evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Lab: Immunohistochemistry (IHC) Indications for Breast Pathology (A59292)

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.Article TextBased on recommendations from the College of American Pathologists, the American Society of Clinical Oncologists (ASCO), and the National Comprehensive Cancer Network (NCCN), hormone receptor assays, estrogen receptor (ER), progesterone receptor (PR), and Her-2/neu are the only current biomarkers that demonstrate standardized value in breast cancer pathology evaluation. Although other biomarkers, such as Ki-67, PI3K, and gene expression assays, have been studied, no proven standardized value has been established. Therefore, this A/B MAC will allow ER, PR, and Her2 testing by IHC for patients with primary invasive breast cancers and recurrent or metastatic cancers.To report an IHC service for an ER, PR, Her2, submit the following claim information:CPTCodeSpecimenUOS88342First single/multiplex stain188341Each additional2To report morphometric analysis,select oneof the following codes based on the type of morphometric analysis:CPTCodeService TypeUOS88360Manual388361Computer-assisted3Note: a unit of service applies to a single separately identifiable specimen.
Draft Article - Billing and Coding: Immunohistochemistry (IHC) Indications for Breast Pathology (DA59292)

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.Article TextBased on recommendations from the College of American Pathologists, the American Society of Clinical Oncologists (ASCO), and the National Comprehensive Cancer Network (NCCN), hormone receptor assays, estrogen receptor (ER), progesterone receptor (PR), and Her-2/neu are the only current biomarkers that demonstrate standardized value in breast cancer pathology evaluation. Although other biomarkers, such as Ki-67, PI3K, and gene expression assays, have been studied, no proven standardized value has been established. Therefore, this A/B MAC will allow ER, PR, and Her2 testing by IHC for patients with primary invasive breast cancers and recurrent or metastatic cancers.To report an IHC service for an ER, PR, Her2, submit the following claim information:CPTCodeSpecimenUOS88342First single/multiplex stain188341Each additional2To report morphometric analysis,select oneof the following codes based on the type of morphometric analysis:CPTCodeService TypeUOS88360Manual388361Computer-assisted3Note: a unit of service applies to a single separately identifiable specimen.
Draft Article - Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains (DA59295)

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 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 Lab: Special Histochemical Stains and Immunohistochemical Stains L35922.To report special histochemical stains and/or immunohistochemical stains services, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)
Draft Article - Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin (DA59311)

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. 100-04, Medicare Claims Processing Manual, Chapter 3, 90.3.1 Allogeneic for Stem Cell TransplantationCMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2,110.23 Stem Cell TransplantationCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 3, 90.3.1 Allogeneic for Stem Cell TransplantationCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing, Chapter 32, 90 Stem Cell Transplantation, 90.1 General and 90.2 HCPCS and Diagnosis Coding  ICD-9-CM ApplicableArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forAllogeneic Hematopoietic Cell Transplantationfor Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell OriginDL39513.The CMS National Coverage Determination (NCD 110.23) for Stem Cell Transplantation describes nationally covered indications for stem cell transplant, the details of which will not be repeated within this article. This article describes additional locally covered indications for stem cell transplant.A pretransplant assessment, even accounting for institutional variations, should establish the extent of disease and provide information about the individual's comorbidities that are likely to impact outcomes.The pretransplant evaluation should include a significant portion of the following elements or documentation of the completion of the institutions pre-established pre-transplant protocol, demonstrating the elements of that protocol.History and physical examination which includes:Detailed historyPhysical examinationAll relevant laboratory studiesA chest radiograph, an electrocardiogram, and a study of cardiac functionPulmonary function testDisease-specific restaging studiesFurther studies may be required depending on signs and symptoms.It is expected that documentation of the pretransplant evaluation be included in the medical record that supports the transplants billing and be available on request.PRETRANSPLANT COUNSELINGThis A/B MAC suggests the following:Fertility preservation discussion, if relevantEnd-of-life and/or advance care planningAllogeneic Hematopoietic Cell Transplantation represents intense therapy for severe disease. Therefore, Palmetto GBA expects documentation relating the precise benefits and risks to a beneficiary in such a way that it is clear the discussion was tailored to the individual patient.Informed consent guidelines should show that patients have an accurate understanding of the risks of HCT. (Deeg & Sandmaier,Determining eligibility for allogeneic hematopoietic transplantation.UpToDate.2022).
Article - Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin and Non-Hodgkin Lymphoma with B-cell or T-cell Origin (A59311)

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. 100-04, Medicare Claims Processing Manual, Chapter 3, 90.3.1 Allogeneic for Stem Cell TransplantationCMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2,110.23 Stem Cell TransplantationCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 3, 90.3.1 Allogeneic for Stem Cell TransplantationCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing, Chapter 32, 90 Stem Cell Transplantation, 90.1 General and 90.2 HCPCS and Diagnosis Coding  ICD-9-CM ApplicableArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forAllogeneic Hematopoietic Cell Transplantationfor Primary Refractory or Relapsed Hodgkin and Non-Hodgkin Lymphoma with B-cell or T-cell OriginDL39513.The CMS National Coverage Determination (NCD 110.23) for Stem Cell Transplantation describes nationally covered indications for stem cell transplant, the details of which will not be repeated within this article. This article describes additional locally covered indications for stem cell transplant.A pretransplant assessment, even accounting for institutional variations, should establish the extent of disease and provide information about the individual's comorbidities that are likely to impact outcomes.The pretransplant evaluation should include a significant portion of the following elements or documentation of the completion of the institutions pre-established pre-transplant protocol, demonstrating the elements of that protocol.History and physical examination which includes:Detailed historyPhysical examinationAll relevant laboratory studiesA chest radiograph, an electrocardiogram, and a study of cardiac functionPulmonary function testDisease-specific restaging studiesFurther studies may be required depending on signs and symptoms.It is expected that documentation of the pretransplant evaluation be included in the medical record that supports the transplants billing and be available on request.PRETRANSPLANT COUNSELINGThis A/B MAC suggests the following:Fertility preservation discussion, if relevantEnd-of-life and/or advance care planningAllogeneic Hematopoietic Cell Transplantation represents intense therapy for severe disease. Therefore, Palmetto GBA expects documentation relating the precise benefits and risks to a beneficiary in such a way that it is clear the discussion was tailored to the individual patient.Informed consent guidelines should show that patients have an accurate understanding of the risks of HCT. (Deeg & Sandmaier,Determining eligibility for allogeneic hematopoietic transplantation.UpToDate.2022).
Article - Billing and Coding: Positron Emission Tomography (PET) Scan for Inflammation and Infection (A59318)

CMS National Coverage PolicyN/AArticle TextDocumentation RequirementsThe 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.The patients medical record should include but is not limited to:Relevant medical historyPhysical examination findingsResults of pertinent tests/proceduresImaging testing performedRationale for decision for PET scan including rationale for PET scan over standard imaging modalities and why PET was necessaryResults of PET scanDocumentation in medical record of the role PET scan plays in clinical managementIn cases of fever of unknown fever curve with temperatures and documentation of  21 days since onset of fever and fevers in the 2 weeks prior to the study.Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient and indicate thereason(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(s) and copies of images. The computerized image reconstruction data should also be maintained.Documentation must be available to Medicare upon request.
Draft Article - Billing and Coding: Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DA57512)

CMS National Coverage PolicyLanguage quoted from 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 LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 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):Section 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.Section 1862(a)(1)(D) refers to limitations on items or devices that are investigational or experimental.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.
Draft Article - Billing and Coding: Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DA57513)

CMS National Coverage PolicyLanguage quoted from 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 LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 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):Section 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.Section 1862(a)(1)(D) refers to limitations on items or devices that are investigational or experimental.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.
Article - Billing and Coding: High Resolution Anoscopy (A59323)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claimArticle TextHigh-resolution anoscopy (HRA) is analogous to cervical colposcopy. During HRA, a lubricated anoscope is inserted into the anal canal. A cotton swab wrapped in gauze and soaked in 3-percent acetic acid is then inserted through the anoscope, and the anoscope is removed, leaving the gauze in place. The acetic acid gives dysplastic epithelium a white appearance. After 2 minutes, the gauze is removed and the anoscope reinserted. A high-resolution colposcope (magnification of 10x to 40x) is used to view the walls of the anus. A biopsy of suspicious tissue can be taken.Anal squamous dysplasia describes a spectrum of diseases that ranges from low-grade squamous intraepithelial lesions (LSIL) to higher grade squamous lesions, or to invasive anal squamous cell carcinoma (SCC). Recent reports have shown a significant increase in squamous lesions in immunocompromised individuals and men who have sex with men (MSM). These lesions are associated with chronic infection with the human papillomavirus (HPV).CPTcodes 46601 and 46607 should be used only in these circumstances: patients with abnormalities on anoscopy, abnormalities in digital rectal examination, history of HPV-related anal disease or abnormalities in anorectal cytology.Current evidence does not support coverage for routine screening in any population at this time. The clinical chart must have documentation of the abnormalities described above.
Draft Article - Billing and Coding: Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence (DA59332)

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 12,40.1 Definition of a Global Surgical Package,40.2 Billing Requirements for Global Surgeries, 40.3 Claims Review for Global Surgeries, 40.4 Adjudication of Claims for Global SurgeriesCMS Internet-Only Manual, Pub. 100-04, Medicare ClaimsProcessing Manual,Chapter 32,40 Sacral Nerve StimulationArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Sacral Nerve Stimulation for the Treatment of Urinary and Fecal IncontinenceDL39543.Note: Components of the Global Surgical Package includes miscellaneous services such as dressing changes; local incisional care; removal of cutaneous sutures and staples, lines, wires, tubes, drains.Note: Minor Surgeries and Endoscopies, separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure are not allowed.Services performed for any given diagnosis must meet all of the indications and limitations stated in the related LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS NCDs, and all Medicare payment rules.
Article - Billing and Coding: Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence (A59332)

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 12,40.1 Definition of a Global Surgical Package,40.2 Billing Requirements for Global Surgeries, 40.3 Claims Review for Global Surgeries, 40.4 Adjudication of Claims for Global SurgeriesCMS Internet-Only Manual, Pub. 100-04, Medicare ClaimsProcessing Manual,Chapter 32,40 Sacral Nerve StimulationArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Sacral Nerve Stimulation for the Treatment of Urinary and Fecal IncontinenceL39543.Note: Components of the Global Surgical Package includes miscellaneous services such as dressing changes; local incisional care; removal of cutaneous sutures and staples, lines, wires, tubes, drains.Note: Minor Surgeries and Endoscopies, separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure are not allowed.Services performed for any given diagnosis must meet all of the indications and limitations stated in the related LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS NCDs, and all Medicare payment rules.
Draft Article - Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains (DA56838)

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, 60.1.1 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 CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Special Histochemical Stains and Immunohistochemical Stains DL35922.Hematoxylin and eosin (H&E) staining provides excellent detail required for tissue-based diagnosis. This is NOT a separate service, as pathology services include routine H&E staining.Some physicians, groups, laboratories and hospitals submit global claims for the services described in the related LCD. In other instances, there are separate individuals or entities providing the professional and the technical services. It is the obligation of each party to recognize that they are responsible for the medical necessity of the services submitted.To report special histochemical stains and/or immunohistochemical stains services, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)
Draft Article - Billing and Coding: Lab: Immunohistochemistry (IHC) Indications for Breast Pathology (DA53704)

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.Article TextBased on recommendations from the College of American Pathologists (CAP), the American Society of Clinical Oncologists (ASCO) and the National Comprehensive Cancer Network (NCCN), hormone receptor assays, estrogen receptor (ER), progesterone receptor (PR), and Her-2/neu are the only current biomarkers that demonstrate standardized value in breast cancer pathology evaluation. Although other biomarkers, such as Ki-67, PI3K, and gene expression assays, have been studied, no proven standardized value has been established. Therefore, this A/B MAC will allow ER, PR, and Her2 testing by IHC for patients with primary invasive breast cancers and recurrent or metastatic cancers.To report an IHC service for an ER, PR, Her2, submit the following claim information:CPTCodeSpecimenUOS88342First single/multiplex stain188341Each additional2To report morphometric analysis,select 1of the following codes based on the type of morphometric analysis:CPTCodeService TypeUOS88360Manual388361Computer-assisted3Note: a unit of service applies to a single separately identifiable specimen.
Draft Article - Billing and Coding: Scalp Cooling for the Prevention of Chemotherapy-Induced Alopecia (DA59371)

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. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2,110.6Scalp Hypothermia During Chemotherapy to Prevent Hair Loss is not a barrier to coverage or to pricing/payment of the Category III Temporary CPTcodes for professional/facility services related to scalp cooling (CPTCodes 0662T and 0663T). The NCD, while very old, serves as a benefit category/policy statement. As indicated in the NCD, the cap itself is considered a supply. Supplies are coverable incident to a physicians professional service and/or hospital outpatient service, meaning that payment for supplies is packaged into the payment for professional services and hospital facility service.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Scalp Cooling for the Prevention of Chemotherapy-Induced AlopeciaDL39573.Documentation RequirementsAll documentation must be maintained in the patients medical record and available to the contractor upon request.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 the medical necessity of the services as directed in the related LCD.