evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: MolDX: Breast Cancer Index® (BCI) Gene Expression Test (A56875)

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, 80.0 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests, 80.1.1 Certification ChangesCMS 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 2310 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: Breast Cancer Index (BCI) Gene Expression Test L37794.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 formalin-fixed, paraffin-embedded (FFPE) tissue from the primary tumor specimen obtained prior to adjuvant treatment.To report a BCI service, please submit the following claim information:Select CPTcode 81518Enter 1 unit of service (UOS)Enter the appropriate DEX Z-code identifier adjacent to the CPTcode in the comment/narrative field for the following 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: Spinal Cord Stimulators for Chronic Pain (A56876)

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) forSpinal Cord Stimulators for Chronic Pain L37632.IndicationsThis A/B MAC will reimburse for placement of a maximum of 2 leads or 16 contacts, and for 2 spinal cord stimulator (SCS) trials per anatomic spinal region per patient per lifetime (with exceptions allowed for technical limitations for the initial trials or for use of different modalities of stimulation, including new technology).If a trial fails, a repeat trial is not appropriate, unless there are extenuating circumstances that lead to trial failure. Appropriate medical documentation to support a repeat trial can be sent on appeal. Generally, electronic analysis services (CPTcodes 95970, 95971 and 95972) are not considered medically necessary, when provided at a frequency more often than once every 30 days. More frequent analysis may be necessary in the first month after implantation.CPTcode 63650 - 2 temporary SCS trials per anatomic spinal region (2 per date of service (DOS)) or (4 units) per patient per lifetime (with exceptions allowed for technical limitations for the initial trials or for use of different modalities of stimulation, including new technology), in place of service office, ambulatory surgery center (ASC), outpatient hospital, or hospital. Since permanent neurostimulator arrays can also be placed percutaneously, code 63650 can be covered more often in place of service ASC, outpatient hospital, or hospital.CPTcode 63655 - 1 permanent SCS per patient per lifetime and must be performed in an ASC, outpatient hospital or hospital.CPTcodes63661 and 63663 - Will not be reimbursed in the office setting since they are included in 63650.TheCPT/HCPCScode(s) may be subject to Correct Coding Initiative (CCI) edits. This article does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.
Article - Billing and Coding: MolDX: HLA-DQB1*06:02 Testing for Narcolepsy (A56881)

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 Manuals, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 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 CodesCMS Internet-Only Manual, Pub. 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: HLA-DQB1*06:02 Testing for Narcolepsy L36485.
Article - Billing and Coding: MolDX: Breast Cancer Index™ (BCI) Gene Expression Test (A56884)

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, 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: Breast Cancer Index (BCI) Gene Expression Test DL37832.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 metPathology 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 is lymph node negativePatient 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 extension of 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:CPT code 81518Enter 1 in the Days/Unit fieldSelect the appropriate ICD-10-CM diagnosisEnter the assigned Z-code in the comment/narrative field for the following claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter 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: HLA Testing for Transplant Histocompatibility (A56885)

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 L38394 LCD addresses limited coverage for gene-drug interactions.CPT81383  The MolDX: HLA-DQB1*06:02 Testing for Narcolepsy L36485 LCD addresses non-coverage of HLA-DQB1*06:02 typing for the diagnosis or management of narcolepsy.
Article - Billing and Coding: MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) (A56887)

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 Manuals, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent LaboratorySpecimen 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: Oncotype DX Breast Cancer for DCIS (Genomic Health)L36951.To report an Oncotype DX Breast Cancer for DCIS service, 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 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: Loss-of-Heterozygosity Based Topographic Genotyping with Pathfinder TG&reg; (A56897)

CMS National Coverage PolicyN/AArticle TextRefer to the Novitas Local Coverage Determination (LCD) L34864 Loss-of -Heterozygosity Based Topographic Genotyping with PathfinderTG, for reasonable and necessary requirements.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.
Article - Billing and Coding: MolDX: Envisia™, Veracyte™, Idiopathic Pulmonary Fibrosis Diagnostic Test (A56898)

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, 80.1.2 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) forMolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test L37857.To report an Envisia Genomic Classifier service, please submit the following claim information:Select CPTcodeEnter 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: MolDX: Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) (A56899)

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. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 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: Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) L36089.To report a Genetic Testing for Hypercoagulability/Thrombophilia service, please submit the following claim information:Select appropriate CPTcodeEnter 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 form
Article - Billing and Coding: Polysomnography and Other Sleep Studies (A56903)

CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity, and documentation requirements described in the associated LCD L36839 Polysomnography and Other Sleep Studies.Diagnostic testing will be considered for coverage if the patient has the symptoms or complaints of one of the conditions listed in L36839.Patients who undergo the diagnostic testing are not considered inpatients, although they may come to the facility in the evening for testing and then leave after testing is over. The overnight stay is considered an integral part of these tests. Documentation must support indications if the patient is admitted.Ordinarily, a single polysomnogram and electroencephalogram (EEG) can diagnose sleep apnea. If more than one such testing session is claimed, the carrier will require persuasive medical evidence justifying the medical necessity for the additional test (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70).Ordinarily, a diagnosis of narcolepsy can be confirmed by three sleep naps. If more than three sleep naps are claimed; the A/B MAC (B) will require persuasive medical evidence justifying the medical necessity for the additional test(s). (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70.)More than one HST per year interval would not be expected. If more than one HST session is performed for suspected OSA, persuasive medical evidence justifying the medical necessity for the additional tests will be required. Similarly, more than two PSG per year interval would not be expected. If more than two PSG sessions are performed for the diagnosis or adjustment of treatment of sleep, pervasive medical evidence justifying the medical necessity for the additional tests will be required upon request. When services are performed in excess of established parameters, they may be subject to review for medical necessity.The routine use of more than one PSG to titrate CPAP therapy would not be considered reasonable and necessary. If more than one CPAP titration PSG is claimed, persuasive medical evidence justifying the medical necessity for the additional tests may be requested.95805 MSLT- includes all the naps done in a single day. Only one (1) unit of service should be submitted.Coding GuidanceWatchPat must be billed as CPT code 95800 or 95801.If a sleep study is performed for less than 6 hours, it should be billed with modifier 52. Providers should report the service provided with the appropriate reduced original charge.
Article - Billing and Coding: Surgical Treatment of Obstructive Sleep Apnea (OSA) (A56905)

CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L34526.Sleep-Disordered Breathing, often referred to as Obstructive Sleep Apnea (OSA), is characterized by frequent episodes of hypopnea or apnea during sleep. Multiple detrimental physiologic changes may result from these hypopneic and apneic episodes. Non-surgical and surgical approaches to obstructive apnea and hypopnea have been developed.The following procedures are not covered at this time.Laser-assisted uvulopalatoplasty (LAUP) is not covered at this time since it is not considered effective for OSA. LAUPmust notbe billed as 42145, Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty). This code is not appropriate for this procedure. If LAUP is billed for denial purposes, it should be coded as 42299, (unlisted procedure, palate, uvula) with "LAUP" in the electronic narrative 2400/SV101-7 equivalent to line 19 of the CMS 1500 form. The claim will be denied as not proven effective.Somnoplasty is a trade name for palate reduction with the Somnoplasty System of Somnus Medical Systems. This is not a term recognized by this Contractor as a covered procedure under Medicare Part B. Therefore Somnoplasty must not be billed as 42145. This code is not appropriate for this procedure. If Somnoplasty is billed for denial purposes, it should be coded as 42299, (unlisted procedure, palate, uvula) with "Somnoplasty" in the electronic narrative 2400/SV101-7 equivalent to line 19 of the CMS 1500 form. This claim will be denied as not proven effective.The Pillar Procedure is a trade name for palatal implants. Palatal implants have not been shown effective for the treatment of obstructive sleep apnea and are not covered. This procedure should be billed by the physician as 42299 (unlisted procedure, palate, uvula) with Pillar Procedure or palatal implant in the electronic narrative 2400/SV101-7 equivalent to line 19 of the CMS 1500 form. This claim will then be denied as not proven effective. Hospital outpatient departments would use code C9727.Submucosal ablation of the tongue base, radiofrequency, one or more sites, per session. (41530) will be denied as investigational and experimental.
Article - Billing and Coding: MolDX: DecisionDx-UM (Uveal Melanoma) (A56906)

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) MolDX: DecisionDx-UM (Uveal Melanoma) L37033.To report a DecisionDx-UM (Uveal Melanoma) service, please submit the following claim information:SelectCPTcode 81552Enter 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