evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Magnetic Resonance Angiography (MRA) (A57779)

CMS National Coverage PolicyN/AArticle TextThis First Coast Billing and Coding Article for Local Coverage Determination (LCD) L34372 Magnetic Resonance Angiography (MRA) provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.Refer to the LCD for reasonable and necessary requirements and limitations.The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.Coding GuidelinesNotice: 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.If the provider of the magnetic resonance angiography study is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physicians order for the studies. The physician must state the reason for the MRA in his order for the test. (CFR, Title 42, Volume 2,Chapter IV, Part 410.32(a) Ordering diagnostic tests.)Utilization GuidelinesIn accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.Compliance with the provisions in LCD L34372, Magnetic Resonance Angiography (MRA) may be monitored and addressed through post payment data analysis and subsequent medical review audits.
Article - Billing and Coding: Peripheral Nerve Blocks (A57788)

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) L33933 Peripheral Nerve Blocks. 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.Refer to the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 2 and Chapter 8 for CPT codes 64400-64530 coding instructions.Refer to LCD L33930 Facet Joint Interventions for Pain Management for information regarding billing paravertebral facet joint blocks on the same date of service.Use of physical medicine and rehabilitation CPT/HCPCS codes (97032, 97139, G0282, G0283) for treatment of neuropathies or peripheral neuropathies caused by underlying systemic diseases is inappropriate.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.Assessment of the outcome of this procedure depends on the patients responses, therefore documentation should include:Whether the block was a diagnostic or therapeutic injectionPre- and post-procedure evaluation of the patientPatient educationWhen preemptive analgesia is performed by a provider other than the surgeon or the anesthesia professional who provides anesthesia/analgesia for the procedure, there must be a compelling patient care reason for the involvement of the additional provider. The rationale for this approach must be clearly documented in the medical record.
Article - Billing and Coding: Spinal Cord Stimulators for Chronic Pain (A57791)

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.Article TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.Physicians with a low trial to permanent implant ratio (less than 50%) will be subject to post-payment review and may be asked to submit documentation as to the patient selection criteria, the radiologic imaging demonstrating proper lead placement, and the medical necessity of the trials. Failure to provide this documentation will be cause for post-payment denial and recoupment of reimbursement. It is understood that all patients may not have a favorable result of the trial implant; but careful selection should find the most appropriate patients.If a trial fails, a repeat trial is not appropriate unless there are extenuating circumstances that lead to trial failure. Appropriate medical documentation to support a repeat trial can be sent on appeal.Documentation RequirementsThe clinical record should include the elements leading to the diagnosis and the therapies tried before the decision to use spinal cord stimulators (SCS).The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary.Utilization Guidelines63650 - Two temporary spinal cord stimulator trials per anatomic spinal region (two per DOS) or (four units) per patient per lifetime (with exceptions allowed for technical limitations for the initial trials or for use of different modalities of stimulation, including new technology), in place of service office, ASC, out-patient hospital, or hospital. Since permanent neurostimulator arrays can also be placed percutaneously, code 63650 can be covered more often in place of service ASC, out-patient hospital, or hospital.63655 - One permanent spinal cord stimulator per patient per lifetime and must be performed in an ASC, out-patient hospital or hospital.63663 - Will not be reimbursed in the office setting since they are included in 63650.
Article - Billing and Coding: Spinal Cord Stimulators for Chronic Pain (A57792)

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.Article TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.Physicians with a low trial to permanent implant ratio (less than 50%) will be subject to post-payment review and may be asked to submit documentation as to the patient selection criteria, the radiologic imaging demonstrating proper lead placement, and the medical necessity of the trials. Failure to provide this documentation will be cause for post-payment denial and recoupment of reimbursement. It is understood that all patients may not have a favorable result of the trial implant; but careful selection should find the most appropriate patients.If a trial fails, a repeat trial is not appropriate unless there are extenuating circumstances that lead to trial failure. Appropriate medical documentation to support a repeat trial can be sent on appeal.Documentation RequirementsThe clinical record should include the elements leading to the diagnosis and the therapies tried before the decision to use spinal cord stimulators (SCS).The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary.Utilization Guidelines63650 - Two temporary spinal cord stimulator trials per anatomic spinal region (two per DOS) or (four units) per patient per lifetime (with exceptions allowed for technical limitations for the initial trials or for use of different modalities of stimulation, including new technology), in place of service office, ASC, out-patient hospital, or hospital. Since permanent neurostimulator arrays can also be placed percutaneously, code 63650 can be covered more often in place of service ASC, out-patient hospital, or hospital.63655 - One permanent spinal cord stimulator per patient per lifetime and must be performed in an ASC, out-patient hospital or hospital.63663 - Will not be reimbursed in the office setting since they are included in 63650.
Article - Billing and Coding: MolDX: Immunohistochemistry (IHC) Indications for Breast Pathology (A57797)

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.Article TextBased on recommendations from the College of American Pathologists, the American Society of Clinical Oncologists (ASCO), and the National Comprehensive Cancer Network (NCCN), hormone receptor assays, estrogen receptor (ER), progesterone receptor (PR), and Her-2/neu are the only current biomarkers that demonstrate standardized value in breast cancer pathology evaluation. Although other biomarkers, such as Ki-67, PI3K, and gene expression assays, have been studied, no proven standardized value has been established. Therefore, MolDX will allow ER, PR, and Her2 testing by IHC for patients with primary invasive breast cancers and recurrent or metastatic cancers.To report an IHC service for an ER, PR, Her2, submit the following claim information:CPT CodeSpecimenUOS88342First single/multiplex stain188341Each additional2To report morphometric analysis,select oneof the following codes based on the type of morphometric analysis:CPT CodeService TypeUOS88360Manual388361Computer-assisted3Note: a unit of service applies to a single separately identifiable specimen.
Article - Billing and Coding: Hepatic (Liver) Function Panel (A57802)

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) L33907 Hepatic (Liver) Function Panel. 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.If the provider of the service is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of the test results and interpretation, along with copies of the ordering/referring physicians order for the studies. The physician must state the clinical indication/medical necessity for each test billed.
Article - Billing and Coding: High Sensitivity C-Reactive Protein (hsCRP) (A57803)

CMS National Coverage PolicyN/AArticle TextThis First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33908 High Sensitivity C-Reactive Protein (hsCRP) provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.Refer to the LCD for reasonable and necessary requirements and limitations.The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.Coding GuidelinesNotice: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 maintained by the ordering/referring physician/qualified nonphysician practitioner must indicate the medical necessity for performing the test and the test results. In addition, if the service exceeds the frequency parameter listed in the LCD, documentation of medical necessity must be submitted upon request.If the provider of the service is other than the ordering/referring physician/nonphysician practitioner, that provider must maintain a copy of test results, along with copies of the ordering/referring physician/nonphysician practitioners order for the test. The clinical indication/medical necessity for the test must be indicated in the order for the test.Utilization GuidelinesIn accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.Compliance with the provisions in LCD L33908, High Sensitivity C-Reactive Protein (hsCRP) may be monitored and addressed through post payment data analysis and subsequent medical review audits.
Article - Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (A57804)

CMS National Coverage PolicyIOM CitationsCMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 23 Fee Schedule Administration and Coding Requirements, Section 10 Reporting ICD Diagnosis and Procedure codes and Section 20.9 National Correct Coding Initiative (NCCI)National Correct Coding Initiative (NCCI) Citation:NCCI Policy Manual for Medicare ServicesChapter XI Medicare Evaluation and Management Services CPT Codes 90000-99999, Section G, OphthalmologySocial 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) L33751 Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI). 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.Utilization ParametersOne month is defined as 28 days. No more than one (1) exam per month will be considered medically reasonable and necessary to manage the patient with retinal conditions undergoing active treatment.CPT code 92132 and 92133 may not be reported more than two (2) times per year. Please refer to the LCD for details on reasonable and necessary guidelines.CPT code 92134 may not be reported more than one (1) time every two (2) months. Please refer to the LCD for details on reasonable and necessary guidelines.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: Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults (A57813)

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.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forRepetitive Transcranial Magnetic Stimulation (rTMS) in Adults L34869.Documentation RequirementsAll documentation must be maintained in the patients medical record and 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 record documentation must support the medical necessity of the services as directed in this policy.
Article - Billing and Coding: MolDX: Next-Generation Sequencing for Solid Tumors (A57831)

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. 100-02, 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 Allowance.CMS 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:Next Generation Sequencing for Solid TumorsL38045.Relevant Article: Billing and Coding: MolDX: Testing of Multiple Genes A57503:To report a Next Generation Sequencing for Solid Tumors service, please submit the following claim information:Select the 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 codeNOTE:When entering the DEX Z-Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies (A57837)

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. 100-02, 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 Allowance.CMS 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: Next Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies L38047.Relevant Article: Billing and Coding: MolDX: Testing of Multiple Genes A57503:To report a Next Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies service, please submit the following claim information:Select the 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 codeNOTE:When entering the DEX Z-Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.