evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Bisphosphonate Drug Therapy (A56907)

CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations, and/or medical necessity described in the related LCD, L34648 Bisphosphonate Drug Therapy.Documentation RequirementsNote:If bone metastasis (C79.51 or C79.52) is the condition being treated, the diagnosis of a primary malignant neoplasm must be present in the patients medical record and available if requested.Information in the medical record including diagnostic information and lab results should support the medical necessity of this service. Based on the indications listed, the specific signs and symptoms must be documented to substantiate the FDA labeled or the FDA off labeled reasons for drug usage. An indication that the patient has been advised to take adequate calcium and vitamin D supplementation should be in the medical record. The medical record must be available on request. Diagnosis codes supporting medical necessity should be submitted on the claim.Evidence in the medical record should clearly support the need for the intravenous administration of bisphosphonates for the treatment of osteoporosis including description of treatment failure of oral or self-administered drugs for osteoporosis and heterotrophic ossification. Lab work should include serum creatinine measured prior to the administration of the drug.Utilization GuidelinesIt is expected that these services would be performed as indicated by current literature and/or standards of practice and should follow the guidelines for administration and safety found in the FDA approved labels for these drugs along with the indications found in the Coverage Indications, Limitations, and/or Medical Necessity section of this policy. When services are performed in excess of established parameters, it may result in medical review to determine if the services were medical necessity.Preventive services other than those payable by statute are excluded from Medicare coverage.Per the Summary and Analysis of Evidence contained in the associated LCD, the breast cancer diagnosis codes included in this Billing and Coding Article will reflect the current NCCN recommendations. It will continue to be required to bill the appropriate breast cancer diagnosis code, along with a bone loss diagnosis code, and a diagnosis code to reflect that the patient is currently receiving adjuvant selective estrogen receptor modulators OR aromatase inhibitor therapy for breast cancer.
Article - Billing and Coding: MDS FISH (A56913)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts with Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2 Travel 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) forMDS FISH L37602.Coding for FISH TestingThere are 2 sets of codes that describe in situ hybridization (ISH). Although the laboratory methods are similar, 1 distinguishes between the 2 sets of codes based on whether the ISH test is an adjunct to a surgical or cytopathology case, versus whether it is part of a clinical, chromosomal analysis. Specifically, the CPTcodes 88271-88291 should be used when the laboratory performs ISH as an ancillary analysis to cytogenetic studies for oncologic or inherited disorders.When a pathologist performsISH techniques as an adjunct to a surgical pathology or cytopathology case,CPTcodes 88365-88377 should be used to distinguish qualitative versus quantitative analysis (computer assisted versus manual).These codes must never be used by a pathologist when ISH is performed as an ancillary analysis to cytogenetic studies.To report an MDS FISH service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Select the appropriate ICD-10-CM codeA DEX Z-Code identifier is not required for FISH testing.
Article - Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (A56916)

CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L34760 Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI).Medicare will consider SCODI medically reasonable and necessary in evaluating retinal disorders, glaucoma, and anterior segment disorders as documented in L34760.Coding Guidelines:For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.Claims for SCODI services (CPT codes 92133 and 92134) are payable under Medicare Part B in the following places of service:The global service is payable in the office (11), nursing facility (32- for Medicare patient not in a Part A stay) and independent clinic (49).The technical component (modifier TC) is payable in the office (11), nursing facility (32- for Medicare patient not in a Part A stay), independent clinic (49), federally qualified health center (50), and rural health clinic (72).The professional component (modifier 26) is payable in the office (11), inpatient hospital (21), Off campus-outpatient hospital (19), On campus- outpatient hospital (22), skilled nursing facility (31), nursing facility (32- for Medicare patient not in a Part A stay), and independent clinic (49).Please review 100-04Medicare Claims Processing Manual, Chapter 32 - Billing Requirements for Special Services, Section 300.2 for Claims Processing Requirements for OPT with Verteporfin Services on Professional Claims and Outpatient Facility Claims.
Article - Billing and Coding: Outpatient Sleep Studies (A56923)

CMS National Coverage PolicyPlease refer to the related LCD, L35050.Article TextRefer to the Novitas Local Coverage Determination (LCD) L35050, Outpatient Sleep Studies, 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 GuidanceWatchPAT must be billed as CPT code 95800 or 95801.While actigraphy coverage is not included in the related LCD, this service may be reported with CPT code 95803 for documentation of coverage of CPAP by NCD but consistent with the related LCD the coverage of interpretation will not be paid separately. CPT code 95803 may also be reported for follow-up CPAP administration if allowed through the DME contractors as an acceptable test.
Article - Billing and Coding: MolDX: Inivata™, InVisionFirst®, Liquid Biopsy for Patients with Lung Cancer (A56924)

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, Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2 Travel Allowance.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Inivata,InVisionFirst, Liquid Biopsy for Patients with Lung Cancer L37870.To report an InvisionFirst Lung service, please submit the following claim information:Select CPTcode 81479Enter 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: MDS FISH (A56926)

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 MDS FISH L37608.Coding for FISH TestingThere are 2 sets of codes that describe in situ hybridization (ISH). Although the laboratory methods are similar, one distinguishes between the 2 sets of codes based on whether the ISH test is an adjunct to a surgical or cytopathology case, versus whether it is part of a clinical, chromosomal analysis. Specifically, the CPTcodes 88271-88291 should be used when the laboratory performs ISH as an ancillary analysis to cytogenetic studies for oncologic or inherited disorders.When a pathologist performsISH techniques as an adjunct to a surgical pathology or cytopathology case,CPTcodes 88365-88377 should be used to distinguish qualitative versus quantitative analysis (computer assisted versus manual).These codes must never be used by a pathologist when ISH is performed as an ancillary analysis to cytogenetic studies.To report an MDS FISH service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Select the appropriate ICD-10-CM codeA DEX Z-Code identifier is not required for FISH testing. If submitting a DEX Z-Code identifier, please submit following the below instructions: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 form
Article - Billing and Coding: BDX-XL2 (A56929)

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. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims,60.1.1 Independent Laboratory Specimen Drawing, and60.2 Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23 10 Reporting ICD Diagnosis and Procedure CodesCMS 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 BDX-XL2 L37031.
Article - Billing and Coding: 4Kscore® Assay (A56932)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2 Travel 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) for4Kscore Assay L36763.
Article - Billing and Coding: MolDX: Prometheus® IBD sgi Diagnostic® Policy (A56933)

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 claimArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: PrometheusIBD sgi DiagnosticPolicyL37260.To receive a PrometheusIBD sgi Diagnosticdenial, please submit the following claim information:Select the applicable CPTcodeEnter 1 unit of service (UOS)An 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 modifierIf submitting a DEX Z-Code identifier, 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 claimIf submitting a DEX Z-Code identifier, enter 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 form
Article - Billing and Coding: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (A56938)

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) L38385, Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea. 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.Implantationof a Hypoglossal Nerve Stimulator (HNS) for treatment of Obstructive Sleep Apnea (OSA) is reported with:CPT code 64582 -Open implantation of both the neurostimulator and its corresponding electrode array.Revision or Replacementof HNS for treatment of OSA is reported with:CPT code 64583- Revision or replacement of chest wall respiratory sensor electrode or electrode array, including connection to existing pulse generator.Replacementof HNS for treatment of OSA is reported with:Per AMA CPT, useCPT code 61886for the Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays.Removalof HNS for treatment of OSA is reported with:CPT code 64584- Removal of chest wall respiratory sensor electrode or electrode array.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.
Article - Billing and Coding: MolDX: Prometheus IBD sgi Diagnostic Policy (A56940)

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 claimArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: Prometheus IBD sgi Diagnostic PolicyL37260.To receive a Prometheus IBD sgi Diagnostic denial, please submit the following claim information:Select the applicable CPTcodeEnter 1 unit of service (UOS)An 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 modifierIf submitting a DEX Z-Code identifier, 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 claimIf submitting a DEX Z-Code identifier, enter 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 form
Article - Billing and Coding: MolDX: MGMT Promoter Methylation Analysis (A56941)

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. 100-04, 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 CodesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, 30 Correct Coding PolicyCMS Internet-Only Manual, Pub. 100-02, Medicare Claims Processing 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: MGMT Promoter Methylation Analysis L35974.To report a MGMT Promoter Methylation Analysis service, please submit the following claim information:Select Bill Type Code 022x  Skilled Nursing  Inpatient (Medicare Part B only)Select CPTcode 81287Enter 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: Biomarkers in Cardiovascular Risk Assessment (A56943)

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 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: Biomarkers in Cardiovascular Risk Assessment L36129.
Article - Billing and Coding: MolDX: Breast Cancer Assay: Prosigna® (A56949)

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 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: Breast Cancer Assay: ProsignaL36125.To report a Prosignaservice, please submit the following claim information:Select CPTcode 81520Enter 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