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

Correction to CR 4061 02/24/2006  4362 R800CP  12/30/2005  Clinical Diagnostic Laboratory Date of Service (DOS) for Archived Specimens  04/03/2006  4156 R795CP  12/30/2005  Redefined Type of Bill (TOB) 14X for Non-Patient Laboratory Specimens -CR 3835 Manualization 04/03/2006  4208 R744CP  11/04/2005  File Descriptions and Instructions for Retrieving the 2006 Fee Schedules and 01/03/2006  4084 Rev #  Issue Date  Subject  Impl Date  CR#  HCPCS through CMS's Mainframe Telecommunications System R734CP  10/28/2005  Redefined Type of Bill (TOB), 14x, for Non-Patient Laboratory Specimens  04/03/2006  3835 R733CP  10/28/2005  Repeat Tests for Automated Multi-Channel Chemistries for End Stage Renal Disease Beneficiaries  04/03/2006  4101 R598CP  06/27/2005  Implementation of Carrier Guidelines for End Stage Renal Disease (ESRD) Reimbursement for Automated Multi-Channel Chemistry (AMCC) Tests 01/01/2006  3890 R595CP  06/24/2005  Implementation of Carrier Guidelines for End Stage Renal Disease (ESRD) Reimbursement for Automated Multi-Channel Chemistry (AMCC) Tests 07/25/2005  3890 R372CP  11/19/2004  Payment for Referred Laboratory Automated Multi-Channel Chemistry (AMCC) Tests  04/04/2005  3483 R289CP  08/27/2004  File Descriptions and Instructions for Retrieving 2004 Pricing Files 01/03/2005  3428 R198CP  06/04/2004  AMCC tests for ESRD -related lab services  01/03/2005  2813 R164CP  04/30/2004  Replaced by Rev 198CP  06/04/2004  2813 R102CP  02/20/2004  New waived tests approved by the Food and Drug Administration under Clinical Laboratory Improvement Amendments of 1988 04/05/2004  3061 R100CP  02/13/2004  Outpatient Clinical Laboratory Tests Furnished by Hospitals with Fewer than 50 beds in Qualified Rural Areas for cost reporting periods beginning during the 2-year period beginning on July 1, 2004. 07/06/2004  3130 Rev #  Issue Date  Subject  Impl Date  CR#  R085CP  02/06/2004  Pricing payment for referred services based upon zip code of where the service was performed  07/06/2004  3090 R079CP  02/06/2004  ESRD Reimbursement for AMCC Tests  07/06/2004  2813 R071CP  01/23/2004  Quarterly updates for NCD edit module for clinical diagnostic lab services  04/05/2004  3032 & 3072 R069CP  01/23/2004  Deletion of requirement to validate that the ESRD beneficiary is in a SNF Part A stay  02/23/2004  2906 R023CP  10/31/2003  Pricing payment for referred services based upon zip code of where the service was performed  4/5/2004 2193 R016CP  10/31/2003  Fee schedule payment for independent laboratories for the technical component of a purchased diagnostic service 04/05/2004  2919 R012CP  10/24/2003  Claims for fecal leukocyte examinations  01/01/2004  2924 R001CP  10/01/2003  Initial Publication of Manual NA NA Back to top of Chapter
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CMS Manual System  Department of Health & Human Services (DHHS)  Pub 100 -08 Medicare Program Integrity  Centers for Medicare & Medicaid Services (CMS)  Transmittal  829 Date: October 2, 2018   Change Request 10901   Transmittal 829, dated October 3, 2018, is being rescinded and replaced by Transmittal 854, dated January 11, 2019, to update 3 business requirements (BR) and their related chapter 13 manual instructions.  This correction will revise BRs 10901.7 and 10901.7.1, including the related section 13.2.4.3, to add language that indicates that MACs have the discretion to host multi -jurisdictional CACs ; revise BR 10901.24, including the related section 13.5.2.2, to strike the words in their proposed LCD and strike the words "meeting logistics" and repla ce with "attendance information"; and BR 10901.26, including the related section 13.5.3, to add language that allows MACs the option of providing a hyperlink to the FDA clearance to market.  All other information remains the same.   SUBJECT: Local Coverage Determinations (LCDs)
(2)in the case ofservices described in section 1832(a)(2) (except those servicesdescribed in subparagraphs (C), (D), (E), (F), (G), (H), and (I) ofsuch section and unless otherwise specified in section 1881)(A)with respectto home health services (other than a covered osteoporosis drug) (asdefined in section 1861(kk)), the amount determined under the prospective paymentsystem under section 1895;(B)with respectto other items and services (except those described in subparagraph(C), (D), or (E) of this paragraph and except as may be provided insection 1886orsection 1888(e)(9))(i)furnished beforeJanuary 1, 1999, the lesser of(I)the reasonablecost of such services, as determined under section 1861(v), or(II)the customarycharges with respect to such services,less the amount a provider may charge as described in clause(ii) of section 1866(a)(2)(A), but in no case may the payment for such otherservices exceed 80 percent of such reasonable cost, or(ii)if such servicesare furnished before January 1, 1999, by a public provider of services,or by another provider which demonstrates to the satisfaction of theSecretary that a significant portion of its patients are low-income(and requests that payment be made under this clause), free of chargeor at nominal charges to the public, 80 percent of the amount determinedin accordance with section 1814(b)(2), or(iii)if such servicesare furnished on or after January 1, 1999, the amount determined undersubsection (t), or(iv)if (and forso long as) the conditions described in section 1814(b)(3) are met, the amounts determinedunder the reimbursement system described in such section;(C)with respectto services described in the second sentence of section 1861(p), 80 percentof the reasonable charges for such services;(D)with respectto clinical diagnostic laboratory tests for which payment is madeunder this part(i)
(Medicare Claims Processing Manual)

c. If the HCPCS codes for components of an item are merged into a single HCPCS code for the item, the single payment amount for the new HCPCS code is equal to the total of the separate single payment amounts for the components.   d. If multiple HCPCS codes for different but similar items are merged into a single HCPCS code, the items to which the new HCPCS codes apply may be furnished by any supplier that has a valid Medicare billing number.  Payment for the new code will be based on the fee schedule methodology, even if single payment amounts were established for the discontinued multiple HCPCS codes.  The old codes will be considered invalid and no longer included in the competitive bidding program for the remainder of the contrac t term.   Contract suppliers must furnish the item(s) described by the new HCPCS code(s) in scenarios (a) through (c) above and submit claims using the new codes.  Notification of a competitive bidding HCPCS code change will occur through program instruction.  Addendum - MPFSDB File Record Layout and Field Descriptions         (Rev. 10356, Issued: 09- 18-2020, Effective Date: 10- 19-2020, Implementation Date: 10-19-2020)   The CMS MPFSDB includes the total fee schedule amount, related component parts, and payment policy indicators.  The record layout is provided below.  Beginning with the 2019 MPFSDB, and thereafter, the MPFSDB File Record Layout will no longer be revised annually in this section for the sole purpose of changing the calendar year, but will only be revised when there is a change to a field.  Previous MPFSD B file layouts (for 2018 and prior) can be found on the CMS web site on the Physician Fee Schedule web page at:  https://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/PhysicianFeeSched/index.html.  MPFSDB File Layout  HEADER RECORD  FIELD #  DATA ELEMENT NAME  LOCATION  PIC 1 Header ID  1-4 x(4) Value Head"  2 Header Number  5 x(1) 3 Data Set Name  6-50 x(45)  4 Record Length  51-53 x(3) 5 Filler  54-54 x(1) 6 Block size  55-58 x(4) 7 Filler  59-59 x(1) 8 Number of Records  Number does not include this header record.  60-69 9(10)  9 Date Created  70-77 x(8) YYYYMMDD  10 Blanks  78-345 x(268)
(Medicare Claims Processing Manual)

10/19/2020 11958 Rev #  Issue Date  Subject  Impl Date  CR#  R10233CP  07/24/2020  Update to the (IOM) Publication 100- 04, Medicare Claims Processing Manual, Chapter 23 -  Fee Schedule Administration and Coding Requirements, Section 20.9 -  Fee Schedule Administration and Coding Requirements  06/16/2020 11782 R10211CP  07/10/2020  Manual Update to Section 20.7 in Chapter 23 of Publication (Pub) 100- 04 08/10/2020 11833 R10136CP   05/15/2020  Update to the (IOM) Publication 100 -04, Medicare Claims Processing Manual, Chapter 23 -  Fee Schedule Administration and Coding Requirements, Section 20.9 -  Fee Schedule Administration and Coding Requirements  Rescinded and replaced by Transmittal 10233  06/16/2020 11782 R4465CP  11/15/2019  Medicare Claims Processing Manual Chapter 23 -  Fee Schedule Administration and Coding Requirements  01/30/2019 10868 R4418CP  10/18/2019  Medicare Physician Fee Schedule Database (MPFSDB) Update to Status Indicators   11/19/2019 11453 R4298CP  05/03/2019  Medicare Physician Fee Schedule Database (MPFSDB) File Record Layout  10/07/2019 11191 R4188CP  12/28/2018  Medicare Claims Processing Manual Chapter 23 -  Fee Schedule Administration and Coding Requirements - Rescinded and replaced by Transmittal 4465 01/30/2019 10868 R4131CP  09/14/2018  Updates to Chapter 23 Fee File Instructions  12/17/2018 10926 R4130CP  09/14/2018  Update to the Medicare Claims Processing Manual, Chapter 23, Section 60.3 10/15/2018 10924 R3931CP  12/01/2017  CY 2018 Update for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule  01/02/2018 10395 Rev #  Issue Date  Subject  Impl Date  CR#  R3903CP  11/03/2017  Annual Medicare Physician Fee Schedule (MPFS) Files Delivery and Implementation and Medicare Physician Fee Schedule Database (MPFSDB) 2018 File Layout Manual  01/02/2018 10218 R3876CP  10/06/2017  Decommission the MCS Maintained HBCRB081 Report (Correct Coding Quarterly Savings Report)
(Medicare Claims Processing Manual)

5893 R1358CP  10/26/2007  Medicare Physician Fee Schedule Database (MPFSDB) 2008 File  01/07/2008 5774 R1005CP  07/21/2006  Medicare Physician Fee Schedule Database (MPFSDB) 2007 File Layout  01/02/2007 5206 R823CP  02/01/2006  New Temporary Code for Battery for Power Mobility Devices  07/03/2006 4253 R614CP  07/22/2005  Medicare Physician Fee Schedule Database (MPFSDB) 2006 File Layout  01/03/2006 3889 R341CP  10/29/2004  Implementation of the Medicare Physician Fee Schedule (MPFS) National Abstract File for Purchased Diagnostic Tests and Interpretations  04/04/2005 3481 Rev #  Issue Date  Subject  Impl Date  CR#  R323CP  10/22/2004  Update Regarding the Use of American Dental Association's (ADA) Current Dental Terminology (CDT) Codes on Medicare Contractors Web Sites and Other Electronic Media  11/22/2004 3499 R286CP  08/27/2004  Medicare Physician Fee Schedule Database (MPFSDB) 2005 File Layout  01/03/2005 3421 R283CP  08/27/2004  2005 Healthcare Common Procedure Coding System (HCPCS) Annual Update Reminder  01/03/2005 3422 R236CP  07/23/2004  2005 DMEPOS Pricing File Record Layout Expansion and New Pricing Procedures for Certain DMEPOS Items Based on Modifiers  01/03/2005 3300 R210CP  06/18/2004  CMS Annual Reminder to Contractors of The ICD -9-CM Update for October 1, 2004 10/04/2004 3303 R127CP  03/26/2004  Annual Spreadsheet Containing an Updated List of HCPCS Codes for Durable Medical Equipment Regional Carrier (DMERC) and Part B Local Carrier Jurisdictions to Reflect Codes That Have Been Added or Discontinued (Deleted) During Each Year  05/26/2004 3139 R126CP  03/26/2004  ICD-9 Coding for Beneficiary Claims  N/A 2857 R095CP  02/06/2004  Eliminate The 90 -Day Grace Period for Billing Discontinued ICD -9-CM Codes  10/01/2004 3094 R089CP  02/06/2004  Eliminating The 90 -Day Grace Period for Billing Discontinued HCPCS Codes  07/06/2004 3093 R066CP  01/16/2004  Quarterly Update to Correct Coding Initiative (CCI) Edits, Version 10 1, Effective April 1, 2004  04/05/2004 2997 Rev #  Issue Date  Subject  Impl Date  CR#  R050CP  12/19/2003  Clarification That Medicare Contractors Will Be Receiving Quarterly Updates for Temporary HCPCS Codes  04/05/2004 2967 R043CP  12/19/2003  Using the American Dental Association's (ADA's) Current Dental Terminology-Fourth Edition (CDT -4) Codes of Contractors Web Sites and Other Electronic Media.  01/20/2004 3003 R037CP  12/08/2003  Adding place of service (POS) code 42 to Field 29 of MFSDB; and 38B, and adding the year 2004 to field 8 Conversion Factor  01/05/2004 2970 R001CP  10/01/2003  Initial Publication of Manual  NA NA Back to top of chapter
Article - Billing and Coding: 4Kscore Test Algorithm (A56287)

CMS National Coverage PolicyN/AArticle TextThis First Coast Billing and Coding Article for Local Coverage Determination (LCD) L37798 4Kscore Test Algorithm provides billing and coding guidance for diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.Refer to the LCD for reasonable and necessary requirements and limitations.The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.Coding GuidelinesNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.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 laboratory prior tothe 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 orderingproviderand patients names and signatures legibly noted to attest that the SDM occurred.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 L37798, 4Kscore Test Algorithm may be monitored and addressed through post payment data analysis and subsequent medical review audits.
Article - Billing and Coding: Therapeutic Apheresis for Familial Hypercholesterolemia (A56289)

CMS National Coverage PolicyN/AArticle TextApheresis Therapeutic Pheresis National Coverage Determination (NCD) (110.14) allows Medicare Administrative Contractor coverage discretion in the use of therapeutic apheresis in the treatment of refractory familial hypercholesterolemia.Note: CMS Medicare Learning Network (MLN) (MM) 4250 does not apply to or restrict this use.CGS will cover plasma apheresis for the treatment of familial hypercholesterolemia that is resistant to appropriate lifestyle changes combined with maximal use of statin agents with or without the use of ezetimibe in:Functional homozygotes with a LDL cholesterol greater than 500mg/dl;Functional heterozygotes with no known cardiovascular disease but a LDL cholesterol greater than 300mg/dl;Functional heterozygotes with known cardiovascular disease and a LDL cholesterol greater than 200mg/dl;Familial hypercholesterolemia in pregnancy when the physician feels usual therapy is inadequate to assure uteroplacental perfusion.All such claims are subject to either pre- or post-pay review by CGS or any of the authorized Medicare auditors. The need for this procedure must be clearly documented in the medical records for each visit including which pharmacologic agents are/have been used and what lifestyle changes have been made and, if a beneficiary was intolerant of statins, the actual findings and symptoms reported. Be sure that the clinical notes are properly signed by the treating provider and dated for the date of service.
Article - Billing and Coding: MolDX: Inivata™, InVisionFirst®, Liquid Biopsy for Patients with Lung Cancer (A56333)

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 15, 80.1.2 A/B MAC (B) Contacts with Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Ch. 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 CodesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer L37921.To report an InvisionFirst  Lung service, please submit the following claim information:Select CPT code 81479Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier 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-Code identifier 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 formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: Breast Cancer Index® (BCI) Gene Expression Test (A56335)

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 Manual System, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.0 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests.CMS Internet-Only Manuals, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.12 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet Online Manual Pub. 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: Breast Cancer Index (BCI) Gene Expression Test L37913.Effective 1/01/2019, MolDX will provide limited coverage for the BCI gene expression test.The BCI test is covered for postmenopausal women with invasive breast cancer when the following criteria are met:Pathology reveals invasive carcinoma of the breast that is ER+ and/or PR+ and HER2 -; andPatient has early-stage disease (T1-3, pN0-N1, M0); andPatient has no evidence of distant breast cancer metastasis (i.e., non-relapsed); andTest results will be used in determining treatment management of the patient for chemotherapy and/or endocrine therapy.MolDX expects this test will be performed once per patient lifetime on FFPE tissue from the primary tumor specimen obtained prior to adjuvant treatment.To bill a BCI service, please provide the following claim information:Select CPT code 81518Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier 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-Code identifier 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 formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: Removal of Benign and Malignant Skin Lesions (A56346)

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 Removal of Benign and Malignant Skin Lesions L33445.When using diagnosis code L82.0 (inflamed seborrheic keratosis), the legible medical records should reference a patients complaint or a physicians physical findings.Check the Medicare Physician Fee Schedule Database (MPFSDB) for the codes where the global policy would be applied. Use modifier 25 appended to the appropriate visit code to indicate that the patient's condition required a significant, separately identifiable service by the same physician on the same day of the procedure that was performed.
Article - Billing and Coding: MolDX: Oncotype DX® Genomic Prostate Score (A56372)

CMS National Coverage PolicyN/AArticle TextThe Oncotype DX Genomic Prostate Score (Genomic Health) is covered for use in very low risk, low risk, and favorable intermediate risk prostate cancer.To bill for Oncotype DX Genomic Prostate Score services, please provide the following claim information:CPT code 0047U for services on or after 01/01/2019.Enter 1 in the Days/Unit fieldFor CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.Enter the appropriate DEX Z-Code identifier 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-Code identifier 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: Rituximab (A56380)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessarydocumentation to process the claimCMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Change Request 10530, Transmittal3996 dated March 9, 2018CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, 40 DiscardedDrugs and BiologicalsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Rituximab L35026.