evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: MolDX: Germline testing for use of PARP inhibitors (A55294)

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.Article TextThe United States (U.S.) Food and Drug Administration (FDA) has approved several poly ADP-ribose polymerase (PARP) inhibitor treatments indicated for patients with ovarian cancer, breast cancer, pancreatic cancer, and prostate cancer.Results of tests that assess for deleterious variants in homologous recombination repair (HRR) genes such as BRCA1 and 2 can be used as an aid in patients who are being considered for treatment with PARP inhibitors in accordance with published guidelines and approved therapeutic product labeling. These genes are often tested as part of routine management of these cancer patients as part of services that interrogate a panel of genes as described in LCD L38972. In rare circumstances limited testing for only a select group of genes may be tested to ensure compliance with FDA indicated drug usage, wherein additional genes outlined in guidelines such as the NCCN are not necessary because the patient does not meet testing criteria for larger panels.According to criteria defined by L38972, billing for these services can occur in the following situation:The patient meets clinical indication for immediate use of a PARP inhibitor for an FDA-approved use ANDThe patient has had no previous germline testing for hereditary cancer or somatic testing of the same cancer that included the genes necessary for testing ANDThe patient does not meet germline testing requirements per existing guidelines or standards of care outlined in policy L38972 requiring more comprehensive testing.To report a service, please submit the following claim information:Select appropriate CPTcodeOne (1) unit of serviceEnter 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 837PItem 19 for paper claimEnter 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 at least one ICD-10-CM diagnosis code.
Article - Billing and Coding: MolDX: Germline testing for use of PARP inhibitors (A55295)

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.Article TextThe United States (U.S.) Food and Drug Administration (FDA) has approved several poly ADP-ribose polymerase (PARP) inhibitor treatments indicated for patients with ovarian cancer, breast cancer, pancreatic cancer, and prostate cancer.Results of tests that assess for deleterious variants in homologous recombination repair (HRR) genes such as BRCA1 and 2 can be used as an aid in patients who are being considered for treatment with PARP inhibitors in accordance with published guidelines and approved therapeutic product labeling. These genes are often tested as part of routine management of these cancer patients as part of services that interrogate a panel of genes as described in LCD L38974. In rare circumstances limited testing for only a select group of genes may be tested to ensure compliance with FDA indicated drug usage, wherein additional genes outlined in guidelines such as the NCCN are not necessary because the patient does not meet testing criteria for larger panels.According to criteria defined by L38974, billing for these services can occur in the following situation:The patient meets clinical indication for immediate use of a PARP inhibitor for an FDA-approved use ANDThe patient has had no previous germline testing for hereditary cancer or somatic testing of the same cancer that included the genes necessary for testing ANDThe patient does not meet germline testing requirements per existing guidelines or standards of care outlined in policy L38974 requiring more comprehensive testing.To report a service, please submit the following claim information:Select appropriate CPTcodeOne (1) unit of serviceEnter 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 837PItem 19 for paper claimEnter 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 at least one ICD-10-CM diagnosis code.
Article - Billing and Coding: Instructions for Lemtrada® (alemtuzumab) When Used in the Treatment of Relapsing Multiple Sclerosis (A55310)

CMS National Coverage PolicyN/AArticle TextLemtradais indicated in the treatment of patients with relapsing forms of multiple sclerosis. The dosage of Lemtradawhen used for this indication is 12mg/day infused for 5 consecutive days, then 12mg/day infused for 3 consecutive days at one interval, one year from the first course of treatment.To submit a claim for LemtradainPart B of A (hospital outpatient) on a UB-04 claim form, the following information must appear on the form:Diagnosis-(Box 66)ICD-10 G35 Multiple Sclerosis (for claims with date of service (DOS) from 10/01/2015 forward)HCPCS drug code-(Field 44)J0202 Injection, alemtuzumab 1mg (DOS 01/01/2016 forward)Narrative (Remarks) in (Field 80) (or electronic equivalent)National Drug Code (NDC)- 58468-0200-1 or 58468-0200-01 Single use vial 12mg/1.2 ml (10mg/ml)Name of Drug (trade and generic)Dose of drug administeredRoute of administrationTo submit a claim for LemtradainPart B on a CMS-1500 claim form, the following information must appear on the form:Diagnosis-(Box 21)ICD-10 G35 Multiple Sclerosis (for claims with DOS from 10/01/2015 forward)HCPCS drug code- (Box 24D)J0202 Injection, alemtuzumab 1mg (DOS 01/01/2016 forward)Narrative- (Box 19) (or electronic equivalent)NDC- 58468-0200-1 or 58468-0200-01 Single use vial 12mg/1.2 ml (10mg/ml)Name of Drug (trade and generic)Dose of drug administeredRoute of administrationNote:This drug is supplied in a single use vial that contains 12mg of alemtuzumab. PerFood and Drug Administration (FDA) labeling, the dose of this drug is 12mg per day, therefore claims reflecting administered dosages other than 12mg perDOS or claims reporting wastage or productNDC numbers other than those listed above will be rejected.
Article - Billing and Coding: Zika Virus Testing by PCR and ELISA Methods (A55326)

CMS National Coverage PolicyN/AArticle TextFor calendar year 2018 CMS has adopted the new 2018 AMA CPT codes for Zika virus testing. For dates of service 1/1/2018 and forward providers should bill using these new codes. For dates of service prior to 1/1/2018 the previous instructions will still apply.Testing for the Zika virus must follow the Food and Drug Administration (FDA) and CDCP guidelines. This article does not address medical necessity but rather proper coding for claims submission.Claims submissions should utilize the coding instructions below regardless of the specimen source. In the narrative section of the claim form (Part A Loop 2300/NTE for EMC claims, or Form Locator 80 on the CMS 1450 form or paper claims, Part B Loop 2400/SV101-7 for EMC claims, or Item 19 on the CMS 1500 form for paper claims) please enter the following verbiage (without quotation marks) as it pertains to the respective tests.For Claims submitted prior to 1/1/2018 use the following guidance:Zika rRT-PCR only  Use CPT 87999 and enter Zika PCR in the narrative field regardless of the CDCP approved proprietary test utilized*Trioplex rRT-PCR  Use CPT 87999 and enter Zika Trioplex*anti-Zika immunoglobulin (IgM)  Use CPT 86790Dengue rRT-PCR only  use CPT 87798Chikungunya rRT-PCR only - use CPT 87798If billing for both Dengue and Chikungunya rRT-PCR  use CPT 87801 once.If a plaque reduction neutralization test (PRNT) is indicated, that testing must be conducted by CDC or by a PRNT laboratory designated by CDC to do confirmatory PRNT testing for the Zika response. The claim for PRNT testing is not submitted to Medicare.Items 1, 2 and 3 above require an FDA Emergency Use Authorization to the respective laboratory. Noridian retains the right to be sent a copy of the respective labs EUA upon request.For claims submitted with dates of service on or after 1/1/2018 use the following instructions:Zika rRT-PCR only - Use CPT 87662Zika virus IgM - Use CPT 86794Dengue rRT-PCR only - use CPT 87798Chikungunya rRT-PCR only - use CPT 87798If billing for both Dengue and Chikungunya rRT-PCR - use CPT87801 once.Diagnosis coding should include at least one of the following ICD-10 codes:CodeDescriptionA92.5Zika virus disease [effective for DOS on or after October 1, 2016]B30.9Viral conjunctivitis, unspecifiedM25.50-M25.579Pain in jointO09.00-O09.93Supervision of high risk pregnancyO28.3Abnormal ultrasonic finding antenatal screening of motherO28.4Abnormal radiological finding on antenatal screening of mother (MRI fetus)O35.00X1-O35.09X9Maternal care for (suspected) central nervous system malformation or damage in fetusR21Rash and other nonspecific skin eruptionR50.9Fever, unspecifiedZ03.73Encounter for suspected fetal anomaly ruled outZ03.79Encounter for other suspected maternal and fetal conditions ruled out.Z03.89Encounter for observation for other suspected diseases and conditions ruled out.Z33.1Pregnant state, incidentalZ34.00-Z34.93Encounter for supervision of normal pregnancy.Z36.89Encounter for other specified antenatal screening
Article - Billing and Coding: Zika Virus Testing by PCR and ELISA Methods (A55327)

CMS National Coverage PolicyN/AArticle TextFor calendar year 2018 CMS has adopted the new 2018 AMA CPT codes for Zika virus testing. For dates of service 1/1/2018 and forward providers should bill using these new codes. For dates of service prior to 1/1/2018 the previous instructions will still apply.Testing for the Zika virus must follow the Food and Drug Administration (FDA) and CDCP guidelines. This article does not address medical necessity but rather proper coding for claims submission.Claims submissions should utilize the coding instructions below regardless of the specimen source. In the narrative section of the claim form (Part A Loop 2300/NTE for EMC claims, or Form Locator 80 on the CMS 1450 form or paper claims, Part B Loop 2400/SV101-7 for EMC claims, or Item 19 on the CMS 1500 form for paper claims) please enter the following verbiage (without quotation marks) as it pertains to the respective tests.For Claims submitted prior to 1/1/2018 use the following guidance:Zika rRT-PCR only  Use CPT 87999 and enter Zika PCR in the narrative field regardless of the CDCP approved proprietary test utilized*Trioplex rRT-PCR  Use CPT 87999 and enter Zika Trioplex*anti-Zika immunoglobulin (IgM)  Use CPT 86790Dengue rRT-PCR only  use CPT 87798Chikungunya rRT-PCR only - use CPT 87798If billing for both Dengue and Chikungunya rRT-PCR  use CPT 87801 once.If a plaque reduction neutralization test (PRNT) is indicated, that testing must be conducted by CDC or by a PRNT laboratory designated by CDC to do confirmatory PRNT testing for the Zika response. The claim for PRNT testing is not submitted to Medicare.Items 1, 2 and 3 above require an FDA Emergency Use Authorization to the respective laboratory. Noridian retains the right to be sent a copy of the respective labs EUA upon request.For claims submitted with dates of service on or after 1/1/2018 use the following instructions:Zika rRT-PCR only  Use CPT 87662Zika virus IgM  Use CPT 86794Dengue rRT-PCR only  use CPT 87798Chikungunya rRT-PCR only - use CPT 8779If billing for both Dengue and Chikungunya rRT-PCR  use CPT 87801 once.Diagnosis coding should include at least one of the following ICD-10 codes:CodeDescriptionA92.5Zika virus disease [effective for DOS on or after October 1, 2016]B30.9Viral conjunctivitis, unspecifiedM25.50-M25.579Pain in jointO09.00-O09.93Supervision of high risk pregnancyO28.3Abnormal ultrasonic finding antenatal screening of motherO28.4Abnormal radiological finding on antenatal screening of mother (MRI fetus)O35.00X1-O35.09X9Maternal care for (suspected) central nervous system malformation in fetusR21Rash and other nonspecific skin eruptionR50.9Fever, unspecifiedZ03.73Encounter for suspected fetal anomaly ruled outZ03.79Encounter for other suspected maternal and fetal conditions ruled out.Z03.89Encounter for observation for other suspected diseases and conditions ruled out.Z33.1Pregnant state, incidentalZ34.00-Z34.93Encounter for supervision of normal pregnancy.Z36.89Encounter for other specified antenatal screening.
Article - Billing and Coding: Retroperitoneal Ultrasound (A55336)

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 Retroperitoneal Ultrasound L34577.A full (complete) or limited abdominal ultrasound (US) (CPT76700, 76705, 76706*), views all structures in the abdomen including those in the retroperitoneal area. Frequently when a retroperitoneal USis performed findings encountered during the exam may warrant that the exam be expanded to become a full abdominal study.It is expected that CPT76770, 76775, 76776 will only be billed when the exam has been limited to retroperitoneal structures. Exams that include structures other than or in addition to, those listed above should be billed as a full (complete) or appropriately limited abdominalUS (CPT76700, 76705, 76706*).It is not appropriate to bill for both a retroperitonealUS study AND a complete (or limited) abdominalUS when a retroperitonealUS study is expanded to include organs and structures outside the retroperitoneum.Utilization GuidelinesIf the physical exam has primary findings for the involvement of non-retroperitoneal structures/organs (gallbladder, liver, spleen, common bile duct, etc.), even though it may be necessary to visualize retroperitoneal structures in the course of the procedure, a full abdominal US would be required in most cases to be diagnostic, and that is the procedure that should be performed and billed.
Article - Billing and Coding: MolDX: VEGFR2 Tests (A55468)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) statutory exclusion covers diagnostic testing "except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member".Article TextVascular endothelial growth factor, subtype 2, (VEGFR2) receptor has been found to be oncogenic. Current studies have targeted VEGFR2 as a potential therapeutic option. However, at present there is insufficient evidence to establish a clear association between VEGFR2 mutations and treatment response. Therefore, the MolDX Team has determined VEGFR2 testing is a statutorily excluded service. MolDX will also deny panels of tests that include the VEGFR2 receptor.To receive a VEGFR2 service denial, please submit the following claim information:CPTcode 81479An 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 837PItem 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: MolDX: VEGFR2 Tests (A55469)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) statutory exclusion covers diagnostic testing "except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member".Article TextVascular endothelial growth factor, subtype 2, (VEGFR2) receptor has been found to be oncogenic. Current studies have targeted VEGFR2 as a potential therapeutic option. However, at present there is insufficient evidence to establish a clear association between VEGFR2 mutations and treatment response. Therefore, the MolDX Team has determined VEGFR2 testing is a statutorily excluded service. MolDX will also deny panels of tests that include the VEGFR2 receptor.To receive a VEGFR2 service denial, please submit the following claim information:CPTcode 81479An 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 modifierSelect the appropriate diagnosis for the patientEnter 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 837PItem 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: Abbreviated Daytime Sleep Study (e.g. PAP-NAP) (A55478)

CMS National Coverage PolicyN/AArticle TextAn abbreviated daytime sleep study (PAP NAP) has been used by some to address poor compliance and enhance individual comfort and tolerance of CPAP/BiPAP. PAP NAP combines psychological and physiological treatments into one procedure during an abbreviated daytime nap session (100-120 minutes). Sleep technicians employ various coaching and monitoring techniques including mask and pressure desensitization, emotion focused therapy to overcome aversive responses to CPAP, mental imagery to divert the individuals attention from the sensations associated with CPAP and physiological exposure to CPAP.An Abbreviated daytime sleep study (PAP-NAP) used as a supplement to standard sleep studies for all indications, including but not limited to, the following are considered integral to the primary procedure and (are) not separately reimbursable.correcting non-compliance, or improving compliance with prescribed CPAPdecreasing anxiety/claustrophobia associated with CPAPpatient educationmask and pressure desensitizationcognitive behavioral therapy (CBT)Limited data from a single study of PAP-NAP is insufficient evidence to form conclusions on the efficacy of this approach in improving compliance with CPAP. No professional guidelines currently recommend use of PAP NAP as a compliance enhancement.Split StudiesIt is not appropriate to bill diagnostic and titration studies separately when performing a split night study.  This is considered one service.Sources of InformationBlueCross BlueShield Association. Medical Policy Reference Manual. (11:2015).Diagnosis and medical management of obstructive sleep apnea syndrome.(2.01.18). Retrieved June 29, 2016 from BlueWeb. (61 articles and/or guidelines reviewed)Centers for Medicare & Medicaid Services. CMS.gov.NCD for sleep testing for obstructive sleep apnea (OSA) (240.4.1).Retrieved June 29, 2016 fromMCPMKrakow, B., Ulibarri, V., Melendrez, D., Kikta, S., Togami, L., & Haynes, P. (2008). A daytime, abbreviated cardio-respiratory sleep study (CPT 95807-52) to acclimate insomnia patients with sleep disordered breathing to positive airway pressure (PAP-NAP).Journal of Clinical Medicine,4 (3), 212-222. (Level 4 evidence)FREQUENTLY ASKED QUESTIONS ABOUT SLEEP CODINGAmerican Academy of Sleep Medicine,March, 2014
Article - Billing and Coding: Abbreviated Daytime Sleep Study (e.g. PAP-NAP) (A55479)

CMS National Coverage PolicyN/AArticle TextAn abbreviated daytime sleep study (PAP NAP) has been used by some to address poor compliance and enhance individual comfort and tolerance of CPAP/BiPAP. PAP NAP combines psychological and physiological treatments into one procedure during an abbreviated daytime nap session (100-120 minutes). Sleep technicians employ various coaching and monitoring techniques including mask and pressure desensitization, emotion focused therapy to overcome aversive responses to CPAP, mental imagery to divert the individuals attention from the sensations associated with CPAP and physiological exposure to CPAP.An Abbreviated daytime sleep study (PAP-NAP) used as a supplement to standard sleep studies for all indications, including but not limited to, the following are considered integral to the primary procedure and (are) not separately reimbursable.correcting non-compliance, or improving compliance with prescribed CPAPdecreasing anxiety/claustrophobia associated with CPAPpatient educationmask and pressure desensitizationcognitive behavioral therapy (CBT)Limited data from a single study of PAP-NAP is insufficient evidence to form conclusions on the efficacy of this approach in improving compliance with CPAP. No professional guidelines currently recommend use of PAP NAP as a compliance enhancement.Split StudiesIt is not appropriate to bill diagnostic and titration studies separately when performing a split night study.  This is considered one service.Sources of InformationBlueCross BlueShield Association. Medical Policy Reference Manual. (11:2015).Diagnosis and medical management of obstructive sleep apnea syndrome.(2.01.18). Retrieved June 29, 2016 from BlueWeb. (61 articles and/or guidelines reviewed)Centers for Medicare & Medicaid Services. CMS.gov.NCD for sleep testing for obstructive sleep apnea (OSA) (240.4.1).Retrieved June 29, 2016 fromMCPMKrakow, B., Ulibarri, V., Melendrez, D., Kikta, S., Togami, L., & Haynes, P. (2008). A daytime, abbreviated cardio-respiratory sleep study (CPT 95807-52) to acclimate insomnia patients with sleep disordered breathing to positive airway pressure (PAP-NAP).Journal of Clinical Medicine,4 (3), 212-222. (Level 4 evidence)FREQUENTLY ASKED QUESTIONS ABOUT SLEEP CODINGAmerican Academy of Sleep Medicine,March, 2014
Article - Billing and Coding: MolDX: STAT3 Gene Testing (A55480)

CMS National Coverage PolicyN/AArticle TextSTAT3 gene testing may be performed during the diagnosis of Autosomal Dominant Hyper IgE Syndrome (AD-HIES). Since management is not determined by the presence or absence of a STAT3 mutation in patients with a probable clinical diagnosis, the MolDX Contractor has determined STAT3 analysis is a statutorily excluded test.To receive a STAT3 analysis service denial, please submit the following claim information:CPT code 814058 - STAT3, targeted sequence analysisAn 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 modifierSelect the appropriate diagnosis for the patientEnter 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 837PItem 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