evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Diagnostic and Therapeutic Esophagogastroduodenoscopy (A57063)

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) L33583 Diagnostic and Therapeutic Esophagogastroduodenoscopy. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.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.The patients medical record (e.g., history and physical, office/progress notes, procedure report) maintained by the ordering/referring physician must clearly indicate the reason for the Esophagogastroduodenoscopy (EGD). Also, the results of the EGD must be included in the patients medical record.
Article - Billing and Coding: Duplex Scan of Lower Extremity Arteries (A57064)

CMS National Coverage PolicyN/AArticle TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33667, Duplex Scan of Lower Extremity Arteries. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.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.Medical record documentation maintained by the ordering/referring physician/nonphysician practitioner must clearly indicate the medical necessity of duplex scan of lower extremity arteries i.e., signs and symptoms, relevant history (including known diagnoses, and/or prior imaging). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Also, the results of the duplex scan of lower extremity arterial studies must be included in the patient's medical record. A hard copy or soft copy convertible to a hard copy provides a permanent record of the study performed and must be of a quality that meets accepted medical standards.If the provider of duplex scan of lower extremity arterial studies is other than the ordering/referring physician/nonphysician practitioner, the provider of the service must maintain a copy of the test results and interpretation, along with copies of the ordering/referring physician/nonphysician practitioners order for the studies. When ordering duplex scan of lower extremity arterial studies, the ordering/referring physician/nonphysician practitioner must state the reason for the duplex scan of lower extremity arteries in his/her order for the test.The provider is responsible for ensuring the medical necessity of procedures and maintaining the medical record, which must be available upon request. Billing providers are encouraged to obtain additional information from referring providers and/or patients or medical records to determine the medical necessity of studies performed. Referring physicians are required to provide appropriate diagnostic information to the performing provider.The medical necessity for performing repeat extremity arterial studies must be clearly documented in the medical record.An order from the treating physician/nonphysician practitioner as required by CFR, Title 42, Volume 2, Chapter IV, Part 410.32(a) Ordering diagnostic tests.
Article - Billing and Coding: Electrocardiography (A57066)

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) L33669 Electrocardiography. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Outpatient hospitals, critical access hospitals and CORFS may use only code 93005 when billing for this service.When billing subsequent electrocardiograms on the same day, use modifier 76 if repeated by the same provider or modifier 77 when repeated by a different provider.When using diagnosis code Z01.810, the medical record must contain information supporting either of the two pre-operative evaluation indications listed under the Indications and Limitations of Coverage and/or Medical Necessity section in the related LCD.If an EKG is being performed to evaluate a patients response to the administration of an agent known to result in cardiac or EKG abnormalities for patients with suspected, or at increased risk of developing cardiovascular disease or dysfunction, then diagnosis code Z79.3, Z79.891 , Z79.899 or Z51.81 should be used. The T diagnoses should be used when the patient is experiencing adverse effects to high risk medications.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.The EKG strip and a copy of the test results should be maintained in the medical record. In addition, the medical record must support that the physician interpreted and agrees with the test results and show that the results are being used to manage the patient.If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physicians order for the studies. The physician must state the clinical indication/medical necessity for the study in the order for the test.
Article - Billing and Coding: Ophthalmic Biometry for Intraocular Lens Power Calculation (A57070)

Hospital Outpatient Claims:The hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patients symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-10-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9).The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.
Article - Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) (A57071)

H40.33X1, H40.33X2, H40.33X3, H40.33X4, H40.41X1, H40.41X2, H40.41X3, h40.41X4, H40.42X1, H40.42X2, H40.42X3, H40.42X4, H40.43X1, H40.43X2, H40.43X3, H40.43X4, H40.51X1, H40.51X2, H40.51X3, H40.51X4, H40.52X1, H40.52X2, H40.52X3, H40.52X4, H40.53X1, H40.53x2, H40.53X3, H40.53X4, H40.61X1, H40.61X2, H40.61X3, H40.61X4, H40.62X1, H40.62X2, H40.62X3, H40.62X4, H40.63X1, H40.63X2, H40.63X3, H40.63X4, H40.811, H40.812, H40.813, H40.821, h40.822, H40.823, H40.831, H40.832, H40.833, H40.89, H40.9, H42, H44.001, H44.002, H44.003, H44.011, H44.012, H44.013, H44.021, H44.022, H44.023, H44.111, H44.112, H44.113, H44.121, H44.122, H44.123, H44.131, H44.132, H44.133, H44.19, H44.21, H44.22, H44.23, H44.30, H44.311, H44.312, H44.313, H44.321, H44.322, H44.323, H44.391, H44.392, H44.393, H44.40, H44.411, H44.412, H44.413, H44.422, H44.423, H44.431, H44.432, H44.433, , H44.441, H44.442, H44.443, H44.50, H44.511, H44.512, H44.513, H44.521, H44.522, H44.523, H44.531, H44.532, H44.533, H44.601, H44.602, H44.603, H44.611, H44.612, H44.613, H44.621, H44.622, H44.623, H44.631, H44.632, H44.633, H44.641, H44.642, H44.643, H44.651, H44.652, H44.653, H44.691, H44.692, H44.693, H44.701, H44.702, H44.703, H44.711, H44.712, H44.713, H44.721, H44.722, H44.723, H44.731, H44.732, H44.733, H44.741, H44.742, H44.743, H44.751, H44.752, H44.753, H44.791, H44.792, H44.793, H44.811, H44.812, H44.813, H44.821, H44.822, H44.823, H44.89, H44.9, Q15.0
Article - Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) (A57071)

For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC. to process their claims.Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.
Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) in the Treatment of Adults with Major Depressive Disorder (A57072)

CMS National Coverage PolicyInternet-Only Manuals (IOMs):CMS IOM Publication 100-08,Medicare Program Integrity Manual,Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCDSocial 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.Title XVIII of the Social Security Act, Section 1862(a)(1)(D) prohibits the payment for any expenses incurred for items or services that are investigational or experimental.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L34998 Transcranial Magnetic Stimulation (TMS) in the Treatment of Adults with Major Depressive Disorder. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceThe ordering provider name and NPI must be included on the claim in the following locations:For Part A claims: Block 78/79 of the UB-04OR2420B for EMCFor Part B claims: Block 17 A and B for paper claims; 2310AOR2420F for EMCNotice: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.Utilization ParametersIt is expected that CPT code 90867 be reported only once per patient for the episode (for the initial planning) and NOT in conjunction with CPT codes 90868 or 90869.CPT code 90867 should not be reported more than once within a 6-week period of time.Do not report CPT code 90869 (motor threshold determination) in conjunction with 90867 or 90868.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.The medical record documentation must support that the attending physician has met with the patient face to face for the initial assessment and for subsequent delivery and management when there is a change in the individuals mental status and/or other significant change in clinical status.The medical record documentation must include evidence of clinical judgment of the treating physician in evaluation of the absolute and relative contraindications in the pre-procedure record for the present episode of care.
Article - Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing (A57077)

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) L36393 Controlled Substance Monitoring and Drugs of Abuse Testing. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Documentation RequirementsNote: Refer to the LCD for documentation requirements, in the patients medical record, of medical necessity for testing ordered on an individual patient basis by the clinician.All 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: B-type Natriuretic Peptide (BNP) Testing (A57083)

CMS National Coverage PolicyLanguage quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review a NCD. See 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Title XVIII of the Social Security Act, 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1862(a)(7) excludes routine physical examinations (screening).Code of Federal Regulations:42 CFR Sections 410.32(a) & 410.32(a)(3) require that clinical laboratory services be orderedand usedpromptly by the physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who is treating the beneficiary.42CFR411.15 excludes from coverage examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury with specific legislative enactments as the only exceptions.CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, 20.4.4 and 20.4.5.CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 9, 100 General Billing RequirementsCMS Manual System, Pub 100-20, One Time Notification, Transmittal 477, dated April 24, 2009, Change Request 6338.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation supporting medical necessity should be legible, maintained in the patient's record, and must be made available to the A/B MAC upon request.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.
Article - Billing and Coding: B-type Natriuretic Peptide (BNP) Testing (A57084)

CMS National Coverage PolicyLanguage quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review a NCD. See 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Title XVIII of the Social Security Act, 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1862(a)(7) excludes routine physical examinations (screening).Code of Federal Regulations:42 CFR Sections 410.32(a) & 410.32(a)(3) require that clinical laboratory services be ordered and used promptly by the physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who is treating the beneficiary.42CFR411.15 excludes from coverage examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury with specific legislative enactments as the only exceptions.CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, 20.4.4 and 20.4.5.CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 9, 100 General Billing Requirements.CMS Manual System, Pub 100-20, One Time Notification, Transmittal 477, dated April 24, 2009, Change Request 6338.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation supporting medical necessity must be legible, maintained in the patient's record, and made available to the A/B MAC upon request.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.
Article - Billing and Coding: MolDX: Repeat Germline Testing (A57100)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claimCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure 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) MolDX: Repeat Germline Testing.