evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: MolDX: EndoPredict Breast Cancer Gene Expression Test (A56997)

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 Manuals, 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, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: EndoPredict Breast Cancer Gene Expression Test L37356.To report an EndoPredict service, please submit the following claim information:Select CPTcode 81522Enter 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
Article - Billing and Coding: MolDX: NRAS Genetic Testing (A56998)

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.100-08, Medicare Benefit Policy Manual, Chapter 3,  3.4.1.3, Diagnosis Code RequirementsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: NRAS Genetic TestingL35442.To report a NRAS Genetic Testing service, please submit the following claim information: Select appropriate CPT code Enter 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 837P Box 19 for paper claim Enter 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 form Select the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease (A56999)

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, Publication 100-04, Medicare Claims Processing Manual, Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual, Publication 100-04 Medicare Claims Processing Manual, Chapter 23 Section 10 "Reporting ICD Diagnosis and Procedure Codes"CMS Internet-Only Manual, Publication 100-04 Medicare Claims Processing Manual, Chapter 12, 30 Correct Coding PolicyArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative DiseaseL36117. For single genes performed by NGS, these tests must demonstrate compliance with L38047 MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies and its accompanying billing and coding article, A54901 Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Next-Generation Sequencing Testing in Cancer.To report Genetic Testing for BCR-ABL Negative Myeloproliferative Disease service, please submit the following claim information:Select appropriate CPTcode Enter 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 837P Box 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 claim Block 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: Multimarker Serum Tests Related to Ovarian Cancer Testing (A57020)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1862(a)(7) excludes routine physical examinations, unless otherwise covered by statute.Code of Federal Regulations:42 CFR, Section 410.32, indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).CMS Publications:CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 16: 20 Services Not Reasonable and NecessaryArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Multimarker Serum Tests Related to Ovarian Cancer Testing.Coding Guidelines: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.CPT coding:CPT code 81500 should be reported when billing for ROMATM.CPT 81503 should be reported when billing for OVA1.CPT 0003U should be reported when billing for OVERA.
Article - Billing and Coding: Autonomic Function Testing (A57024)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833 (e). This section states that no payment shall be made to any provider for any claims that lack necessary information to process the claim.Title XVIII of the Social Security Act section 1862 (a)(1)(A). This section allows coverage and payment of those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act section 1862 (a)(7). This section excludes routine physical examinations and services.CMS Manual System, Pub 100-08,Medicare Program Integrity Manual, Chapter 3, Part 3.2.3 Requesting Addition Documentation During Prepayment and Post-payment review.42 CFR Section 410.32(a) indicates diagnostic tests are payable only when the physician who is treating the beneficiary for a specific medical problem uses the results in such treatment.Article TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Autonomic Function 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.Do not report 95922 in conjunction with 95921Documentation Requirements:Medical record documentation maintained by the performing provider must clearly support the medical necessity for ANS testing as well as the test reports and interpretation. Supportive documentation showing medically reasonable and necessary indications as outlined in this LCD are expected to be documented in the medical record and be available upon request. This documentation includes, but is not limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or procedures used to rule out more common causes of autonomic signs or symptoms.General professional standards with FDA clearance apply for all equipment used in ANS testing.Utilization Guidelines:Diagnostic testing may be allowed once to confirm or exclude specific autonomic disease.For patients with diagnosed autonomic disorders, repeat testing is governed by a change in clinical status or response to a therapeutic intervention. If a repeat test is needed, it is not expected to exceed once per year.Providers who perform these tests on an unusually high proportion of their patients, or at frequencies exceeding once per year may be subject to medical review.Providers who do not have tilt tables and are using the code range 95921-95924 may be subject to medical review.
Article - Billing and Coding: Ultrasound, Soft Tissues of Head and Neck (A57029)

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) L34027, Ultrasound, Soft Tissues of Head and Neck. 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.
Article - Billing and Coding: ProMark® Risk Score (A57034)

CMS National Coverage PolicyCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceTitle 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: ProMarkRisk ScoreL36675.To report a ProMarkassay service, please submit the following claim information: Select CPT code 81479 Enter 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 claim Enter 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 form Select ICD-10-CM code C61
Article - Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment (A57037)

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 claimCMS Internet-Only Manuals, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS Internet Online 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: Biomarkers in Cardiovascular Risk Assessment L36358.
Article - Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment (A57055)

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 claimCMS Internet-Only Manuals, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS Internet Online 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: Biomarkers in Cardiovascular Risk Assessment L36362.
Article - Billing and Coding: Aortography and Peripheral Angiography (A57056)

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) L36767 Aortography and Peripheral Angiography. 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.CMS issued HCPCS code G0278 for femoral or iliac angiography when done at the time of coronary angiography. Medicare would not expect to see a high percentage of femoral or iliac angiography done at the same time of coronary studies, and such billing could be subject to review.Documentation RequirementsAll documentation must be maintained in the patients 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 operating physician should retain in the patients medical records the history and physical examination and notes documenting the evaluation and management of one of the Medicare covered conditions/diagnoses, including relevant clinical signs/symptoms or abnormal diagnostic test results.The treating physician order for the renal angiography performed at the time of cardiac catheterization must specifically request this extra angiographic service with documentation supporting medical necessity and made available upon request.
Article - Billing and Coding: Diagnostic Aerosol or Vapor Inhalation (A57058)

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) L33969 Diagnostic Aerosol or Vapor Inhalation. 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.Documentation that the service was performed for sputum induction/mobilization or bronchodilation for diagnostic purposes must be included in the patients medical record. This information is normally found in the office/progress notes, hospital notes, and/or procedure report.
Article - Billing and Coding: Biomarker Testing for Neuroendocrine Tumors/Neoplasms (A57059)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Code of Federal Regulations:42 CFR, Section 410.32, indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).CMS Publications:CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 80.1  Laboratory services must meet applicable requirements of CLIACMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 80.6. 5 which describes the Surgical/Cytopathology Exception.CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 16, Section 40.7 Billing for Noncovered Clinical Laboratory Tests Section and 120.1 Clarification of the Use of the Term Screening or ScreenCMS Publication 100-04,Medicare Claims Processing Manual, Chapter 30, Section 50 Advance Beneficiary Notice of Noncoverage (ABN)CMS Publication 100-08,Medicare Program Integrity Manual, Chapter 13, Local Coverage DeterminationsCMS National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Chapter 10, Pathology/Laboratory Services, (A) IntroductionCMS National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Chapter 10 Pathology/Laboratory Services which addresses reflex testing.Article TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) forBiomarker Testing for Neuroendocrine Tumors/Neoplasms.CPT code 0007M is considered not medically necessary and will be automatically denied as a non-covered procedure.
Article - Billing and Coding: Visual Electrophysiology Testing (A57060)

CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Code of Federal Regulations:42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).Article TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) forVisual Electrophysiology 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.