohistochemical Stains L36805.To report special histochemical stains and/or immunohistochemical stains services, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)
Article - Billing and Coding: Vitamin D Assay Testing (A57736)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.42CFR410.32(a) requires a clinical diagnostic test be ordered by the physician who is treating the patient for a specific medical problem and uses the results in the management of the beneficiarys specific problem.MBPM Internet Only Manual (IOM 100-02), Chapter 6, Section 20.4.3 applies 42CFR410.32 to hospitals.Article TextThis article contains coding or other guidelines that complement the local coverage determination (LCD) for Vitamin D Assay Testing.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.DocumentationDocumentation must justify the test(s) chosen for a particular disease entity. Various component sources of 25-OH Vitamin D, such as stored D or diet-derived D, should not be billed separately.If Vitamin D level is between 20 and 50 ng/ml and patient is clinically stable, documentation in the patient's medical record for repeat testing must clearly indicate the necessity of the test.
Article - Billing and Coding: Trigger Point Injections (A57751)

CMS National Coverage PolicyInternet-Only Manuals (IOM):CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 1, Section 30.3 AcupunctureChapter 1, Part 2, Section 150.7 Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing AgentsSocial 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 TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35010, Trigger Point Injections. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice: 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.Only one code from20552or20553should be reported on any particular day, no matter how many sites or regions are injected.
Article - Billing and Coding: Wireless Capsule Endoscopy (A57753)

CMS National Coverage PolicyN/AArticle TextRefer to Local Coverage Determination (LCD) L35089, Wireless Capsule Endoscopy, for reasonable and necessary requirements.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.
Article - Billing and Coding: Vitamin B12 Injections (A57755)

CMS National Coverage PolicySocial 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 TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33967 Vitamin B12Injections. Please refer to the LCD for reasonable and necessary requirements.Coding GuidelinesNotice: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.Documentation RequirementsAll documentation must be maintained in the patient's 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.Progress notes and laboratory test results indicating present or past values of serum B12as well as supporting the treatment for the identified diagnosis(es) need to be maintained and made available upon request in the event a review is required.A serum B12level is not required if vitamin B12is administered in conjunction with pemetrexed or pralatrexate. The medical record should reflect the patient is being treated with pemetrexed or pralatrexate.
Article - Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) (A57772)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1 Clinical Laboratory Services.CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual Pub 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure Codes.Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Diagnostic Tests (MDT) L36807.To report a Molecular Diagnostic Test service, please submit the following claim information:Select appropriate CPT codeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code 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 837PBox 19 for paper claimEnter the appropriate DEX Z-Code 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 claimBlock 80 for the UB04 claim formNOTE:When entering the DEX Z-Code on 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: Breast Cancer Index® (BCI) Gene Expression Test (A57773)

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 claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.0 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests, 80.1.1 Certification ChangesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 2310 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: Breast Cancer Index (BCI) Gene Expression Test.Effective 1/01/2019, MolDX will provide limited coverage for the BCI gene expression test.The BCI test is covered for postmenopausal women with invasive breast cancer when the following criteria are met:Pathology reveals invasive carcinoma of the breast that is ER+ and/or PR+ and HER2 -; andPatient has early-stage disease (T1-3, pN0-N1, M0); andPatient has no evidence of distant breast cancer metastasis (i.e., non-relapsed); andTest results will be used in determining treatment management of the patient for chemotherapy and/or endocrine therapy.MolDX expects this test will be performed once per patient lifetime on formalin-fixed, paraffin-embedded (FFPE) tissue from the primary tumor specimen obtained prior to adjuvant treatment.To report a BCI service, please submit the following claim information:Select CPTcode 81518Enter 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
Article - Billing and Coding: MolDX: Breast Cancer Index™ (BCI) Gene Expression Test (A57774)

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 claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.0 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests, 80.1.1 Certification ChangesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 2310 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: Breast Cancer Index (BCI) Gene Expression Test.Effective 1/01/2019, MolDX will provide limited coverage for the BCI gene expression test.The BCI test is covered for postmenopausal women with invasive breast cancer when the following criteria are met:Pathology reveals invasive carcinoma of the breast that is ER+ and/or PR+ and HER2 -; andPatient has early-stage disease (T1-3, pN0-N1, M0); andPatient has no evidence of distant breast cancer metastasis (i.e., non-relapsed); andTest results will be used in determining treatment management of the patient for chemotherapy and/or endocrine therapy.MolDX expects this test will be performed once per patient lifetime on formalin-fixed, paraffin-embedded (FFPE) tissue from the primary tumor specimen obtained prior to adjuvant treatment.To report a BCI service, please submit the following claim information:Select CPTcode 81518Enter unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following 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