evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Cataract Extraction (A59556)

Potential vision testing,Corneal Topography,Anterior or Posterior Segment Ocular Coherence Tomography,Formal visual fields,Fluorescein angiography,External photography,Corneal pachymetry/Specular microscopy,Specialized color vision testing,Electrophysiologic testing,Fundus photography,Extended ophthalmoscopy, andOphthalmic ultrasound B scanIn general, any performed ancillary testing must be conducted so as not to deliberately bias the decision toward the performance of surgery (e.g., glare testing done on abnormally high settings inconsistent with the instructions of the testing devices manufacturer, etc.).When billing ICD-10 codes H26.231, H26.232, H26.233, H26.221, H26.222, H26.211, H26.212, H26.213, H26.221, H26.222, H26.223, E08.36, E09.36, E10.36, E11.36, E13.36 or H28 note that coding guidelines require that the ICD-10 code for the underlying condition must appear and be coded first on the claim. For ICD-10 codes H26.31, H26.32, H26.33 and H26.8, coding guidelines require that the causative agent be identified on the claim.
Draft Article - Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains (DA57733)

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 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 DL36805.Hematoxylin and eosin (H&E) staining provides excellent detail required for tissue-based diagnosis. This is NOT a separate service, as pathology services include routine H&E staining.Some physicians, groups, laboratories and hospitals submit global claims for the services described in the related LCD. In other instances, there are separate individuals or entities providing the professional and the technical services. It is the obligation of each party to recognize that they are responsible for the medical necessity of the services submitted.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)
Draft Article - Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM) (DA58213)

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) L38686 Implantable Continuous Glucose Monitors (I-CGM). Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceImplantationof an implantable continuous glucose monitor (I-CGM) that meets the appropriate criteria as mentioned in LCD L38686 Implantable Continuous Glucose Monitors (I-CGM) is reportedfor either the 90 day or 180 day implantable sensor.For 90 day implantable glucose sensor report:CPTcode 0446T- Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient trainingRemovalof an I-CGM is reported with:CPTcode 0447T- Removal of implantable interstitial glucose sensor from subcutaneous pocket via incisionRemoval with immediate subsequent replacementof an I-CGM is reported with:CPTcode 0448T- Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activationNotice: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.
Draft Article - Billing and Coding: MolDX: Molecular Testing for Risk Stratification of Thyroid Nodules (DA59560)

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 claimCMS 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 Testing for Risk Stratification of Thyroid Nodules DL39720.MolDX expects this test will be performed once per patient lifetime. Should the unlikely situation of a second, unrelated thyroid nodule with indeterminate pathology occur, coverage may be considered upon appeal with support documentation.To report a service, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Draft Article - Billing and Coding: Bisphosphonate Drug Therapy (DA56907)

CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations, and/or medical necessity described in the associated LCD L34648 Biphosphonate Drug Therapy.Documentation RequirementsNote:If bone metastasis (C79.51 or C79.52) is the condition being treated, the diagnosis of a primary malignant neoplasm must be present in the patients medical record and available if requested.Information in the medical record including diagnostic information and lab results should support the medical necessity of this service. Based on the indications listed, the specific signs and symptoms must be documented to substantiate the FDA labeled or the FDA off labeled reasons for drug usage. An indication that the patient has been advised to take adequate calcium and vitamin D supplementation should be in the medical record. The medical record must be available on request. Diagnosis codes supporting medical necessity should be submitted on the claim.Evidence in the medical record should clearly support the need for the intravenous administration of bisphosphonates for the treatment of osteoporosis including description of treatment failure of oral or self-administered drugs for osteoporosis and heterotrophic ossification. Lab work should include serum creatinine measured prior to the administration of the drug.Utilization GuidelinesIt is expected that these services would be performed as indicated by current literature and/or standards of practice and should follow the guidelines for administration and safety found in the FDA approved labels for these drugs along with the indications found in the Coverage Indications, Limitations, and/or Medical Necessity section of this policy. When services are performed in excess of established parameters, it may result in medical review to determine if the services were medical necessity.Preventive services other than those payable by statute are excluded from Medicare coverage.Per the Summary and Analysis of Evidence contained in the associated LCD, the breast cancer diagnosis codes included in this Billing and Coding Article will reflect the current NCCN recommendations. It will continue to be required to bill the appropriate breast cancer diagnosis code, along with a bone loss diagnosis code, and a diagnosis code to reflect that the patient is currently receiving adjuvant selective estrogen receptor modulators OR aromatase inhibitor therapy for breast cancer.
Draft Article - Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM) (DA58116)

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) DL38657 Implantable Continuous Glucose Monitors (I-CGM). Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceImplantationof an implantable continuous glucose monitor (I-CGM) that meets the appropriate criteria as mentioned in LCD DL38657 Implantable Continuous Glucose Monitors (I-CGM) is reported for either the 90 day or 180 day implantable sensor.For 90 day implantable glucose sensor report:CPT code 0446T - Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient trainingRemovalof an I-CGM is reported with:CPT code 0447T - Removal of implantable interstitial glucose sensor from subcutaneous pocket via incisionRemoval with immediate subsequent replacementof an I-CGM is reported with:CPT code 0448T - Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activationNotice: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.
Draft Article - Billing and Coding: Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor (DA56690)

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 Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor DL37761.
Draft Article - Billing and Coding: KidneyIntelX and KidneyIntelX.dkd Testing (DA59595)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for KidneyInteX and KidneyIntelX.dkd testing.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 InformationThe KidneylntelX or KidneyIntelX.dkd test is considered reasonable and necessaryonce in a lifetimewhen all criteria in the LCD's Indications of Coverage section are met.Please report PLA code 0105U for services rendered on or after 9/1/2023 through 12/31/2023.Please report PLS code 0407U for services rendered on or after 1/1/2024.
Draft Article - Billing and Coding: Computed Tomography Cerebral Perfusion Analysis (CTP) (DA58354)

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. 100-04, Medicare Claims Processing Manual, Chapter 13, 20 Payment Conditions for Radiology ServicesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 20.9 National Correct Coding Initiative (NCCI) and 30 Services Paid Under the Medicare Physicians Fee ScheduleArticle TextThe information in this article contains billing, coding or other guidelines that complements the Local Coverage Determination (LCD) for Computed Tomography Cerebral Perfusion Analysis (CTP) DL38769.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD (seeCoverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, the reason for the tests, an interpretive report and copies of images. The computerized image reconstruction data should also be maintained.
Draft Article - Billing and Coding: Lower Esophageal Magnetic Sphincter Augmentation (DA59654)

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 Lower Esophageal Magnetic Sphincter Augmentation DL39780.
Article - Billing and Coding: Artificial Hearts and Percutaneous Endovascular Cardiac Assist Procedures and Devices (A59657)

CMS National Coverage PolicyN/AArticle TextEffective for dates of service on/after February 3, 2014.Noridian will cover the percutaneous insertion of an endovascular cardiac assist device itself under limited conditions. Until the literature clearly demonstrates the efficacy of the treatment approach, coverage may be made only in the following two life-threatening situations and only when external counterpulsation (intraaortic balloon pump, IABP) is not expected to be sufficient; Cardiogenic shock or Severe decompensated heart failure with threatening multi-organ failure.This service will only be covered when the FDA approval guidelines are strictly followed.Due to the expansion of NCD 20.9.1-Ventricular Assist Devices (VADs) to include left ventricular assist devices for long-term (destination therapy) mechanical circulatory support per Change Request 12290, Noridian will cover artificial hearts for destination therapy whenallthe criteria outlined NCD 20.9.1 are met and the FDA approval guidelines are strictly followed effective December 1, 2020.
Article - Billing and Coding: Artificial Hearts and Percutaneous Endovascular Cardiac Assist Procedures and Devices (A59658)

CMS National Coverage PolicyN/AArticle TextEffective for dates of service on/after February 3, 2014.Noridian will cover the percutaneous insertion of an endovascular cardiac assist device itself under limited conditions. Until the literature clearly demonstrates the efficacy of the treatment approach, coverage may be made only in the following two life-threatening situations and only when external counterpulsation (intraaortic balloon pump, IABP) is not expected to be sufficient; Cardiogenic shock or Severe decompensated heart failure with threatening multi-organ failure.This service will only be covered when the FDA approval guidelines are strictly followed.Due to the expansion of NCD 20.9.1-Ventricular Assist Devices (VADs) to include left ventricular assist devices for long-term (destination therapy) mechanical circulatory support per Change Request 12290, Noridian will cover artificial hearts for destination therapy whenallthe criteria outlined NCD 20.9.1 are met and the FDA approval guidelines are strictly followed effective December 1, 2020.
Draft Article - Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM) (DA58110)

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) L38617 Implantable Continuous Glucose Monitors (I-CGM). 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.For 90-day implantable glucose sensor report:CPT code 0446T - Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient trainingRemovalof an I-CGM is reported with:CPT code 0447T - Removal of implantable interstitial glucose sensor from subcutaneous pocket via incisionRemoval with immediate subsequent replacementof an I-CGM is reported with:CPT code 0448T - Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activationDocumentation 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.
Draft Article - Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM) (DA58136)

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) L38664 Implantable Continuous Glucose Monitors (I-CGM). 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.For 90-day implantable glucose sensor report:CPT code 0446T - Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient trainingRemovalof an I-CGM is reported with:CPT code 0447T - Removal of implantable interstitial glucose sensor from subcutaneous pocket via incisionRemoval with immediate subsequent replacementof an I-CGM is reported with:CPT code 0448T - Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activationDocumentation 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.
Draft Article - Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) (DA59672)

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 Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) DL39797.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 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 (SeeCoverage Indications, Limitations and/or Medical Necessity). 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.