evekhm/cms_iom_3000 huggingface dataset:
(Medicare Claims Processing Manual)

For services on or after October 1, 2015, the following ICD-10 diagnosis code is  covered for bariatric surgery if certain other conditions are met:  E66.01 - Morbid (severe) obesity due to excess calories  Effective for services performed on and after February 12, 2009, type 2 diabetes mellitus (T2DM) is considered a comorbid condition related to morbid obesity for covered bariatric surgery procedures in Medicare beneficiaries with a BMI 35. When T2DM is the comorbid condition related to morbid obesity, the claim must include a covered ICD procedure code, ICD diagnosis code E66.01 as a primary diagnosis, a covered ICD diagnosis code indicating T2DM as a secondary diagnosis, and an ICD diagnosis code indicating a BMI  35 as a secondary diagnosis.   150.5 - ICD Diagnosis Codes for BMI 35 (Rev. 11021; Issued: 10-01- 21; Effective: 10 -29-21; Implementation: 10-29-21)  The following ICD- 10 diagnosis codes identify BMI 35:   Z68.35 - Body Mass Index 35.0-35.9, adult  Z68.36 - Body Mass Index 36.0-36.9, adult  Z68.37 - Body Mass Index 37.0-37.9, adult  Z68.38 - Body Mass Index 38.0-38.9, adult Z68.39 - Body Mass Index 39.0-39.9, adult  Z68.41 - Body Mass Index 40.0-44.9, adult  Z68.42 - Body Mass Index 45.0-49.9, adult  Z68.43 - Body Mass Index 50.0-59.9, adult  Z68.44 - Body Mass Index 60.0-69.9, adult  Z68.45 - Body Mass Index 70.0 and over, adult  150.5.1  ICD Codes for Type II Diabetes Mellitus Complication  (Rev. 11021; Issued: 10-01- 21; Effective: 10 -29-21; Implementation: 10-29-21)
(Medicare Claims Processing Manual)

C. Billing   In order to receive Medicare coverage for patients participating in post -approval extension studies, providers shall submit both the FDA acknowledgement letter and the CMS letter providing coverage for the extension study to their contractor. Additionally, providers shall submit any other materials contractors would require for FDA -approved post - approval studies.  In response, contractors will issue a letter assigning an effective date for each facilitys participation in the extension study. Providers may bill for procedures performed in the extension study for dates of service on and after the assigned effective d ate. Providers billing A/B MACs (A) must bill using the most current ICD-10-CM is applicable, Indications for PTA of the Carotid Artery Concurrent with Stenting (must bill one of these primary codes to meet coverage under 20.7B2, 20.7B3, 20.7B4)   I63.031  Cerebral infarction due to thrombosis of right carotid artery  I63.032  Cerebral infarction due to thrombosis of left carotid artery  I63.033  Cerebral infarction due to thrombosis of bilateral carotid arteries  I63.131  Cerebral infarction due to embolism of right carotid artery  I63.132  Cerebral infarction due to embolism of left carotid artery  I63.133  Cerebral infarction due to embolism of bilateral carotid arteries  I63.231  Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries  I63.232  Cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries  I63.233  Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries  I65.21  Occlusion and stenosis of right carotid artery  I65.22  Occlusion and stenosis of left carotid artery  I65.23  Occlusion and stenosis of bilateral carotid arteries    ICD-10-PCS codes may be used.
Article - NCD - Pharmacogenomic Testing for Warfarin Response (A53848)

CMS National Coverage PolicyN/AArticle TextBased on National Coverage Determination (NCD) 90.1 - Pharmacogenomic Testing for Warfarin Response, gene testing on CYP2C9 and/or VKORC1 will only be covered through coverage with evidence development (CED). Testing will be limited to once in a lifetime per beneficiary. Only genetic testing services for beneficiaries who meet the NCD criteria and are enrolled in a clinical trial will be reimbursed.Lab providers that perform services on eligible beneficiaries and described by Current Procedural Terminology (CPT) codes 81227 and 81355 must submit the following claim items:Healthcare Common Procedure Coding System (HCPCS) code:G9143(warfarin responsiveness testing by genetic technique using any method, any number of specimen(s))ICD-10-CM code:Z00.6(Examination of participant in clinical trial)HCPCS modifierQO(Investigational clinical service provided in a clinical research study that is in an approved clinical research study)Enter the appropriate identifier adjacent to HCPCS code G9143 in the comment/narrative field of the electronic or paper claim.Note:Report only HCPCS code G9143 and 1 unit of service. Do not report CPT codes 81227 and/or 81355 on the claim.References:Medicare National Coverage Determinations (NCD) 90.1 - Pharmacogenomic Testing for warfarin ResponseMedicare Claims Processing Manual (Pub 100-04), Chapter 32, Section 250 - Pharmacogenomic Testing for warfarin Response.
Article - Dropless Cataract Surgery (A53916)

CMS National Coverage PolicyN/AArticle TextNoridian Healthcare Solutions has become aware of a relatively new technique where a retrozonular or intravitreal injection of compounded antibiotics and or steroids are administered at the conclusion of cataract surgery (CPT 66984 or 66982 or related codes) as a means of reducing or eliminating the need for post-operative topical medications ("dropless" cataract surgery).Noridian states that such injections are integral to the surgery being performed and are bundled with the cataract surgery code for both the physician and facility. Therefore, billing either Medicare or the patient for these services separately is not appropriate. Furthermore, because they are considered integral to and bundled with these codes, it is inappropriate to include such services when performed  as a separately itemized part of a "package" related to the insertion of a premium intraocular lens.There may be rare cases where services represented by intravitreal injection code (67028) and a drug code (J-series) need to be provided in the contralateral eye. In such cases the surgical code and the injection and drug codes should be appended with either a RT or a LT to reflect which eye the cataract surgery was performed on and which eye received the injection. Do not use modifier -59 in such cases as the claim will deny.
Article - Dropless Cataract Surgery (A53918)

CMS National Coverage PolicyN/AArticle TextNoridian Healthcare Solutions has become aware of a relatively new technique where a retrozonular or intravitreal injection of compounded antibiotics and or steroids are administered at the conclusion of cataract surgery (CPT 66984 or 66982 or related codes) as a means of reducing or eliminating the need for post-operative topical medications ("dropless" cataract surgery).Noridian states that such injections are integral to the surgery being performed and are bundled with the cataract surgery code for both the physician and facility. Therefore, billing either Medicare or the patient for these services separately is not appropriate. Furthermore, because they are considered integral to and bundled with these codes, it is inappropriate to include such services when performed as a separately itemized part of a "package" related to the insertion of a premium intraocular lens.There may be rare cases where services represented by intravitreal injection code (67028) and a drug code (J-series) need to be provided in the contralateral eye. In such cases the surgical code and the injection and drug codes should be appended with either a RT or a LT to reflect which eye the cataract surgery was performed on and which eye received the injection. Do not use modifier -59 in such cases as the claim will deny.
Article - Fracture of Ribs with Internal Fixation (A53931)

CMS National Coverage PolicyN/AArticle TextMost injuries to the chest wall do not result in long-term respiratory dysfunction and operative indications for chest wall injuries are rare. Recent studies have explored the option of internal fixation of rib fracture for treatment of complex rib fractures, including flail chest, open fracture, symptomatic nonunion, and thoracotomy for other indications. Flail chest is diagnosed when multiple, consecutive ribs are fractured in two or more places, creating an incompetent region of the chest wall.Internal Fixation is indicated to stabilize and provide fixation for fractures, fusions, and osteotomies of the ribs. The Modular RibLoc System consists of plates and screws for fractures, fusions, and osteotomies. The plates are pre-contoured to minimize bending that is done intra-operatively. Instrumentation is supplied with the implants to aid in the insertion of the plates and screws. All plates and screws are manufactured from titanium or titanium alloy.Palmetto GBA will cover CPT codes 21812 and 21813. CPT 21811 is not covered, as in most instances fractures involving 1-3 ribs do not require internal fixation.
Article - Billing and Coding: Spinal Fusion Services: Documentation Requirements (A53972)

CMS National Coverage PolicyN/AArticle TextNoridian Medical Review team and CERT contractor has identified multiple errors regarding documentation to support the medical necessity of spinal fusion procedures. This article clarifies medical necessity and documentation requirements regarding spinal fusion procedures.Medical NecessityHistory and PhysicalDuration/character/location/radiation of painActivity of daily living (ADL) limitationsPhysical examinationEvidence/support of prior conservative treatment measure(s) attempted*Imaging reports pertinent to performed procedureOperative report(s)Outpatient records before, during and after the procedure that support the medical necessity of performed procedures*Note: physician statement that conservative treatment measures were completed is not supportive in and by itself; contractors do require the documentation of these measures.Documentation ErrorsThe most common reason for denial of spinal fusion services is lack of specific information regarding conservative treatment measures which were attempted and failed prior to surgery. The statement "failed conservative/outpatient treatment" is not sufficient evidence of medical necessity for the procedure or inpatient admission. A detailed medical record will help to support the reasonableness of the claim.Conservative treatment modalities include but are not limited to:Physical TherapyOccupational TherapyJoint Injections/Epidural InjectionsAnti-inflammatory/Analgesic medicationsAssistive device useActivity modificationExerciseSituations arise where a fusion is approved without conservative treatment being documented clearly when an emergent situation such as "cauda equina syndrome" is present. Also if an imaging report showing severe cord compression, osteophyte formation impinging on the spinal cord, loose pedicle screws affecting stability, severe fibrosis or formation of scar tissue compressing cord or nerves, and the patient's history and physical findings correlate to the imaging the surgeon should clearly document these findings and the reasons that such findings require imminent intervention.
Article - Billing and Coding: Spinal Fusion Services: Documentation Requirements (A53975)

CMS National Coverage PolicyN/AArticle TextNoridian Medical Review team and CERT contractor has identified multiple errors regarding documentation to support the medical necessity of spinal fusion procedures. This article clarifies medical necessity and documentation requirements regarding spinal fusion procedures.Medical NecessityHistory and PhysicalDuration/character/location/radiation of painActivity of daily living (ADL) limitationsPhysical examinationEvidence/support of prior conservative treatment measure(s) attempted*Imaging reports pertinent to performed procedureOperative report(s)Outpatient records before, during and after the procedure that support the medical necessity of performed procedures*Note: physician statement that conservative treatment measures were completed is not supportive in and by itself; contractors do require the documentation of these measures.Documentation ErrorsThe most common reason for denial of spinal fusion services is lack of specific information regarding conservative treatment measures which were attempted and failed prior to surgery. The statement "failed conservative/outpatient treatment" is not sufficient evidence of medical necessity for the procedure or inpatient admission. A detailed medical record will help to support the reasonableness of the claim.Conservative treatment modalities include but are not limited to:Physical TherapyOccupational TherapyJoint Injections/Epidural InjectionsAnti-inflammatory/Analgesic medicationsAssistive device useActivity modificationExerciseSituations arise where a fusion is approved without conservative treatment being documented clearly when an emergent situation such as "cauda equina syndrome" is present. Also if an imaging report showing severe cord compression, osteophyte formation impinging on the spinal cord, loose pedicle screws affecting stability, severe fibrosis or formation of scar tissue compressing cord or nerves, and the patient's history and physical findings correlate to the imaging the surgeon should clearly document these findings and the reasons that such findings require imminent intervention.
Article - Billing and Coding: Percutaneous Ventricular Assist Device (A53986)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claimArticle TextPercutaneous insertion of an endovascular cardiac assist device will be covered under limited conditions. Until the literature clearly demonstrates the efficacy of the treatment approach, coverage may be made only in the following three life-threatening situations and only when external counterpulsation (intra-aortic balloon pump, IABP) is not expected to be sufficient:Cardiogenic shock ICD-10-CM code R57.0; orSevere decompensated heart failure with threatening multi-organ failure, represented by one of the following ICD-10 codes: I50.21, I50.23, I50.41, I50.43, I97.110, I97.111, I97.130, I97.131; orComplications/disturbances of the circulatory system intra-operatively or postoperatively: I97.790, I97.791, I97.88 and I97.89.This service will only be covered when the FDA approval guidelines are strictly adhered to.
Article - Billing and Coding: Percutaneous Ventricular Assist Device (A53988)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claimArticle TextPercutaneous insertion of an endovascular cardiac assist device will be covered under limited conditions. Until the literature clearly demonstrates the efficacy of the treatment approach, coverage may be made only in the following three life-threatening situations and only when external counterpulsation (intraaortic balloon pump, IABP) is not expected to be sufficient:Cardiogenic shock ICD-10-CM code R57.0; orSevere decompensated heart failure with threatening multi-organ failure, represented by one of the following ICD-10 codes: I50.21, I50.23, I50.41, I50.43, I97.110, I97.111, I97.130, I97.131; orComplications/disturbances of the circulatory system intra-operatively or postoperatively: I97.790, I97.791, I97.88 and I97.89.This service will only be covered when the FDA approval guidelines are strictly adhered to.Part A Providers: ICD-10-PCS codes:5A02116 - Assistance with Cardiac Output using Other Pump, Intermittent5A0211D -Assistance with Cardiac Output using Impeller Pump, Intermittent5A02216 - Assistance with Cardiac Output using Other Pump, Continuous5A0221D - Assistance with Cardiac Output using Impeller Pump, ContinuousFor Part A Services only, the provider should bill the appropriate procedure code on the UB-04 as this is an inpatient only procedure.
Article - Billing and Coding: MolDX: FDA-Approved BRAF Tests (A54018)

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 TextTwo tests have met the FDA criteria for BRAF genetic testing:Effective 09/07/2012cobas 4800 BRAF V600to detect the presence of a mutation in the BRAF gene in melanoma cells and determine if a patient is eligible for Zelboraf (vemurafenib), a treatment indicated for a melanoma that cannot be surgically excised or has spread in the body.Effective 5/29/13ThxID BRAF V600/Kto detect the BRAF V600E and V600K mutations in selecting melanoma patients whose tumors carry the BRAF V600E mutation for treatment with dabrafenib [Tafinlar] and as an aid in selecting melanoma patients whose tumors carry the BRAF V600E or V600K mutation for treatment with trametinib [Mekinist].To report an FDA approved or laboratory developed test (LDT) BRAF V600 test kit service, please submit the following claim information:CPTcode 81210Enter the appropriate DEX Z-Codeidentifier 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-Codeidentifier 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 diagnosis.NOTE: MolDX will apply NPI to ID editing on FDA approved BRAF kits. All labs that submit claims for a BRAF V600 test kitMUSTregister the test and confirm theUNMODIFIEDuse of the kit. Tests may be registered on theDEX Diagnostics Exchangehttps://app.dexzcodes.com/loginThis article reflects the FDA-approved indications on article creation date. MolDX will allow future FDA approved and amended indications for these tests.
Article - Billing and Coding: MolDX: FDA-Approved EGFR Tests (A54021)

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 TextTwo tests have met the FDA criteria for EGFR genetic testing:1. Effective 6/01/16cobas EGFR Mutation Testis a real-time PCR test for the qualitative detection of defined mutations of the epidermal growth factor receptor (EGFR) gene in non-small cell lung cancer (NSCLC) patients. Defined EGFR mutations are detected using DNA isolated from formalin-fixed paraffin-embedded tumor tissue (FFPET) or circulating-free tumor DNA (cfDNA) from plasma derived from EDTA anti-coagulated peripheral whole blood.The test is indicated as a companion diagnostic to aid in selecting NSCLC patients for treatment with the targeted therapies listed in the Table below in accordance with the approved therapeutic product labeling:DrugFFPETPlasmaTARCEVA(erlotinib)Exon 19 deletions and L858RExon 19 deletions and L858RTAGRISSO (osimertinib)T790MPatients with positive cobas EGFR Mutation Test v2 test results using plasma specimens for the presence of EGFR exon 19 deletions or L858R mutations are eligible for treatment with TARCEVA (erlotinib). Patients who are negative for these mutations by this test should be reflexed to routine biopsy and testing for EGFR mutations with the FFPET sample type.2.Effective7/12/13therascreen EGFR RGQPCR kit for the detection of the epidermal growth factor receptor (EGFR) gene for non-small cell lung cancer (NSCLC) tumor tissue to help select patients with NSCLC for whom GILOTRIF (afatinib), an EGFR tyrosine kinase inhibitor (TKI), is indicated.To report an FDA approved or laboratory developed test (LDT) EGFR test kit service, please submit the following claim information:CPTcode: 81235Enter 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 formICD-10-CM codesNOTE:MolDX will apply NPI to ID editing on FDA approved EGFR kits. All labs that submit claims for an EGFR kitMUSTregister the test and confirm theUNMODIFIEDuse of the kit.This article reflects the FDA-approved indications on article creation date. MolDX will allow future FDA approved and amended indications for these tests.
Article - Billing and Coding: MolDX: MMACHC Test (A54035)

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 reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body memberArticle TextMethylmalonic aciduria (cobalamin deficiency) cblC type, with homocystinuria (MMACHC) is associated with the most common error of vitamin B12 metabolism. Although considered a disease of infancy or childhood, some individuals develop symptoms in adulthood. However to date, the exact function of the protein encoded by this gene is not known. Therefore, MMACHC testing does not meet the clinical utility requirements for a Medicare Benefit and is considered a statutorily excluded service. MolDX will also deny panels of tests that include the MMACHC gene.To receive a MMACHC service denial, please submit the following claim information:CPT code 81404-MMACHC, fgsAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierEnter the appropriate DEX Z-Codeidentifier 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-Codeidentifier 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 form
Article - Billing and Coding: Arthroscopic Lavage and Arthroscopic Debridement for Osteoarthritic Knees (A54061)

CMS National Coverage PolicyN/AArticle TextThis article is being published to update the provider community on coverage for Arthroscopic Lavage and Arthroscopic Debridement for Osteoarthritic Knees.National Coverage Determination (NCD) 150.9 issued in 2004 describes Medicare coverage for Arthroscopic Lavage and Arthroscopic Debridement for Osteoarthritic Knees. In this NCD, non-covered indications are:Arthroscopic lavage used alone for the osteoarthritic kneeArthroscopic debridement for osteoarthritic patients presenting with knee pain only; or,Arthroscopic debridement and lavage with or without debridement for patients presenting with severe osteoarthritisCPT 29871  Arthroscopy, knee, surgical; for infection, lavage and drainage is used to describe the service covered by NCD 150.9.All other indications for coverage of arthroscopic lavage remain at Contractor discretion.Resources:NCD 150.9 Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic KneeCMS Change Request 3281