evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Transesophageal Echocardiography (TEE) (A56505)

CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states thatno 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) L35016, Transesophageal Echocardiography (TEE). 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.CPT code 93355 is used to report TEE services during transcatheter intracardiac therapies. CPT code 93355 is reported once per intervention and only by an individual who is not performing the interventional procedure. CPT code 93355 includes the work of passing the endoscopic ultrasound transducer through the mouth into the esophagus, when performed by the individual performing the TEE, diagnostic transesophageal echocardiography and ongoing manipulation of the transducer to guide sizing and/or placement of implants, determination of adequacy of the intervention, and assessment for potential complications. Real-time image acquisition, measurements, and interpretation of image(s), documentation of completion of the intervention, and final written report are included in this code.CPT code 93312 (HCPCS code C8925 for Outpatient Prospective Payment System [OPPS]) should be billed when contrast is used or CPT code 93315 (HCPCS code C8926 for OPPS billing when contrast is used) for the complete procedure, including probe placement, image acquisition, interpretation and report. CPT code 93315 (HCPCS code C8926 for OPPS billing when contrast is used) should be used for congenital anomalies only.Hospitals should use guidelines and descriptors associated with the applicable Level 1 CPT code(s) to bill for echocardiograms without contrast.All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.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.
Article - Billing and Coding: Octreotide Acetate for Injectable Suspension (Sandostatin® LAR Depot) (A56531)

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, 50.3 Incident to Requirements, 50.4.3 Examples of Not Reasonable and Necessary, 50.4.4 Payment for Antigens and Immunizations, 50.4.4.2 Immunizations, 50.4.5 Off-Label Use of Drugs and Biologicals in an Anti-Cancer Chemotherapeutic Regimen, 50.4.5.1 Process for Amending the List of Compendia for Determination of Medically-Accepted Indications for Off-Label Uses of Drugs and Biologicals in an Anti-Cancer Chemotherapeutic Regimen, 50.4.6 Less Than Effective Drug and 50.4.7 Denial of Medicare Payment for Compounded Drugs Produced in Violation of Federal Food, Drug, and Cosmetic ActArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Octreotide Acetate for Injectable Suspension (Sandostatin LAR Depot) L33438.When ICD-10-CM codes T38.895A, T38.895D, T38.895S, T43.215A, T43.215D, T43.215S, T43.225A, T43.225D, T43.225S, T50.995A, T50.995D or T50.995S is submitted for chemotherapy induced diarrhea (CID); the medical record must document the covered chemotherapy agent(s) causing the CID and the previous antidiarrheal treatments that have become ineffective.If ICD-10-CM codes C25.4, C26.0, D13.7, D13.91 and D13.99 are submitted on the claim, the medical record must document that the patients diagnosis is VIPoma.If ICD-10-CM code R79.89 is submitted on the claim, the patients record must document abnormal findings leading to suspicion of VIPoma.If ICD-10-CM code R94.7 is submitted on the claim, the patients record must document an abnormal octreotide scan leading to suspicion of VIPoma.
Article - Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (A56537)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Scanning Computerized Ophthalmic Imaging (L34380).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:The patient's medical record must contain documentation that fully supports the medical necessity for servicesincluded within the 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: Allergen Immunotherapy (A56538)

CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Sections 20.2 Physician Expense for Allergy Treatment and 50.4.4.1 AntigensCMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 12, Section 200 Allergy Testing and ImmunotherapySocial 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) L36240 (Allergen Immunotherapy). 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.Please refer to the CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 12, Section 200 Allergy Testing and Immunotherapy for instructions on billing for allergy services.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 should support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code should describe the service performed.Documentation of any therapeutic expectations, level of antigens, time frame for administration, and any adjustments to the expectation based on local reactions, systemic reactions, missed dosing will need to be very clear in the medical records.Documentation for all references to the therapeutic effective dose in the medical record should be referenced to the maintenance concentrate and should be noted as a volume-to-volume dilution (e.g., 1:100 vol/vol dilution of maintenance concentrate).In the event that allergen immunotherapy is administered to a patient in a home setting, medical record documentation must clearly demonstrate that the benefits of immunotherapy outweigh the risks, include a copy of the patients informed consent, and include validation regarding the training and ability of the individual administering the injection to recognize and manage immunotherapy reactions, particularly anaphylaxis.
Article - Billing and Coding: Prostate Rectal Spacers (A56539)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) forProstate Rectal Spacers.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.
Article - Billing and Coding: Biomarkers Overview (A56541)

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) L35062 Biomarkers Overview. 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.It is the expectation, that when reporting ICD-10 codes the code representing the highest level of specificity documented in the medical record should be reported and unspecified codes should only be used when they are the code that most accurately reflects what is known about the patient's condition at the time of the encounter.Utilization ParametersCPT code 81490, Autoimmune (rheumatoid arthritis), is limited to two services per rolling year per beneficiary.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.
Article - Billing and Coding: BRCA1 and BRCA2 Genetic Testing (A56542)

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) L36715, BRCA1 and BRCA2 Genetic Testing. 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.
Article - Billing and Coding: Hospice - Renal Care (A56545)

CMS National Coverage PolicyCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, 30.2, 30.2.2, and 30.3Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Hospice Renal Care L34559.
Article - Billing and Coding: Panretinal (Scatter) Laser Photocoagulation (A56550)

CMS National Coverage PolicyN/AArticle TextThis article contains codingand other guidelines that complement the Local Coverage Determination (LCD) for Panretinal (Scatter) Laser Photocoagulation (PRP).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.Use modifiers LT/RT to indicate operative site. Claims submitted without modifier -RT, -LT, or -50 (in the rare event both eyes are treated on the same day/session) will be returned as unprocessable under 1833[e]).Panretinal laser photocoagulation is usually performed in two or more sessions (staged surgery). Payment may be made only once during the global period of the initial procedure. Reimbursement for subsequent sessions in the postoperative period of the initial procedure is included in the allowance of the initial procedure.Medicare allowance generally includes reimbursement for related procedures performed on the same eye during the global surgery period of the first procedure. Therefore, procedure codes 67208, 67210 or 67227 would be covered only if they represented clearly distinct and different procedures with different indications and were not re-operations or treatment of complications. Such services, and other totally unrelated services, should be billed with a modifier -79 (unilateral procedure or service by the same physician during the post-operative period).Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD.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: Visual Fields Testing (A56551)

CMS National Coverage PolicyN/AArticle TextThisarticlecontains codingand other guidelines that complement the Local Coverage Determination (LCD) for Visual Fields 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.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Article - Billing and Coding: Allergy Testing (A56558)

CMS National Coverage PolicyInternet-Only Manuals (IOMs):CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 12, Section 200 Allergy Testing and ImmunotherapySocial 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) L36241, Allergy Testing. 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.Consistent with the related LCD, CPT code 82785 Gammaglobulin [immunoglobulin]; IgE is not appropriate in most general allergy testing. Please refer to the LCD for details on medically reasonable and necessary guidelines.It is not usually necessary to report CPT code 86003 Allergen specific IgE; quantitative or semiquantitative, crude allergen extract (in vitro testing) in addition to skin testing. Please see the related LCD for medically reasonable and necessary guidelines.Documentation Requirements:All 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 medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.Prior to performance of allergy testing, there must be evidence in the medical record that a history has been obtained, indicating the possible presence of allergy.This history should support that attempts to narrow the area of investigation were taken so that the minimal number of necessary skin tests might deliver a diagnosis.The history should support that the selection of antigens was based on the patient specific history and physician examination.The medical record must indicate which allergy test(s) were used, the interpretation(s), and measurement (in mm) of reaction size of both wheal and erythema response or a standardized grading system in vivo testing (as applicable).
Article - Billing and Coding: Allergy Skin Testing (A56559)

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, 20.2 Physician Expense for Allergy TreatmentArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Allergy Skin Testing L33417.
Article - Billing and Coding: Health and Behavior Assessment/Intervention (A56562)

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 claimArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Health and Behavior Assessment/Intervention L37638.CPTcode 90901 Biofeedback is also not covered as a health and behavioral intervention.
Article - Billing and Coding: Brain Natriuretic Peptide (BNP) Level (A56565)

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, 80.1 Clinical Laboratory ServicesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Brain Natriuretic Peptide (BNP) Level L33422.
Article - Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (A56572)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF).Provisions in this article and the LCD only address Vertebral Augmentation for Osteoporotic Vertebral Compression Fracture (VCF). Coverage will remain available for medically necessary procedures for other conditions not included in this article/LCD.Coding GuidelinesProcedure 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.All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.Specific Coding GuidelinesNo separate payment for venography performed during the operative session may be allowed and it should not be separately billed.This LCD will not affect the use of this treatment for cancer related diagnoses.Exclusion for total number of levels involved will not apply for a diagnosis of multiple myeloma.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related 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.