evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing (A56645)

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) L35006, Controlled Substance Monitoring and Drugs of Abuse Testing. Please refer to the LCD for reasonable and necessary requirements and limitations.Coding Guidance: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.Utilization ParametersConsistent with the related LCD:It is not appropriate to report more than twelve (12) presumptive UDT testing (CPT code 80305, 80306, or 80307) testing services per calendar year.As stated in the related LCD, an exception will be made for patients with documented diagnoses consistent with a substance abuse disorder (SUD). It is not appropriate to report more than three (3) presumptive UDT tests (80305, 80306, or 80307) in seven (7) days when billed with any of the ICD-10 codes noted in ICD-10 Group 1 Paragraph.It is not appropriate to report more than twelve (12) definitive UDT testing services (CPT/HCPCS code G0480, G0481, G0482, G0483, or G0659) per calendar year for chronic opioid therapy (COT), as noted in ICD-10 Group 2 Paragraph. Refer to the related LCD for more information.It is not appropriate to report more than one (1) presumptive test result per patient per date of service regardless of the number of billing providers.Documentation RequirementsNote: Refer to the LCD for documentation requirements, in the patients medical record, of medical necessity for testing ordered on an individual patient basis by the clinician.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: Micro-Invasive Glaucoma Surgery (MIGS) (A56647)

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) L38233, Micro-Invasive Glaucoma Surgery (MIGS). 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.Utilization ParametersMedicare may cover only1 unit per eye, per date of service of CPT code 66989 or 66991for insertion of glaucoma drainage device(s) into the trabecular meshwork (e.g., iStent, or iStentinject), performed in conjunction with cataract surgery and when the medically reasonable and necessary criteria as stated in the LCD are met. Although more than one drainage device into the trabecular meshwork of a single eye on a single day of service, may be performed using an insertion tool loaded with more than one device, (e.g., iStentinject) once the insertion tool is deployed within the eye, the work and clinical skill required to place additional device(s) is equivalent to placement of other U.S. Food and Drug Administration (FDA) cleared devices, described by the same codes. Therefore, only one unit of 66989 or 66991 per eye per day may be billed, regardless of the number of devices inserted into a single eye on the same date of service.Medicare may cover only1 unit per eye, per date of service of CPT code 0449Tfor insertion of glaucoma drainage device(s) into the subconjunctival space (e.g., XEN45), when the medically reasonable and necessary criteria as stated in the LCD are met.Note:CPT Code 0450T for additional device insertion is not covered.Note: CPT code 0671T does not need to be reported with any of the following codes: 66982, 66983, 66984, 66987, and 66988.Documentation RequirementsAll documentation must be maintained in the patient's medical record and must support the medical necessity of the services as directed in this article and be 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: Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia (A56648)

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 10, 10.1.10.4 Claim Submission and Processing, 30.11 Exhibit: Chart Summarizing the Effects of NOA/Claim Actions on the HH PPS Episode File, 40.1 Notice of Admission (NOA), 40.2 HH PPS Claims, 70.1 General, 90 Medical and Other Health Services Submitted Using Type of Bill 034x, and 90.1 Osteoporosis Injections as HHA BenefitCMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, 6.2.4 Coding and 6.2.7 Medical Review of Home Health Demand BillsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forHome Health-Surface Electrical Stimulation in the Treatment of Dysphagia L34565.
Article - Billing and Coding: 4Kscore Test Algorithm (A56653)

CMS National Coverage PolicyN/AArticle TextThis article provides coding guidance forthe Local Coverage Determination (LCD) L37792 4Kscore Test Algorithm which will become effective on December 30, 2019. Refer to L37792 for reasonable and necessary guidelines.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.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record should support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code should describe the service performed.Documentation of shared decision making (SDM) concerning the 4Kscore testing, between the ordering provider and patient, must be present in the medical record and a copy of same shall be provided to the performing laboratorypriorto the test being performed.A simple notation that SDM occurred is insufficient for documentation. The actual process must be documented in the patients record.The document(s) shall be dated and include the ordering provider and patients names and signatures legibly noted to attest that the SDM occurred.
Article - Billing and Coding: Cosmetic and Reconstructive Surgery (A56658)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, 120 Cosmetic Surgery, 140 Dental Services Exclusion and 180 Services Related to and Required as a Result of Services Which Are Not Covered Under MedicareCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, 260 Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (FLS), 260.1 Policy, 260.2 Billing Instructions, 260.2.1 Hospital Billing Instructions, 260.2.2 Practitioner Billing InstructionsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) Cosmetic and Reconstructive Surgery L33428.
Article - Billing and Coding: Trastuzumab – Trastuzumab Biologics (A56660)

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) L34026 (Trastuzumab  Trastuzumab Biologics). 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.Utilization GuidelinesIn accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.Compliance with the provisions in LCD L34026 Trastuzumab  Trastuzumab Biologics may be monitored and addressed through post payment data analysis and subsequent medical review audits.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 maintained by the ordering/referring physician must substantiate the medical need for the use of these chemotherapy drugs by clearly indicating the condition for which these drugs are being used. This might include the type of cancer, staging, if applicable, prior therapy and the patients response to that therapy. This documentation is usually found in the history and physical or in the office/progress notes.If the provider of the service is other than the ordering/referring physician, that provider must maintain copies of the ordering/referring physicians order for the chemotherapy drug. The physician must state the clinical indication/medical need for using the chemotherapy drug in the order.Dosage and AdministrationFor specific dosage and administration, please refer to the FDA approved drug label for recommended dosages for specific FDA indications. This can be accessed athttps://labels.fda.gov/.
Article - Billing and Coding: Hospice - Liver Disease (A56669)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1813 (a)(4)(A)(i) drugs and biologicals provided in a hospice programCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, 30.2, 30.2.2, and 30.3Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Hospice - Liver Disease L34544.
Article - Billing and Coding: Nonobstetric Pelvic Ultrasound (A56671)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) states that no payment shall be made to any provider 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 Nonobstetric Pelvic Ultrasound L37636.Indications76856is a complete evaluation and must minimally include:Female: description and measurements of the uterus and adnexal structures, measurement of the endometrium and bladder, and a description of any pelvic pathology.Male: evaluation and measurement of the bladder, evaluation of the prostate and seminal vesicles and any pelvic pathology.76857is a limited study and typically focuses on one or more elements listed under 76856 and/or the reevaluation of one or more pelvic abnormalities.LimitationsPost voiding residual bladder volume is not reimbursable by CPTcodes 76856 and 76857. Measurement of post voiding residual should be billed using CPTcode 51798.
Article - Billing and Coding: Electroretinography (ERG) (A56672)

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) L37371, Electroretinography (ERG). 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.When reporting ICD-10 code Z79.899, the medical record must reflect the medication administered as well as the underlying condition for which it was given.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: Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus (A56674)

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.Title XVIII of the Social Security Act, 1835(a)(2)(A) Procedure for payment of claims of providers of servicesCMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, 6.2.4Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forHome Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus L35132.
Article - Billing and Coding: Homocysteine Level, Serum (A56675)

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. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code RequirementsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forHomocysteine Level, Serum L34419.Limitations:Serum homocysteine levels will not be covered other than for suspected B12/folate deficiency, or for risk stratification for the conditions noted in theICD-10-CM Codes that Support Medical Necessitysection of this article. It is covered only once in a lifetime for the initial determination for risk stratification. Subsequent determinations will be covered only if appropriate treatment does not correct the anemia or symptoms.
Article - Billing and Coding: Hospice – HIV Disease (A56677)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Title XVIII of the Social Security Act, 1813(a)(4)(A)(i) addresses drugs and biologicals provided in a hospice program.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, 30.2 Payment Rates, 30.2.2 Service Intensity Add-on (SIA) Payments, and 30.3 Data Required on the Institutional Claim to A/B MAC (HHH)CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9, 80.2 PaymentArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forHospice  HIV Disease L34566.
Article - Billing and Coding: Hospice The Adult Failure To Thrive Syndrome (A56679)

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 11, 30.2 Payment Rates, 30.2.2 Service Intensity Add-on (SIA) Payments, 30.3 Data Required on the Institutional Claim to A/B MAC (HHH), and 30.4 Claims From Medicare Advantage OrganizationsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forHospice The Adult Failure To Thrive Syndrome L34558.Hospices may not report diagnosis codes that cannot be used as the principal diagnosis according to ICD-10-CM Coding Guidelines or require further compliance with various ICD-10-CM coding conventions, such as those that have principal diagnosis code sequencing guidelines. Hospices may not report debility, failure to thrive, or dementia codes classified as unspecified as principal hospice diagnoses on the hospice claim.
Article - Billing and Coding: Diagnostic Abdominal Aortography and Renal Angiography (A56682)

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) L35092, Diagnostic Abdominal Aortography and Renal Angiography. 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.CMS issued HCPCS code G0278 for femoral or iliac angiography when done at the time of coronary angiography.Documentation RequirementsAll documentation must be maintained in the patients 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: Intraoperative Radiation Therapy (A56684)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary information to process that claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forIntraoperative Radiation Therapy L37779.ICD-10-CM diagnosis codes supporting medical necessity must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.
Article - Billing and Coding: Partial Hospitalization Programs (A56685)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) states that no payment shall be made to any provider for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, 260.1 Special Partial Hospitalization Billing Requirements for Hospitals, Community Mental Health Centers, and Critical Access HospitalsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forPartial Hospitalization Programs L37633.LimitationsNoncovered-Reasonable and Necessary DenialsCPTcodes 90875 and 90876
Article - Billing and Coding: HbA1c (A56686)

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, 120.2 Implementation and Updates of Negotiated National Coverage Determinations (NCDs) for Clinical Diagnostic Laboratory ServicesCMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code Requirements42 CFR 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: ConditionsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for HbA1c L33431.
Article - Billing and Coding: Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor (A56690)

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 Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor DL37761.