evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Patients Supplied Donated or Free-of-Charge Drug (A55044)

CMS National Coverage PolicyN/AArticle TextThe Medicare Program provides limited benefits for outpatient drugs. The program covers drugs that are furnished "incident to" a physician's service, provided that the drugs are not usually self-administered by the patients who take them, and is reasonable and necessary for the diagnosis or treatment of the illness or injury according to accepted standards of medical practice.In order to meet all the general requirements for coverage under the "incident to" provision an FDA approved drug or biological must be furnished by a physician and administered by the physician or by auxiliary personnel employed by the physician and under the physician's personal supervision.The charge, if any, for the drug or biological must be included in the physician's bill and the cost of the drug or biological must represent an expense to the physician.Pharmacies cannot bill Medicare Part B for drugs furnished to a physician for administration to a Medicare beneficiary.Pharmacies, suppliers and providers cannot bill Medicare Part B for drugs dispensed directly to a beneficiary for administration "incident to" a physician service, such as refilling an implanted drug pump.Providers can bill Medicare only when such drugs are purchased by the physician, from the pharmacy, and administered in the physician's office.Donated or Free-of-Charge DrugTo avoid a chemotherapy or other drug administration code denial, a drug code must be present on the same or prior claim. Enter the below information in the appropriate Part A or Part B electronic claim or the equivalent Part A UB04 or Part B CMS-1500 claim form.Part ALoop 2400 Segment SV202-7 or Box 80Enter "Drug Donated"Enter code description, strength and dosage - if billing a Not Otherwise Classified (NOC) HCPCS codeLoop 2400 Segment SV202-2 or Box 44Enter drug (HCPCS) codeLoop 2300 Segment CLM02 or Box 47 and 48Enter $0.01 for the billed amountPart BLoop 2400 Segment SV101-7 for the 5010A1 837P or Item 19Enter "Drug Donated"Enter code description, strength and dosage - if billing a Not Otherwise Classified (NOC) HCPCS codeLoop 2400 Segment SV101-2 or Item 24DEnter drug (HCPCS) codeLoop 2300 CLM02 or Item 28Enter $0.01 for the billed amountThis will allow the claim processing system to register the drug claim as being allowed which should allow the administration.NOTE:Per the "incident to" guidelines explained above and in the CMS Internet-Only Manual (IOM) Publication 100-02, Chapter 15, Sections 50 and 50.3(MBPM). Providers areNOTallowed to instruct their patients to purchase the drug themselves and then bring them to the provider's office for administration. If the drug is not supplied as a donation or free of charge, then the provider must provide the drug under incident to guidelines.
Article - Billing and Coding: Patients Supplied Donated or Free-of-Charge Drug (A55045)

CMS National Coverage PolicyN/AArticle TextThe Medicare Program provides limited benefits for outpatient drugs. The program covers drugs that are furnished "incident to" a physician's service, provided that the drugs are not usually self-administered by the patients who take them, and is reasonable and necessary for the diagnosis or treatment of the illness or injury according to accepted standards of medical practice.In order to meet all the general requirements for coverage under the "incident to" provision an FDA approved drug or biological must be furnished by a physician and administered by the physician or by auxiliary personnel employed by the physician and under the physician's personal supervision.The charge, if any, for the drug or biological must be included in the physician's bill and the cost of the drug or biological must represent an expense to the physician.Pharmacies cannot bill Medicare Part B for drugs furnished to a physician for administration to a Medicare beneficiary.Pharmacies, suppliers and providers cannot bill Medicare Part B for drugs dispensed directly to a beneficiary for administration "incident to" a physician service, such as refilling an implanted drug pump.Providers can bill Medicare only when such drugs are purchased by the physician, from the pharmacy, and administered in the physician's office.Donated or Free-of-Charge DrugTo avoid a chemotherapy or other drug administration code denial, a drug code must be present on the same or prior claim. Enter the below information in the appropriate Part A or Part B electronic claim or the equivalent Part A UB04 or Part B CMS-1500 claim form.Part ALoop 2400 Segment SV202-7 or Box 80Enter "Drug Donated"Enter code description, strength and dosage - if billing a Not Otherwise Classified (NOC) HCPCS codeLoop 2400 Segment SV202-2 or Box 44Enter drug (HCPCS) codeLoop 2300 Segment CLM02 or Box 47 and 48Enter $0.01 for the billed amountPart BLoop 2400 Segment SV101-7 for the 5010A1 837P or Item 19Enter "Drug Donated"Enter code description, strength and dosage - if billing a Not Otherwise Classified (NOC) HCPCS codeLoop 2400 Segment SV101-2 or Item 24DEnter drug (HCPCS) codeLoop 2300 CLM02 or Item 28Enter $0.01 for the billed amountThis will allow the claim processing system to register the drug claim as being allowed which should allow the administration.NOTE:Per the "incident to" guidelines explained above and in the CMS Internet-Only Manual (IOM) Publication 100-02, Chapter 15, Sections 50 and 50.3(MBPM). Providers areNOTallowed to instruct their patients to purchase the drug themselves and then bring them to the provider's office for administration. If the drug is not supplied as a donation or free of charge, then the provider must provide the drug under incident to guidelines.
Article - Billing and Coding: Testopel Coverage (A55056)

CMS National Coverage PolicyN/AArticle TextInjectable testosterone pellets (brand name Testopel) may be covered, by Medicare, for the FDA approved indication, if the service meets all Medicare coverage requirements quoted below verbatim in the Internet Only Manual (IOM)Medicare Benefit Policy Manual(MBPM) Chapter 15, Section 50.4.3.2MBPMInjection Method Not IndicatedMedication given by injection (parenterally) is not covered if standard medical practice indicates that the administration of the medication by mouth (orally) is effective and is an accepted or preferred method of administration. For example, the accepted standard of medical practice for the treatment of certain diseases is to initiate therapy with parenteral penicillin and to complete therapy with oral penicillin. Carriers exclude the entire charge for penicillin injections given after the initiation of therapy if oral penicillin is indicated unless there are special medical circumstances that justify additional injections."The Noridian Contractor Medical Directors (CMDs) believe that the use of this product should be rare since the "accepted method of medical practice" is to administer testosterone transdermally, but there may be reasons that require this injectable medication. Compliance with Medicare requirements is subject to review by the Recovery Auditors.A submitted claim form must contain the below information.In Item 19 of CMS-1500 paper claim form or Loop 2400/SV101-7 for electronic claimsEnter word "Testopel"Enter drug dosage given (include milligrams delivered only)NOTE:Medicare may only cover the number of pellets actually implanted in the patient (maximum of six pellets); wastage is not covered. Use of additional pellets may be paid on appeal if the documentation supports medical necessity as determined by the FDA approved drug label and the service complies with all Medicare requirements as indicated above.Item 24D or electronic equivalentEnter J3490
Article - Billing and Coding: Testopel Coverage (A55057)

CMS National Coverage PolicyN/AArticle TextInjectable testosterone pellets (brand name Testopel) may be covered, by Medicare, for the FDA approved indication, if the service meets all Medicare coverage requirements quoted below verbatim in the Internet Only Manual (IOM)Medicare Benefit Policy Manual(MBPM) Chapter 15, Section 50.4.3.2MBPMInjection Method Not IndicatedMedication given by injection (parenterally) is not covered if standard medical practice indicates that the administration of the medication by mouth (orally) is effective and is an accepted or preferred method of administration. For example, the accepted standard of medical practice for the treatment of certain diseases is to initiate therapy with parenteral penicillin and to complete therapy with oral penicillin. Carriers exclude the entire charge for penicillin injections given after the initiation of therapy if oral penicillin is indicated unless there are special medical circumstances that justify additional injections."The Noridian Contractor Medical Directors (CMDs) believe that the use of this product should be rare since the "accepted method of medical practice" is to administer testosterone transdermally, but there may be reasons that require this injectable medication. Compliance with Medicare requirements is subject to review by the Recovery Auditors.A submitted claim form must contain the below information.In Item 19 of CMS-1500 paper claim form or Loop 2400/SV101-7 for electronic claimsEnter word "Testopel"Enter drug dosage given (include milligrams delivered only)NOTE:Medicare may only cover the number of pellets actually implanted in the patient (maximum of six pellets); wastage is not covered. Use of additional pellets may be paid on appeal if the documentation supports medical necessity as determined by the FDA approved drug label and the service complies with all Medicare requirements as indicated above.Item 24D or electronic equivalentEnter J3490
Article - Waiver of Face-to-Face Visit for Home Dialysis Patients (A55058)

CMS National Coverage PolicyN/AArticle TextPhysician management services for patients on dialysis are usually paid for a full month of management services.  For in-center dialysis patients, this is billed and paid based on the number of face-to-face visits made during the month and the age bracket of the patient.  For home dialysis patients there is a single fee based on the age bracket of the patient.   Medicare requires that physicians billing this service must provide certain minimal services including at least one face-to-face visit each month to assess the condition of the vascular access.Since 2011, CMS has allowed payment of the ESRD Monthly Capitation (MCP) for certain home dialysis patients even when the physician has not actually had a face-to-face visit; this requires an individual waiver at contractor discretion (IOM 100-04, Chapter 8, Section 140.1.1).  Starting July 7, 2016, physicians may request this waiver by appending the -52 modifier (reduced services) to the appropriate monthly capitation CPT code (90963  90966).Place the words, No Face-to-Face in Item 19 (or electronic equivalent).  Noridian may request medical records to assess whether the notes support that thephysician actively and adequately managed the care of the home dialysis patient throughout the month.  Noridian expects that requests for these waivers will be unusual.References:Internet Only Manual (IOM), Publication 100-04,Medicare Claims Processing Manual,Chapter 8, Section 140.1.1 atMCPM
Article - Waiver of Face-to-Face Visit for Home Dialysis Patients (A55059)

CMS National Coverage PolicyN/AArticle TextPhysician management services for patients on dialysis are usually paid for a full month of management services.  For in-center dialysis patients, this is billed and paid based on the number of face-to-face visits made during the month and the age bracket of the patient.  For home dialysis patients there is a single fee based on the age bracket of the patient.   Medicare requires that physicians billing this service must provide certain minimal services including at least one face-to-face visit each month to assess the condition of the vascular access.Since 2011, CMS has allowed payment of the ESRD Monthly Capitation (MCP) for certain home dialysis patients even when the physician has not actually had a face-to-face visit; this requires an individual waiver at contractor discretion (IOM 100-04, Chapter 8, Section 140.1.1).  Starting July 7, 2016, physicians may request this waiver by appending the -52 modifier (reduced services) to the appropriate monthly capitation CPT code (90963  90966).Place the words, No Face-to-Face in Item 19 (or electronic equivalent).  Noridian may request medical records to assess whether the notes support that thephysician actively and adequately managed the care of the home dialysis patient throughout the month.  Noridian expects that requests for these waivers will be unusual.References:Internet Only Manual (IOM), Publication 100-04,Medicare Claims Processing Manual,Chapter 8, Section 140.1.1 atMCPM
Article - Billing and Coding: IUD (Hormone-Eluting) for Endometrial Hyperplasia - CPT 58999 (A55061)

CMS National Coverage PolicyN/AArticle TextProviders are aware that Medicare does not allow payment for contraceptive devices or medication. For this reason the service, 58300, insertion of intrauterine device (IUD) has an "N" status in the Medicare Physician Fee Schedule, which means the service cannot be covered when billed to Medicare.Noridian is aware that insertion of a progestin-containing intrauterine device (IUD) is an alternative method of managing endometrial hyperplasia in patients who are not reasonable surgical candidates or who wish to preserve fertility. Noridian has determined that the use of a progestin containing IUD may be approved for use in the Medicare beneficiary who presents with endometrial hyperplasia without atypia.Since the CPT code for IUD insertion will be auto-denied, providers should bill this service using CPT 58999 and an appropriate diagnosis for endometrial hyperplasia, including the product description "hormone IUD for endometrial hyperplasia" in Item 19 of the CMS-1500 form or the electronic equivalent.Acceptable CPT Code for Billing IUD InsertionCPTDESCRIPTION58999 UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NON-OBSTETRICAL)Acceptable ICD-10-CM Codes for Billing IUD InsertionICD-10-CM CodesDescriptionN85.00 ENDOMETRIAL HYPERPLASIA, unspecifiedN85.01 SIMPLE ENDOMETRIAL HYPERPLASIA WITHOUT ATYPIAThe medical record must clearly document the specific clinical circumstances evidencing this medical necessity.Effective Immediately
Article - Billing and Coding: IUD (Hormone-Eluting) for Endometrial Hyperplasia - CPT 58999 (A55062)

CMS National Coverage PolicyN/AArticle TextProviders are aware that Medicare does not allow payment for contraceptive devices or medication. For this reason the service, 58300, insertion of intrauterine device (IUD) has an "N" status in the Medicare Physician Fee Schedule, which means the service cannot be covered when billed to Medicare.Noridian is aware that insertion of a progestin-containing intrauterine device (IUD) is an alternative method of managing endometrial hyperplasia in patients who are not reasonable surgical candidates or who wish to preserve fertility. Noridian has determined that the use of a progestin containing IUD may be approved for use in the Medicare beneficiary who presents with endometrial hyperplasia without atypia.Since the CPT code for IUD insertion will be auto-denied, providers should bill this service using CPT 58999 and an appropriate diagnosis for endometrial hyperplasia, including the product description "hormone IUD for endometrial hyperplasia" in Item 19 of the CMS-1500 form or the electronic equivalent.Acceptable CPT Code for Billing IUD InsertionCPTDESCRIPTION58999 UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NON-OBSTETRICAL)Acceptable ICD-10-CM Codes for Billing IUD InsertionICD-10-CM CodesDescriptionN85.00 ENDOMETRIAL HYPERPLASIA, unspecifiedN85.01 SIMPLE ENDOMETRIAL HYPERPLASIA WITHOUT ATYPIAThe medical record must clearly document the specific clinical circumstances evidencing this medical necessity.Effective Immediately
Article - Billing and Coding: Screening Colonoscopy Converted to a Diagnostic and/or Therapeutic Colonoscopy (A55069)

CMS National Coverage PolicyTitle XVIII of the Social Security Act 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claimArticle TextIf during a colonoscopy a pathology is encountered that necessitates an intervention which converts the screening colonoscopy to a diagnostic/therapeutic colonoscopy, the appropriate CPTcodewhich includes the PT modifier for the diagnostic/therapeutic colonoscopy must be submitted with an appropriate diagnosis to justify the procedure such as Z80.0-Family history of malignant neoplasm of digestive organs.1) Choose the correct CPTcodewhich describes the procedure that was attempted.2) Append the PT modifier to the CPTcode. The PT modifier indicates a screening colonoscopy has been converted to a diagnostic test or other procedure.3) Use an appropriate ICD-10 diagnosis code to indicate the procedure was a screening procedure. The diagnosis Z80.0- Family history of malignant neoplasm of digestive organs is an example of a diagnosis that can be used to indicate screening of beneficiaries at high risk.
Article - Billing and Coding: Once in a Lifetime Abdominal Aortic Aneurysm (AAA) Screening Article (A55071)

CMS National Coverage PolicyCMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 110.2 and 110.3.2Title XVIII of the Social Security Act, 1833(e)Article TextOnce in a lifetime abdominal aortic aneurysm (AAA) screening is only covered under certain specified conditions.When billing for AAA screenings, the following ICD-10 codes should be billed:* Z13.6 for the encounter for screeningfor cardiovascular disordersand either** The most appropriate code for tobacco usage: Z87.891, F17.210, F17.211, F17.213, F17.218 and F17.219OR* Z84.89 for family history of other specified conditionsNote:CPTcode76706 is the only ultrasound service that is payable for AAA screening under Medicare services. No other CPT/HCPCS codes are covered.Per the CMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 110.2 and 110.3.2,Payment may be made for a one-time ultrasound screening for AAA for beneficiaries who meet the following criteria:(i) receives a referral for such an ultrasound screening from the beneficiarys attending physician, physician assistant, nurse practitioner or clinical nurse specialist;(ii) receives such ultrasound screening from a provider or supplier who is authorized to provide covered ultrasound diagnostic services;(iii) has not been previously furnished such an ultrasound screening under the Medicare Program; and(iv) is included in at least one of the following risk categories-(I) has a family history of abdominal aortic aneurysm;(II) is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; or(III) is a beneficiary who manifests other risk factors in a beneficiary category recommended for screening by the United States Preventive Services Task Force regarding AAA, as specified by the Secretary of Health and Human Services, through the national coverage determination process.****For risk category (I) note that Z84.89 is an other specified code and requires that the condition be reflected in the medical record, therefore family history of abdominal aortic aneurysm must be documented in the medical record.**For risk category (II)***For risk category (III) USPST does not currently have any additional screening recommendations at B or above grade at this time.Effective for services furnished on or after January 1, 2017, the following code, modifiers, and type of service (TOS)are used for AAA screening services:CPTcode76706: Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA)Short Descriptor:Us abdl aorta screen AAAModifiers: TC, 26TOS: 4Bill Types: 12x, 13x, 22x, 23x, 71x, 73x, 85x
Article - Billing and Coding: MolDX: CHD7 Gene Analysis (A55085)

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 for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Article TextCHD7gene testing may be performed during the diagnosis of CHARGE Syndrome. Since clinical symptoms and diagnosis usually occur prior to Medicare eligibility and carrier testing is not a covered benefit, the MolDXContractor has determinedCHD7gene testing is a statutorily excluded service. MolDX will also deny tests that include one or more ofCHD7tests reported with CPT code 81479 as statutorily excluded services.To receive aCHD7analysis service denial, please submit the following claim information:Select appropriate CPT code81407CHD7, full gene sequencing81479 all otherCHD7testingAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a known statutorily excluded service, append with a GY modifierEnter 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 837PItem19 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: CHD7 Gene Analysis (A55086)

CMS National Coverage PolicySec. 1862 (1)(A) Statutory Exclusion covers diagnostic testing except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,Article TextCHD7gene testing may be performed during the diagnosis of CHARGE Syndrome. Since clinical symptoms and diagnosis usually occur prior to Medicare eligibility and carrier testing is not a covered benefit, the MolDXContractor has determinedCHD7gene testing is a statutorily excluded service. MolDX will also deny tests that include one or more ofCHD7tests reported with CPT code 81479 as statutorily excluded services.To receive aCHD7analysis service denial, please submit the following claim information:Select appropriate CPT code81407CHD7, full gene sequencing81479 all otherCHD7testingAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a known statutorily excluded service, append with a GY modifierEnter 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 837PItem 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