evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Virtual Colonoscopy (CT Colonography) (A56772)

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 claimCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, 30 Computerized Axial Tomography (CT) ProceduresCMS Internet-Only Manuals, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code RequirementsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Virtual Colonoscopy (CT Colonography) L33452.LimitationsCPTCode - 74263 Computed tomographic (CT) colonography (i.e., virtual colonoscopy), screening, including image postprocessing is never covered.
Article - Billing and Coding: Neurophysiology Evoked Potentials (NEPs) (A56773)

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) L34975 (Neurophysiology Evoked Potentials [NEPs]). 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 codes forSomatosensory Evoked Potentials and Responses (SEPs/SERs):95925, 95926, 95927, 95928, 95929, 95938, 95939.CPT codes forBrainstem Auditory Evoked Potentials and Responses (BAEPs/BAERs):92651, 92652, 92653.CPT code forVisual Evoked Potentials or Responses (VEPs/VERs):95930.
Article - Billing and Coding: Ophthalmic Angiography (Fluorescein and Indocyanine Green) (A56774)

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) forOphthalmic Angiography (Fluorescein and Indocyanine Green)L34426.
Article - Billing and Coding: Magnetic Resonance Angiography (A56775)

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.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, 40.1.1 Magnetic Resonance Angiography (MRA) Coverage Summary and 40.1.2 HCPCS Coding Requirements.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forMagnetic Resonance Angiography L34424.
Article - Billing and Coding: Total Joint Arthroplasty (A56777)

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. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code RequirementsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Total Joint Arthroplasty L33456.
Article - Billing and Coding: Nonvascular Extremity Ultrasound (A56787)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that compliment the LCD for Nonvascular Extremity Ultrasound.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or 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.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned.A permanent record of the ultrasound and its interpretation should be kept on file in the patient's record. The record should include all of the following:Images of all appropriate areas, labeled with exam date, patient identification, and image orientation; anddocumentation of the variations from normal, accompanied by measurements;formal interpretation.Results of all testing should be shared with the referring physician. Documentation must be available to Medicare upon request.Utilization Guidelines:Services in excess of two tests per extremity in six months will be considered not medically necessary.
Article - Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases (A56793)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or 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.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed.Specific Coding Guidelines:Regarding Acute Myelogenous Leukemia (AML), Myelodysplastic Syndromes (MDS), and Myeloproliferative Neoplasms (MPN), the following guidelines apply:Targeted genomic sequence analysis panel, hematolymphoid neoplasm, DNA analysis, and RNA analysis 5-50 genes (CPT 81450 or 81451) is a useful representation of the aggregate of these gene tests, and may be used as long as the panel contains, at a minimum, 5 or more gene tests for molecular biomarkers determined to meet Medicare coverage criteria (for example, NCCN Biomarkers Compendium Evidence Category I or 2A and associated clinical utility).The specified coverage indications are in line with NCCN recommendations. Evaluation of other genes or genomic sequences not addressed by NCCN or other professional guidelines are not precluded, but their inclusion in panels recognized by this code should not be interpreted as endorsement of such testing by genomic sequencing procedures and laboratories and users of such testing are advised to adhere to traditional regulatory and institutional oversight mechanisms to assure their clinical validity and utility.
(Medicare Claims Processing Manual)

10/21/2005 Clarification and Update to Hospital Billing Instructions and Payment for Epoetin Alfa and Darbepoetin Alfa (Aranesp) for Beneficiaries with End Stage Renal Disease  04/03/2006 4103 R701CP 10/07/2005 New Diagnosis Code Requirements for Method II Home Dialysis Claims  11/07/2005 4095 R634CP 08/03/2005 Guidelines for Payment of Vaccines (Pneumococcal Pneumonia Virus, Influenza Virus, and Hepatitis B Virus) and their Administration at Renal Dialysis Facilities  01/03/2006 3936 R610CP 07/22/2005 Guidelines for Payment of Vaccines (Pneumococcal Pneumonia Virus, Influenza 01/03/2006 3936 Rev #  Issue Date  Subject  Impl Date  CR #  Virus, and Hepatitis B Virus) and their Administration at Renal Dialys is Facilities  R598CP  06/27/2005 Implementation of Carrier Guidelines for End Stage Renal Disease Reimbursement For Automated Multi- Channel Chemistry Test Supplemental To Change Request 2813  01/01/2006 3890 R595CP 06/24/2005 Implementation of Carrier Guidelines for End Stage Renal Disease Reimbursement For Automated Multi -Channel Chemistry Tests Supplemental To Change Request 2813 07/25/3005 3890 R477CP 02/18/2005 New Case -Mix Adjusted End Stage Renal Disease Composite Payment Rates and New Composite Rate Exceptions Window for Pediatric ESRD Facilities  04/04/2005 3720 R447CP 01/21/2005 CWF Editing for Method Selection on DMERC Claims for EPO and Aranesp  07/05/2005 3547 R373CP 11/19/2004 New ESRD Composite Payment Rates Effective January 1, 2005 01/03/2005 3554 R370CP 11/19/2004 New Case -Mix Adjusted End Stage Renal Disease Composite Payment Rates and New Composite Rate Exceptions Window for Pediatric ESRD Facilities  04/04/2005 3572 R257CP 07/30/2004 Informs the FISS to carry at least two Payments Limits for ESRD  01/03/2005 3332 R197CP 06/04/2004 Epoetin Alfa  10/04/2004 3184 R146CP  04/23/2004 Dialysis Provider Number Series  10/04/2004 3176 R118CP  03/05/2004 Epoetin Alfa  04/05/2004 2984 R116CP  03/05/2004 DMERC Claims Processing Instructions  04/05/2004 3019 R110CP  02/27/2004 Drugs Furnished in Dialysis  03/29/2004 3078 R101CP  02/20/2004 Processing Requests for Composite Rate Exception  04/01/2004 3119 Rev #  Issue Date  Subject  Impl Date  CR #  R082CP  02/06/2004 Utilization of REMIS for Carrier Claims Adjudication 07/06/2004 3066 R031CP  11/21/2003 Dialysis Provider Number Series  N/A 2877 R001CP  10/01/2003 Initial Publication of  Manual  NA NA Back to top of Chapter
Article - Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee) (A56796)

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) L36007,Lower Extremity Major Joint Replacement (Hip and Knee). 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.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: Fluid Jet System Treatment for LUTs/BPH (A56797)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Fluid Jet System Treatment for LUTS/BPH.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or 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.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed.
Article - Billing and Coding: Magnetic Resonance Angiography (MRA) (A56805)

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) L34865, Magnetic Resonance Angiography (MRA). 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.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: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (A56825)

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 Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) L34431.SCODI (92133, 92134) and fundus photography (92250) are mutually exclusive codes. However, there may be a limited number of clinical situations in which it is necessary to perform both techniques in order to evaluate and treat the patient. In these situations, both CPT codes may be reported appending modifier 59 to indicate a distinct procedural service. Documentation supportive of the need to perform both techniques should be clear in the medical record.
Article - Billing and Coding: B-type Natriuretic Peptide (BNP) Testing (A56826)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for B-type Natriuretic Peptide (BNP) TestingCoding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or 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.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included withinthe 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. Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned. Documentation must be available to Medicare upon request.Utilization Guidelines:Frequency of testing should be guided by the clinical circumstances and evidence-based literature.
Article - Billing and Coding: Proton Beam Therapy (A56827)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Proton Beam Therapy.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or 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.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Documentation Requirements:The 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.Documentation in the patient medical record must:Support one or more medical necessity requirement(s) as provided under the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy.Include a treatment prescription that defines the goals of the treatment plan- including specific dose-volume parameters for the target and nearby critical structures- as well as pertinent details of beam delivery, such as method of beam modulation, field arrangement, and expected positional and range uncertainties.Include a treatment plan, signed by a physician, which meets the prescribed dose-volume parameters for the clinical target volume (CTV) and surrounding organs at risk (OARs) in the presence of expected uncertainties.Describe the target setup verification methodology, including patient positioning, immobilization and use of image guidance.Include verification of planned dose distribution via independent dose calculation or physical measurement.
Article - Billing and Coding: Reduction Mammaplasty (A56837)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Reduction Mammaplasty.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or 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.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Documentation Requirements:The 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.Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned.Documentation must be available to Medicare upon request.
Article - Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains (A56838)

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: Special Histochemical Stains and Immunohistochemical Stains L35922.To report special histochemical stains and/or immunohistochemical stains services, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)
Article - Billing and Coding: Vitamin D; 25 hydroxy, includes fraction(s), if performed (A56841)

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) L33771 Vitamin D; 25 hydroxy, includes fraction(s), if performed. 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.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.The results of the Vitamin D testing and the resulting treatment regimen must be documented in the patients medical record. This information includes, but is not limited to relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures usually found in hospital/office progress notes and written laboratory reports.