evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells (A58185)

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, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 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 MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells L38645In accordance with the LCD , the following tests are reasonable and necessary:Biocept Target Selector HER2 AssayAndrogen Receptor Variant (AR-V7) Protein TestTo report a service, please submit the following claim information:Select CPTcode 81479Enter 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 837PItem 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: MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer (A58187)

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 LaboratoriesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer L38649.To report a service, please submit the following claim information:Select the 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 837PItem 19 for paper claimEnter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM codeNOTE: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: Guardant360® (A58192)

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, 80.0, 80.1.1, 80.2. Clinical Laboratory servicesCMS Internet-Only Manual Publication 100-04,Medicare Claims Processing Manual, Chapter 23, 10 "Reporting ICD Diagnosis and Procedure Codes"Article TextCoverage will continue on a case by case basis utilizing the following criteria until such time a more comprehensive non-proprietary local coverage determination can be developed.Guardant360remains covered for patients with non-CNS originated solid tumors who meet the criteria of NCD 90.2 when the following conditions are met:Patient has been diagnosed with a recurrent, relapsed, refractory, metastatic, or advanced solid tumor that did not originate from the central nervous system. Patients who would meet all of the indications on the FDA label for larotrectinib if they are found to have an NTRK mutation may be considered to have advanced cancer,andPatient has not previously been tested with the Guardant360 test for the same primary cancer. For a patient who has been tested previously using Guardant360 for a cancer, that patient may only be tested againwhen the patient has a new primary cancer diagnosis. In a patient with previously tested primary cancer, who has evidence of new malignant growth, that growth may be considered to be a different primary cancer if it does not originate from the same cell line or it is physiologically different enough that it responds differently to treatment than the previously tested cancer,andPatient is untreated for the primary cancer being tested or the patient is not responding to treatment (e.g. progression or new lesions on treatment),andThe patient has decided to seek further cancer treatment with the following conditions:The patient is a candidate for further treatment with a drug that is either FDA-approved for that patients cancer, or has an NCCN 1 or NCCN 2A recommendation for that patients cancer,andThe FDA-approved indication or NCCN recommendation is based upon information about the presence or absence of a genetic biomarker tested for in the Guardant360 assay,andTissue-based CGP is infeasible (i.e., quantity not sufficient for tissue-based CGP or invasive biopsy is medically contraindicated)orspecifically in NSLC Tissue-based CGP has shown no actionable mutations.If no alteration is detected by Guardant360 or if ctDNA is insufficient/not detected, tissue-based genotyping should be considered.
Article - Billing and Coding: MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells (A58205)

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, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 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 MolDX: Phenotypic Biomarker Detection from Circulating Tumor Cells L38678.In accordance with the related LCD, the following test is reasonable and necessary:Biocept Target Selector HER2 AssayAndrogen Receptor Variant (AR-V7) Protein TestTo report a 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: Transurethral Waterjet Ablation of the Prostate (A58209)

CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title 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 billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD L38682 Transurethral Waterjet Ablation of the Prostate.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.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: MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer (A58211)

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 LaboratoriesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer L38684.To report a service, please submit the following claim information:Select the 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 formSelect the appropriate ICD-10-CM codeNOTE: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: Implantable Continuous Glucose Monitors (I-CGM) (A58213)

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) L38686 Implantable Continuous Glucose Monitors (I-CGM). Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceImplantationof an implantable continuous glucose monitor (I-CGM) that meets the appropriate criteria as mentioned in LCD L38686 Implantable Continuous Glucose Monitors (I-CGM) is reportedfor either the 90 day or 180 day implantable sensor.For 90 day implantable glucose sensor report:CPTcode 0446T- Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient trainingRemovalof an I-CGM is reported with:CPTcode 0447T- Removal of implantable interstitial glucose sensor from subcutaneous pocket via incisionRemoval with immediate subsequent replacementof an I-CGM is reported with:CPTcode 0448T- Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activationNotice: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.
Article - Billing and Coding: Guardant360® (A58214)

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, 80.0, 80.1.1, 80.2. Clinical Laboratory servicesCMS Internet-Only Manual Publication 100-04,Medicare Claims Processing Manual, Chapter 23, 10 "Reporting ICD Diagnosis and Procedure Codes"Article TextCoverage will continue on a case by case basis utilizing the following criteria until such time a more comprehensive non-proprietary local coverage determination can be developed.Guardant360remains covered for patients with non-CNS originated solid tumors who meet the criteria of NCD 90.2 when the following conditions are met:Patient has been diagnosed with a recurrent, relapsed, refractory, metastatic, or advanced solid tumor that did not originate from the central nervous system. Patients who would meet all of the indications on the FDA label for larotrectinib if they are found to have an NTRK mutation may be considered to have advanced cancer,andPatient has not previously been tested with the Guardant360 test for the same primary cancer. For a patient who has been tested previously using Guardant360 for a cancer, that patient may only be tested again when the patient has a new primary cancer diagnosis. In a patient with previously tested primary cancer, who has evidence of new malignant growth, that growth may be considered to be a different primary cancer if it does not originate from the same cell line or it is physiologically different enough that it responds differently to treatment than the previously tested cancer,andPatient is untreated for the primary cancer being tested or the patient is not responding to treatment (e.g. progression or new lesions on treatment),andThe patient has decided to seek further cancer treatment with the following conditions:The patient is a candidate for further treatment with a drug that is either FDA-approved for that patients cancer, or has an NCCN 1 or NCCN 2A recommendation for that patients cancer,andThe FDA-approved indication or NCCN recommendation is based upon information about the presence or absence of a genetic biomarker tested for in the Guardant360 assay,andTissue-based CGP is infeasible (i.e., quantity not sufficient for tissue-based CGP or invasive biopsy is medically contraindicated)orspecifically in NSLC Tissue-based CGP has shown no actionable mutations.If no alteration is detected by Guardant360 or if ctDNA is insufficient/not detected, tissue-based genotyping should be considered.
Article - Billing and Coding: Screening for Cervical Cancer with Human Papillomavirus (HPV) (A58216)

CMS National Coverage PolicyIOM Citations:CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 4, Section 210.2.1 Screening for Cervical Cancer with Human Papillomavirus (HPV) Testing (Effective July 9, 2015)Social 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 TextIt has come to our attention that services submitted for screening for cervical cancer with Human Papillomavirus (HPV) Testing have been reported incorrectly. This Billing and Coding Article provides billing and coding guidance for these services.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered as if they are covered. When billing for non-covered services, use the appropriate modifier.Consistent with National Coverage Determination (NCD) 210.2.1 screening HPV services are to be billed with Healthcare Common Procedure Coding System (HCPCS) code G0476. These services require dual diagnosis codes. The primary International Statistical Classification of Diseases and Related Health Problems, 10threvision, (ICD-10) code Z11.51 must be reported along with one of the following secondary ICD-10-CM diagnosis codes: Z01.411 or Z01.419.It is incorrect to report these screening services with Current Procedural Terminology (CPT) code 87624 [Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types].Please refer to NCD 210.2.1 for complete information on screening for cervical cancer with Human Papillomavirus (HPV).
Article - Billing and Coding: Computed Tomography Cerebral Perfusion Analysis (CTP) (A58218)

CMS National Coverage PolicyN/AArticle TextDocumentation RequirementsThe patients medical record should include but is not limited to: The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit, Relevant medical history Results of pertinent tests/procedures Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.) Performance of the study in a stoke centerEffective 12/12/2021 please append computed tomography cerebral perfusion analysis identified with CPT 0042T with the KX modifier to attest the CTP analysis was performed in a certified stroke center.If the service is provided in the emergency room (POS 23) the ER must be part of the certified stroke center to qualify for coverage.The patient's medical record must contain documentation that fully supports the medical necessity for services included within this 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.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 willbe returned.The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, the reason for the tests, an interpretive report and copies of images. The computerized image reconstruction data should also be maintained.Documentation must be available to Medicare upon request.
Article - Billing and Coding: Computed Tomography Cerebral Perfusion Analysis (CTP) (A58223)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Computed Tomography Cerebral Perfusion Analysis (CTP).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 patients medical record should include but is not limited to: The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit, Relevant medical history Results of pertinent tests/procedures Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.) Performance of the study in a stoke centerThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the attached LCD. (See "Indications and Limitations of Coverage" of the LCD.) 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 denied.The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, the reason for the tests, an interpretive report and copies of images. The computerized image reconstruction data should also be maintained.
Article - Billing and Coding: Computed Tomography Cerebral Perfusion Analysis (CTP) (A58225)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Computed Tomography Cerebral Perfusion Analysis (CTP).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 patients medical record should include but is not limited to: The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit, Relevant medical history Results of pertinent tests/procedures Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.) Performance of the study in a stoke centerThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the attached LCD. (See "Indications and Limitations of Coverage" of the LCD.) 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 denied.The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, the reason for the tests, an interpretive report and copies of images. The computerized image reconstruction data should also be maintained.