evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Independent Diagnostic Testing Facilities (IDTF) (A58559)

95939Board Certified* Neurologist or PhysiatristABRET: R. EPT or R. EEG T.95943Board Certified* Neurologist or PhysiatristAAET: R. NCS.T95957Board Certified* NeurologistABRET: R. EEG T95958Board Certified* NeurologistABRET: R. EEG T95965Board Certified* Neurosurgeon or NeurologistABRET: R. EEG T95966Board Certified* Neurosurgeon or NeurologistABRET: R. EEG T95967Board Certified* Neurosurgeon or NeurologistABRET: R. EEG T95976Board Certified* Neurosurgeon or NeurologistABRET: R. EEG T95977Board Certified* Neurosurgeon or NeurologistABRET: R. EEG T95983Board Certified* Neurosurgeon or NeurologistABRET: R. EEG T95984Board Certified* PhysicianN/A96105Psychiatrist, Clinical Psychologist or Qualified Independent PsychologistPhysician service code - must be performed by a physician96110Psychiatrist, Clinical Psychologist or Qualified Independent PsychologistPhysician service code - must be performed by a physician96116Board Certified* Physician or PsychologistPhysician Service Code - must be performed by a physician or other qualified health care professional99151Board Certified* PhysicianPhysician Service Code - must be performed by a physician or other qualified health care professional99152Board Certified* PhysicianRN99153Board Certified* PhysicianRN99155Board Certified* PhysicianRN99156Board Certified* PhysicianRN99157Board Certified* PhysicianRN99202Board Certified* PhysicianRN99211Board Certified* PhysicianRN99453Board Certified* PhysicianRN99454Board Certified* PhysicianRN99457Board Certified* PhysicianRN99458Board Certified* PhysicianRNThese associations hold licenses and/or certifications and are approved to perform in areas of expertise within the bounds of organization:American Association of Electrodiagnostic Technologists (AAET)American Board of Electrodiagnostic Medicine (ABEM)American Board of Family Medicine (ABFM)American Board of Internal Medicine (ABIM)American Board of Medical Specialties (ABMS)American Board of Nuclear Medicine (ABNM)American Board of Otolaryngology (ABOto)American Board of Psychiatry and Neurology (ABPN)American Board of Physical Therapy Specialties (ABPTS)American Board of Registration of Electroencephalographic and Evoked Potential Technologists (ABRET)American Board of Sleep Medicine (ABSM)American Osteopathic Association (AOA)American Registry of Diagnostic Medical Sonographers (ARDMS)American Registry of Magnetic Resonance Imaging Technologists (ARMRIT)The American Registry of Radiologic Technologists (ARRT)American Society of Neuroimaging (ASN)Board of Registered Polysomnographic Technologists (BRPT)Cardiovascular Credentialing International (CCI)The International Society for Clinical Densitometry (ISCD)Joint Commission on Allied Health Personnel in Ophthalmology (JCAHPO)National Board for Respiratory Care (NBRC)National Healthcare Association (NHA)Nuclear Medicine Technology Certification Board (NMTCB)The Board of Certification of the Ophthalmic Photographers' Society (OPS)Physical Medicine and Rehabilitation (PMR)United Council for Neurologic Subspecialties (UCNS)
Article - Billing and Coding: Respiratory Pathogen Panel Testing (A58575)

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) L38916, 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: Respiratory Pathogen Panel Testing (A58577)

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) L38918, 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: Cataract Extraction (including Complex Cataract Surgery) (A58592)

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) L38926, Cataract Extraction (including Complex Cataract Surgery). 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.The primary diagnosis submitted by the physician performing the preoperative ophthalmologic evaluation must be cataract (ICD-10-CM codes listed in the "ICD-10 Codes that Support Medical Necessity" section of this article).The diagnoses submitted by the physician performing the evaluation and management component of the preoperative workup, when it is medically necessary, should indicate cataract (ICD-10-CM codes listed in the "ICD-10 Codes that Support Medical Necessity" section of this article) as the primary or secondary diagnosis.Complex cataract extraction should require devices or techniques not generally used in routine cataract surgery.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.When complex cataract procedures are reported the medical record must support that devices or techniques not generally used in routine cataract surgery were used, for example:Insertion of iris retractors through additional incisionsMechanical expansion of the pupil using iris hooksCreation of a sector iridectomy with subsequent suture repair of iris sphincterUse of intraoperative iris expansion device to maintain pupil dilation (i.e., Malyugin ring), iris sphincterotomies created with scissorsThe need to support the lens implant with permanent intraocular suturesPlacement of a capsular support ring is necessary to allow secure placement of an intraocular lens
Article - Billing and Coding: IDTFs and Low Dose CT Scan for Lung Cancer Screening for CPT Code 71271 (A58641)

CMS National Coverage PolicyCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 35, 50 Therapeutic ProceduresCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 18, 220.4 Preventive and Screening ServicesCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 13, 20.3 Anti-Markup Payment LimitationArticle TextThe Centers for Medicare & Medicaid Services (CMS) has authorized a screening benefit for lung cancer using low dose computed tomography (LDCT) scanning.There are two CPT/HCPCS codes associated with this benefit: G0296 for the initial visit and 71271 for the scan and subsequent intervention. The descriptions for these codes are:G0296 - Counseling visit to discuss need for lung cancer screening using LDCT (service is for eligibility determination and shared decision making)71271 - Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s)Independent Diagnostic Testing Facilities (IDTFs) are enrolled for diagnostic testing only and are not permitted to perform therapeutic activities (CMS Internet-Only Manual, Pub 100-04, Chapter 35). IDTFs may perform the LDCT scan associated with this benefit (when all requirements for coverage, including a physicians order, are met; see Change Request 9246). However, since the code 71271 also includes a therapeutic activity(smoking cessation interventions must be made available for current smokers), this service must be billed by a physician. The physician and IDTF must have a business arrangement for cooperatively providing this portion of the benefit and the IDTF shall look to the physician for payment. Physicians billing for a purchased service, such as the CT scan, should be aware of the anti-markup provisions summarized in the CMS Internet Only-Manual 100-04, Chapter 13, Section 20.3.
(Medicare Claims Processing Manual)

Applicable to PET Scan Services for Carriers  08/01/2006 5054 R822CP  02/01/2006 Update of Radiopharmaceutical Imaging Agents HCPCS Codes Applicable to PET Scan Services  07/03/2006 4270 R795CP  12/30/2005 Redefined Type of Bill 14 X for Non- Patient Laboratory Specimens  04/03/2006 4208 R716CP  10/21/2005 Modifiers for Transportation of Portable X -rays (R0075) When Billed by Skilled Nursing Facilities (SNFs)  04/03/2006 4039 R628CP  07/29/2005 Radiopharmaceutical Diagnostic Imaging Agents Codes Applicable to PET Scan Services Performed on or After January 28, 2005 10/31/2005 3945 Rev #  Issue Date  Subject  Impl Date  CR#  R627CP  07/29/2005 New Low Osmolar Contrast Material (LOCM) HCPCS Codes/Payment Criteria/Payment Level  10/31/2005 3902 R527CP  04/15/2005 New Coding for FDG PET Scans and Billing Requirements for Specific Indications of Cervical Cancer  04/18/2005 3741 R501CP  03/11/2005 Bone Mass Measurements -  Procedure Coding 04/11/2005 3719 R428CP  01/14/2005 Update to Billing Requirements for FDG -PET Scans for Use in the Differential Diagnosis of Alzheimer's Disease (AD) and Fronto- Temporal Dementia (FTD) and Update to the FI Billing Requirements for Special Payment Procedures for ALL PET Scan Claims for Servi ces Performed in a Critical Access Hospital (CAH)  04/04/2005 3640 R343CP  10/29/2004 Clarification: Modifiers for Transportation of Portable X -rays (R0075)  04/04/2005 3280 R310CP  10/01/2004 Billing Requirements for Positron Emission Tomography (PET) Scans for Dementia and Neurodegenerative Diseases  10/04/2004 3426 R223CP  07/02/2004 PET Scans and Related Claims Processing  N/A 3304 R135CP  04/02/2004 Purchased Diagnostic Test -  Carriers  N/A 1658 R001CP  10/01/2003 Initial Publication of Manual  NA NA Back to top of Chapter
Article - Billing and Coding: IUD (Hormone-Eluting) for Endometrial Hyperplasia - CPT 58999 (A58649)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that reflect proper billing for insertion of an IUD (Hormone-Eluting) for Endometrial Hyperplasia.- CPT Code 58999.Coding Information:The diagnosis code(s) must best describe the patient's condition for which the service was performed.Medicare does not allow payment for contraceptive devices or medication. For this reason the service, 58300, insertion of intrauterine device (IUD) has an "N" status in the Medicare Physician Fee Schedule, which means the service cannot be covered when billed to Medicare.National Government Services (NGS) is aware that insertion of a progestin-containing intrauterine device (IUD) is an alternative method of managing endometrial hyperplasia in patients who are not reasonable surgical candidates or who wish to preserve fertility. NGS has determined that the use of a progestin containing IUD may be approved for use in the Medicare beneficiary who presents with endometrial hyperplasia without atypia.Since the CPT code for IUD insertion will be auto-denied, providers should bill this service using CPT 58999 and an appropriate diagnosis for endometrial hyperplasia, including the product description "hormone IUD for endometrial hyperplasia" in Item 19 of the CMS-1500 form or the electronic equivalent.Coding Information:The diagnosis code(s) must best describe the patient's condition for which the service was performed.DocumentationThe medical record must clearly document the specific clinical circumstances evidencing this medical necessity.
Article - MolDX: Algorithm definition as a component of a laboratory test (A58650)

CMS National Coverage PolicyN/AArticle TextThe aim of this article is to promote a shared understanding of the term "algorithm" within the context of a clinical laboratory test. The objective of this article is to communicate the attributes of an algorithm as defined by this contractor within the stated context. The presence or absence of an algorithm as part of a lab service may be relevant to understanding the components of that service for coding or valuation purposes.An algorithm may be considered a meaningful and independent component of a laboratory process when ALL the following conditions are met:It is an unambiguous problem-solving operation that includes deploying a set of rules or calculations requiring computer processing;The test result (or a component of the result) is the calculated output of this process, and not an intermediary process;The same or similar test result could not be obtained without the use of this process;The input for the computation is derived from biological samples using analytical processes, and must include data from the sample submitted for the test;The process must:Either be required for the analytical result, ORIf adjunct to the analytical result as a post-analytical process, the calculation itself must be independently found to be reasonable and necessary apart from the other components of the test.Examples:A gene expression profile test wherein sequencing data must be compared in a calculation to an existing and validated set of profiles to bin it in one of several possible risk stratification groups would require the use of an algorithm as defined above.A next generation sequencing (NGS) test that uses computation to identify variants in a sampleis notconsidered as using an algorithm in this context. The calculation in this scenario is seen as an intermediary process.Calculations using only clinical information not derived from analytical services on biological samplesare notconsidered algorithms in this context. Examples would include using the clinical information from the patient in a calculation to assess their risk stratification or using a similar process to identify relevant clinical annotations derived from literature as associations with sequencing variants.A test that inputs resultant analytical processes that are reasonable and necessary (such as gene variants or protein markers) that are post processed by computation, but wherein that subsequent computation is not independently established as reasonable and necessary above and beyond the other lab components, shall not be considered an algorithm as a valid component of a laboratory test.
Article - Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer (A58652)

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 L38966.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 A57503.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: Thyroid Nodule Molecular Testing (A58656)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Thyroid Nodule Molecular 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. 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 attached 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.