evekhm/cms_iom_3000 huggingface dataset:
Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)

L1980 (ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (SINGLE BAR 'BK' ORTHOSIS), CUSTOM FABRICATED) describes a custom fabricated AFO designed to control inversion and eversion motions of the ankle foot complex. Primary construction is a single metal upright (medial or lateral) joined to a rigid calf band, free motion ankle joint, and stirrup component attached to an orthopedic shoe. Height of calf cuff/band terminates well above the ankle (usually to near the top of the calf) and is fastened around the lower leg above the ankle.Included in the code are components for closures and attaching the footwear.This AFO is custom fabricated per the DMEPOS quality standards, Appendix C.L1990 (ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (DOUBLE BAR 'BK' ORTHOSIS), CUSTOM FABRICATED) describes a custom fabricated AFO designed to control inversion and eversion motions of the ankle foot complex. Primary construction are two metal uprights (medial and lateral) joined to a rigid calf band, free motion ankle joints, and stirrup component attached to an orthopedic shoe. Height of calf cuff/band terminates well above the ankle (usually to near the top of the calf) and is fastened around the lower leg above the ankle. Included in the code are components for closures and attaching the footwear. This AFO is custom fabricated per the DMEPOS quality standards, Appendix C.Code L4631 describes a Charcots restraint orthotic walker (CROW) orthosis. Code L4631 is a custom fabricated ankle-foot orthosis which has all of the following characteristics:
Article - Speech Generating Devices (SGD) - Policy Article (A52469)

Ocular tracking device, any type, describes an SGD accessory used with an SGD or SGD software to allow a speech-impaired person to use his or her eyes to communicate. Ocular tracking devices track the users eye movement and determine where on screen their gaze is targeted.Head control mouse, any type, describes an SGD accessory that monitors head movement and translates those movements into actions by the pointer on the SGD screen.Alternative input device, any type, describes any accessory other than an ocular tracking device or head control mouse, not integrated into the SGD hardware, used to control the actions of an SGD. Examples of alternative input devices include (not all-inclusive): specialty keyboards, joysticks, trackballs, trackpads, buddy buttons, jelly beans, beamers, roller balls, round pads, pal pads.Protective key guard, any type describes an overlay for a keyboard, alternative input device or SGD screen that assists the beneficiary in preventing inadvertent selection of a button, icon or other input.Protective case or cover, any type describes any protective case or cover used to enclose the SGD to prevent the ingress of liquids, dirt, dust, etc. (see above Coding Guidelines for more information).Carrying case, includes shoulder strap or carrying handle, any type describes any soft-sided or hard-sided carrying container for the SGD and any related accessories (See Non-Medical Necessity Coverage and Payment Rules for more information).Electronic components that allow the SGD to be operated by the drive control interface of a power wheelchair.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Article - Refractive Lenses - Policy Article (A52499)

When billing claims for deluxe frames, use code V2020 for the cost of standard frames and a second line item using code V2025 for the difference between the charges for the deluxe frames and the standard frames.When billing claims for progressive lenses, use the appropriate code for the standard bifocal (V2200, V2201, V2202, V2203, V2204, V2205, V2206, V2207, V2208, V2209, V2210, V2211, V2212, V2213, V2214, V2215, V2218, V2219, V2220, V2221,V2299) or trifocal (V2300, V2301, V2302, V2303, V2304, V2305, V2306, V2307, V2308, V2309, V2310, V2311, V2312, V2313, V2314, V2315, V2318, V2319, V2320, V2321,V2399) lenses and a second line item using code V2781 for the difference between the charge for the progressive lens and the standard lens.The RT and/or LT modifiers must be used with all HCPCS codes in this policy except codes V2020, V2025 and V2600. Effective for claims with dates of service (DOS) on or after 3/1/2019, when lenses are provided bilaterally and the same code is used for both lenses, bill each item on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line and billed with 2 UOS. Claims billed without modifiers RT and/or LT, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.PROSEDevicePROSE(BostonSight, Needham, MA) devices are designed to rest on the sclera or white part of the eye and are used to treat ocular surface diseases, including some types of "dry eye." For Medicare billing purposes correct HCPCS coding for this item is determined based upon the condition(s) being treated. When the PROSEdevice is used as a treatment for either of the following indications listed below, the correct HCPCS code to use is V2627 (SCLERAL COVER SHELL):Treatment of an eye rendered sightless and shrunken by inflammatory disease; or,Treatment of "dry eye" where the PROSEdevice serves as a substitute for the function of the diseased lacrimal gland.When the PROSEdevice is used for any conditions other than those listed above, the device must be coded with HCPCS code V2531 (CONTACT LENS, SCLERAL, GAS PERMEABLE, PER LENS (FOR CONTACT LENS MODIFICATION, SEE 92325)) and is subject to the Medicare refractive lens statutory coverage exclusion.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC)Contractor for guidance on the correct coding of these items.
Article - Spinal Orthoses: TLSO and LSO - Policy Article (A52500)

Codes L0450, L0454, L0455, L0621, L0625, and L0628 may only be used for orthoses that are made primarily of nonelastic material (e.g., canvas, cotton or nylon).CODING VERIFICATION REVIEWThe only products which may be billed using the following list of HCPCS codes are those for which a written coding verification review (CVR) has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor and subsequently published on the Product Classification List (PCL). Information concerning the documentation that must be submitted to the PDAC for a CVR can be found on the PDAC web site or by contacting the PDAC. A PCL with products which have received a coding verification can be found on the PDAC web site. The effective date of the CVR is included for each code.Effective for claims with dates of service on or after July 1, 2010:L0450, L0454, L0456, L0458, L0460, L0462, L0464, L0466, L0468, L0470, L0472, L0488, L0490, L0491, L0492, L0625, L0626, L0627, L0628, L0630, L0631, L0633, L0635, L0637, L0639Effective for claims with dates of service on or after January 1, 2014:L0455, L0457, L0467, L0469, L0641, L0642, L0643, L0648, L0649, L0650, L0651There are two categories of custom fabricated spinal orthoses (codes L0452, L0480, L0482, L0484, L0486,L0629, L0632, L0634, L0636, L0638, and L0640):Orthoses that are custom fabricated by a manufacturer/central fabrication facility and then sent to someone other than the beneficiary. Effective for claims with dates of service on or after July 1, 2010, these items may be billed using one of these codes only if they are listed in the Product Classification List on the PDAC web site.Orthoses that are custom fabricated from raw materials and are dispensed directly to the beneficiary by the entity that fabricated the orthosis. These items do not have to be listed on the PDAC web site in order to be billed using a custom fabricated spinal orthosis code. However, the supplier must provide a list of the materials that were used and a description of the custom fabrication process on request.If a product is billed to Medicare using a HCPCS code that requires written coding verification review, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.Suppliers should contact the PDAC Contractor for guidance on the correct coding of these items.
Article - External Infusion Pumps - Policy Article (A52507)

Infusion PumpSCIg PreparationE0779J1555, J1559, J1561, J1562, J1569E0781J1575E0779 or E0781J1551, J1558Professional ServicesProfessional services include nursing services, training and education (not otherwise paid for as durable medical equipment), remote monitoring, and monitoring services for the provision of home infusion therapy furnished by a qualified home infusion supplier with administration of certain transitional home infusion drugs administered through an item of DME.For claims with dates of service on or after January 01, 2019 through December 31, 2020, codes G0068, G0069, and G0070 are used to bill for the professional services rendered on the applicable infusion drug administration calendar day for each payment category. Providers should report visit length in 15-minute increments (15 minutes = 1unit). Suppliers must ensure that the appropriate drug associated with the visit is billed with the visit or no more than 30 days prior to the visit.In the event that multiple visits occur on the same date of service, suppliers must only bill for one visit and should report the highest paying visit with the applicable drug. Claims reporting multiple visits on the same line item date of service will be returned as unprocessable.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Article - Respiratory Assist Devices - Policy Article (A52517)

HCPCS codes E0470, E0471, E0472, E0561, E0562, A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046For E0467 claims with dates of service before April 3, 2020:Claims for any of the HCPCS codes listed above that are submitted on the same claim or that overlap any date(s) of service for E0467 is considered to be unbundling.In addition, any claim for repair (HCPCS code K0739 for labor and any HCPCS code for replacement items) of beneficiary-owned equipment identified by HCPCS codes listed above is considered as unbundling if the date(s) of service for the repair overlaps any date(s) of service for code E0467.Claims for code E0467 with a date(s) of service that overlaps date(s) of service for any of the following scenarios are considered as a claim for same or similar equipment when the beneficiary:Is currently in a rental month for any of the items listed aboveOwns any of the equipment listed above that has not reached the end of its reasonable useful lifetime.For E0467 claims with dates of service on or after April 3, 2020:Any claim for repair (HCPCS code K0739 for labor and any HCPCS code for replacement items) of beneficiary-owned equipment identified by HCPCS codes listed above is considered as unbundling if the date(s) of service for the repair overlaps any date(s) of service for code E0467.Claims for code E0467 with a date(s) of service that overlaps date(s) of service in a rental month for any of the items listed above are considered as a claim for same or similar equipment.CODING VERIFICATION REVIEWThe only products which may be billed using the following list of HCPCS codes are those for which a written coding verification review (CVR) has been made by the PDAC contractor and subsequently published on the Product Classification List (PCL). Information concerning the documentation that must be submitted to the PDAC for a CVR can be found on the PDAC website or by contacting the PDAC. A PCL with products which have received a coding verification can be found on the PDAC website. The effective date of the CVR is included for each code.Effective for claims with dates of service on or after January 1, 2022:E0467If a product is billed to Medicare using a HCPCS code that requires written CVR, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Article - Self-Administered Drug Exclusion List: and Biologicals Excluded from Coverage - Medical Policy Article (A52527)

CMS National Coverage PolicyN/AArticle TextThe table below lists drugs that are not covered by Medicare, the effective date of non-coverage, and the rationale. (Please see "Process for Determining Self-Administered Drug Exclusions  Medical Policy Article") The column, "Brand Names," provides one or more examples but not all. Information about drugs not separately reimbursed or not covered for reasons other than "usually self-administered," is found in other Part A and Part B MAC publications and sites.In the interest of consistent Medicare, the CGS Administrators Part A MAC will follow the coverage decision for self-administered drugs as determined by the Part B MAC in each respective state. HCPCS codes for the same drugs that apply only to providers that bill the Part A MAC (e.g., HCPCS codes used for drugs billable under the Outpatient Prospective Payment System [OPPS]) are included when applicable.The use of the JA and JB modifiers is required for drugs which have one HCPCS Level II (J or Q) code but multiple routes of administration. Drugs that fall under this category will be marked with an asterisk (*) and must be billed with the JA modifier for the intravenous infusion of the drug or billed with the JB modifier for the subcutaneous injection form of administration.Claims billed with the JA modifier are not part of the SAD exclusion. The Contractor will process claims with the JA modifier applying the policy that not only the drug is medically reasonable and necessary, but also that the route of administration is medically reasonable and necessary.Subcutaneously administered drugs listed on the Usually Self-Administered list will be denied as a benefit exclusion. Claims for drugs marked with an asterisk (*) billed without either a JA or JB modifier will also be denied.And mark all applicable drugs with *.
Article - Traumeel Injections (A52537)

CMS National Coverage PolicyN/AArticle TextCGS has determined that the injection of Traumeel, a homeopathic formulation, into the soft tissues, ligaments or other structures of the foot or ankle is not medically necessary. There are no published studies on Traumeel injections in humans in the peer-reviewed literature.CPT codes 20550-20553 will be denied if the material injected is determined to be Traumeel.HCPCS code J3490 will be denied when used to denote Traumeel.
Article - Vacuum Erection Devices (VED) - Policy Article (A52712)

CMS National Coverage PolicyN/AArticle TextNON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Vacuum erection devices (L7900) and related supplies are considered Prosthetic Devices under the Prosthetic Devices benefit category (Social Security Act 1861(s)(8)). For dates of service on or after July 1, 2015, codes L7900 and L7902 are statutorily non-covered based on the Achieving a Better Life Experience (ABLE) Act of 2014 (see Social Security Act 1834(a)(1)(I)).REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated.The required Face-to-Face Encounter and Written Order Prior to Delivery List list is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD prior to delivery, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) contractor for guidance on the correct coding of these items.
Article - Billing and Coding: Nerve Blockade for Treatment of Chronic Pain and Neuropathy (A52725)

CMS National Coverage PolicyN/AArticle TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.LCD L35457 states, "Nerve blockade and/or electrical stimulation are non-covered for the treatment of metabolic peripheral neuropathy. The peer-reviewed medical literature has not demonstrated the efficacy or clinical utility of nerve blockade or electrical stimulation, alone or used together, in the diagnosis and/or treatment of neuropathic pain."The use of peripheral nerve blocks for treating diabetic neuropathy is not considered reasonable and/or necessary and is not covered by Medicare Part A or B. Such use of peripheral nerve blocks is not supported by the current peer reviewed, published, evidence based scientific literature nor by specialty society guidelines. Claims are subject to review and recoupment.This notification does not affect those regional/local blocks done as part of an operative procedure (for example wound debridement in the operating room) when performed as an adjunct to or the sole means of regional/local anesthesia for the procedure.For somatic nerve blocks, it is inappropriate to bill for fluoroscopy (CPTcodes 77002 or 77003) with a 59 modifier when the procedure(s) billed on that date of service for the same patient by the same provider are included in the CPTdescription of the procedure(s) performed.Documentation RequirementsAll documentation must be maintained in the patients medical record and 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 record must include the physician or non-physician practitioner responsible for and providing the care of the patient.The submitted medical record should support the use of the selected diagnosis code(s). The submitted CPT/HCPCS code should describe the service performed.Sources:Neurology 2011;76;1758; V. Bril, J. England, G.M. Franklin, et al. Evidence-based guideline:Treatment of painful diabetic neuropathy: Report of the American Academy of Neurology, the American Association of Neuromuscular and Neurodiagnostic Medicine, and the American Academy of Physical Medicine and RehabilitationThis information is current as of February 7, 2013American Family Physician 2010;82(2):151-158 T. Lindsay, B. Rodgers, V. Savath, K. HettingerTreating Diabetic Peripheral Neuropathic Pain
(Medicare Program Integrity Manual)

2873  R047PI  07/25/2003  CMS Mandated Edits  08/08/2003  2517  R046PI  07/25/2003  Prepayment Edits  08/01/2003  2681  R039PI  03/14/2003  MR Review and Documentation  04/01/2003  2417  R038PI  02/03/2003  When Contractors May Publish Coverage/Coding Articles In Their Bulletins And Web Sites  02/14/2003  2120  R035PI  11/29/2002  Types of Prepayment and Postpayment Review  01/01/2003  2418  R033PI  11/01/2002  FY 2003 Budget Performance Requirements  11/01/2002  2407  R032PI  10/25/2002  Consent Settlements, CMPs Delegated to CMS and Referrals to OIG  10/25/2002  2333  R031PI  10/25/2002  Revised Prepayment Edits  09/01/2002  1793  R017PIM  12/12/2001  Reorganizes chapter 3, sections 4, 5, and 6 and Removes reference to outdated MCM and MIM overpayment collection instructions and lists the more current CFR citations instead.  04/01/2002  1891  R016PIM  11/28/2001  Adds Various Program Memoranda for BI Requests for Information, O rganizational Requirements, Unsolicited Voluntary Refund Checks, Anti -Kickback Statute Implications  11/28/2001  1732  R013PIM  09/26/2001  Administrative Relief from Medical Review and Benefit Integrity in Disaster Situations  09/26/2001  1879  R003PIM  11/22/2000  Complete Replacement of PIM Revision 1.  NA 1292  R001PIM  06/2000  Initial Release of Manual  NA 931 Back to top of Chapter
Article - Non-Payment for Prefabricated Splints (A52754)

CMS National Coverage PolicyN/AArticle TextNoridian has noted that providers have been advised by some coding sources to report a splint application code for the application of "off the shelf" or pre-packaged splints. While it may be appropriate to bill for the actual splint, Noridian strongly disagrees with the advice to bill separately for the application of these splints. The application of the pre-packaged splint is a packaged service when performed on the same day as an E/M service or other procedure but, in no case, may this type of splint application be separately billed.The CPT codes: 29105, 29125, 29126, 29130, 29131, 97760, 97799 are not appropriate to bill in addition to a splint code that has a "fitting" included in the descriptor. Be aware that a large range of "L" codes do include "fitting" in the descriptor
Article - Therapy Driving Evaluations (A52759)

CMS National Coverage PolicyN/AArticle TextMedicare does not reimburse evaluations performed solely to assess a beneficiary's ability to drive a vehicle. In order for a service to be covered, the service must have a benefit category in the statute Title 18 of the Social Security Act (SSA), it must not be excluded, and it must be reasonable and necessary. There is no benefit category for driving evaluations.In addition, both screening (except as specifically exempted by statute) and routine physical examinations are excluded from coverage. 42 United States Code (USC) 1395y (a) describes routine physical checkups as:1. Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptom, complaint, or injury.2. Examinations required by insurance companies, business establishments, government agencies or other third parties.For Medicare purposes, when services provided are related solely to driving, they are not reasonable or necessary for the diagnosis or treatment of an illness or injury and are excluded from coverage under the program by SSA 1862(a)(1).This is a statutory exclusion. The beneficiary is liable for the charges and no Advance Beneficiary Notice of Noncoverage (ABN) is required. However, providers are encouraged to provide a voluntary ABN. Append modifier GX (Notice of Liability Issue, Voluntary under Payer Policy) to any billed line item.Sources: CMS Internet Only Manual (IOM), Medicare Claims Processing Manual, Publication 100-04, Chapter 1 Section 60 Social Security Act (SSA) Sections 1861 and 1862(a)(1) 42CFR 411.15(a)