evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Neulasta® (pegfilgrastim) Onpro® Kit / UDENYCA® ONBODY™ (On-body Injector) (A54682)

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 TextNeulastaand UDENYCAare leukocyte growth factors indicated to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia.Neulastaand UDENYCAare currently available in 2 distinct delivery options. When administered to the patient by means of the prefilled syringe, the appropriate coding procedure is to report the HCPCS code for both the drug (J2506 or Q5111) and the administration of the drug (CPTcode 96372).Part B ProvidersWhen Neulastaor UDENYCAare administered to the patient by means of a pegfilgrastim injection device such as the NeulastaDelivery Kit (Onpro) or the UDENYCAONBODY, the provider does not inject the drug, but instead fills the injector device with the drug and applies the injector device to the patient. The drug is delivered to the patient approximately 27 hours after the activation of the injector device. No CPTcode specific to the procedure for employing the Onproexisted at the time of the introduction of this device. Providers were instructed to use CPTcode 96372 as an interim measure for reporting the administration of Neulastausing this drug delivery method. As of 1/1/2017, a new CPTcode (96377) became effective which specifically addresses the use of the Onpro/ONBODY device. Identify the injector device using CPTcode 96377 in the medical record to distinguish it from the use of theprefilled syringe which should be identified with CPTcode 96372.Outpatient Hospital ProvidersThere has been no change to the information released in the Outpatient Hospital Final Rule for 2017:For Calendar Year 2017, CPTcode 96377 (Application of on-body injector (includes cannula insertion) for timed subcutaneous injection) is assigned status indicator N (Items and Services Packaged into APC Rates) to indicate that the service is paid under the Outpatient Prospective Payment System (OPPS). However, payment for the administration of NeulastaOnpro/UDENYCAONBODY is bundled into the payment for other services and not separately payable.
Article - Billing and Coding: MolDX: Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C) Testing (A54685)

CMS National Coverage PolicyN/AArticle TextEffective for dates of service on and after February 7, 2013ARVD/C, characterized by fatty replacement of heart cells predominantly in the right ventricle of the heart, is most often inherited as an autosomal dominant disease that may be associated with testing in at least seven genes (RYR2, TMEM43, DSP, PKP2, DSG2, DSC2 and JUP). Genetic testing may be performed in panels of 5-7 of these genes and disease-causing mutation is expected to be identified in 42-55% of cases. Testing would be performed to confirm an established diagnosis or on individuals already diagnosed with ARVD/C to identify family members at risk. Therefore, MolDX has determined that testing for ARVD/C is a statutorily excluded test.To receive an ARVD/C panel test denial, please submit the following claim information:CPTcode 81439An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientEnter the appropriate DEX Z-codeTMidentifier adjacent to the CPT code in the comment/narrative field for the following claim field/types:Line SV202-7 for 837I Part A or Loop 2400 or SV101-7 for the 5010A1 837P for Part BBlock 80 for Part A or Box 19 for Part B paper claim
Article - Billing and Coding: MolDX: BCR-ABL (A54686)

CMS National Coverage PolicyN/AArticle TextEffective for dates of service on and after 4/15/13Breakpoint testing for BCR-ABL1 is commonly performed as a combination or panel of tests. To report multiple tests assigned a single ID, submit CPTcode 81479. This guideline includes the following CPTcode combinations:81206 and 8120781206, 81207, and 81208CPTcodes 81206, 81207, and 81208 may only be reported when performed as a single test.To submit a claim for BCR-ABL translocation analysis by NGS, use CPT81479 and one (1) UOS with the assigned DEX Z-code.To report the FDA-approved MRDx BCR-ABL Test use the CPTcode 0040U.Refer to Billing and Coding: MolDX: Testing of Multiple Genes A57910 for additional information regarding single-gene and panel testing of genes.
Article - Billing and Coding: MolDX: FDA-Approved KRAS Tests (A54688)

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 TextTwo tests have met the FDA criteria for KRAS genetic testing:Effective 7/6/2012therascreen KRAS to detect seven somatic mutations in the human KRAS oncogene was developed to aid in the identification of CRC patients for treatment with Erbitux (cetuximab).Effective 5/7/2015cobas KRAS to detect mutations in codons 12 and 13 of the KRAS gene was developed to aid in identification of CRC patients for treatment with Erbitux (cetuximab) or Vectibix (panitumumab).To report an FDA approved or laboratory developed test (LDT) KRAS, service, please submit the following claim information:Select the appropriate CPT codeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the 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 diagnosis.NOTE:MolDX will apply NPI to ID editing on FDA approved KRAS kits. All labs that submit claims for a KRAS, codon 12 and 13 test kitMUSTregister the test and confirm theUNMODIFIEDuse of the kit. Tests may be registered on the DEXTMDiagnostics Exchange:https://app.dexzcodes.com/loginThis article reflects the FDA-approved indications on article creation date. MolDX will allow future FDA approved and amended indications for these tests.
Article - Billing and Coding: Germline testing for use of PARP inhibitors (A54689)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Article TextThe United States (U.S.) Food and Drug Administration (FDA) has approved several poly ADP-ribose polymerase (PARP) inhibitor treatments indicated for patients with ovarian cancer, breast cancer, pancreatic cancer, and prostate cancer.Results of tests that assess for deleterious variants in homologous recombination repair (HRR) genes such as BRCA1 and 2 can be used as an aid in patients who are being considered for treatment with PARP inhibitors in accordance with published guidelines and approved therapeutic product labeling. These genes are often tested as part of routine management of these cancer patients as part of services that interrogate a panel of genes as described in LCD L38966. In rare circumstances limited testing for only a select group of genes may be tested to ensure compliance with FDA indicated drug usage, wherein additional genes outlined in guidelines such as the NCCN are not necessary because the patient does not meet testing criteria for larger panels.According to criteria defined by L38966, billing for these services can occur in the following situation:The patient meets clinical indication for immediate use of a PARP inhibitor for an FDA-approved use ANDThe patient has had no previous germline testing for hereditary cancer or somatic testing of the same cancer that included the genes necessary for testing ANDThe patient does not meet germline testing requirements per existing guidelines or standards of care outlined in policy L38966 requiring more comprehensive testing.To report a service, please submit the following claim information:Select appropriate CPTcodeOne (1) unit of serviceEnter 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 837PItem 19 for paper claimEnter 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 at least one ICD-10-CM diagnosis code.
Article - Billing and Coding: FDA approves Iluvien for Diabetic Macular Edema (A54750)

CMS National Coverage PolicyN/AArticle TextOn September 26, 2014, The US Food and Drug Administration approved ILUVIEN (fluocinolone acetonide intravitreal implant) 0.19 mg for the treatment of diabetic macular edema (DME) in patients who have been previously treated with a course of corticosteroids and did not have a clinically significant rise in intraocular pressure. ILUVIEN is an intravitreal implant of fluocinolone acetonide and is the first DME treatment to deliver 36 months of continuous, low-dose corticosteroid with a single injection. The ILUVIEN intravitreal implant is designed to release fluocinolone acetonide/day at an initial rate of 0.25 g/day.To submit a Part B claim:Submit HCPCS code J7313 (fluocinolone acetonide intravitreal implant,0.19 mg )Total Dosage 0.19 mg, placed in narrative fieldOne of the ICD-10 diagnoses below.
Article - Billing and Coding: Medicare Preventive Coverage for Certain Vaccines (A54767)

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 TextMedicare provides preventive coverage only for certain vaccines. These include:Novel Coronavirus (COVID-19): guidance can be found here -https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/vaccine-pricingInfluenza: once per flu season (codes 90630, 90653-90657, 90660-90662, 90672-90674, 90682, 90685-90689, 90694, 90756, Q2034-Q2039)Claim should contain HCPCS G0008 and ICD-10 Z23Effective for dates of service 8/01/2017-12/31/2017 claims for Flucelvax Quadrivalent influenza vaccine should be billed utilizing HCPCS Q2039 (Influenza virus vaccine, not otherwise specified).Note:Claims billed for dates of service prior to 12/31/2017, if submitted on or after 01/01/2018, must bill HCPCS Q2039 for the claim to process correctly.Note:CPTcode 90694 is effective for claims processed with dates of service on or after 7/1/2020.Pneumococcal: An initial pneumococcal vaccine to Medicare beneficiaries who have never received the vaccine under Medicare Part B; and a different, second pneumococcal vaccine 1 year after the first vaccine was administered (codes 90670, 90671, 90677 and 90732)Claim should contain HCPCS G0009 and ICD-10 Z23Pneumococcal and Seasonal Influenza Virus Vaccines received during the same visit (use seasonal influenza virus and pneumococcal vaccine codes)Claim should contain HCPCS G0008 AND G0009 AND ICD-10 Z23Hepatitis B: for persons at intermediate-to high-risk only (codes 90739-90740, 90743-90744, 90746-90747, 90759). People who are considered high or medium risk for hepatitis B are:Those with End-Stage Renal Disease (ESRD) also known as kidney failureHemophiliacsClients and staff at institutions for the developmentally disabledThose who live in the same household as a hepatitis B carrierHomosexual menIllicit drug usersHealth care professionals who have frequent contact with blood or other body fluids during routine work-Claim should contain HCPCS G0010 and ICD-10 Z23Other immunizations are covered under Medicare only if they are directly related to the treatment of an injury or direct exposure:Rabies (90675-90676)Claim should contain Z20.3Tetanus (90702, 90714, and 90715)Claims should be coded with the diagnosis appropriate to the injury- see theICD-10-CM Codes that Support Medical Necessitysection of this article.
Article - Billing and Coding: Cardiac Blood Pool Imaging (Multiple Gated Acquisition Scanning- MUGA, Ventriculography) When Performed in Conjunction with Cardiotoxic Chemotherapy (A54768)

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 TextVentriculography is sometimes referred to as multiple gated acquisition scanning (MUGA) or cardiac blood pool imaging and is primarily used to evaluate valvular disease and cardiomyopathies.When billing claims for cardiac radionuclide imaging for cardiac blood pool imaging (MUGA, ventriculography) for patients receiving cardiotoxic chemotherapy, use the following CPTcodes:78472, 78473, 78481, 78483, 78494, 78496Coding for Cardiac Blood Pool Imaging (MUGA, Ventriculography) for Cardiac Radionuclide Imaging:Priorto the initiation of cardiotoxic chemotherapy:Code Z01.89 and the appropriate code from the C code or D code familyDuring or for interval assessmentof cardiotoxic chemotherapy use the appropriate code for the encounter:T45.1X5AT45.1X5DT45.1X5SAt the completionof cardiotoxic chemotherapy:Code Z08Use the additional secondary code to identify the personal history of malignant neoplasm (Z85) as per Correct Coding Initiative (CCI) guidelines and the appropriate code from the C code or D code family.*For appropriate C codes, D codes and appropriate Z85 codes for billing cardiac blood pool imaging (MUGA, ventriculography) refer to theCovered ICD-10 Codessection of this article.
Article - Billing and Coding: Urine Drug Testing (A54799)

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 LaboratoriesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for Urine Drug Testing L35724.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.
Article - Billing and Coding: MolDX: Short Tandem Repeat (STR) Markers and Chimerism (CPT® codes 81265-81268) (A54830)

CMS National Coverage PolicyN/AArticle TextPlease note that CPTcodes 81265 and 81266 describe services performed for recipient/donor testing and twin zygosity. Laboratories are encouraged to register tests based on the use of the test. Through the MolDX identification process, tests registered for recipient/donor testing will be considered for payment and tests for twin zygosity will be denied as a statutorily excluded service. The following instructions outline the correct reporting of recipient/donor testing for transplant services.Chimerism analysis to identify appropriate donors and monitor engraftment success or disease reoccurrence is a covered Medicare service.Code 81265 should be reported with one unit of service (UOS). Except in rare cases, this service would only be performed once per lifetime.Code 81266, when used in bone marrow transplants to report an additional double-cord blood sample, is a covered service.Code 81267 should be used post transplantation to confirm successful engraftment or disease reoccurrence. Although the original donor specimen may be referenced, an additional 81265 should NOT be submitted in addition to the 81267 service. For labs that hold the pre-transplant specimen (81265 and/or 81266) until after the transplant occurs, use 81267 plus 81265 and 81266 if necessary.Note: Code 81267 should be reported for the findings of the pre and post-transplant comparison.Code 81268 should be used to report chimerism using a buccal or other germline tissue specimen from the recipient post-transplantation. For labs that hold the pre-transplant specimen (81265 and/or 81266) until after the transplant occurs, use 81267 plus 81265 and 81266 if necessary.MolDX would not expect to see a claim for 81265 pre-transplant and an additional 81265 and 81267 post-transplant or a claim for 81265 pre-transplant and an additional claim for 81268.EXCEPTIONS:Although the initial chimerism testing, code 81265, for engraftment is usually limited to once in a lifetime, MolDX recognizes special circumstances may require an additional service and will consider approval on a case-by-case basis through the appeal process.NOTE: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: CDH1 Genetic Testing (A54835)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body memberArticle TextCDH1 testing is utilized in patients with specified cancers as an adjunctive test. CDH1 testing has also been recommended as a screening test for other cancers. However, screening for individuals at risk for cancer is not a Medicare benefit and is statutorily excluded.To receive a CDH1 test denial, please submit the following claim information:CPT 81406 - CDH1, full gene sequenceAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierEnter the appropriate DEX Z-Codeidentifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Codeidentifier 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 formIn rare cases in which HDGC is suspected in a Medicare beneficiary, MolDX will review the documentation on a case-by-case basis.
Article - Billing and Coding: MolDX: CDH1 Genetic Testing (A54878)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body memberArticle TextCDH1 testing is utilized in patients with specified cancers as an adjunctive test. CDH1 testing has also been recommended as a screening test for other cancers. However, screening for individuals at risk for cancer is not a Medicare benefit and is statutorily excluded.To receive a CDH1 test denial, please submit the following claim information:CPT81406 - CDH1, full gene sequenceAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierEnter the appropriate DEX Z-codeTMidentifier 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-codeTMidentifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 8371 electronic claimBlock 80 for paper claimIn rare cases in which HDGC is suspected in a Medicare beneficiary, MolDX will review the documentation on a case-by-case basis.
Article - Billing and Coding: Bariatric Surgery for Treatment of Co-Morbidities Conditions Related to Morbid Obesity (A54923)

CMS National Coverage PolicyN/AArticle TextItalicized fontrepresents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national NCD language/wording.Bariatric Surgery for Treatment of Morbid Obesity is a payable Medicare service when billed in accordance with instructions outlined in:CMS Pub 100-03Medicare National Coverage Determinations (NCD) Manual,Chapter 1  Coverage Determinations, Part 2 (Sections 90-160.2), Section 100.1 - Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid Obesity (Effective September 24, 2013).CMS Pub 100-04Medicare Claims Processing Manual,Chapter 32  Billing Requirements for Special Services, Section 150- Billing Requirements for Bariatric Surgery for Morbid Obesity.This local coverage Article lists the additional diagnoses that are covered for bariatric surgery for treatment of co-morbid conditions related to morbid obesityfor the procedure codes for Part A providers found in CMS Pub 100-04Medicare Claims Processing Manual, Chapter 32  Billing requirements for Special Services, Section 150- Billing Requirements for Bariatric Surgery for Morbid Obesity; and the listed CPT codes in the article. The diagnoses codes listed in section150.5.1 -ICD Codes for Type II Diabetes Mellitus Complication are not included in this article but are covered based on the IOM.
NCA - Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (CAG-00439R) - Decision Memo

However, two guideline organizations do not comment on a low dose CT lung cancer screening registry. The current National Comprehensive Cancer Network (NCCN) guidelines Version 1. 2021 (NCCN, 2020) do not comment on the necessity of registries for low dose CT lung cancer screening. No changes regarding registries are noted in the updated 2021 NCCN guidelines (Wood, NCCN, 2021). Additionally, the American College of Radiology (ACR) Appropriateness Criteria expert panel (Donnelly, 2018) does not make any statements about registries for low dose CT lung cancer screening.Thus, we will remove the criteria for imaging facilities to participate in a CMS-approved low dose CT lung cancer screening registry.Given that three published studies use the Lung Cancer Screening Registry administered by the American College of Radiology fulfilled the purpose as outlined in the previous NCD and that the most recent 2021 USPSTF recommendation statement has changed to having no comment on the need for a lung cancer registry, we will remove the radiology imaging facility eligibility criteria for collecting and submitting data to a CMS-approved low dose CT lung cancer screening registry which is likely to reduce the burden of administrative paperwork on providers and institutions.Health DisparitiesLung cancer incidences are more common in men than women and highest in African American men (NCI, 2021).