evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea (A57149)

CMS National Coverage PolicyN/AArticle TextRefer to the Local Coverage Determination (LCD) L38307, Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, 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.Coding GuidelinesImplantationof a Hypoglossal Nerve Stimulator (HSN) for treatment of OSA utilizes 2 CPT codes:Beginning 01/01/2022use single code:CPT 64582Open implantation of hypoglossal nerve stimulator array, pulse generator, and distal respiratory sensor electrode or electrode arrayCoding InformationEffective 1/1/22 CPT code 64568 is no longer used for hypoglossal nerve stimulator due to development of specific CPT codes for this technology 64582-64584Documentation 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 diagnosis code(s).Informational Only:Removal, revisions and replacements related to implantable devices are addressed inMedicare Benefit Policy Manual, Chapter 16, Section 180, Services Related to and Required as a Result of Services Which Are Not Covered Under MedicareEffective 1/1/22 0466T, 0467T and 0468T are deleted codes. Services for revision, replacement or removal of hypoglossal nerve stimulator components should be billed with:CPT 64583Revision or replacement of hypoglossal nerve stimulator array and distal respiratory sensor electrode or electrode array, including connections to existing pulse generatorCPT 64584removal of hypoglossal nerve rose stimulator array pulse generator, and distal respiratory sensor electrode or electrode arrayUtilization GuidelinesIn accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Draft Article - Billing and Coding: MolDX: SelectMDx for Prostate Cancer (DA57153)

CMS National Coverage PolicyN/AArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: SelectMDx for Prostate Cancer(DL38247).To report a SelectMDX for Prostate Testing service, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: Blood Product Molecular Antigen Typing (A57155)

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.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Blood Product Molecular Antigen Typing L38249.Blood product antigen typing is a germline test and the use of panels 0001U and 0084U will be limited to once in a beneficiary lifetime.The individual codes 0180U-0201U, 0221U and 0222U and codes 81105-81112 are also germline tests. These will be noncovered as multiple antigens must be utilized as part of a comprehensive antigen evaluation and will be considered only as part of a panel.To report aBlood Product Molecular Antigen Typingservice, please submit the following claim information:Select the appropriate CPTor PLA codeEnter 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 formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs) (A57161)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A). Allows coverage and payment for only those services that are considered to be medically reasonable and necessary.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. 100-03,Medicare National Coverage Determinations Manual,Chapter 1, Part 4, 250.4.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.1) CPT codes 17106, 17107 and 17108 describe treatment of lesions that are usually cosmetic. When using these CPT codes the clinical records should clearly document the medical necessity of such treatment and why the procedure is not cosmetic.2) CPT codes 11055, 11056 and 11057 describe treatment of hyperkeratotic lesions (e.g., corns and calluses). Coverage for these three codes is described in the Medicare Internet Only Manual.
Article - Billing and Coding: Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs) (A57162)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A). Allows coverage and payment for only those services that are considered to be medically reasonable and necessary.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. 100-03,Medicare National Coverage Determinations Manual,Chapter 1, Part 4, 250.4.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.1) CPT codes 17106, 17107 and 17108 describe treatment of lesions that are usually cosmetic. When using these CPT codes the clinical records should clearly document the medical necessity of such treatment and why the procedure is not cosmetic.2) CPT codes 11055, 11056 and 11057 describe treatment of hyperkeratotic lesions (e.g., corns and calluses). Coverage for these three codes is described in the Medicare Internet Only Manual.
Article - Billing and Coding: MolDX: Melanoma Risk Stratification Molecular Testing (A57165)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet Only Manual Pub. 100-04 Medicare Claims Processing Manual, Chapter 23  10 Reporting ICD Diagnosis and Procedure Codes.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 AllowanceArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: Melanoma Risk Stratification Molecular Testing DL38016.To report a molecular diagnostic service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 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
Draft Article - Billing and Coding: MolDX: Razor 14-Gene Lung Cancer Assay (DA57171)

CMS National Coverage PolicyN/AArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: Razor 14-Gene Lung Cancer Assay(DL38284).To report a Razor 14-Gene Lung Cancer Assay service, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Draft Article - Billing and Coding: MolDX: Pharmacogenomics Testing (DA57175)

CMS National Coverage PolicyN/AArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: Pharmacogenomics Testing(DL38394).To report a Pharmacogenomics Testing service, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: Transesophageal Echocardiogram (A57179)

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) L33756, Transesophageal Echocardiogram. 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.If the service of the cardiologist is requested for a specific reason, his professional services would be billed with CPT 93314 or 93317 with the 26 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.If the provider of transesophageal echocardiography studies is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician's order for the studies. When ordering transesophageal echocardiography studies, the ordering/referring physician must state the reason for the study in his order.An order from the treating physician/nonphysician practitioner as required by CFR, Title 42, Volume 2, Chapter IV, Part 410.32(a) Ordering diagnostic tests.
Article - Billing and Coding: Allergy Testing (A57181)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made for items or 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.Title XVIII of the Social Security Act, 1862(a)(7) and 42 Code of Federal Regulations, 411.15, exclude routine physical examinations.Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Manual System, Pub. 100-03,Medicare National Coverage Determinations Manual,Chapter 1, Part 2, 110.11; food allergy testing and treatment.CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 12, 200; allergy testing and immunotherapy.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation RequirementsIt is expected that supportive documentation evidencing the condition and treatment will be documented in the medical record and be available to the Contractor upon request.Documentation, such as ICD-10-CM codes, supporting the medical necessity of the service must be submitted with each claim. Claims submitted without such evidence will be denied as not medically reasonable and necessary.Utilization GuidelinesThe evaluation of an inhalant may require up to 90 prick-puncture tests followed by up to 40 intracutaneous tests which are usually performed when prick/puncture tests are negative.Sometimes 60 intracutaneous tests performed via multi test, in lieu of prick puncture, may be appropriate for selected patients (for example young children, older adults and needle phobic individuals.)The number of percutaneous tests performed for the evaluation of food sensitivity may require up to 40 tests.The total number of tests, i.e. prick or intracutaneous, should not exceed generally accepted standards of testing set forth by professional associations. Exceeding these parameters may be justified if preliminary testing failed and immunotherapy failed to control symptoms.In California, for CPT code 95004, among patients treated by Allergists, over half required fewer than 100 tests. The great majority required less than 120-130 tests, and only 5% required more than 200 tests. Some of the high-test group includes repeat testing necessitated by unsatisfactory response to clinical treatment and a clinical need for further investigation. For CPT code 95024, among patients treated by Allergists, over half required only 12 tests, and only 5% required 70 or more tests. High-utilization testing may be selected for medical review when inconsistent with clinical practice norms.
Article - Billing and Coding: Serum Magnesium (A57189)

CMS National Coverage PolicyTitle XVIII of the Social Security Act; Section 1862(a)(7). This section excludes routine physical examinations.Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically 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; Section 1833(e). This section prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.Article TextThe following coding and billing guidance is to be used with its associated Local Coverage Determination.Documentation must be made available to Medicare upon request. Failure to do so, may result in denial of claims.Documentation of the medical necessity of the test must be retained in the ordering physician's patient medical record. Documentation should state the signs/symptoms and/or diagnosis that caused the need of the test procedure.Laboratories must maintain the record of the physician's order for the test.Medical records must contain the lab test results.When requesting an individual consideration through the written redetermination (formerly appeal) process, providers must include all relevant medical records and literature that supports the request. At a minimum two (2) Phase II studies (human feasibility studies suggesting efficacy, pilots) or one (1) Phase III study (primary evidence of safety and efficacy, pivotal) must be submitted for the Medical Director's review.
Article - Billing and Coding: Blepharoplasty, Eyelid Surgery, and Brow Lift (A57190)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be medically 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.Title XVIII of the Social Security Act, 1862(a)(10), prohibits payment for cosmetic surgery; procedures performed only to approve appearances without a functional benefit are not covered by Medicare, except as required for the prompt repair of accidental injury or for improvement of the functioning of a malformed body member.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 16, 20, Services not reasonable and necessary.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 16, 120, Cosmetic Surgery.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Other requirementsThe medical record documentation must support the medical necessity of the services as directed in this policy.All documentation must be maintained in the patients medical record and 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)).Documentation must support CMS signature requirements as described in the Medicare Program Integrity Manual (Pub. 100-08), Chapter 3.A pre-operative exam and operative report must be available.The submitted medical record must support the use of the selected ICD10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
Article - Billing and Coding: Blepharoplasty, Eyelid Surgery, and Brow Lift (A57191)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be medically 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.Title XVIII of the Social Security Act, 1862(a)(10), prohibits payment for cosmetic surgery; procedures performed only to approve appearances without a functional benefit are not covered by Medicare, except as required for the prompt repair of accidental injury or for improvement of the functioning of a malformed body member.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 16, 20, Services not reasonable and necessary.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 16, 120, Cosmetic Surgery.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Other requirementsThe medical record documentation must support the medical necessity of the services as directed in this policy.All documentation must be maintained in the patients medical record and 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)).Documentation must support CMS signature requirements as described in the Medicare Program Integrity Manual (Pub. 100-08), Chapter 3.A pre-operative exam and operative report must be available.The submitted medical record must support the use of the selected ICD10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
Article - Billing and Coding: Serum Magnesium (A57198)

CMS National Coverage PolicyTitle XVIII of the Social Security Act; Section 1862(a)(7). This section excludes routine physical examinations.Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically 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; Section 1833(e). This section prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.Article TextThe following coding and billing guidance is to be used with its associated Local Coverage Determination.Documentation must be made available to Medicare upon request. Failure to do so, may result in denial of claims.Documentation of the medical necessity of the test must be retained in the ordering physician's patient medical record. Documentation should state the signs/symptoms and/or diagnosis that caused the need of the test procedure.Laboratories must maintain the record of the physician's order for the test.Medical records must contain the lab test results.When requesting an individual consideration through the written redetermination (formerly appeal) process, providers must include all relevant medical records and literature that supports the request. At a minimum two (2) Phase II studies (human feasibility studies suggesting efficacy, pilots) or one (1) Phase III study (primary evidence of safety and efficacy, pivotal) must be submitted for the Medical Director's review.