evekhm/cms_iom_3000 huggingface dataset:
(Medicare Claims Processing Manual)

Submitted to Carriers  04/03/2006  4097 R727CP  10/28/2005  Annual Type of Service (TOS)  01/03/2006  4145 R549CP  04/29/2005  Update to the Place of Service (POS) Code Set to Add a Code for Pharmacy  10/03/2005  3819 R511CP  03/28/2005  Type of Service (TOS) Corrections  04/18/2005  3788 R506CP  03/18/2005  Updated Manual Instructions for Item 24G (Days or Units)  07/01/2005  3753 R476CP  02/18/2005  Type of Service (TOS) Corrections  04/04/2005  3717 R400CP  12/16/2004  Incorrect Reporting of MTUS Indicator When Drugs are Billed Using an NDC Code  04/04/2005  3435 R359CP  11/04/2004  2005 Annual Type of Service (TOS)  01/03/2005  3519 R349CP  10/29/2004  2005 Annual Type of Service (TOS)  01/03/2005  3519 R335CP  10/29/2004  Correction of Reporting of MTUS Indicator When Drugs are Billed Using an NDC Code   Rescinded and replaced by Transmittal 400 04/04/2005  3435 R317CP  10/22/2004  Clarification to Chapter 26  N/A 3431 R228CP  07/16/2004  Lab and Carrier Processing of Claims for Reference Lab Services When there is No 08/16/2004  3267 Rev #  Issue Date  Subject  Impl Date  CR#  Face -to-Face Encounter with the Beneficiary  R153CP  04/30/2004  Correction of Type of Service (TOS) Inconsistencies  10/04/2004  3189 R148CP  04/23/2004  Describing the Identity of the Ordering and Supervising Physician on Form CMS -1500 Paper Claim  05/24/2004  3138 R145CP  04/23/2004  Deletion of the Data Element Requirements Matrix for Carriers from Chapter 1 and Chapter 26  05/24/2004  3164 R121CP  03/19/2004  Manualization of Program Memorandum B -03-040, CR 2730, Dated May 16, 2003, Regarding Place of Service (POS) Codes and Revises the Wording of the Group Home Code, 14  04/01/2004  3087 R108CP  02/27/2004  Correction of Type of Service (TOS) Inconsistencies in CR 2929 03/29/2004  3018 R005CP  10/10/2003  Update to 2004 HCPCS/Type of Service Crosswalk  01/01/2004  2929 R001CP  10/01/2003  Initial Publication of Manual  NA NA Back to top of Chapter
Article - Billing and Coding: MolDX: CDH1 Genetic Testing (A55970)

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 member.Article 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 837PItem 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 (A55971)

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 member.Article 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 837PItem 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: E&M Coding for Oral Surgeons (A56006)

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 TextPalmetto GBA has determined that Provider Specialty 19(oral surgeons) is appropriate to file E&M claims (99202-99215), in a limited fashion, when evaluating patients for sleep apnea to determine their suitability for placement of an oral device.All requirements for the E&M code selected must be met to bill the appropriate level of care. After a decision to perform the surgery is made, any preoperative or postoperative visits will be considered to be part of the bundled payment for the surgery.
Article - Billing and Coding: FDA Approved CLL Companion Diagnostic Test (A56008)

CMS National Coverage PolicyN/AArticle TextEffective April 11, 2016, the FDA approved venetoclax (VENCLEXTA/AbbVie), a new drug treatment for patients with B-cell chronic lymphocytic leukemia (CLL) with 17p deletion and at least one prior therapy, and a new indication for Vysis CLL FISH Probe Kit, a laboratory test to detect 17p deletion, as a companion diagnostic for venetoclax.Venetoclax is an inhibitor that binds directly to the BCL-2 protein whose overexpression has been associated with resistance to chemotherapeutics. The 17p deletion is more frequently observed in treated patients than in patients who have received no treatment. Therefore, venetoclax has been approved for patients with previous treatment for CLL with the 17p deletion as detected by the Vysis CLL FISH Probe Kit. Vysis CLL FISH Probe Kit is not intended for monitoring of residual disease.Palmetto GBA will only cover 17p deletion detection by FISH testing services when performed using validated assays. To date, Vysis CLL FISH Probe Kit is the only FDA validated and approved assay for the detection of the 17p deletion as the companion diagnostic for Venetoclax. Vysis CLL FISH Probe Kit services may only be billed by a CLIA certified lab. Vysis Fish Probe Kit by Abbott Molecular meets the reasonable and necessary criteria for Medicare reimbursement.To report a Vysis FISH Probe kit service, please submit the following claim information:When medically necessary and enumeration is performed, reviewed, and interpreted by a physician or pathologist:Select the CPTcode 88374 or 88377 for your service as appropriate and enter 2 units of service (UOS)When medically necessary and enumeration is performed and reviewed by a cytotechnologistSelect the CPTcode 88271 and 88275 for your service as appropriate and enter 4 units and 1 unit of service respectively (UOS)Select the CPTcode 88291 with 1 unit of service for physician interpretationAdditional Information:To bill the PC component, the pathologist must read and interpret the raw data. Per Chapter 10, Version 16.3 in the NCCI Policy Manual for Medicare Services, physicians may not report the professional component provided by the technician or scientist.Note:This billing and coding guideline ONLY applies to the UNMODIFIED, Vysis CLL FISH Probe Kit by Abbott for patients with CLL who have received at least one prior therapy and who are potential candidates for venetoclax.
Article - Billing and Coding: Topical HBO and Physician Related Service Billing and Coding Guidelines (A56025)

CMS National Coverage PolicyN/AArticle TextEffective April 3, 2017, the Centers for Medicare and Medicaid (CMS) decided that no National Coverage Determination (NCD) is appropriate at this time concerning the use of topical oxygen for the treatment of chronic wounds. As a result, CMS amended the NCD on Hyperbaric Oxygen Therapy (NCD 20.29) by removing Section C, Topical Application of Oxygen, and Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by the local Medicare Administrative Contractors (MACs). The CMS decision to remove the section on topical application of oxygen from the HBO NCD was because the topical application of oxygen does not meet the definition of hyperbaric oxygen therapy. (see CR 10220 issued 11/17/2017).In addition, CMS adds this note, Though a MAC may decide to cover this procedure, there shall be no coverage for any separate or additional payment for any physicians professional services related to this procedure. Presently, the two HCPCS codes for topical oxygen therapy (E0446 and A4575) are designated as DME jurisdiction and since CMS has instructed the local MACs to not allow a physician service with topical oxygen, Noridian does not expect to see any claims for this service in either Part A or Part B.To bill for denial of related physician services enter 99199-related to Topical HBO 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 claimsSourcesCMS Change Request 10220;Transmittal 203andTransmittal 3921Internet Only Manual, Pub 100-04-Claims Processing Manual;Chapter 32, Section 30.2
Article - Billing and Coding: Topical HBO and Physician Related Service Billing and Coding Guidelines (A56026)

CMS National Coverage PolicyN/AArticle TextEffective April 3, 2017, the Centers for Medicare and Medicaid (CMS) decided that no National Coverage Determination (NCD) is appropriate at this time concerning the use of topical oxygen for the treatment of chronic wounds. As a result, CMS amended the NCD on Hyperbaric Oxygen Therapy (NCD 20.29) by removing Section C, Topical Application of Oxygen, and Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by the local Medicare Administrative Contractors (MACs). The CMS decision to remove the section on topical application of oxygen from the HBO NCD was because the topical application of oxygen does not meet the definition of hyperbaric oxygen therapy. (see CR 10220 issued 11/17/2017).In addition, CMS adds this note, Though a MAC may decide to cover this procedure, there shall be no coverage for any separate or additional payment for any physicians professional services related to this procedure. Presently, the two HCPCS codes for topical oxygen therapy (E0446 and A4575) are designated as DME jurisdiction and since CMS has instructed the local MACs to not allow a physician service with topical oxygen, Noridian does not expect to see any claims for this service in either Part A or Part B.To bill for denial of related physician services enter 99199-related to Topical HBO 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 claimsSourcesCMS Change Request 10220;Transmittal 203andTransmittal 3921Internet Only Manual, Pub 100-04-Claims Processing Manual;Chapter 32, Section 30.2
Article - Billing and Coding: Piriformis Injections (A56027)

CMS National Coverage PolicyN/AArticle TextThis article replacesallprior instructions for billing and performing a piriformis muscle injection.Piriformis syndrome may be a common cause of back, buttock and leg pain due to injury to the piriformis muscle. This clinical syndrome is due to compression of the sciatic nerve by the piriformis muscle and may be identical in clinical presentation to low back pain (LBP) with associated LS, S1 radiculopathy due to discogenic and/or lower lumbar facet arthropathy with foraminal narrowing. Patients may also demonstrate both of these clinical entities simultaneously. This diagnostic dilemma highlights the need for patients with LBP and associated radicular pain to undergo a complete history and physical examination.Noridian Healthcare Solutions (Noridian) has noted that CPT codes 72195-72197 (Magnetic resonance (e.g., proton) imaging, pelvis) are being used for mapping purposes prior to injection of the piriformis muscle and surrounding muscle groups (i.e., gemelli and obturator intemus muscles). However, there is no clear clinical evidence that doing an MRI, CT Scan or EMG for placement of the needle into the piriformis or to inject the sciatic nerve is of more benefit than using common land marks.Coding ClarificationFor these reasons, the MRI CPT Codes 72195-72197 will be denied when billed in conjunction with injection of the piriformis muscle or surrounding muscle groups.Noridian has also noted that providers have been using both CPT codes 64999 (unlisted procedure nervous system) and 64445 (Injection anesthetic agent; sciatic nerve, single) for the injection of the piriformis muscle and surrounding muscle groups. This is not the correct way to code. When the clinical notes reflect direct nerve block to the sciatic nerve, 64445 should be used. When the injection focus is in the piriformis muscle or surrounding muscle groups, 20552 should be used. Per CPT Assistant December 2011, Volume 21, Issue 12 page 8;There is a significant difference in the work and procedure, as well as intent, between an injection of the piriformis muscle and the perineural injection of the sciatic nerve. The sciatic nerve injection code (64445) should not be used to report a piriformis injection.Source:CPT Assistant December 2011, Volume 21, Issue 12 page 8.
Article - Billing and Coding: Piriformis Injections (A56028)

CMS National Coverage PolicyN/AArticle TextThis article replacesallprior instructions for billing and performing a piriformis muscle injection.Piriformis syndrome may be a common cause of back, buttock and leg pain due to injury to the piriformis muscle. This clinical syndrome is due to compression of the sciatic nerve by the piriformis muscle and may be identical in clinical presentation to low back pain (LBP) with associated LS, S1 radiculopathy due to discogenic and/or lower lumbar facet arthropathy with foraminal narrowing. Patients may also demonstrate both of these clinical entities simultaneously. This diagnostic dilemma highlights the need for patients with LBP and associated radicular pain to undergo a complete history and physical examination.Noridian Healthcare Solutions (Noridian) has noted that CPT codes 72195-72197 (Magnetic resonance (e.g., proton) imaging, pelvis) are being used for mapping purposes prior to injection of the piriformis muscle and surrounding muscle groups (i.e., gemelli and obturator intemus muscles). However, there is no clear clinical evidence that doing an MRI, CT Scan or EMG for placement of the needle into the piriformis or to inject the sciatic nerve is of more benefit than using common land marks.Coding ClarificationFor these reasons, the MRI CPT Codes 72195-72197 will be denied when billed in conjunction with injection of the piriformis muscle or surrounding muscle groups.Noridian has also noted that providers have been using both CPT codes 64999 (unlisted procedure nervous system) and 64445 (Injection anesthetic agent; sciatic nerve, single) for the injection of the piriformis muscle and surrounding muscle groups. This is not the correct way to code. When the clinical notes reflect direct nerve block to the sciatic nerve, 64445 should be used. When the injection focus is in the piriformis muscle or surrounding muscle groups, 20552 should be used. Per CPT Assistant December 2011, Volume 21, Issue 12 page 8;There is a significant difference in the work and procedure, as well as intent, between an injection of the piriformis muscle and the perineural injection of the sciatic nerve. The sciatic nerve injection code (64445) should not be used to report a piriformis injection.Source:CPT Assistant December 2011, Volume 21, Issue 12 page 8.
Article - Billing and Coding: Nerve Blockade for Treatment of Chronic Pain and Neuropathy (A56034)

CMS National Coverage PolicyN/AArticle TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.LCD L35456 states, "Nerve blockade and/or electrical stimulation are non-covered for the treatment of metabolic peripheral neuropathy. The peer-reviewed medical literature has not demonstrated the efficacy or clinical utility of nerve blockade or electrical stimulation, alone or used together, in the diagnosis and/or treatment of neuropathic pain."The use of peripheral nerve blocks for treating diabetic neuropathy is not considered reasonable and/or necessary and is not covered by Medicare Part A or B. Such use of peripheral nerve blocks is not supported by the current peer reviewed, published, evidence based scientific literature nor by specialty society guidelines. Claims are subject to review and recoupment.This notification does not affect those regional/local blocks done as part of an operative procedure (for example wound debridement in the operating room) when performed as an adjunct to or the sole means of regional/local anesthesia for the procedure.For somatic nerve blocks, it is inappropriate to bill for fluoroscopy (CPTcodes 77002 or 77003) with a 59 modifier when the procedure(s) billed on that date of service for the same patient by the same provider are included in the CPTdescription of the procedure(s) performed.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 record must include the physician or non-physician practitioner responsible for and providing the care of the patient.The submitted medical record should support the use of the selected diagnosis code(s). The submitted CPT/HCPCS code should describe the service performed.Sources:Neurology 2011;76;1758; V. Bril, J. England, G.M. Franklin, et al. Evidence-based guideline:Treatment of painful diabetic neuropathy: Report of the American Academy of Neurology, the American Association of Neuromuscular and Neurodiagnostic Medicine, and the American Academy of Physical Medicine and RehabilitationThis information is current as of February 7, 2013American Family Physician 2010;82(2):151-158 T. Lindsay, B. Rodgers, V. Savath, K. HettingerTreating Diabetic Peripheral Neuropathic Pain
Article - Billing and Coding: FDA Approved CLL Companion Diagnostic Test (A56050)

CMS National Coverage PolicyN/AArticle TextEffective April 11, 2016, the FDA approved venetoclax (VENCLEXTA/AbbVie), a new drug treatment for patients with B-cell chronic lymphocytic leukemia (CLL) with 17p deletion and at least one prior therapy, and a new indication for Vysis CLL FISH Probe Kit, a laboratory test to detect 17p deletion, as a companion diagnostic for venetoclax.Venetoclax is an inhibitor that binds directly to the BCL-2 protein whose overexpression has been associated with resistance to chemotherapeutics. The 17p deletion is more frequently observed in treated patients than in patients who have received no treatment. Therefore, venetoclax has been approved for patients with previous treatment for CLL with the 17p deletion as detected by the Vysis CLL FISH Probe Kit. Vysis CLL FISH Probe Kit is not intended for monitoring of residual disease.CGS Administrators will only cover 17p deletion detection by FISH testing services when performed using validated assays. To date, Vysis CLL FISH Probe Kit is the only FDA validated and approved assay for the detection of the 17p deletion as the companion diagnostic for Venetoclax. Vysis CLL FISH Probe Kit services may only be billed by a CLIA certified lab. Vysis Fish Probe Kit by Abbott Molecular meets the reasonable and necessary criteria for Medicare reimbursement.To report a Vysis FISH Probe kit service, please submit the following claim information:When medically necessary and enumeration is performed, reviewed, and interpreted by a physician or pathologist:Select the CPTcode 88374 or 88377 for your service as appropriate and enter 2 units of service (UOS)When medically necessary and enumeration is performed and reviewed by a cytotechnologistSelect the CPTcode 88271 and 88275 for your service as appropriate and enter 4 units and 1 unit of service respectively (UOS)Select the CPTcode 88291 with 1 unit of service for physician interpretationAdditional Information:To bill the PC component, the pathologist must read and interpret the raw data. Per Chapter 10, Version 16.3 in the NCCI Policy Manual for Medicare Services, physicians may not report the professional component provided by the technician or scientist.Note:This billing and coding guideline ONLY applies to the UNMODIFIED, Vysis CLL FISH Probe Kit by Abbott for patients with CLL who have received at least one prior therapy and who are potential candidates for venetoclax.
Article - Billing and Coding: In Vitro Chemosensitivity & Chemoresistance Assays (A56071)

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, Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1, Clinical Laboratory Services.CMS 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 In Vitro Chemosensitivity & Chemoresistance Assays L37628.To receive a CSRA denial, please submit the following claim information:CPTcodeAn 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 modifier