evekhm/cms_iom_3000 huggingface dataset:
Draft Article - Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) (DA59682)

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 Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) DL39802.Coding InformationProcedure codes may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and National Provider Identifier (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 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise, the symptoms prompting the performance of the test should be reported.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD (SeeCoverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Medical record documentation must be available to Medicare upon request.
Draft Article - Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) (DA59695)

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 Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) DL39810.Coding InformationProcedure codes may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and National Provider Identifier (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 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise, the symptoms prompting the performance of the test should be reported.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD (SeeCoverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Medical record documentation must be available to Medicare upon request.
Draft Article - Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) (DA59697)

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 Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) DL39812.Coding InformationProcedure codes may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and National Provider Identifier (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 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise, the symptoms prompting the performance of the test should be reported.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD (SeeCoverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Medical record documentation must be available to Medicare upon request.
(Medicare Part D Manual)

Sponsor A  Plan EFG (non- formulary and/or UM criteria)  Yes Non- formulary change; potential interruption of coverage  Sponsor B  Plan JKL (on formulary)  No No interruption of coverage   Sponsor B  Plan JKL (non- formulary and/or UM criteria)  Yes Non- formulary change; potential interruption of coverage  Sponsor A  Plan  DEF (non-formulary)  [filled  under exception]  Any Sponsor  Any Plan  (on formulary)   No No interruption of coverage   Sponsor A  Plan DEF (non- formulary)   Yes Plans may approve an exception or transition to a formulary item prior to the new contract year  Sponsor A  Plan DEF (on formulary, with UM criteria)   Yes Plans may approve an exception or transition to a formulary item prior to the new contract year  Sponsor B  Plan MNO (non -formulary and/or UM criteria)  Yes Potential interruption of coverage     Transmittals Issued for this Chapter   Rev #  Issue Date  Subject  Impl Date  CR#  R18PDB  01/15/2016  Chapter 6 Part D Drugs and Formulary Requirements  01/15/2016  01/15/2016  R10PDB  02/12/2010  Chapter 6 Part D Drugs and Formulary Requirements  03/01/2010  N/A R2PDB  07/18/2008  Initial release of chapter  07/18/2008  N/A
(Medicare Benefit Policy Manual)

The above described letter, serving as the provider's determination of program reimbursement, shall include the following language:   This notice is the Medicare contractors final determination for purposes of appeal rights.  If you disagree with this determination, you may file an appeal, in accordance with 42 CFR 418.311 and 42 CFR, part 405, subpart R.  The appeal should be filed wi th either the applicable Medicare contractor or the Provider Reimbursement Review Board (PRRB), depending on the amount in controversy.  Appeal requests must be in writing and be filed within 180 days from the date of this determination.                                        Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12400BP   12/06/2023 Hospice Benefit Policy Manual Updates Related to the Addition of Marriage and Family Therapists (MFTs) or Mental Health Counselors (MHCs) to the Hospice Interdisciplinary Team  01/02/2024  13437  R12385BP   11/30/2023 Hospice Benefit Policy Manual Updates Related to the Addition of Marriage and Family Therapists (MFTs) or Mental Health Counselors (MHCs) to the Hospice Interdisciplinary Team - Rescinded and Replaced by Transmittal 12400  01/02/2024  13437  R11056BP  10/22/2021 Manual Updates for Clarification on the Election Statement Addendum and Extension of the Hospice Cap Calculation Methodology 12/22/2021  12491  R10437BP  11/06/2020 Manual Updates Related to the Hospice Election Statement and the Implementation of the Election Statement Addendum  12/09/2020  12015  R246BP  09/14/2018 Manual Updates Related to Payment Policy Changes Affecting the Hospice Aggregate Cap Calculation and the Designation of Hospice Attending Physicians  12/17/2018  10517  R209BP  05/08/2015 Updates on Hospice Election Form, Revocation, and Attending Physician 05/04/2015  9114 R205BP  04/03/2015 Updates on Hospice Election Form, Revocation, and Attending Physician  Rescinded and replaced by Transmittal 209 05/04/2015  9114 R188BP  05/01/2014 Updates and Clarifications to the Hospice Policy Chapter of the Benefit Policy Manual  08/04/2014  8727 R156BP  06/01/2012 Updates to Caps and Limitations on Hospice Payments  07/02/2012  7838 R141BP  03/02/2011 New Hospice Certification Requirements and Revised Conditions of Participation (CoPs) 03/23/2011  7337 R121BP  02/05/2010 Medicare Systems Edits Refinements Related to Hospice Services  07/06/2010  6778 R28BP  12/03/2004 Hospice Pre- Election Evaluation and Counseling Services  01/03/2005  3585 R22BP  10/24/2004 Nurse Practitioners As Attending Physicians in the Medicare Hospice Benefit  06/28/2004  3226 R15BP  06/15/2004 Nurse Practitioners As Attending Physicians in the Medicare Hospice Benefit  N/A 3226 R1BP  10/01/2003 Introduction to the Benefit Policy Manual  N/A N/A Back to top of Chapter
(Change Management Web Portal - CR Detail)

C.   Immunosuppressive Drugs  See the Med icare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 50.5. 1 and the Medicare  Claim s Processing Manual, Chapter 17, Drugs and Biologicals,  80.3.  300.1 - Obsolete or Unreliable Diagnostic Tests (Rev. 48, Issued:  03-17-06; Effectiv e/Implementation Dates:  06-19-06) CIM 50-34  A.   Diagno stic Tests   Do not routinely pay for the followin g diagnosti c tests b ecause they are o bsolete and have been replaced by m ore advanced procedures.  The listed tests m ay be paid for only if the medical need for the procedure is satisfactorily jus tified by the physician who perform s it.  When the se rvices are su bject to the Qua lity Im provem ent Organiza tion ( QIO) Review, the QIO is responsible for determ ining that satisfactory m edical jus tification exists.    When the services are no t subject to QIO Review, the in termediary or carrier is responsible for determ ining that satisfactory m edical justification exis ts.  This includes:   Amylase, blood isoenzym es, electrophoretic,  Chro mium, blood,  Guanase, blood,  Zinc sulphate turbidity, blood,  Skin test, ca t scra tch fever,  Skin test, lymphopathia venereum ,  Circulation tim e, one test,  Cephalin f loccula tion,  Congo red, blood,  Hormones, adrenocorticotropin quantita tive an imal te sts,  Hormones, adrenocorticotropin quantitative bioassay,  Thymol turbidity, blood,   Skin test, ac tinom ycosis,  Skin test, br ucello sis,  Skin test, ps ittacosis,  Skin test, tr ichinosis,  Calcium , feces, 24-hour quantitative,   Starch, feces , screen ing,  Chymotrypsin, duodenal contents,  Gastric analysis, peps in,  Gastric analysis, tubeles s,  Calcium  saturation clo tting tim e,  Capilla ry fragility te st (R umpel-Leed e),   Colloida l gold,  Bendiens test for cancer and tubercu losis,  Bolens test for cancer,  Rehfuss test for gastric acidity, and  Serum  seromucoid assay for cancer and other d iseases.  B.   Cardiovascular Tests   Do not pay for the following phonocardiograph y and vectorcardiography diagnostic tests because they have been determ ined to be out moded and of little clinical value.  They include :   Phonocardiogram  with or without E CG lead; with supervision during recording with interpretation and report (when e quipm ent is supplied by the physician),  Phonocardiogram ; tracing only, without interpretation and report (e.g., w hen equipm ent is supplied b y the hospita l, clinic ),  Phonocardiogram ; interpretation and report,  Phonocardiogram  with ECG lead, with indir ect carotid artery and/or jugular vein tracing, and/or apex cardiogram ; with inte rpretation and repo rt,  Phonocardiogram ; without interpretation and report,  Phonocardiogram ; interpre tation and report only,   Intracard iac,  Vectorcardiogram  (VCG), w ith or without ECG; with interpretation and report,  Vectorcardiogram ; tracing only, without interpretation and report, and  Vectorcardiogram ; interp retation and report only.
(Medicare National Coverage Determinations Manual)

280.14 Infusion Pumps CIM 60-14 280.5 Safety Roller CIM 60-15 280.6 Pneumatic Compression Devices CIM 60-16 240.4 Continuous Positive Airway Pressure (CPAP) CIM 60-17 280.7 Hospital Beds CIM 60-18 280.8 Air-Fluidized Bed CIM 60-19 280.13 Transcutaneous Electrical Nerve Stimulators (TENS) CIM 60-20 240.5 Intrapulmonary Percussive Ventilator (IPV) CIM 60-21 NCD Section Title CIM Section  160.18 Vagus Nerve Stimulation for Treatment of Seizures CIM 60-22 50.1 Speech Generating Devices CIM 60-23 230.8 Non-Implantable Pelvic Flood Electrical Stimulator CIM 60-24 270.2 Noncontact Normothermic Wound Therapy (NNWT) CIM 60-25 280.2 White Cane for Use by a Blind Person CIM 60-3 240.2 Home Use of Oxygen CIM 60-4 280.9 Power Operated Vehicles That May Be Used as Wheelchairs CIM 60-5 280.3 Specially Sized Wheelchairs CIM 60-6 20.8.2 Self-Contained Pacemaker Monitors CIM 60-7 280.4 Seat Lift CIM 60-8 280.1 Durable Medical Equipment Reference List CIM 60-9 80.5 Scleral Shell CIM 65.3 80.4 Hydrophilic Contact Lenses CIM 65-1 180.2 Enteral and Parenteral Nutritional Therapy CIM 65-10 230.16 Bladder Stimulators (Pacemakers) CIM 65-11 160.19 Phrenic Nerve Stimulator CIM 65-13 50.3 Cochlear Implantation CIM 65-14 20.9 Artificial Hearts and Related Devices CIM 65-16 50.4 Tracheostomy Speaking Valve CIM 65-165 230.17 Urinary Drainage Bags CIM 65-17 230.18 Sacral Nerve Stimulation for Urinary IncontinenceCIM 65-18 NCD Section Title CIM Section  Incontinence 160.24 Deep Brain Stimulation for Essential Tremor and Parkinsons Disease CIM 65-19 230.15 Electrical Continence Aid CIM 65-2 160.6 Carotid Sinus Nerve Stimulator CIM 65-4 50.2 Electronic Speech Aids CIM 65-5 20.8 Cardiac Pacemakers CIM 65-6 80.12 Intraocular Lenses (IOLs) CIM 65-7 160.7 Electrical Nerve Stimulators CIM 65-8 230.10 Incontinence Control Devices CIM 65-9 280.11 Corset Used as Hernia Support CIM 70-1 280.12 Sykes Hernia Control CIM 70-2 280.10 Prosthetic Shoe CIM 70-3 170.1 Institutional and Home Care Patient Education Programs  CIM 80-1 40.1 Diabetes Outpatient Self-Management Training CIM 80-2 180.1 Medical Nutrition Therapy CIM 80-3 290.1 Home Health Visits to a Blind Diabetic CIM 90-1 290.2 Home Health Nurses' Visits to Patients Requiring Heparin Injections CIM 90-2
1.2_BofA_120907.pdf

Page 1 of 6Medicare Summary Noticefor Part B (Medical Insurance)The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid ServicesTHIS IS NOT A BILLJENNIFER WASHINGTON  TEMPORARY ADDRESS NAMESTREET ADDRESSCITY, ST 12345-6789Your Deductible StatusYour deductible is what you must pay for most health services before Medicare begins to pay. Part B Deductible:  You have now met $85.00  of your $162.00  deductible for 2011. Be Informed!Register at www.MyMedicare.gov for direct access to your Original Medicare claims, track your preventive services and print an On the Go report to share with your provider. Visit the Web site to sign up and access your personal Medicare information.Notice for Jennifer WashingtonMedicare Number XXX-XX-1234ADate of This Notice September 16, 2011Claims Processed  BetweenJune 15   September 15, 2011Your Claims & Costs This PeriodDid Medicare Approve All Services? YESSee page 2 for how to double-check this notice.Total You May Be Billed $0.00Facilities with Claims This PeriodJuly 19  August 22, 2011  The New York and Presbyterian HospitalSaba que puede recibir este aviso y otro tipo de ayuda de Medicare en espaol? Llame y hable con un agente en espaol.     agent ,  Mandarin .                   1-800-MEDICARE (1-800-633-4227)Exhibit 1.2  B of ATHIS IS NOT A BILL | Page 2 of 6 Jennifer WashingtonMaking the Most of Your Medicare   How to Check This NoticeDo you recognize the name of each facility?  Check the dates.Did you get the claims listed?  Do they match those listed on your receipts and bills? If you already paid the bill, did you pay the right amount?  Check the maximum you may be billed. See if the claim was sent to your Medicare supplement insurance (Medigap) plan or other insurer. That plan may pay your share.  How to Report FraudIf you think a facility or business is involved in fraud, call us at 1-800-MEDICARE (1-800-633-4227).Some examples of fraud include offers for free medical services, or billing you for Medicare services you didnt get. If we determine that your tip led to uncovering fraud, you may qualify for a reward.You can make a difference!  Last year, Medicare saved tax-payers $4 billion the largest sum ever recovered in a single yearthanks to people who reported suspicious activity to Medicare.
1.6_PartB_Assigned_120907.pdf

Page 1 of 5Medicare Summary Noticefor Part B (Medical Insurance)The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid ServicesYour Deductible StatusYour deductible is what you must pay for most health services before Medicare begins to pay. Part B Deductible:  You have now met $85.00  of your $162.00  deductible for 2011. Be Informed!Register at www.MyMedicare.gov for direct access to your Original Medicare claims, track your preventive services and print an On the Go report to share with your provider. Visit the Web site to sign up and access your personal Medicare information.THIS IS NOT A BILLJENNIFER WASHINGTON  TEMPORARY ADDRESS NAMESTREET ADDRESSCITY, ST 12345-6789Your Claims & Costs This PeriodDid Medicare Approve All Services? NONumber of Services Medicare Denied 2See claims starting on page 3. Look for NO in the Service Approved? column. See the last page for how to handle a denied claim. Total You May Be Billed $150.86Providers with Claims This PeriodJune 18, 2011  Susan Jones, M.D.June 28, 2011  Craig I. Secosan, M.D. June 29  June 30, 2011  Edward J. Mcginley M.D. Saba que puede recibir este aviso y otro tipo de ayuda de Medicare en espaol? Llame y hable con un agente en espaol.     agent ,  Mandarin .                   1-800-MEDICARE (1-800-633-4227)Notice for Jennifer WashingtonMedicare Number XXX-XX-1234ADate of This Notice September 16, 2011Claims Processed  BetweenJune 15   September 15, 2011Exhibit 1.6  Part B, AssignedTHIS IS NOT A BILL | Page 2 of 5 Jennifer WashingtonMaking the Most of Your Medicare   How to Check This NoticeDo you recognize the name of each doctor or provider?  Check the dates. Did you have an appointment that day? Did you get the services listed?  Do they match those listed on your receipts and bills?If you already paid the bill, did you pay the right amount?  Check the maximum you may be billed. See if the claim was sent to your Medicare supplement insurance (Medigap) plan or other insurer. That plan may pay your share.   How to Report FraudIf you think a provider or business is involved in fraud, call us at 1-800-MEDICARE  (1-800-633-4227). Some examples of fraud include offers for free medical services, or billing you for Medicare services you didnt get. If we determine that your tip led to uncovering fraud, you may qualify for a reward.You can make a difference!  Last year, Medicare saved tax-payers $4 billion the largest sum ever recovered in a single yearthanks to people who reported suspicious activity to Medicare.
2.12_Combined_PartB_120907.pdf

Page 1 of 8Medicare Summary Noticefor Part B (Medical Insurance)The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid ServicesYour Deductible StatusYour deductible is what you must pay for most health services before Medicare begins to pay. Part B Deductible:  You have now met your $162.00  deductible for 2011. Be Informed!Register at www.MyMedicare.gov for direct access to your Original Medicare claims, track your preventive services and print an On the Go report to share with your provider. Visit the Web site to sign up and access your personal Medicare information.THIS IS NOT A BILLJENNIFER WASHINGTON  TEMPORARY ADDRESS NAMESTREET ADDRESSCITY, ST 12345-6789Your Claims & Costs This PeriodDid Medicare Approve All Services? NONumber of Services Medicare Denied 2See claims starting on page 3. Look for NO in the Service Approved? column. See the last page for how to handle a denied claim. Total You May Be Billed $27.30Providers with Claims This PeriodJune 18  20, 2011  Susan Jones, M.D.June 9  June 24, 2011  Behavioral Medicine Ins Saba que puede recibir este aviso y otro tipo de ayuda de Medicare en espaol? Llame y hable con un agente en espaol.     agent ,  Mandarin .                   1-800-MEDICARE (1-800-633-4227)Notice for Jennifer WashingtonMedicare Number XXX-XX-1234ADate of This Notice September 16, 2011Claims Processed  BetweenJune 15   September 15, 2011Exhibit 2.12  Combined Claims, Part B Assigned and UnassignedTHIS IS NOT A BILL | Page 2 of 8 Jennifer WashingtonMaking the Most of Your Medicare   How to Check This NoticeDo you recognize the name of each doctor or provider?  Check the dates. Did you have an appointment that day? Did you get the services listed?  Do they match those listed on your receipts and bills?If you already paid the bill, did you pay the right amount?  Check the maximum you may be billed. See if the claim was sent to your Medicare supplement insurance (Medigap) plan or other insurer. That plan may pay your share.   How to Report FraudIf you think a provider or business is involved in fraud, call us at 1-800-MEDICARE  (1-800-633-4227). Some examples of fraud include offers for free medical services, or billing you for Medicare services you didnt get. If we determine that your tip led to uncovering fraud, you may qualify for a reward.You can make a difference!  Last year, Medicare saved tax-payers $4 billion the largest sum ever recovered in a single yearthanks to people who reported suspicious activity to Medicare.
2.13_Pay_120907.pdf

MEDICARE PART B CHECKDO NOT DESTROYPLEASE CASH AS SOON AS POSSIBLEHARRIETT I ANSARI BAHMAN  9 JOCKEY LANENEW CITY, NY 10956-6608MEDICARE PAYMENTFOR HEALTH INSURANCE  SOCIAL SECURITY ACTExhibit 2.13  Pay Check PageMEDICARE PART B CHECKDO NOT DESTROYPLEASE CASH AS SOON AS POSSIBLEHARRIETT I ANSARI BAHMAN  9 JOCKEY LANENEW CITY, NY 10956-6608MEDICARE PAYMENTFOR HEALTH INSURANCE  SOCIAL SECURITY ACTMedicare Summary Noticefor Part B (Medical Insurance)The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid ServicesExhibit 2.13  Pay Check Page with Title BarMedicare Summary Noticefor Part B (Medical Insurance)The Official Summary of Your Medicare Claims from the Centers for Medicare & Medicaid ServicesYour Deductible StatusYour deductible is what you must pay for most health services before Medicare begins to pay. Part B Deductible:  You have now met your $162.00  deductible for 2011. Be Informed!Register at www.MyMedicare.gov for direct access to your Original Medicare claims, track your preventive services and print an On the Go report to share with your provider. Visit the Web site to sign up and access your personal Medicare information.HARRIETT I ANSARI BAHMAN  9 JOCKEY LANENEW CITY, NY 10956-6608Saba que puede recibir este aviso y otro tipo de ayuda de Medicare en espaol? Llame y hable con un agente en espaol.     agent ,  Mandarin .                   1-800-MEDICARE (1-800-633-4227)Your Claims & Costs This PeriodDid Medicare Approve All Services? YESSee page 2 for how to double-check this notice.Total You May Be Billed $0.00Providers with Claims This PeriodJune 18, 2011  Bruce M RodinPage 1 of 4CHECK ENCLOSEDThis Is Not A BillNotice for Jennifer WashingtonMedicare Number XXX-XX-1234ADate of This Notice July 15, 2011Claims Processed July 15, 2011Exhibit 2.13  Pay MSN page 1