evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Coenzyme Q10 (CoQ10) (A55715)

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, 80.0, 80.1.1, 80.2. Clinical Laboratory services.CMS 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 TextCoenzyme Q10 (CoQ10 or Q10) supplementation is purported to prolong life and prevent age-related functional declines; inhibit the development and/or progression of atherosclerosis; have value as an adjunct to conventional medical therapy in the treatment of congestive heart failure, conventional angina therapy, and cancer; provide protection against myocardial damage during ischemia-reperfusion during cardiac surgery; provide benefit in the treatment of hypertension, CV disease and diabetes; play a role in neurodegenerative diseases such as Parkinsons disease, Huntingtons disease and Friedreichs ataxia; enhance athletic performance and enhance fertility. As such, serum or other body fluid testing for Q10 levels has been advocated. However, the scientific evidence to support coverage for Q10 testing for any purpose is controversial and/or limited for all diseases. Consequently, Q10 testing is not reasonable and necessary (LCD L37022), and claims for testing will be denied.To receive a Q10 service denial, please submit the following claim information:CPT code 82542For a voluntary issued Advanced Beneficiary Notice (ABN), append with GX modifierSelect the appropriate diagnosis for the patient
Article - Billing and Coding: Lab: Flow Cytometry (A55717)

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 CodesCMS 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 Lab: Flow Cytometry L34513.Flow cytometry is a complex laboratory process to examine body fluids, including blood and cerebrospinal fluid (CSF), bone marrow, and components of the lymphoreticular system, such as lymph nodes, tonsil, and spleen. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. LCD L34513 Flow Cytometry outlines the coverage criteria for flow cytometry testing. When covered, testing is limited to no more than 24 markers without additional medical necessity documentation.Flow cytometry for the detection and/or identification or enumeration of bacteria or viruses in patients with chronic rhinosinusitis with or without polyps is investigational/experimental and is not a Medicare benefit.To report a Flow Cytometry service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Select the appropriate ICD-10-CM code
Article - Sipuleucel-T (Provenge®) - Coverage Criteria for Prostate Cancer – Clarification (A55719)

CMS National Coverage PolicyN/AArticle TextSipuleucel-T (Provenge) is an autologous cellular immunotherapy, FDA-approved for the treatment of asymptomatic or minimally symptomatic metastatic castrate resistant (hormone refractory) prostate cancer.The production of Sipuleucel-T involves collection of the patients own cells (leukapheresis), culture with a proprietary antigen complex, and re-infusion of the antigen-activated patient cells back to the donor. Provenge is administered as three intravenous infusions, generally two weeks apart. When infused back into the patient, usually three days after leukapheresis, the patient-specific medication (autologous cellular therapy) stimulates a positive immunogenic response against the prostate cancer.For coverage, patient records must document that the product is being used according to the NCD 110.22.If the documentation does not describe the criteria above, does not meet all the requirements of the NCD on sipuleucel-T,is inconsistent with the FDA label and/or is not received, the services will be denied. Off-label use of this treatment is not covered unless it meets the requirements for off-label use of chemotherapeutic drugs in the Internet Only Manual 100-02 (Benefit Policy), Chapter 15 (Covered Services), Section 50.4.5.Noridian may coversipuleucel-Tfor the above condition when all requirements are met including the following coding instructions. (NOTE: Noridian will not allow payment for any off-label use of this treatment):For dates of service on/after July 1, 2011, use the following HCPCS code: Q2043 Sipuleucel-T auto CD54+.For dates of service prior to July 1, 2011, use one of the following HCPCS code: J3490, J3590 or C9273 (being replaced by Q2043).The payment of HCPCS Q2043 includes collection of patients cells, activation with PAP-CM-CSF, including leukapheresis and all other preparatory procedures associated withsipuleucel-T. The code Q2043 does not include theadministrationof the treatments. CPT code 96365, intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to one (1) hour will be allowed for the administration of Q2043.Medicare will allow a maximum of three (3) infusions per lifetime.Sources: Internet Only Manual (IOM) Medicare National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Section 110.22, IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 32, Section 280; Transmittal 133, Change Request (CR)7431 dated July 8, 2011; Transmittal 2254, CR 7431 dated July 8, 2011.
Article - Wound care (L37166): Medicare Part A/B local coverage determination (LCD) comment summary (A55757)

Contractor response:The contractor agrees that this statement is incorrect. There are active wound care management CPT codes that reference removal of biofilm and may be reported for such debridement. Please reference CPT and coding guidelines.Comment #19:A number of commenters requested removal of utilization guidelines for low-frequency, non-contact, non-thermal ultrasound (MIST Therapy) while several commenters supported the guidelines.Contractor response:The utilization guidelines have not been changed for MIST Therapy. Guidelines for the use of low-frequency, non-contact, non-thermal ultrasound (MIST Therapy) are supported by the manufacturer.Comment #20:Comments were submitted requesting removal of the debridement frequency limitation for debridement codes involving muscle / fascia or bone. Commenters expressed concern that five muscle debridement services per calendar year would not allow for appropriate wound care especially for bedridden decubitus patients that may have different wounds at different times in a given calendar year.Contractor response:Debridement codes involving fascia or bone would be expected to lessen over a period of time as the wound heals. Data analysis illustrates that a minority of beneficiaries receiving wound care actually receive more than five debridements involving muscle/fascia or bone in a rolling 360 day period. Debridements of an unusually prolonged or excessive number should be accompanied by meticulous documentation illustrating that the service is both medical necessary and reasonable. It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. Utilization of more than five debridement codes involving fascia or bone in a rolling 360 day period may be subject to pre or post payment medical review (records requested).Comment #21:Several commenters expressed concerns with wording throughout the LCD and requested clarification or removal of specific statements.Contractor response:Comments related to wording or style, not relevant to coverage, were too numerous to be addressed on the comment response document. All comments were reviewed and noted.
Article - Billing and Coding: Lab: Coenzyme Q10 (CoQ10) (A55769)

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 On-Line Manual, Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, 80.0, 80.1.1, 80.2. Clinical Laboratory services.CMS Internet-Only Manuals, Publication 100-04,Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.12 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet Online Manual Pub. 100-04 (Medicare Claims Processing Manual), Chapter 23 (Section 10) "Reporting ICD Diagnosis and Procedure Codes."Article TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.To receive a Q10 service denial, please submit the following claim information:CPTcode 82542For a voluntary issued Advanced Beneficiary Notice (ABN), append with GX modifier
Article - Billing and Coding: Lab: Coenzyme Q10 (CoQ10) (A55770)

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 On-Line Manual, Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, 80.0, 80.1.1, 80.2. Clinical Laboratory services.CMS Internet-Only Manuals, Publication 100-04,Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.12 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet Online Manual Pub. 100-04 (Medicare Claims Processing Manual), Chapter 23 (Section 10) "Reporting ICD Diagnosis and Procedure Codes."Article TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.To receive a Q10 service denial, please submit the following claim information:CPTcode 82542For a voluntary issued Advanced Beneficiary Notice (ABN), append with GX modifier
Article - Billing and Coding: Reporting a Non-Covered Test Performed in Preparation for a Non-Covered Procedure (A55774)

CMS National Coverage PolicyN/AArticle TextWhen a diagnostic test is necessary for the performance of a non-covered service, that test typically may not be covered. For instance, when planning a cataract surgery using a non-covered, presbyopia and astigmatism correcting intraocular lens, it is often necessary to first perform a computerized corneal typography. Noridian wishes to remind providers to report this appropriately as a non-covered test by submitting the code 92025 with a -GY modifier.Effective ImmediatelyReference:Internet Only Manual (IOM)Medicare National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Part 1, Section 10.1;IOMMedicare Claims Processing Manual, Publication 100-04, Chapter 32, Section 120.
Article - Billing and Coding: Reporting a Non-Covered Test Performed in Preparation for a Non-Covered Procedure (A55775)

CMS National Coverage PolicyN/AArticle TextWhen a diagnostic test is necessary for the performance of a non-covered service, that test typically may not be covered. For instance, when planning a cataract surgery using a non-covered, presbyopia and astigmatism correcting intraocular lens, it is often necessary to first perform a computerized corneal typography. Noridian wishes to remind providers to report this appropriately as a non-covered test by submitting the code 92025 with a -GY modifier.Effective ImmediatelyReference:Internet Only Manual (IOM)Medicare National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Part 1, Section 10.1;IOMMedicare Claims Processing Manual, Publication 100-04, Chapter 32, Section 120.
(Medicare Claims Processing Manual)

10/07/2019 11361 R4391CP  09/06/2019 Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model  07/01/2019 10971 R4337CP    07/18/2019 Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model - Rescinded and Replaced by Transmittal 4391  07/01/2019 10971 R4308CP  05/16/2019 Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model - Rescinded and Replaced by Transmittal 4337  07/01/2019 10971 R4295CP  05/03/2019 Update to the Internet Only Manual (IOM) Publication (Pub.) 100- 04, Chapter 4  08/27/2019 11274 R4308CP  05/16/2019 Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model  07/01/2019 10971
Article - Billing and Coding: Diagnostic Colonoscopy (A55937)

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) L33671 (Diagnostic Colonoscopy). 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.Medical record documentation (office/progress notes) maintained by the ordering/referring physician must indicate the medical necessity of the colonoscopy procedure. The procedure results/report and any associated pathology report must be included in the patient's medical record.If the provider of the colonoscopy is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of procedure results/report and pathology report along with copies of the ordering/referring physician's order for the procedure.The patients medical record should contain documentation to support an incomplete procedure.
42 CFR § 410.32 - Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. | Electronic Code of Federal Regulations (e-CFR) | US Law | LII / Legal Information Institute

htmlGlobal site tag (gtag.js) - Google AnalyticsGoogle tag (gtag.js)42 CFR  410.32 - Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. | Electronic Code of Federal Regulations (e-CFR) | US Law | LII / Legal Information Instituteschema.org metadata/schema.orgAPI urlinclude adcodemobile: vignettes and page-leveladsense/adsense/include adcodePlease help us improve our site!No thank youSkip to main contentCornell LawSchoolSearchCornellToggle navigationPlease helpus improve our site!Support Us!SearchAboutLIIWho We AreWhat We DoWho Pays For ThisContact UsGet thelawConstitutionSupreme CourtU.S. CodeCFRFederal RulesFederal Rules of Appellate ProcedureFederal Rules of Civil ProcedureFederal Rules of Criminal ProcedureFederal Rules of EvidenceFederal Rules of Bankruptcy ProcedureU.C.C.Law by jurisdictionState lawUniform lawsFederal lawWorld lawLawyer directoryLegal encyclopediaBusiness lawConstitutional lawCriminal lawFamily lawEmployment lawMoney and FinancesMore...Help outGiveSponsorAdvertiseCreatePromoteJoin Lawyer DirectoryLIIElectronic Code of Federal Regulations (e-CFR)Title 42Public HealthCHAPTER IVCENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER BMEDICARE PROGRAMPART 410SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITSSubpart BMedical and Other Health Services 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.42 CFR  410.32 - Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.CFRTable of Popular Namesprev|next'text' content area
42 CFR § 410.32 - Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. | Electronic Code of Federal Regulations (e-CFR) | US Law | LII / Legal Information Institute

(3)Claims review.(i)Documentation requirements.Except for tests described in paragraph (a)(3) introductory text, upon request byCMS, the entity submitting the claim must provide the following information:(A)Documentation of the order for theservicebilled (including information sufficient to enableCMSto identify and contact the orderingphysicianor nonphysician practitioner).(B)Documentation showing accurate processing of the order and submission of the claim.(C)Diagnostic or other medical information supplied to the laboratory by the orderingphysicianornonphysician practitioner, including any ICD9CM code or narrative description supplied.(ii)Services that are not reasonable and necessary.If the documentation provided underparagraph (d)(3)(i)of this section does not demonstrate that theserviceis reasonable and necessary,CMStakes the following actions:(A)Provides the orderingphysicianornonphysician practitionerinformation sufficient to identify the claim being reviewed.(B)Requests from the orderingphysicianornonphysician practitionerthose parts of abeneficiary's medical record that are relevant to the specific claim(s) being reviewed.(C)If the orderingphysicianornonphysician practitionerdoes not supply the documentation requested, informs the entity submitting the claim(s) that the documentation has not been supplied and denies the claim.(iii)Medical necessity.The entity submitting the claim may request additional diagnostic and other medical information from the orderingphysicianornonphysician practitionerto document that theservicesit bills are reasonable and necessary. If the entity requests additional documentation, it must request material relevant to the medical necessity of the specific test(s), taking into consideration current rules and regulations onpatientconfidentiality.(4)Automatic denial and manual review.
42 CFR § 410.32 - Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. | Electronic Code of Federal Regulations (e-CFR) | US Law | LII / Legal Information Institute

(i)General rule.Except as provided inparagraph (d)(4)(ii)of this section,CMSdoes not deny a claim forservicesthat exceed utilization parameters without reviewing all relevant documentation that is submitted with the claim (for example, justifications prepared by providers, primary and secondary diagnoses, and copies of medical records).(ii)Exceptions.CMSmay automatically deny a claim without manual review if a national coverage decision or LMRP specifies the circumstances under which theserviceis denied, or theserviceis specifically excluded fromMedicarecoverage by law.(e)Diagnostic laboratory tests furnished in hospitals and CAHs.The provisions of paragraphs (a) and (d)(2) through (d)(4) of this section, inclusive, of this section apply to all diagnostic laboratory test furnished byhospitalsandCAHsto outpatients.[62 FR 59098, Oct. 31, 1997, as amended at63 FR 26308, May 12, 1998;63 FR 53307, Oct. 5, 1998;63 FR 58906, Nov. 2, 1998;64 FR 59440, Nov. 2, 1999;66 FR 58809, Nov. 23, 2001;69 FR 66421, Nov. 15, 2004;72 FR 66398, Nov. 27, 2007;75 FR 73615, Nov. 29, 2010;77 FR 69361, Nov. 16, 2012;83 FR 60073, Nov. 23, 2018;85 FR 19286, Apr. 6, 2020;85 FR 27620, May 8, 2020;85 FR 54871, Sept. 2, 2020;85 FR 85026, Dec. 28, 2020;87 FR 70223, Nov. 18, 2022;88 FR 79525, Nov. 16, 2023]'notes' content areaPublic Health Service ActCFR ToolboxLaw about... Articles from WexTable of Popular NamesParallel Table of AuthoritiesAccessibilityAbout LIIContact usAdvertise hereHelpTerms of usePrivacy
(Medicare Claims Processing Manual)

Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12411CP  12/14/2023  New Place of Service (POS) Code 27 -  "Outreach Site/Street  01/02/2024  13314  R12254CP  09/20/2023  New Place of Service (POS) Code 27 -  "Outreach Site/Street   Rescinded and Replaced by Transmittal  12411 01/02/2024  13314  R12231CP  08/31/2023  New Dental Specialty Codes for Medicare  01/02/2024  13323  R12202CP   08/10/2023  New Place of Service (POS) Code 27 -  "Outreach Site/Street   Rescinded and Replaced by Transmittal  12254 01/02/2024  13314  R11437CP  05/27/2022  New/Modifications to the Place of Service (POS) Codes for Telehealth  04/04/2022  12427  R11045CP  10/13/2021  New/Modifications to the Place of Service (POS) Codes for Telehealth - Rescinded and Replaced by Transmittal 4472 04/04/2022  12427  R10341CP  09/04/2020  Internet Only Manual Update to Pub. 100-04, Chapter 16, Section 60.1.2 and Pub. 100-04, Chapter 26, Section 10.4, Item 19  10/06/2020  11935 R10124CP  05/08/2020  New Physician Specialty Code for Micrographic Dermatologic Surgery (MDS) and Adult Congenital Heart Disease (ACHD) and a New Supplier Specialty Code for Home Infusion Therapy Services  10/05/2020  11750  12/05/2019  New Medicare Provider Specialty Code (D5) and Billing Codes for Opioid Treatment Programs and New Place of Service Code 58  01/06/2020  11353 R4388CP  09/06/2019  Manual Updates to Chapters 1, 22, 24, 26, and 31 in Publication (Pub.) 100- 04 10/07/2019  11331