evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease (A58359)

CMS National Coverage PolicyN/AArticle TextThe information in the Supplemental Instructions Article contains billing, coding, or other guidelines that complement the Noridian LCD for Non-Invasive Fractional Flow Reserves for Stable Ischemic Heart Disease.Procedure codes may be subject to National Correct Coding Initiative edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.As this service constitutes post-procedure analysis of a previously performed study (CCTA), the name and NPI of the referring/ordering physician that submitted imaging data for FFRct review must be reported on the claim.An Advance Beneficiary Notice of Non-coverage may be used for services that are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 30for complete instructions.The patients medical record must document all of the following:The clinical findings that led to the initial performance of the CCTA, and the CCTA must be fully reviewed before the performance of FFRct. (as evidenced by the submission of the Coronary Computed Tomographic Angiography Report)Description of symptoms consistent with stable ischemic heart disease.Body mass indexFractional Flow Reserve analysis report&mdash;&mdash;&mdash;panel&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;panel&mdash;&mdash;&mdash;Coding Information
Article - Billing and Coding: Colon Capsule Endoscopy (A58362)

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) L38777 Colon Capsule Endoscopy (CCE). 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.For the purposes of this Article, ICD-10-CM codeZ53.8indicates that the instrument colonoscopy has been attempted and was incomplete and Z53.09 indicates the procedure is contraindicated when a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training determined from an evaluation of the patient that optical colonoscopy cannot be safely attempted.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: Extracorporeal Shock Wave Therapy (ESWT) (A58367)

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 Extracorporeal Shock Wave Therapy (ESWT)L38775.
Article - Billing and Coding: MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (A58371)

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 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease L38303.To report a Prostate Genomic Classifier service, please submit the following claim information:Select applicable 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 ICD-10-CM code C61
Article - Billing and Coding: Dexamethasone Intracanalicular Ophthalmic Insert (Dextenza®) (A58392)

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 Dexamethasone Intracanalicular Ophthalmic Insert (Dextenza)L38792.
Article - Billing and Coding: Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease (A58406)

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 claimCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 30 Financial Liability ProtectionsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease L38278.As this service constitutes post-procedure analysis of a previously performed study (CCTA), the name and National Provider Identifier (NPI) of the referring/ordering physician that submitted imaging data for FFRCTreview must be reported on the claim.An Advance Beneficiary Notice (ABN) of non-coverage may be used for services that are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 30 for complete instructions.The patients medical record must document all of the following:The clinical findings that led to the initial performance of the CCTA, and the CCTA must be fully reviewed before the performance of FFRCT(as evidenced by the submission of the Coronary Computed Tomographic Angiography Report)Description of symptoms consistent with stable ischemic heart diseaseFractional Flow Reserve analysis report
Article - Billing and Coding: Colon Capsule Endoscopy (CCE) (A58410)

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) L38805 Colon Capsule Endoscopy (CCE). 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.For the purposes of this Billing and Coding Article, ICD-10-CM diagnosis codeZ53.8indicates that the instrument colonoscopy has been attempted and was incomplete and ICD-10-CM diagnosis codeZ53.09indicates the procedure is contraindicated when a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training determined from an evaluation of the patient that optical colonoscopy cannot be safely attempted.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: Colon Capsule Endoscopy (CCE) (A58414)

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) L38807 Colon Capsule Endoscopy (CCE). 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.For the purposes of this Billing and Coding Article, ICD-10-CM diagnosis codeZ53.8indicates that the instrument colonoscopy has been attempted and was incomplete and ICD-10-CM diagnosis codeZ53.09indicates the procedure is contraindicated when a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training determined from an evaluation of the patient that optical colonoscopy cannot be safely attempted.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: Diagnostic Colonoscopy (A58428)

CMS National Coverage PolicySocial Security Act (Title XVIII) Standard ReferencesTitle 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) L38812 (Diagnostic Colonoscopy). 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.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.Medical record documentation (office/progress notes) maintained by the ordering/referring physician must indicate the medical necessity of the colonoscopy procedure. The procedure results/report and any associated pathology report must be included in the patient's medical record.If the provider of the colonoscopy is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of procedure results/report and pathology report along with copies of the ordering/referring physician's order for the procedure.The patients medical record should contain documentation to support an incomplete procedure.
Article - Billing and Coding: Colon Capsule Endoscopy (CCE) (A58436)

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) L38824, Colon Capsule Endoscopy (CCE). Please refer to the LCD for reasonable and necessary requirements.Coding Information:Notice: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.For the purposes of this Billing and Coding Article, ICD-10-CM diagnosis codeZ53.8indicates that the instrument colonoscopy has been attempted and was incomplete and ICD-10-CM diagnosis codeZ53.09indicates the procedure is contraindicated when a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training determined from an evaluation of the patient that optical colonoscopy cannot be safely attempted.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 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: Colon Capsule Endoscopy (CCE) (A58438)

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) L38826, Colon Capsule Endoscopy (CCE). Please refer to the LCD for reasonable and necessary requirements.Coding Information:Notice: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.For the purposes of this Billing and Coding Article, ICD-10-CM diagnosis codeZ53.8indicates that the instrument colonoscopy has been attempted and was incomplete and ICD-10-CM diagnosis codeZ53.09indicates the procedure is contraindicated when a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training determined from an evaluation of the patient that optical colonoscopy cannot be safely attempted.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 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: Colon Capsule Endoscopy (CCE) (A58471)

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 TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD L38837 Colon Capsule Endoscopy (CCE).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.For the purposes of this Billing and Coding Article, ICD-10-CM diagnosis codeZ53.8indicates that the instrument colonoscopy has been attempted and was incomplete and ICD-10-CM diagnosis codeZ53.09indicates the procedure is contraindicated when a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training determined from an evaluation of the patient that optical colonoscopy cannot be safely attempted.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: Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease (A58473)

CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L38839 for Non-Invasive Fractional Flow Reserves (FFR) for Ischemic Heart Disease.Procedure codes may be subject to National Correct Coding Initiative edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.As this service constitutes post-procedure analysis of a previously performed study Coronary Computed Tomographic Angiography (CCTA), the name and NPI of the referring/ordering physician that submitted imaging data for FFRct review must be reported on the claim.An Advance Beneficiary Notice of Non-coverage may be used for services that are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30 for complete instructions.The patients medical record must document all of the following:The clinical findings that led to the initial performance of the CCTA, and the CCTA must be fully reviewed before the performance of FFRct. (as evidenced by the submission of the Coronary Computed Tomographic Angiography Report)Description of symptoms consistent with stable ischemic heart diseaseBody mass indexFractional Flow Reserve analysis report
Article - Billing and Coding: Complex Drug Administration Coding (A58527)

Anifrolumab-fniaSaphneloJ0491belataceptNulojixJ0485bezlotoxumabZinplavaJ0565eculizumabSolirisJ1300edaravoneRadicavaJ1301filgrastim (g-csf) excludes biosimilars***Neupogen***J1442***filgrastim-sndz, biosimilar***Zarxio***Q5101***filgrastim-aafi***Nivestym***Q5110***golimumabSimponi AriaJ1602natalizumabTysabriJ2323octreotide acetate non-depot**Sandostatin**J2354**patisiranOnpattroJ0222remdesivirVekluryJ0248reslizumabCinqairJ2786ustekinumab*Stelara*J3358*vedolizumabEntyvioJ3380*Effective September 23, 2016, IV ustekinumab (Stelara) should be billed with HCPCS J3590 (OPPS: C9399 for dates of service (DOS)before04/01/2017; C9487 for DOS from 04/01/2017 to 06/30/17, Q9989 for DOS from 07/01/2017-12/31/17 and J3358 for DOS 01/01/2018 and after) for the initial IV dose of Stelarawhen used for Crohns disease and Ulcerative Colitis. Each subsequent subcutaneous dosemustbe billed with J3357. This IV formulation is now FDA approved for Crohns disease and Ulcerative Colitis. On and after July 31, 2017, both the drug and administration should be billed on the same claim with no other drugs or administration to prevent inappropriate claim rejection.**When billing octreotide acetate (HCPCS code J2354), append the JA modifier for the IV formulation or the JB modifier for the subcutaneous formulation. The subcutaneous (SQ) form is on the Self-Administered Drug Exclusion List (SAD List).***When billing filgrastim (HCPCS codes J1442, Q5101, Q5110), append the JA modifier for the IV formulation or the JB modifier for the subcutaneous formulation.****When billing abatacept (HCPCS code J0129), append the JA modifier for the IV formulation or the JB modifier for the subcutaneous formulation. The SQ form is on the SAD List.