evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (A56573)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF).Provisions in this article and the LCD only address Vertebral Augmentation for Osteoporotic Vertebral Compression Fracture (VCF). Coverage will remain available for medically necessary procedures for other conditions not included in this article/LCD.Coding GuidelinesProcedure 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.All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.Specific Coding GuidelinesNo separate payment for venography performed during the operative session may be allowed and it should not be separately billed.This LCD will not affect the use of this treatment for cancer related diagnoses.Exclusion for total number of levels involved will not apply for a diagnosis of multiple myeloma.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related 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.
Article - Billing and Coding: Computerized Axial Tomography (CT), Thorax (A56580)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim that lacks the necessary information to process that claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Computerized Axial Tomography (CT), Thorax L33459.Reordering Identical Type of Imaging Examination:No imaging examination (pertaining to an identical CPTcode only) should be ordered more frequently than 6 times per calendar year. Furthermore, this frequency limit shall only apply to the following outpatient Places of Service (POS): office (11), outpatient hospital (22), independent clinic (49), rural health clinic (72) and independent diagnostic testing facility (IDTF).
Article - Billing and Coding: Surface Electrical Stimulation in the Treatment of Dysphagia (A56584)

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 claimArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Surface Electrical Stimulation in the Treatment of Dysphagia L34578.
Article - Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS) (A56588)

CMS National Coverage PolicyN/AArticle TextThisarticle contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Micro-Invasive Glaucoma Surgery (MIGS).Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed.Specific Coding Guideline:Effective for services rendered on or after 1/1/2022, codes 0191T and 0376T are being replaced by CPT codes 66989, 66991.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services. included in the 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. The medical record and/or test results documenting medical necessity should be maintained and made available on request. iStent, iStent inject, and Hydrus must be performed in conjunction with cataract surgery on the same date of service and documented in the medical record.
Article - Billing and Coding: Blood Glucose Monitoring in a Skilled Nursing Facility (SNF) (A56591)

CMS National Coverage PolicyPlease refer to the Local Coverage Determination (LCD), L34834, Blood Glucose Monitoring in a Skilled Nursing Facility (SNF).Article TextRefer to the Novitas Local Coverage Determination (LCD) L34834, Blood Glucose Monitoring in a Skilled Nursing Facility (SNF), for reasonable and necessary requirements.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.Coding InformationThe material for examination may be from any source unless otherwise specified in the code descriptor. When an analyte is measured in multiple specimens from different sources or in specimens that are obtained at different times, the analyte is reported separately for each source and for each specimen.
Article - Billing and Coding: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs) (A56596)

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, 60.1.2 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 Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs) (L37364).This contractor will provide limited coverage for Gastrointestinal Pathogen (GIP) molecular assays identified by multiplex nucleic acid amplification tests (NAATs). In immune competent beneficiaries, coverage is limited to no more than 5 bacterial targets (when not testing for clostridium difficile). Testing for 6-11 pathogens is covered when there is a clinical concern for clostridium difficile colitis, and clostridium difficile is one of the pathogens being tested.Testing for 12 or more organisms will only be covered in critically ill or immunosuppressed patients.This contractor expects that critically ill patients will be tested and managed in the appropriate inpatient facility. As such, for critically ill patients, only Part A claims should be submitted.ICD-10-CM diagnosis codes supporting medical necessity must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.Any diagnosis submitted must have documentation in the patients record to support coverage and medical necessity.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.Billing and Coding Information:To bill for GIP molecular assays identified by multiplex NAATs, please provide the following claim information:If the panel being used does not have its own proprietary CPTcode, use CPTcode 87505, 87506 or 87507For dates of service on or after 7/1/2019, laboratories billing for services using the BioFire FilmArray Gastrointestinal (GI) Panel (BioFire Diagnostics) should report 0097UEnter 1 unit of service (UOS)Enter the appropriate 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 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 formICD-10-CM diagnosis code(s) as set forth below.
Article - Billing and Coding: Cardiac Rhythm Device Evaluation (A56602)

CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states thatno 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) L34833, Cardiac Rhythm Device Evaluation. 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.CPT code 93292 should be reported when billing Medicare Part B for the analysis of a Wearable Defibrillator System.CPT Codes 93260, 93261, 93279-93292 are reported per procedure.Utilization ParametersCPT Codes 93293, 93294, 93295 and 93296 are reported no more than once every 90 days.Do not report CPT codes 93293, 93294, 93295 and 93296, if the monitoring period is less than 30 days.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: B-type Natriuretic Peptide (BNP) Testing (A56605)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e)prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for B-type Natriuretic Peptide (BNP) Testing L34410.
Article - Billing and Coding: Continuous Peripheral Nerve Blocks (CPNB) (A56607)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) states that no payment shall be made to any provider for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 20.9 National Correct Coding Initiative (NCCI)Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forContinuous Peripheral Nerve Blocks (CPNB) L37641.LimitationsReimbursement for the control or management of pain in the immediate postoperative period is bundled into the payment for the procedure, surgical or anesthetic - regardless of the method by which the care provider, including the anesthesiologist, decides to manage pain.
Article - Billing and Coding: Biomarker Testing for Prostate Cancer Diagnosis (A56609)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines related to Biomarker Testing for Prostate Cancer and is designed to aid in correct billing. Use of the CPT codes below in the CPT/HCPCS section do not guarantee coverage.Specific Coding InformationThe CPT codes are considered medically necessary when ordered by a physician or other qualified health care professional.The ordering provider must be familiar with the proper parameters of use of each test that they may be ordering.An LCD is not currently available due to the fluid nature of this area of medicine.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.ReferencesSuggested references include peer reviewed literature, compendiums such as NCCN or guidelines from professional organizations or societies.
Article - Billing and Coding: Hospice Cardiopulmonary Conditions (A56610)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1814(i) Payment for Hospice CareTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 10, 40.2 HH PPS ClaimsCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, 30.2 Payment Rates, 30.2.2 Service Intensity Add-on (SIA) Payments, 30.3 Data Required on the Institutional Claim to A/B MAC (HHH)Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Hospice Cardiopulmonary Conditions L34548.
Article - Billing and Coding: Corneal Pachymetry (A56611)

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.42 CFR 411.15(b)(2) and (c) addresses particular services excluded from coverage.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forCorneal Pachymetry L34512.
Article - Billing and Coding: CT of the Head (A56612)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) states that no payment shall be made to any provider for any claim which lacks the necessary information to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for CT of the Head L34417.1. The ICD-10 codes R51.9 (Headache, unspecified) and G44.1 (Vascular headache, not elsewhere classified) will only be covered in the following situations:a. The patient is suffering from headaches and a head injury. Head computed tomography (CT) is performed to rule out the possibility of an intracranial bleed.b. The patient is suffering from headaches unusual in duration (greater than 2 weeks) not responding to medical therapy. Head CT is performed to rule out the possibility of a tumor.c. The patient is suffering from new onset headache (less than 2 weeks) suggestive of intracranial bleeding as evidenced by signs (e.g., weakness or paralysis), symptoms (e.g., blurred vision, nausea and vomiting), or clinical history.2. Any claim billed with ICD-10 code R51.9 (Headache, unspecified) or G44.1 (Vascular headache, not elsewhere classified) may be subject to manual review.3. Claims billed with ICD-10 codes S09.19XA (Other specified injury of muscle and tendon of head, initial encounter), S09.19XD (Other specified injury of muscle and tendon of head, subsequent encounter) , S09.19XS (Other specified injury of muscle and tendon of head, sequela), S09.8XXA (Other specified injuries of head, initial encounter), S09.8XXD (Other specified injuries of head, subsequent encounter), S09.8XXS (Other specified injuries of head, sequela), S09.90XA (Unspecified injury of head, initial encounter), S09.90XD (Unspecified injury of head, subsequent encounter), or S09.90XS (Unspecified injury of head, sequela) should have documented associated signs and symptoms to support the need for CT scan of the head and may be subject to manual review.
Article - Billing and Coding: Cataract Surgery (A56613)

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 100-04, Medicare Claims Processing Manual, Chapter 12, 40.6 Claims for Multiple Surgeries and 40.7 Claims for Bilateral SurgeriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Cataract Surgery L34413.When billing ICD-10 codes H26.231, H26.232, H26.233, H26.221, H26.222, H26.211, H26.212, H26.213, H26.221, H26.222, H26.223, E08.36, E09.36, E10.36, E11.36, E13.36 or H28 note that coding guidelines require that the ICD-10 code for the underlying condition must appear and be coded first on the claim. For ICD-10 codes H26.31, H26.32, H26.33 and H26.8, coding guidelines require that the causative agent be identified on the claim.
Article - Billing and Coding: Psychiatric Inpatient Hospitalization (A56614)

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 claimArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forPsychiatric Inpatient Hospitalization L34570.Limitations:Listing an ICD-10-CM code in the mental disorders category (F01.50-F99) does not assure coverage of the specific service.
Article - Billing and Coding: Cataract Extraction (including Complex Cataract Surgery) (A56615)

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) L35091, 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: Swallowing Studies for Dysphagia (A56621)

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. 100-08, Medicare Program Integrity 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 Swallowing Studies for Dysphagia L33449.Utilization GuidelinesCPTcodes 70370, 70371 and 74230 describe the complete procedure and should not be billed more than 1 time per patient on the same date of service.Only 1 of the above codes should be billed per patient on the same date of service.