evekhm/cms_iom_3000 huggingface dataset:
Article - Self-Administered Drug Exclusion List: Medical Policy Article (A53022)

CMS National Coverage PolicyN/AArticle TextCoverage for self-administered drugs for both Part A and Part B is determined by the MAC Contractor in each jurisdiction. HCPCS codes used under Outpatient Prospective Payment System (OPPS) are included, in addition to the codes used for Part B claims, when appropriate.The table below lists drugs that are not covered by Medicare, the effective date of non-coverage, and the rationale. (Please see Process for Determining Self-Administered Drug Exclusions  Medical Policy Article). The column, Brand Names, provides one or more examples but may not include all brand names.Information about drugs not separately reimbursed or not covered for reasons other than usually self-administered, is detailed in Part A and Part B MAC publications and postings available elsewhere.Route of Administration ModifierThe use of the JA and JB modifiers is required for drugs which have one HCPCS Level II (J or Q) code but multiple routes of administration. Drugs that fall under this category will be marked with an asterisk (*) and must be billed with the JA modifier for the intravenous infusion of the drug or billed with the JB modifier for the subcutaneous injection form of administration. Subcutaneously administered drugs listed on the Usually Self-Administered list will be denied as a benefit exclusion. Claims for drugs marked with an asterisk (*) billed without either a JA or JB modifier will also be denied.
Social Security Act §1833

html  PUBLIC "-//W3C//DTD HTML 4.01//EN"SSA INTERNET HEAD SCRIPTSSocial Security Act 1833BANNERSkip to main contentSocial SecuritySearchMenuEspaolSign inSITE NAVIGATION#include virtual="/framework/includes/english/navigation.shtml"PAGE TITLECompilation of the Social Security LawsCONTENT
Social Security Act §1833

(2)in the case ofservices described in section 1832(a)(2) (except those servicesdescribed in subparagraphs (C), (D), (E), (F), (G), (H), and (I) ofsuch section and unless otherwise specified in section 1881)(A)with respectto home health services (other than a covered osteoporosis drug) (asdefined in section 1861(kk)), the amount determined under the prospective paymentsystem under section 1895;(B)with respectto other items and services (except those described in subparagraph(C), (D), or (E) of this paragraph and except as may be provided insection 1886orsection 1888(e)(9))(i)furnished beforeJanuary 1, 1999, the lesser of(I)the reasonablecost of such services, as determined under section 1861(v), or(II)the customarycharges with respect to such services,less the amount a provider may charge as described in clause(ii) of section 1866(a)(2)(A), but in no case may the payment for such otherservices exceed 80 percent of such reasonable cost, or(ii)if such servicesare furnished before January 1, 1999, by a public provider of services,or by another provider which demonstrates to the satisfaction of theSecretary that a significant portion of its patients are low-income(and requests that payment be made under this clause), free of chargeor at nominal charges to the public, 80 percent of the amount determinedin accordance with section 1814(b)(2), or(iii)if such servicesare furnished on or after January 1, 1999, the amount determined undersubsection (t), or(iv)if (and forso long as) the conditions described in section 1814(b)(3) are met, the amounts determinedunder the reimbursement system described in such section;(C)with respectto services described in the second sentence of section 1861(p), 80 percentof the reasonable charges for such services;(D)with respectto clinical diagnostic laboratory tests for which payment is madeunder this part(i)
Social Security Act §1833

[141]P.L. 114-10, 101(e)(2) Appended subsection (z). EffectiveApril 16, 2015.[142]P.L. 114-10, 514(a); directed adding new subsection, also designatedas (z), to Section 1833. Effective April 16, 2015P.L. 115271, 6083(b) redesignated this subsection (z)as subsection (aa). Effective October 24, 2018.[143]P.L. 115271,6083(b)(2), added new subsection (bb). Effective October 24,2018.[144]21U.S.C. 823(g).END CONTENTPAGE FOOTERFooter menuSSA INTERNET BODY SCRIPTS
Article - Billing and Coding: Endometrial Hyperplasia Treatment (A53043)

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.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.Article TextTreatment of endometrial hyperplasia with the insertion of a hormone-containing intrauterine device (IUD) is an accepted method to manage endometrial hyperplasia for patients with abnormal uterine bleeding and who are unable to tolerate oral megestrol or are at high risk for complications of oral megestrol.Effective for dates of service on and after 02/01/12, Palmetto GBA will reimburse IUD insertion services for patients who meet these criteria.Since IUD insertion services auto-deny, submit the following claim information:CPTcode 58999ICD-10 codes N84.0 or N85.00-N85.02Enter hormone IUD in the comment/narrative field of the CMS-1500 claim form or the equivalent electronic claim field
Article - Billing and Coding: CPT Code 97755 - Assistive Technology Assessment (A53053)

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 claimArticle TextCPTcode 97755, assistive technology assessment (for example, to restore, augment or compensate for an existing function, optimize functional tasks and/or maximize environmental accessibility), direct 1-on-1 contact with written report, each 15 minutes, is related to the following local coverage determinations (LCDs): Outpatient Physical Therapy (L34428) Outpatient Occupational Therapy (L34427) Home Health-Occupational Therapy (L34560) Home Health-Physical Therapy (L34564)This is an assessment code, per each 15 minutes, and must be accompanied by a written report explaining the nature and complexity of the assistive technology needed by the patient. This can include: testing multiple components/systems to determine optimal interface between client and technology applications and determining the appropriateness of commercial (off the shelf) components/systems. If the service provided by a physical or occupational therapist is more clearly defined by another CPTcode (for example, 97535 self-care/home management training), it should be used instead.It would be inappropriate to use the CPTcode 97755 for services other than for those who have lost the use of their limbs and who can benefit from new technology advancements. CPT97755 should only be billed by occupational and physical therapists that have the additional knowledge and expertise of the assistive technology that is required for these individuals.For rationale, clinical example and description of CPT97755, please refer to CPT2004 Changes: An Insider's View, American Medical Association (2003).
Article - Home-Based Fall Evaluations and Interventions (A53055)

CMS National Coverage PolicyN/AArticle TextThe goal of this article is to provide a framework for the communication of information that both clinicians and Medicare need to make patient-centered decisions.Services provided by HHAs under the 32x bill type are reimbursed under the Home Health Prospective Payment System (HH PPS), while those delivered under the 34x bill type are reimbursed as Part B Outpatient Rehabilitation Services. Part B Outpatient Rehabilitation Services (with the exception of those furnished by or under arrangements with a hospital) are subject to the financial limitations described in the CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 5, Section 10.2.Thisarticle underscores the importance of a comprehensive evaluation of the circumstances surrounding the documented fall event(s). It is important that a comprehensive examination and evaluation including a detailed history as well as neurological/sensory, musculoskeletal, and vascular/cardiopulmonary systems reviews be documented. Palmetto GBA is addressing this need through an approach called Going Beyond Diagnosis(GBD). GBD promotes use of the International Classification of Functioning Disability and Health (ICF) to capture and organize the information necessary to support the clinical and administrative needs of HHAs performing home-based fall evaluations and interventions.
Article - Hospice: Documenting Weight Loss for Beneficiaries with Non-Neoplastic Conditions (A53056)

CMS National Coverage PolicyN/AArticle TextWeight has long been used as a measure of nutritional status. Both absolute body weight and changes in body weight have prognostic significance. The documentation of absolute body weight provides information at a specified point in time, while changes in body weight allow clinicians to gauge a given patient's response to treatment over time.If hospice organizations record percent weight loss as an indicator of nutritional status, this A/B HHH MAC expects to see supporting documentation of the absolute weights used to calculate the percent decrease. The reporting of absolute weights strengthens documentation of percent change in weight over time (e.g., > 10% weight loss over the last 6 months with weight decreasing from 110 pounds to 95 pounds). This A/B HHH MAC encourages hospice providers to include absolute weights in their responses to additional documentation requests (ADRs).Unsupported percent weight loss in the medical record may result in a denial if other documentation does not lend support to impaired nutritional status.
Article - Billing and Coding: Ophthalmology: Extended Ophthalmoscopy and Fundus Photography (A53060)

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. 100-02, Medicare Benefit Policy Manual, Chapter 15, 280.1 Glaucoma ScreeningCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, 40.1.A Components of a Global Surgical PackageCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 18, 70 Glaucoma Screening Services,70.1 Claims Submission Requirements and Applicable HCPCS Codes,70.1.1 HCPCS and Diagnosis Coding,70.1.1.1 Additional Coding Applicable to Claims Submitted to A/B MACs (A),70.1.1.2 Special Billing Instructions for RHCs and FQHCs,70.1.2 Edits,70.2 Payment Methodology,70.3 Determining the 11-Month Period,70.4 Remittance Advice Notices,70.5 MSN MessagesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) fortheOphthalmology: Extended Ophthalmoscopy and Fundus PhotographyL33467.General ophthalmoscopy and biomicroscopy are part of an ophthalmologic examination. These codes are included in and are not separately payable when an extended ophthalmoscopy code is billed, but these should still be documented in the patients medical record.If extended ophthalmoscopy is done without a drawing or does not meet indicated standards, the service is not separately payable and will be considered part of a general ophthalmologic exam or E&M service.PART BFundus photography is a bilateral service on the Medicare Physician Fee Schedule Data Base. Services performed unilaterally are subject to a reduction in fee. [Use 52 modifier to indicate unilateral service; -RT and LT are not required in this circumstance.]CPTcodes92201 and 92202 should not be billed if fundus photography is performed.Extended ophthalmoscopy (CPTcodes 92201, 92202) performed during the global surgery period of an ophthalmologic surgery procedure, by the same provider performing the surgery, will not be separately payable unless unrelated to the condition for which the surgery was performed. This circumstance can be indicated by reporting a modifier -76 or -79 depending on the date of service.CPTcode 92227 is not for routine screening, but is covered for evaluation of asymptomatic patients at risk with known disease (e.g., diabetes mellitus) that is likely to cause retinal disease when the test is ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).CPTcode 92228 is a covered service when ordered by the treating physician(or other treating practitioner acting within the scope of his or her license and Medicare requirements).
Article - Billing and Coding: Outpatient Occupational Therapy (A53064)

The payment for hot or cold packs is bundled into the payment for other covered services and is not reimbursable.Ice massage should be reported using this code.Self-Care Home Management Training (CPTcode 97535)When instructing the patient in a self-management program, use the code that best describes the focus of the self-management activity. For example, if the instruction given is for exercises to be done at home to improve range of motion (ROM) or strength, use 97110; if instructing the patient in balance or coordination activities at home, use 97112; if teaching the patient aquatic exercises to use as an independent program in the community pool, use 97113.This code should not be used globally for all home instructions.Note:When identifying orthotics fitting and training seeCPTcode 97760.Orthotics Training (CPTcode 97760)For entities subject to the related LCD, assessment of the patient regarding the orthotic, measurement and/or fitting, supplies to fabricate or modify the orthotic, and time associated with making the orthotic should not be reported with CPTcode 97760, unless the entities are certain that duplicate payments will not be made to Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) suppliers using the "L" code.Aquatic Therapy with Therapeutic ExercisesNote:Aquatic therapy with therapeutic exercise should not be billed in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers).
Article - Billing and Coding: Outpatient Physical Therapy (A53065)

Supportive Documentation Recommendations for G0281 and G0329 Etiology and duration of wound Type of prior treatments by a physician, non-physician practitioner, nurse and/or therapist that failed, including the duration of the failed treatment Stage of wound Description of wound: length, width, depth, grid drawing and/or photographs Amount, frequency, color, odor, type of exudate Evidence of infection, undermining, or tunneling Nutritional status Co-morbidities (e.g., diabetes mellitus, peripheral vascular disease) Pressure support surfaces in use Patients functional level Skilled plan of treatment, including specific frequency of the modality Changing plan of treatment based on clinical judgment of the patients response or lack of response to treatment Frequent skilled observation and assessment of wound healing (at least weekly, but preferably with each treatment session)Note: HCPCS G0282 - Electrical stimulation, (unattended), to 1 or more areas, for wound care other than described in G0281. This code is not covered by Medicare.Self-Care/Home Management Training (CPTcode 97535)When instructing the patient in a self-management program, use the code that best describes the focus of the self-management activity. For example, if the instruction given is for exercises to be done at home to improve range of motion (ROM) or strength, use 97110; if instructing the patient in balance or coordination activities at home, use 97112; if instructing the patient's spouse or caregiver how to assist the patient up/down steps using an assistive device to get into and out of the home, use 97116; if teaching the patient aquatic exercises to use as an independent program in the community pool, use 97113.Hot/Cold Packs (CPTcode 97010)The payment for hot or cold packs is bundled into the payment for other covered services and is not reimbursable. Ice massage should be reported usingCPTcode 97010.Direct 1-on-1 ContactRegardless of the procedure or modality being performed, if the patient is not receiving direct 1-on-1 contact but is being supervised by the therapist, the group therapy code should be used.Orthotic Management and Training and Prosthetic Training (CPTcode 97760)For entities subject to the related LCD, assessment of the patient regarding the orthotic, measurement and/or fitting, supplies to fabricate or modify the orthotic, and time associated with making the orthotic should not be reported with CPTcode 97760, unless the entities are certain that duplicate payments will not be made to Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) suppliers using the "L" code.Community/Work Reintegration (CPTcode 97537)Should be utilized when a patient is trained in the use of assistive technology to assist with mobility, seating systems, and environmental control systems for use in the community.
Social Security Act §1861

html  PUBLIC "-//W3C//DTD HTML 4.01//EN"SSA INTERNET HEAD SCRIPTSSocial Security Act 1861BANNERSkip to main contentSocial SecuritySearchMenuEspaolSign inSITE NAVIGATION#include virtual="/framework/includes/english/navigation.shtml"PAGE TITLECompilation of the Social Security LawsCONTENTThere is a more recent version of this section in the official Social Security ActStatute Compilation.
Social Security Act §1861

(jjj)[544]Opioid Use DisorderTreatement Services; Opioid Treatment Program.(1)Opioiduse disorder treatment services.Theterm opioid use disorder treatment services means itemsand services that are furnished by an opioid treatment program forthe treatment of opioid use disorder, including(A)opioid agonistand antagonist treatment medications (including oral, injected, orimplanted versions) that are approved by the Food and Drug Administrationunder section 505 of the Federal Food, Drug, and Cosmetic Act[545]for use in thetreatment of opioid use disorder;(B)dispensingand administration of such medications, if applicable;(C)substanceuse counseling by a professional to the extent authorized under Statelaw to furnish such services;(D)individualand group therapy with a physician or psychologist (or other mentalhealth professional to the extent authorized under State law);(E)toxicologytesting, and(F)other itemsand services that the Secretary determines are appropriate (but inno event to include meals or transportation).(2)Opioidtreatment Program.The term opioidtreatment program means an entity that is an opioid treatmentprogram (as defined in section 8.2[546]of title 42 of the Codeof Federal Regulations, or any successor regulation) that(A)is enrolledunder section 1866(j)(B)has in effecta certification by the Substance Abuse and Mental Health ServicesAdministration for such a program;(C)is accreditedby an accrediting body approved by the Substance Abuse and MentalHealth Services Administration; and(D)meets suchadditional conditions as the Secretary may find necessary to ensure(i)the health andsafety of individuals being furnished services under such program;and(ii)the effectiveand efficient furnishing of such services.
Federal Register :: Request Access

html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN"       "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd"Federal Register :: Request AccessThe Federal RegisterThe Daily Journal of the United States GovernmentRequest AccessRequest AccessDue to aggressive automated scraping of FederalRegister.gov and eCFR.gov, programmatic access to these sites is limited to access to our extensive developer APIs.If you are human user receiving this message, we can add your IP address to a set of IPs that can access FederalRegister.gov & eCFR.gov; complete the CAPTCHA (bot test) below and click "Request Access". This process will be necessary for each IP address you wish to access the site from, requests are valid for approximately one quarter (three months) after which the process may need to be repeated.Request Access for 99.18.140.166An official website of the United States government.If you want to request a wider IP range, first request access for your current IP, and then use the "Site Feedback" button found in the lower left-hand side to make the request.
Article - Billing and Coding: Sclerosing of Varicose Veins (A53079)

CMS National Coverage PolicyN/AArticle TextImportant Coding AlertNoridian is revising this article to further clarify that CPT37241 is not an acceptable choice of procedure codes for treatment of symptoms of varicose veins of the lower extremity regardless of the method used.Noridians Local Coverage Determination, Treatment of Varicose Veins of the Lower Extremities; L34209 (JEA and JEB)/L34010 (JFA and JFB) provides coverage criteria for the treatment of varicose veins and the CPTcodes that are expected to be utilized for billing this service.As previously noted, a product for the treatment of varicose veins has appeared on the market for which the products information states that it utilizes both a sclerosing agent and a rotating wire which allegedly mixes the agent and possibly macerates any clots in the area.Noridian has been informed that some providers may have been recommended to use CPT37241 when using this device for the treatment of varicose veins. This advice is incorrect. CPT37241 must not be used to bill for the treatment of varicose veins of the lower extremities with this or similar devices.When using the ClariVein device in the treatment of varicose veins before January 1, 2017, Noridian recommends billing with CPTcode 36299. The sclerosing agent is bundled into the procedure code and is not separately reimbursable. ClariVein must be entered in Item 19 of the CMS-1500 form or the electronic notepad equivalent. For dates of service on and after January 1, 2017 providers should use CPT36473 for first vein (Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated) and 36474 (Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) If billing for both extremities it is appropriate to append modifier RT or LT to the respective claim line.Based on the intensity of service for CPTcode 37241, Noridian no longer allows payment for claims using this CPTin Place of Service 11  Office effective June 6, 2016.