evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: RAST Type Tests (A56844)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for RAST Type Tests.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and 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 Section 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 Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included withinthe relatedLCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned.Documentation must be available to Medicare upon request.Utilization Guidelines:It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.
Article - Billing and Coding: Venous Angioplasty with or without Stent Placement for the Treatment of Chronic Cerebrospinal Venous Insufficiency (A56845)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Venous Angioplasty with or without Stent Placement for the Treatment of Chronic Cerebrospinal Venous Insufficiency.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and 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 Section 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 Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Article - Billing and Coding: Multiple Imaging in Oncology (A56848)

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) L35391, Multiple Imaging in Oncology. 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.
Article - Billing and Coding: MolDX: Percepta® Bronchial Genomic Classifier (A56849)

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.CMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual Publication 100-04 Medicare Claims Processing Manual, Chapter 23 Section 10 "Reporting ICD Diagnosis and Procedure Codes"Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: PerceptaBronchial Genomic Classifier L36854.To report a PerceptaBronchial Genomic Classifier service, please submit the following claim information:Select CPTcode 81479.Enter 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 837Box 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code.
Article - Billing and Coding: Laparoscopic Sleeve Gastrectomy for Severe Obesity (A56852)

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 32, 150.1 General, 150.2 HCPCS Procedure Codes for Bariatric Surgery, 150.3 ICD Procedure Codes for Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity (A/MACs only), 150.4 ICD Diagnosis Codes for Bariatric Surgery, 150.5 ICD Diagnosis Codes for BMI 35, 150.5.1 ICD Codes for Type II Diabetes Mellitus Complication, 150.6 Claims Guidance for Payment, 150.7 Medicare Summary Notices (MSNs) and Claim Adjustment Reason Codes and 150.8 B/MAC Billing RequirementsCMS 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) for Laparoscopic Sleeve Gastrectomy for Severe Obesity L34576.
Article - Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) (A56853)

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 claim.CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual,Chapter 15, 80.1 Clinical Laboratory ServicesCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 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) forMolDX: Molecular Diagnostic Tests (MDT) L35025.To report a Molecular Diagnostic Test service, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter 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 formNOTE:When entering the DEX Z-Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: MolDX: HLA-DQB1*06:02 Testing for Narcolepsy (A56857)

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.CMS Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15,80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual Publication 100-04 Medicare Claims Processing Manual, Chapter 23 Section 10 "Reporting ICD Diagnosis and Procedure Codes"Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: HLA-DQB1*06:02 Testing for Narcolepsy L36464.
Article - Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility (A56859)

CMS National Coverage PolicyCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Inpatient Hospital Billing, Chapter 3, Section 90 Billing Transplant ServicesTitle 42 CFR 412 Prospective Payment Systems for Inpatient Hospital ServicesArticle TextMedicare covers the following solid organ transplants: kidney, heart, lung, heart/lung, liver, pancreas, pancreas/kidney, and intestinal/multi-visceral. Medicare also covers stem cell transplants for certain conditions.Claims for CPTcodes used to describe Human Leukocyte Antigen (HLA) testing used for transplant histocompatibility testing will be denied. See below for further explanation on correct billing for these services. This does not refer to HLA testing for non-transplant services.HLA testing for histocompatibility testing as part of transplantation are part of solid organ acquisition services.Services for organ transplants must be billed as described in theCenters for Medicare and Medicaid Services (CMS) Internet-Only Manual, Pub100-04, Medicare Claims Processing Manual, Inpatient Hospital Billing, Chapter 3 Section 90 and as described in the Electronic Code of Federal Regulations, Title 42, Public Health, Part 412 Prospective Payment Systems for Inpatient Hospital Services. The acquisition costs of hearts, kidneys, livers, lungs, pancreas, and intestines (or multivisceral organs) incurred by approved transplantation centers are paid on a reasonable cost basis by approved transplant centers; they are not billed as stand-alone laboratory services.HLA typing is a component of the acquisition services for an allogeneic stem cell transplant as well. Payment for these acquisition services is included in the MS-DRG payment for the allogeneic stem cell transplant when the transplant occurs in the inpatient setting and in the OPPS APC payment for the allogeneic stem cell transplant when the transplant occurs in the outpatient setting. The Medicare contractor does not make separate payment for these acquisition services, because hospitals may bill and receive payment only for services provided to the Medicare beneficiary who is the recipient of the stem cell transplant and whose illness is being treated with the stem cell transplant. Unlike the acquisition costs of solid organs for transplant (e.g., hearts and kidneys), which are paid on a reasonable cost basis, acquisition costs for allogeneic stem cells are included in prospective payment.Acquisition charges do not apply to autologous transplants.HLA CPTcodesunrelated to transplant testinghave coverage as outlined in the following Local Coverage Determinations (LCDs):CPT81381 The MolDX: Pharmacogenomics Testing L38294 LCD addresses limited coverage for gene-drug interactions.CPT81383  The MolDX: HLA-DQB1*06:02 Testing for Narcolepsy L36464 LCD addresses non-coverage of HLA-DQB1*06:02 typing for the diagnosis or management of narcolepsy.
Article - Billing and Coding: Select Minimally Invasive GERD Procedures (A56863)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Select Minimally Invasive GERD Procedures.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and 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 Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included withintheLCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Article - Billing and Coding: Outpatient Speech Language Pathology (A56868)

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. 100-02, Medicare Benefit Policy Manual, Chapter 12, 20.1 Required Services, 30 Rules for Provision of Services, and 30.1 Rules for Payment of CORF ServicesCMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 220 Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance, 220.1 Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services, 220.4 Functional ReportingCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 5, 10 Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services-General, 10.5 Notification for Beneficiaries Exceeding Financial Limitations, 10.6 Functional Reporting, 10.7 Multiple Procedure Payment Reductions for Outpatient Rehabilitation Services, 20 HCPCS Coding Requirement, 20.2 Reporting of Service Units With HCPCS, and 40.2 Applicable Types of Bill, 40.3 Applicable Revenue Codes, 40.4 Edit Requirements for Revenue Codes, and 40.5 Line Item Date of Service ReportingCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, 30.3 Audiology ServicesCMS 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) forOutpatient Speech Language Pathology L34429.Evaluation/Re-evaluationNote:Current Procedural Terminology (CPT) does not define a re-evaluation code for Speech Language Pathology: use the evaluation code.1.Treatment of speech, language, voice, communication, and/or auditory processing disorder (CPTcode 92507); individualRegarding speech-generating devices (SGDs), use CPTcode 92607 and 92608 for selection and prescription; use CPTcode 92609 for programming and modification.2.Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals (CPTcode 92508)Note:Regardlessof the therapy being performed, if the patient is not receiving direct 1-on-1 contact but is being supervised by the therapist, the group therapy code should be used.
Article - Billing and Coding: Use of Laterality Modifiers (A56869)

CMS National Coverage PolicyN/AArticle TextIn order to facilitate claims processing and avoid denials for duplicate claims, claims which contain CPT/HCPCS codes describing services performed on anatomic structures that can be distinguished as left or right require laterality modifiers. This article is not a comprehensive listing of all such codes; however, all claims involving the CPTcodes included in this article will be rejected unless the appropriate laterality modifiers (-RT; -LT) for unilateral procedures are reported. Bilateral procedures should be indicated by the appropriate modifier for bilateral procedures. CPTcodes that are designated in their description asunilateral or bilateraldo not require additional laterality modifiers.Claim lines for CPT/HCPCS codes requiring use of the RT and LT modifiers, submitted without the RT and/or LT modifiers or with the RT/LT on a single claim line will be rejected as incorrect coding.
Article - Billing and Coding: MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) (A56870)

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.CMS Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.2A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual Publication 100-04 Medicare Claims Processing Manual, Chapter 23 Section 10 "Reporting ICD Diagnosis and Procedure Codes"Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: Oncotype DXBreast Cancer for DCIS (Genomic Health) L36912.To report an Oncotype DXBreast Cancer for DCISservice, please submit the following claim information:Select PLA code 0045UEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: In Vitro Chemosensitivity & Chemoresistance Assays (A56871)

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.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80, Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests,80.1, Clinical Laboratory Services.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 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 In Vitro Chemosensitivity & Chemoresistance Assays L34554.To receive a CSRA denial, please submit the following claim information:CPTcodeAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifier
Article - Billing and Coding: GlycoMark® Testing for Glycemic Control (A56872)

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, 60.1.1 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure Codes.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for GlycoMark Testing for Glycemic Control L36761.To receive a GlycoMark test denial, please submit the following claim information:CPTcode 84378 or 84999An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifier
Article - Billing and Coding: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (A56874)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Stereotactic Radiation and Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT).Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed.SRS is typically performed in a single session. If more than one session is required, SBRT codes must be used.Documentation Requirements:All documentation must be available upon request of the Medicare contractor.The patient's record must support the necessity and frequency of treatment. The medical record must clearly indicate the critical nature of the anatomy or other circumstances necessitating the services, the patient's functional status and a description of current performance status (Karnofsky Performance Status).Documentation should include the date and the current treatment dose.Coverage may be considered at the Redetermination (Appeal) level on an individual basis for lesions when documentation clearly supports the necessity for high radiation dose per fraction and the necessity to avoid surrounding tissue exposure. When requesting an individual consideration through the written redetermination (formerly appeal) process, providers must include all relevant medical records and literature that supports the request. At a minimum two (2) Phase II studies (human feasibility studies suggesting efficacy, pilots) or one (1) Phase III study (primary evidence of safety and efficacy, pivotal) must be submitted for the Contractor Medical Directors review.Treatment devices, complex (CPT code 77334) is limited to one unit for each collimator in a linear accelerator system or one for each helmet in a cobalt-60 system. If the total number of units exceeds six (6) or the number of isocenters plus three (3) when multiple isocenters are necessary, a detailed explanation of medical necessity must be documented in the medical record. Documentation must specify factors, such as, multiple isocenters, irregularity of target volume(s), proximity of critical structures or other reasons which justify the units of service for dosimetry or treatment devices.Utilization Guidelines:Codes 77373, G0339 and G0340 will payonly once per day of treatment regardless of the number of sessions or lesions. CPT code 77435 code will pay only once per course of therapy.