evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Sclerosing of Varicose Veins (A53084)

CMS National Coverage PolicyN/AArticle TextImportant Coding AlertNoridian is revising this article to further clarify that CPT37241 is not an acceptable choice of procedure codes for treatment of symptoms of varicose veins of the lower extremity regardless of the method used.Noridians Local Coverage Determination, Treatment of Varicose Veins of the Lower Extremities; L34209 (JEA and JEB)/L34010 (JFA and JFB) provides coverage criteria for the treatment of varicose veins and the CPTcodes that are expected to be utilized for billing this service.As previously noted, a product for the treatment of varicose veins has appeared on the market for which the products information states that it utilizes both a sclerosing agent and a rotating wire which allegedly mixes the agent and possibly macerates any clots in the area.Noridian has been informed that some providers may have been recommended to use CPT37241 when using this device for the treatment of varicose veins. This advice is incorrect. CPT37241 must not be used to bill for the treatment of varicose veins of the lower extremities with this or similar devices.When using the ClariVein device in the treatment of varicose veins before January 1, 2017, Noridian recommends billing with CPTcode 36299. The sclerosing agent is bundled into the procedure code and is not separately reimbursable. ClariVein must be entered in Item 19 of the CMS-1500 form or the electronic notepad equivalent. For dates of service on and after January 1, 2017 providers should use CPT36473 for first vein (Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated) and 36474 (Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) If billing for both extremities it is appropriate to append modifier RT or LT to the respective claim line.Based on the intensity of service for CPTcode 37241, Noridian no longer allows payment for claims using this CPTin place of Service 11  Office, effective June 6, 2016.
Article - Billing and Coding: Lab: Bladder/Urothelial Tumor Markers (A53095)

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: Bladder/Urothelial Tumor Markers L33420.This A/B MAC will only cover bladder tumor marker fluorescence in situ hybridization (FISH) testing services when performed using validated assays. To date, UroVysion Bladder Cancer Kit is the only Federal Drug Administration (FDA) approved assay that is designed to detect aneuploidy for chromosomes 3, 7, 17 and loss of the 9p21 locus via FISH. The assay is performed on urine specimens from persons with hematuria suspected of having bladder cancer as an aid for initial diagnosis of bladder carcinoma and subsequent monitoring for tumor recurrence in patients previously diagnosed with bladder cancer. UroVysion Bladder Kit services may only be billed by a CLIA certified lab.To bill UroVysion Bladder Kit services, submit the following claim information:Select CPTcode 88120 or 88121 as appropriateLaboratories reporting only the technical component for a UroVysion service should append the appropriate code 88120 or 88121 with the TC modifier.All other services that meet the code 88120 or 88121 definition performed by any provider type MUST bill the following claim information.Select CPTcode 88120 or 88121 as appropriateNote:Physicians may NOT submit claims for a code 88120 and 88121 professional component when the interpretive information is provided by a lab technician or scientist. Per Chapter 10 in the NCCI Policy Manual for Medicare Services, Version 16.3, the physician work component requires a physician to read, quantitate and interpret the tissues/cells stained with the probes(s). Physicians who knowingly report and provide interpretation based on the documented results of another professional may be subject to additional corrective action including Recovery Audit Contractor (RAC) or fraud referrals.To report a Bladder/Urothelial Tumor Marker service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Select the appropriate ICD-10 code
Article - Billing and Coding: MolDX: Afirma™ Assay by Veracyte Update (A53098)

CMS National Coverage PolicyN/AArticle TextThe MolDX Team has completed the Afirma assessment and determined that the test meets criteria for analytical and clinical validity, and clinical utility as a reasonable and necessary Medicare benefit. Effective 10/01/2015, MolDX will reimburse Afirma services for patients with the following conditions (patient must have 1 and 2):Patients with one or more thyroid nodules with a history or characteristics suggesting malignancy such as:Nodule growth over timeFamily history of thyroid cancerHoarseness, difficulty swallowing or breathingHistory of exposure to ionizing radiationHard nodule compared with rest of gland consistencyPresence of cervical adenopathyHave an indeterminate follicular pathology on fine needle aspirationMolDX expects this test will be performed once per patient lifetime. Should the unlikely situation of a second, unrelated thyroid nodule with indeterminate pathology occur, coverage may be considered upon appeal with support documentation.To report an Afirma service, please submit the following claim information:Select the appropriate CPTcodeSelect the appropriate ICD-10-CM diagnosis.Enter 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 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 form
Article - Billing and Coding: MolDX: bioTheranostics Cancer TYPE ID® Update (A53101)

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. 100-02, 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 TextEffective November 19, 2012, Cancer TYPE ID, an RT-PCR 92-gene assay, has been assigned a DEX Z-Codeidentifier. To bill for Cancer TYPE ID, please provide the following claim information:CPT code: 81540- Oncology (tumor of unknown origin) mRNA gene expression of 92 genesEnter 1 in the Days/Unit fieldEnter DEX Z-Codeidentifier 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 DEX Z-Codeidentifier 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.Note: MolDX expects this test to ONLY be ordered by the treating physician.
Article - Billing and Coding: MolDX: MammaPrint (A53104)

CMS National Coverage PolicyN/AArticle TextMammaPrint is a diagnostic test that analyzes the gene expression profile of FFPE breast cancer tissue samples to assess a patients' risk for distant metastasis.The test can be performed using either a FDA-cleared in vitro microarray assay or a next generation sequencing (NGS)-based assay. Each assay has been assigned a unique Z-code identifier in the DEX Registry.MammaPrintwas prospectively validated as a microarray assay in the 6,693 patient MINDACT trial in early stage breast cancer, <5cm up to 3 positive lymph nodes and independent of receptor status. The MammaprintNGS test has demonstrated technically equivalent performance to the predicate microarray test.To bill for MammaPrintservices, submit the following claim information:Enter 1 in the Days/Unit fieldFor CPTnon-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information. For dates of service on or after 1/1/2022, use CPT code 81523 for the test if performed by NGS.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 formOnly one test- NGS or microarray may be performed on a given date of service for a given patient.Note:MolDX expects this test may be performed upon occasion twice per patient lifetime for bilateral disease. Should a patient experience an additional occurrence, coverage may be considered with supporting documentation through the appeal process.
Article - Billing and Coding: MolDX: Oncotype DX® Breast Cancer Assay (A53105)

CMS National Coverage PolicyN/AArticle TextNOTE:The Oncotype DX Breast Cancer Assay and the Oncotype DX DCIS Score are different tests and should NOT be submitted with the same Z-Code Identifier. Because this article ONLY addresses Oncotype DX Breast, the diagnosis codes for breast carcinoma in situ have been removed.Oncotype DX & reg Breast was developed for patients with the following findings:estrogen-receptor positive, node-negative carcinoma of the breastestrogen-receptor positive micrometastases of carcinoma of the breast, andestrogen-receptor positive breast carcinoma with 1-3 positive nodesTo bill an Oncotype Breast service, please provide the following claim information:CPTcode 81519  Oncology (breast)Enter 1 in the Days/Unit fieldSelect the appropriate ICD-10-CM code.Enter 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 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 form
Article - MolDX: Oncotype DX® Colon Cancer Assay Update (A53106)

CMS National Coverage PolicyN/AArticle TextThe Oncotype DX Colon Cancer Assay, developed to predict the recurrence risk for patients with Stage II colon cancer, has been assigned a unique identifier. To bill an Oncotype DX Colon service, please provide the following claim information:CPT code 81525-Oncology (colon), mRNA gene expression of 21 genesEnter 1 in the Days/Unit fieldFor CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.Enter the appropriate DEX Z-Codeidentifier 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-Codeidentifier 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: ResponseDX Tissue of Origin® (A53108)

CMS National Coverage PolicyN/AArticle TextTissue of Origin, a microarray-based gene expression assay designed to determine the similarity of unknown or unresolved tumors to cancers from 1 of 15 known tumors of origin, has been assigned a unique identifier. To bill for Tissue of Origin services, please provide the following claim information:CPTcode 81504  Oncology (tissue of origin)Enter 1 in the Days/Unit fieldSelect the appropriate ICD-10-CM diagnosis.Enter 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 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 formNote: MolDX expects this test to ONLY be ordered by the treating physician.
Article - Billing and Coding: Therapy Driving Evaluations (A53289)

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)
Article - Billing and Coding: Therapy Driving Evaluations (A53292)

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)
Article - Sterilization (A53356)

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: Aflibercept (EYLEA®) (A53387)

CMS National Coverage PolicyN/AArticle TextEffective November 18, 2011, September 21, 2012, July 29, 2014, October 6, 2014, March 25, 2015, and May 13, 2019respectively, Aflibercept(EYLEA) was approved by the Food and Drug Administration (FDA) for the treatment of patients with:Neovascular (Wet) Aged-related Macular Degeneration (AMD)Macular Edema following Retinal Vein Occlusion (RVO)Diabetic Macular Edema (DME)Diabetic Retinopathy (DR)For AMD the recommended dose is 2 mg (0.05 mL) administered by intravitreal injection every four weeks for the first 12 weeks (3 months), followed by 2 mg (0.05 mL) once every8 weeks (2 months) by intravitreal injection. AlthoughEYLEAmay be dosed as frequently as 2 mg every 4 weeks (monthly), additional efficacy was not demonstrated in most patients whenEYLEAwasdosed every 4 weeks compared to every 8 weeks. Some patients may need every 4 week (monthly) dosing after the first 12 weeks (3 months).For Macular Edema following RVO the recommended dose is 2 mg (0.05 mL) administered by intravitreal injection once every4 weeks (monthly).For DME the recommended dose is 2 mg (0.05mL) once every 4 weeks (monthly)for the first 5 injections, and then 2 mg (0.05 mL) every 2 months (8 weeks) by intravitreal injection. AlthoughEYLEAmay be dosed as frequently as 2 mg every 4 weeks (monthly), additional efficacy was not demonstrated in most patients whenEYLEAwasdosed every 4 weeks compared to every 8 weeks. Some patients may need every 4 week (monthly) dosing after the first 20 weeks (5months).For Diabetic retinopathy (DR) the recommended dose is 2 mg (0.05 mL) once every 4 weeks (monthly) for the first 5 injections, followed by 2 mg (0.05 mL) once every 8 weeks (every 2 months). Although may be administered every 4 weeks, additional efficacy has not been demonstrated (compared with every 8 week administration); some patients may require every 4 week (monthly) dosing after the first 20 weeks of therapy (5 months).To bill aflibercept services, submit the following claim information on CMS Form 1500: J0177 OR J0178 67028  Intravitreal injection of a pharmacologic agent (separate procedure)Note:It is not reasonable and necessary to inject more than one anti-vascular endothelial growth factor (VEGF) medication (bevacizumab, ranibizumab, aflibercept) in the same eye during the same treatment session. It is not typical to inject one anti-VEGF medication in one eye and another in the other eye. If different medications are injected into each eye during the same DOS, the rationale for this therapy must be documented in the medical record and the billing modifier (RT/LT) must be appended to the correct drug.Intravitreal injection for the treatment of macular edema more frequently than every 4 weeks regardless of which drug is used for any given injection i.e., alternating drugs every 2 weeks will not be covered.
Article - Videostroboscopy and Nasopharyngoscopy Procedures Performed by Speech-Language Pathologists (SLPs) (A53430)

CMS National Coverage PolicyN/AArticle TextSpeech-language pathologists (SLPs) are trained in basic laryngeal examination related to speech and dysfunctional swallowing conditions. Since an SLP does not have the experience or knowledge to biopsy a neoplasm or an anatomical pathologic condition, Palmetto PGA will reimburse a videostroboscopy and nasopharyngoscopy service when an SLP performs the service under the direct supervision of a physician credentialed by the hospital to perform the services.
Article - Anesthetic 'Caine Drugs' (A53432)

CMS National Coverage PolicyN/AArticle TextAnesthetic drugs such as Bupivacaine (Marcaine), Bupivacaine (Sensorcaine), Chloroprocaine (Nesacaine), Lidocaine (Xylocaine), Mepivacaine (Carbocaine), etc., when administered for chronic pain control are not covered by Medicare.The CMS Internet-Only Manual, Pub. 100-04, Chapter 12, Section 50 specifies that Palmetto GBA may not allow separate payment for the anesthesia service performed by the physician who also furnishes the medical or surgical service. In that case, payment for the anesthesia service is made through the payment for the medical or surgical service. For example, Palmetto GBA may not allow separate payment for the surgeon's performance of a local or surgical anesthesia if the surgeon also performs the surgical procedure.