evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication (A56384)

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 that claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication.After the initial 36 treatment sessions or 12 weeks (whichever comes first) beneficiaries may be eligible for another 36 treatment sessions with another referral from a physician. The requirements of this second referral are the same as for the initial referral. All claims submitted for additional sessions after the first 36 sessions or the initial 12 week period must append modifier -KX to the CPT code for this service in order to attest that those requirements have been fulfilled.ICD-10-CM diagnosis codes supporting medical necessity must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.Any diagnosis submitted must have documentation in the patients record to support coverage and medical necessity.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: Upper Gastrointestinal Endoscopy and Visualization (A56389)

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) for Upper Gastrointestinal Endoscopy and Visualization L34434.All unlisted procedure codes billed for services are subject to development and medical review.
Article - Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic (A56394)

CMS National Coverage PolicyN/AArticle TextThis article only applies todiagnosticcolonoscopies and sigmoidoscopies. Sigmoidoscopy and colonoscopy testing allows for the direct visualization of the lower gastrointestinal tract. Inspection is performed with an illuminated tube. These procedures are performed to detect polyps, tumors and other lesions of the intestines. The site of pathology can be identified during a colonoscopy and a biopsy can be obtained. Refer to associated LCD L34614.Refer to the Medicare Internet Only Manuals (IOM) for coverage of colorectal cancer screening procedures.Documentation RequirementsThe medical record should support the medical reasonableness, necessity and frequency of the diagnostic test performed. This documentation should be made available to the Contractor upon request.Documentation must indicate the precise areas scoped and the depth reached during colonoscopy.Utilization GuidelinesIt is expected that these services would be performed as indicated by current medical literature and/or standards of practice.
Article - Billing and Coding: Endoscopic Treatment of GERD (A56395)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A). Allows coverage and payment for only those services that are considered to be reasonable and necessary.Title XVIII of the Social Security Act, 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Change Request 10901 Local Coverage Determinations (LCDs) Implementation date January 8, 2019.IOM 100-08Medicare Program Integrity Manual, Chapter 13-Local Coverage Determinations.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD L34659.Benefits are not available for endoluminal treatment for Gastroesophageal Reflux Disease (GERD) using the Stretta procedure, the Bard EndoCinch Suturing System, Plicator, or similar treatments as these procedures are not considered reasonable and necessary for the diagnosis or treatment of an injury or disease.Currently, these procedures are considered non-covered due to the fact that current peer-reviewed literature does not support the efficacy of the services. Claims will be denied as not proven effective.Coverage is appropriate for the TIF (Transoral Incisionless Fundoplication) procedure, example EsophyX, documentation must support the indications listed in L34659.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See the Coverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, and any other records that describe or support the evaluation and treatment of the patient. Documentation should be available to the Contractor upon request.
Article - Billing and Coding: Endovenous Stenting (A56414)

CMS National Coverage PolicySocial Security Act (Title XVIII) Standard Reference: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) L37893 Endovenous Stenting. Please refer to the LCD for reasonable and necessary requirements.Medicare reimbursement for endovenous stenting is limited to the treatment of severely symptomatic venous obstructions as outlined in the related LCD.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.Claims must be submitted with an ICD-10-CM code that represents the reason the procedure was done. The ICD-10-CM code must be billed to the highest level of specificity for that code set. The ICD-10-CM code must be linked to the appropriate procedure code.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 should list type and length of conservative treatment as applicable per the LCD.Pre- and post-deployment intervention images should be obtained and made available upon request. Intermediate stages pertinent to the endovascular procedure may also be documented with images. Details should include the position of the device, and when appropriate, the nature of the obstruction (if a determination can be made regarding the etiology), and effect of the device on target or nontarget vessels.Medical record documentation should list guide catheter used, as well as stent type, diameter and length.
Article - Billing and Coding: Assays for Vitamins and Metabolic Function (A56416)

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) L34914, Assays for Vitamins and Metabolic Function. 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.The following tests currently do not have specific codes assigned for the test.CPT code 84999 should be used to bill the following tests and a note should be added to identify which test was performed in the Remarks area of the claim for Part A and the Narrative area of the claim for Part B:Functional intracellular analysisTotal antioxidant functionDocumentation RequirementsAll documentation must be maintained in the patients 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: Frequency of Laboratory Tests (A56420)

CMS National Coverage PolicyPlease refer to the Local Coverage Determination (LCD) L35099, Frequency of Laboratory Tests.Article TextRefer to the Novitas Local Coverage Determination (LCD) L35099, Frequency of Laboratory Tests, for reasonable and necessary requirements and frequency limitations.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. Per CMS Medicare Learning Network (MLN) Medicare Matters number MM8863, the use of NCCI-associated modifiers should NOT be used to bypass a procedure-to-procedure (PTP) edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.Refer to the NCDs for the procedure code list of ICD-10-CM codes that are considered covered by Medicare at:https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/LabNCDsICD10.html
Article - Billing and Coding: CT of the Abdomen and Pelvis (A56421)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) states that no payment shall be made to any provider for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 6, 20.1.2 Other Excluded Services Beyond the Scope of a SNF Part A BenefitCMS Internet-Only Manual, Pub. 100-20, One-Time Notification, Transmittal 477, dated April 24, 2009, Change Request 6338Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for CT of the Abdomen and Pelvis L34415.
Article - Billing and Coding: Bariatric Surgical Management of Morbid Obesity (A56422)

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) L35022 (Bariatric Surgical Management). 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.CPT code 43659 should be used when BOTH the gastric band and subcutaneous port components were removed AND replaced.CPT code 43843 should be used to bill the following test and a note should be added to identify the specific test performed in the Remarks area of the claim for Part A and the Narrative area of the claim for Part B:Open-sleeve gastrectomyNot otherwise classified (NOC) CPT code 43999 should be used to bill the following tests and a note should be added to identify the specific test performed in the Remarks area of the claim for Part A and the Narrative area of the claim for Part B:Laparoscopic vertical-banded gastroplastyOpen adjustable gastric bandingCoverage for selected bariatric surgery procedures on patients who meet national and local coverage criteria set forth in the LCD requires reporting three appropriate diagnoses. Report the primary diagnosis as E66.01 (morbid obesity). Report a secondary diagnosis fromICD-10 Code group 1 and a tertiary diagnosis fromICD-10 Code group 2.
Article - Billing and Coding: Topical Oxygen Therapy (A56431)

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.42 CFR 410.27(f) Therapeutic outpatient hospital or CAH services and supplies incident to a physicians or nonphysician practitioners service: ConditionsCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, 30.1 Billing Requirements for HBO Therapy for the Treatment of Diabetic Wounds of the Lower ExtremitiesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Topical Oxygen Therapy L37873 Local Coverage Determination (LCD).
Article - Billing and Coding: eVox&reg; System and Other Electroencephalograph Testing for Memory Loss (A56440)

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 TexteVox, BrainView NeuralScan and VoxNeuro are Class II medical devices cleared by theU.S. Food & Drug Administration (FDA)that acquire, display, and store the electrical activity of a patients brain, including electroencephalograph (EEG) and event-related potentials (ERPs), by placing two or more electrodes on the head. These devices map areas of the brain and measure brain activity. Using analytical software the test findings are placed into interpretable results assisting the physician in making a diagnosis and decision about a patients brain function.Novitas has seen the eVoxSystem billed to Medicare using the following Current Procedural Terminology (CPT) codes 92650, 92653, 95816, 95930, 95957 and 96146.Coding GuidanceCPT codes 92650, 92653, 95816, 95930, 95957 and 96146 represent separate services for digital analysis of EEG, EEG recording, and visual and auditory evoked potential testing. The eVoxSystem and similar tests describe a panel of tests that should be billed using the unlisted neurological or neuromuscular diagnostic procedure code. The panel of tests does not accurately reflect the testing, the work units nor the inherent training described by the CPT codes listed above. Therefore, it is incorrect coding to bill the individual CPT codes listed above when performing the eVoxSystem or other electroencephalograph testing for memory loss.When billing for eVoxSystem, BrainView NeuralScan, VoxNeuro or similar systems CPT code 95999 should be reported on the claim with one unit of service. The term for the device (e.g., eVoxSystem, BrainView Neural Scan System, VoxNeuro, etc.) should be reported in the Remarks area of the claim for Part A and the Narrative area of the claim for Part B.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
Article - Billing and Coding: Cardiac Radionuclide Imaging (A56476)

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 TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Cardiac Radionuclide Imaging L33457.Claims submitted for stress tests performed as preoperative evaluation of patients without symptoms of coronary artery disease (CAD) who are deemed to be at moderate risk must document 1 of the following at-risk conditions in the medical record: diabetes mellitus (DM) with complications, peripheral vascular disease (PVD), aortic aneurysm or cerebrovascular disease.
Article - Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS) (A56491)

CMS National Coverage PolicyN/AArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy for L37578-Micro-Invasive Glaucoma Surgery (MIGS).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.Coding GuidanceFor noncomplex cataract removal with insertion of aqueous drainage system, use CPT 66991.For complex cataract removal with intraocular lens implant and concomitant intraocular aqueous drainage device, use CPT code 66989.Please refer to the "Limitations" section in the related LCD for additional information.For Part A claims:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formFor Part B claims:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimFrequency LimitationsMedicare may cover only 1 unit per eye, per date of service of CPT code 66991 and 66989 for insertion of glaucoma drainage device(s) into the trabecular meshwork (e.g., iStent, or iStentinject), when performed in conjunction with cataract surgery and when the medically reasonable and necessary criteria as stated in the LCD are met. Although more than one drainage device into the trabecular meshwork of a single eye on a single day of service, using an insertion tool loaded with more than one device, (e.g., iStentinject), may be performed, once the insertion tool is deployed within the eye, there is negligible increase in work or expense. Therefore only one unit of 66991 and 66989 per eye, per day may be billed, regardless of the number of devices inserted into a single eye on the date of service.Medicare may cover only1 unit per eye, per date of service of CPT code 0449Tfor insertion of glaucoma drainage device(s) into the subconjunctival space (e.g., XEN45), when the medically reasonable and necessary criteria as stated in the LCD are met.Documentation RequirementsAll documentation must be maintained in the patient's medical record and must support the medical necessity of the services as directed in this article and be 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: Hospice - Neurological Conditions (A56502)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1813 (a)(4)(A)(i) drugs and biologicals provided in a hospice programTitle 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 11, 30.2 Payment Rates, 30.2.2 Service Intensity Add-on (SIA) Payments, and 30.3 Data Required on the Institutional Claim to A/B MAC (HHH)Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Hospice  Neurological Conditions L34547.
Article - Billing and Coding: Blepharoplasty, Eyelid Surgery, and Brow Lift (A56503)

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 30, 20.2.1 Categorical DenialsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Blepharoplasty, Eyelid Surgery, and Brow Lift L34411.