evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Surgical Treatment of Nails (A59028)

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 23, 20.9 National Correct Coding Initiative (NCCI)Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) forSurgical Treatment of Nails L39258.Coding GuidelinesWhen billing for non-covered services, use the appropriate modifier.When CPTcode 11730, 11732 or 11750 is reported, it represents all services performed on that nail for that date of service (DOS).When lateral and medial sides of a nail are involved, do not report a separate code for each border.Reporting CPTcodes 11730 or 11732 (avulsion) with CPTcode 11750 (excision) and/or 11765 (wedge resection) for the same digit on the same DOS is not correct coding.Reporting CPTcode 11750 (excision) with CPTcode 11765 (wedge resection) for the same digit on the same DOS is not correct coding.Reporting CPTcode 11765 for the removal of a small piece of the skin and/or the nail without local anesthesia is not correct coding.If CPTprocedure codes 11730, 11750, or 11765 are performed on different nails, report the procedure performed with 1 unit of service (UOS) and append with the appropriate identifying digit modifiers.For every subsequent avulsion, CPTcode 11732 is reported as the add-on code with 1 UOS and the appropriate identifying digit modifier appended.CPT codes 11730 and 11732 for partial or complete nail avulsion, if billed for the same finger less than 16 weeks or the same toe less than 32 weeks, must include the following criteria:For a medically reasonable and necessary repeat nail excision on the same finger or toe. The medical record documentation must be specific as to the indication, such as ingrown nail of the opposite border or new significant pathology on the same border recently treated;For a medically reasonable and necessary repeat nail avulsion of the same toenail or fingernail performed more often than every 32 weeks (8 months) for toenails or every 16 weeks (4 months) for fingernails. The medical record documentation must be specific as to the indication, such as ingrown nail of the opposite border or new significant pathology on the same border recently treated.
Article - Billing and Coding: Hyaluronic Acid Injections for Knee Osteoarthritis (A59030)

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 ClaimsProcessing Manual,Chapter 12,30.6.7(D) Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201-99215) -Drug Administration Services and E/M Visits Billed on Same Day of ServiceCMS Internet-Only Manual, Pub. 100-04, Medicare ClaimsProcessing Manual,Chapter 17,40 Discarded Drugs and Biologicals and90.2 Drugs, Biologicals, and RadiopharmaceuticalsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Hyaluronic Acid Injections for Knee OsteoarthritisL39260.*Note:The prescribing information for the dose and frequency of administration should be consistent with theUnited States (U.S.) Food and Drug Administration (FDA) approved labeling.Billing subsequent injections in a series (EJ modifier):Use EJ modifier with the HCPCS code for the drug administered to indicate subsequent injections of a series. Do not use this modifier for the first injection of each series. A series is defined as a set of injections for each joint and each treatment.JW Modifier Requirement:Effective January 1, 2017, the Centers for Medicare and Medicaid Services (CMS) issued CR 9603, regarding the use of the JW modifier for discarded Part B drugs and biologicals. Providers are required to use the JW modifier for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded (except those provided under the CAP for Part B drugs and biologicals). Document the discarded drug or biological in the patients medical record when submitting claims with unused Part B drugs or biologicals from single use vials or single use packages that are appropriately discarded.Billing the injection procedure:The CPTcode (procedure code) 20610 or 20611 (with ultrasound guidance) may be billed for the intra-articular injection in addition to the drug.If an aspiration and an injection procedure are performed at the same session, bill only 1 unit for CPTcode 20610 or 20611.When additional substances simultaneously administer (e.g., cortisone, anesthetics) with viscosupplementation, only 1 injection service is allowed per knee.The appropriate site modifier (RT or LT) must be appended to CPTcode 20610 or CPTcode 20611 to indicate if the service was performed unilaterally and modifier (50) must be appended to indicate if the service was performed bilaterally.An Evaluation and Management (E&M) service may be appropriate if the decision to start the series of injections is made after an evaluation during the same visit. Indicate this by using an E&M code with modifier -25.An E&M service should not be reported for subsequent injections unless there was a separately identifiable problem for which the E&M service was required and rendered.
Article - Billing and Coding: MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia (A59032)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia.To receive a denial, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia (A59034)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia.To receive a denial, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: Bone Mass Measurement (A59040)

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 13,140.1 Payment Methodology and HCPCS Coding.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Bone Mass Measurement L39268.Coding GuidelinesProcedure codes may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.Specific Coding GuidelinesNo separate payment for venography performed during the operative session may be allowed and it should not be separately billed.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related 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: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin (A59042)

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 OriginL39270.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: MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia (A59051)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia.To receive a denial, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Sterilization (A59060)

CMS National Coverage PolicyN/AArticle TextSterilization means any medical procedure, treatment or operation for the sole purpose of rendering an individual permanently incapable of reproducing and not related to the repair of a damaged/dysfunctional body part.Under the Medicare Program guidelines the coverage of sterilization is limited to necessary treatment of an illness or injury. An example of necessary treatment is the removal of a uterus or removal of diseased ovaries (bilateral oophorectomy) because of a tumor, or bilateral orchiectomy in the case of prostate cancer.Elective hysterectomy, tubal ligation and vasectomy in the absence of a disease for which sterilization is considered an effective treatment is not covered. In addition, no payment would be made for sterilization procedures if it is a preventive measure e.g., a physician believes pregnancy would cause overall endangerment to a woman's health, or as a measure to prevent the possible development of, or effect on a mental condition, should pregnancy occur. (Section 1862(a)(1)(A) of the Social Security Act and 42 CFR 411.15(k).Claims will be denied on postpay review and payment recouped if the pathological evidence of the necessity to perform any of these procedures to treat an illness or injury is absent and/or when the primary objective is to achieve sterilization.
Article - Billing and Coding: eVox&reg; System and Other Electroencephalograph Testing for Memory Loss (A59086)

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.First Coast 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.
Draft Article - Billing and Coding: MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer (DA58028)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15,80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer DL38576.To report a service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Draft Article - Billing and Coding: MolDX: Molecular Assays for the Diagnosis of Cutaneous Melanoma (DA59109)

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 Manuals, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Assays for the Diagnosis of Cutaneous Melanoma.Please submit the following claim information:Regarding the myPathMelanoma assay:Select CPT code 81479 for dates of service prior to 7/1/2019Select proprietary CPT code 0090U for dates of service on or after 7/1/2019Regarding other molecular assays for the diagnosis of cutaneous melanoma:Select CPT code 81479 if there is not an applicable CPT or PLA code listed belowOnly 1 test may be billed per patient per melanocytic lesion.Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: Molecular Assays for the Diagnosis of Cutaneous Melanoma (A59109)

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 Manuals, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 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 MolDX: Molecular Assays for the Diagnosis of Cutaneous Melanoma.Please submit the following claim information:Regarding the myPathMelanoma assay:Select CPTcode 81479 for dates of service prior to 7/1/2019Select proprietary CPTcode 0090U for dates of service on or after 7/1/2019Regarding other molecular assays for the diagnosis of cutaneous melanoma:Select CPTcode 81479 if there is not an applicable CPT or PLA code listed belowOnly 1 test may be billed per patient per melanocytic lesion.Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code