evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer (A58734)

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 TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer L39017.To report a service, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM codeRegarding single-gene and panel testing of genes-Refer to Billing and Coding: MolDX: Testing of Multiple Genes A57910.Tier 1 and/or Tier 2 individual biomarker CPTcodes should not be used for a single gene or any combination of genes when testing is performed as part of a NGS or other multiplexing technology panel.
Article - Billing and Coding: Platelet Rich Plasma Injections for Non-Wound Injections (A58737)

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 Platelet Rich Plasma Injections for Non-Wound Injections L39023.
Article - Billing and Coding: Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ) (A58739)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Minimally invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ)L39025.Coding InformationProcedure codes may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and National Provider Identifier (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 RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See Indications and Limitations of Coverage section) This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Medical record documentation must be available to Medicare upon request.
Article - Billing and Coding: Respiratory Pathogen Panel Testing (A58741)

CMS National Coverage PolicyIOM Citations:CMS IOM Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 80.1 Clinical Laboratory ServicesCMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 16 Laboratory ServicesChapter 23, Section 10 Reporting ICD Diagnosis and Procedure Codes, Section 20.9 National Correct Coding Initiative (NCCI), Section 40 Clinical Diagnostic Laboratory Fee ScheduleCMS IOM Publication 100-08,Medicare Program Integrity Manual,Chapter 3, Section 3.4.1.3 Diagnosis Code RequirementsSocial 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.National Correct Coding Initiative:NCCI Policy Manual for Medicare ServicesChapter 10, Pathology and Laboratory Services (CPT Codes 80000-89999), Section K MicrobiologyArticle TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39027, Respiratory Pathogen Panel Testing. 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.A respiratory pathogen panel test is a single service with a single unit of service (UOS=1). A respiratory pathogen panel testmust not be unbundled and billed as individual componentsregardless of the fact that the panel reports multiple individual pathogens and/or targets.The term "panel" refers to all respiratory pathogens tested in the outpatient setting on a single date of service from a single biologic specimen, not ordered as a reflex test.Please note: The services addressed in this article and related LCD are not applicable to providers submitting claims on institutional claim forms.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 medical recordMUSTsupport that the test was completed in a Part B setting that is equipped to deliver timely resultsANDfor patients where the test demonstrates that clinical management can result in an improved health outcome.
Article - Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer (A58756)

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 TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer L39040.To report a service, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM codeRegarding single-gene and panel testing of genes-Refer to Billing and Coding: MolDX: Testing of Multiple Genes A57880.Tier 1 and/or Tier 2 individual biomarker CPT codes should not be used for a single gene or any combination of genes when testing is performed as part of a NGS or other multiplexing technology panel.
Article - Billing and Coding: MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer (A58759)

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 LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer L39042.To report a Molecular Biomarkers to Risk-Stratify Patients at Increased Risk for Prostate Cancer service, please submit the following claim information:Select the appropriate CPT codeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM codeNOTE:When entering the DEX Z-Code on the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.Additional information:Only one molecular biomarker test may be performed per date of service.Only one molecular biomarker test may be performed for a given clinical indication, as allowed by the policy.
Article - Billing and Coding: Platelet Rich Plasma Injections for Non-Wound Injections (A58788)

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 Platelet Rich Plasma Injections for Non-Wound Injections L39058.NOTE:0232T is the HCPCS code representing platelet rich plasma injection, any site.It is Noridian's expectation that the HCPCS code P9020 (platelet rich plasma, each unit) be billed for one or more units of PRP transfused in the treatment of the conditions/coagulopathies for which it is indicated. This code MUST NOT be used to describe the injection of PRP into a specific site.The Center for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) 270.3 outlines the coverage of PRP for the treatment of certain chronic non-healing wounds. Please refer to NCD 270.3 for further information regarding coverage indications. Should PRP meet nationally covered indication as stated in NCD 270.3, HCPCS codes G0460/G0465 must be used accordingly.Do not use code 86965, Pooling of platelets or blood products for injection(s) of platelet rich plasma. Injections that utilize a kit to create the platelet rich plasma, must be billed with category III code 0232T, and according to the CPT codebook is not a transfusion medicine service.
Article - Billing and Coding: Platelet Rich Plasma Injections for Non-Wound Injections (A58790)

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 Platelet Rich Plasma Injections for Non-Wound Injections L39060.NOTE:0232T is the HCPCS code representing platelet rich plasma injection, any site.It is Noridian's expectation that the HCPCS code P9020 (platelet rich plasma, each unit) be billed for one or more units of PRP transfused in the treatment of the conditions/coagulopathies for which it is indicated. This code MUST NOT be used to describe the injection of PRP into a specific site.The Center for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) 270.3 outlines the coverage of PRP for the treatment of certain chronic non-healing wounds. Please refer to NCD 270.3 for further information regarding coverage indications. Should PRP meet nationally covered indication as stated in NCD 270.3, HCPCS codes G0460/G0465 must be used accordingly.Do not use code 86965, Pooling of platelets or blood products for injection(s) of platelet rich plasma. Injections that utilize a kit to create the platelet rich plasma, must be billed with category III code 0232T, and according to the CPT codebook is not a transfusion medicine service.
Article - Billing and Coding: Pharmacogenomics Testing (A58801)

procainamidePronestyl, Procanpoor metabolizersNonspecific (NAT)81479sulfamethoxazole and trimethoprimSulfatrim, Bactrimpoor metabolizersNonspecific (NAT)81479sulfasalazineAzulfidinepoor metabolizersSLCO1B181328, 0423UsimvastatinFloLipid, Zocor521 TC or 521 CC (intermediate or poor function transporters)NUDT15 and/orTPMT81306, 81335, 0286UazathioprineImuran, Azasanintermediate or poor metabolizersNUDT15 and/orTPMT81306, 81335, 0286UmercaptopurinePurixan, Purinetholintermediate or poor metabolizersNUDT15 and/orTPMT81306, 81335, 0286UthioguanineTabloidintermediate or poor metabolizersUGT1A181350belinostatBeleodaq*28/*28 (poor metabolizers)UGT1A181350irinotecanCamptosar*1/*6, *1/*28 (intermediate metabolizers) or *6/*6, *6/*28, *28/*28 (poor metabolizers)UGT1A181350nilotinibTasigna*28/*28 (poor metabolizers)UGT1A181350pazopanibVotrient*28/*28 (poor metabolizers)UGT1A181350sacituzumabgovitecan-hziyTrodelvy*28/*28 (poor metabolizers)VKORC181355warfarinCoumadin-1639G>A variant carriersThe CPT codes relevant to the related LCD are listed in the coding section below. If no CPT code is available for the gene(s) being tested, the unlisted molecular pathology procedure code 81479 should be used as indicated below.Utilization ParametersGermline testing may be performed once in a lifetime per beneficiary.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 provider performing the service must have a record of what drug(s) is/are being considered and for what indication to ensure the test performed is medically reasonable and necessary.The clinical record must clearly show the use of or intent to prescribe a drug that has known drug-gene interactions that require a PGx test to be ordered to define the safe use of that drug in that patient.Coding InformationWhen more than two codes from this list are submitted for the same beneficiary on the same date of service, the claims processing system will deny every code submitted after the first two services. However, if a lab runs more than two distinct procedural services from this list on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service. Billing the 59 modifier may result in a request for medical records.The molecular pathology codes include all analytical services performed during the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification, and detection).
Article - Billing and Coding: Platelet Rich Plasma (A58808)

CMS National Coverage PolicyIOM Citations:CMS Internet-Only Manual, Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 4, Section 270.3 Blood-Derived Products for Chronic Non-healing WoundsSocial 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 forLocal Coverage Determination (LCD) L39068, Platelet Rich Plasma. Please refer to the LCD for reasonable and necessary requirements.Note:For coverage information regarding G0465, please refer to NCD 270.3, Blood-Derived Products for Chronic Non-Healing Wounds.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.All PRP and related services provided outside of NCD 270.3 guidelines will be denied.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: Platelet Rich Plasma (A58810)

CMS National Coverage PolicyIOM Citations:CMS Internet-Only Manual, Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 4, Section 270.3 Blood-Derived Products for Chronic Non-healing WoundsSocial 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) L39071, Platelet Rich Plasma. Please refer to the LCD for reasonable and necessary requirements.Note:For coverage information regarding G0465, please refer to NCD 270.3, Blood-Derived Products for Chronic Non-Healing Wounds.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.All PRP and related services provided outside of NCD 270.3 guidelines will be denied.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: Pharmacogenomics Testing (A58812)

procainamidePronestyl, Procanpoor metabolizersNonspecific (NAT)81479sulfamethoxazole and trimethoprimSulfatrim, Bactrimpoor metabolizersNonspecific (NAT)81479sulfasalazineAzulfidinepoor metabolizersSLCO1B181328, 0423UsimvastatinFloLipid, Zocor521 TC or 521 CC (intermediate or poor function transporters)NUDT15 and/orTPMT81306, 81335, 0286UazathioprineImuran, Azasanintermediate or poor metabolizersNUDT15 and/orTPMT81306, 81335, 0286UmercaptopurinePurixan, Purinetholintermediate or poor metabolizersNUDT15 and/orTPMT81306, 81335, 0286UthioguanineTabloidintermediate or poor metabolizersUGT1A181350belinostatBeleodaq*28/*28 (poor metabolizers)UGT1A181350irinotecanCamptosar*1/*6, *1/*28 (intermediate metabolizers) or *6/*6, *6/*28, *28/*28 (poor metabolizers)UGT1A181350nilotinibTasigna*28/*28 (poor metabolizers)UGT1A181350pazopanibVotrient*28/*28 (poor metabolizers)UGT1A181350sacituzumabgovitecan-hziyTrodelvy*28/*28 (poor metabolizers)VKORC181355warfarinCoumadin-1639G>A variant carriersThe CPT codes relevant to the related LCD are listed in the coding section below. If no CPT code is available for the gene(s) being tested, the unlisted molecular pathology procedure code 81479 should be used as indicated below.Utilization ParametersGermline testing may be performed once in a lifetime per beneficiary.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 provider performing the service must have a record of what drug(s) is/are being considered and for what indication to ensure the test performed is medically reasonable and necessary.The clinical record must clearly show the use of or intent to prescribe a drug that has known drug-gene interactions that require a PGx test to be ordered to define the safe use of that drug in that patient.Coding InformationWhen more than two codes from this list are submitted for the same beneficiary on the same date of service, the claims processing system will deny every code submitted after the first two services. However, if a lab runs more than two distinct procedural services from this list on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service. Billing the 59 modifier may result in a request for medical records.The molecular pathology codes include all analytical services performed during the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification, and detection).