evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: Cardiac Computed Tomography & Angiography (CCTA) (A56691)

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) forCardiac Computed Tomography & Angiography (CCTA) L33423.Refer to the Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease L38278 LCD and related billing and coding article A58406 for more information regarding the use of add-on analysis of CCTA.
Article - Billing and Coding: Respiratory Therapy (Respiratory Care) (A56717)

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. 100-02, Medicare Benefit Policy Manual, Chapter 12, 30.1 Rules for Payment of CORF Services and 40.5 Respiratory Therapy ServicesFederal Register: December 31, 2002 (Volume 67, Number 251) p 79999-80000 Final rule revisions to payment policies specific to G0237-G0239Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forRespiratory Therapy (Respiratory Care) L34430.Therapeutic procedures whose principle aim is to treat a respiratory impairment should be identified using the G0237-G0239 series of HCPCS codes. CPTcodes 97000 to 97799 are not to be billed by professionals involved in treating respiratory conditions, unless these services are delivered by physical or occupational therapists and meet the other requirements for physical and occupational therapy services.
Article - Billing and Coding: Intravenous Immunoglobulin (IVIG) (A56718)

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.Title XVIII of the Social Security Act, 1842(b)(18)(C) and (p)(1), describes payment for services that may be furnished by a practitioner. Requests for payment, or bills submitted shall include the appropriate diagnosis code(s).CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, 80.6 Intravenous Immune Globulin.CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code Requirements.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Intravenous Immunoglobulin (IVIG) L34580.Note:With respect to HCPCS codes J2792 Injection, Rho D immune globulin (human), solvent detergent (WINRho) and J2791 Injection immune globulin (human), (Rhophylac), thisarticle only addresses their use intravenously.
Article - Billing and Coding: Intraoperative Neurophysiological Testing (A56722)

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) L35003, Intraoperative Neurophysiological Testing. 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 95940 is reported per 15 minutes of service. CPT Code 95940 requires reporting only the portion of time the monitoring professional was physically present in the operating room providing one-on-one patient monitoring, and no other cases may be monitored at the same time. Time spent in the operating room is cumulative. To determine units of service of 95940, use the total minutes monitoring in the operating room one-on-one. Monitoring may begin prior to incision (e.g., when positioning on the table is a time of risk). Report continuous intraoperative neurophysiologic monitoring in the operating room (95940) in addition to the services related to monitoring from outside the operating room (G0453), and interpret the baseline studies, and to remove electrodes at the end of the procedure.When services support the covered indications in the related LCD, reimbursement may be made for the following places of service (POS):Off Campus-Outpatient Hospital (POS 19)Inpatient Hospital (POS 21)On Campus-Outpatient Hospital (POS 22)Ambulatory Surgical Center (POS 24)
Article - Billing and Coding: Wireless Gastrointestinal Motility Monitoring Systems (A56724)

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 23, 10.1 general rules for diagnosis codes.CMS Internet-Only Manual, Publication 100-08,Medicare Program Integrity Manual,Chapter 3, 3.4.1.3 diagnosis code requirements.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Wireless Gastrointestinal Motility Monitoring Systems L33455.
Article - Billing and Coding: Intensity Modulated Radiation Therapy (IMRT) (A56725)

CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833 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) L36711, Intensity Modulated Radiation Therapy (IMRT). 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.
Article - Billing and Coding: Magnetic Resonance Imaging of the Orbit, Face, and/or Neck (A56729)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(a)(2)(E) related to outpatient hospital radiology services.Title 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 13, 40 Magnetic Resonance Imaging (MRI) ProceduresArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Magnetic Resonance Imaging of the Orbit, Face, and/or Neck L34425.
Article - Billing and Coding: Respiratory Therapy and Oximetry Services (A56730)

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) forRespiratory Therapy and Oximetry Services L33446.CPTcode 31720 is payable only if it is personally performed by the physician (or qualified Non-Physician Practitioner (NPP)).Note:CPTcodes 94760, 94761 and 94762 are bundled by the Correct Coding Initiative (CCI) with critical care services. Therefore, CPTcodes 94760, 94761 and 94762 cannot be paid separately when billed with critical care CPTcodes (99291 and 99292).CPTcode94762is considered medically necessary when performed for any of the following reasons:The patient has a condition for which intermittent arterial blood gas sampling is likely to miss important variations.The patient has a condition resulting in hypoxemia and there is a need to assess supplemental oxygen requirements and/or a therapeutic regimen.Payment can be allowed for CPTcode 31720 only if supporting documentation demonstrates the service was personally performed by the physician or NPP when this service falls within his scope of practice.Payment for CPTcode 31720 may be allowed, on an individual consideration basis, for respiratory treatments for 3 consecutive days or 3 identical services within a 30-day time frame. Additional payment may be allowed for respiratory therapy treatments exceeding these parameters only if medical necessity can be established by medical documentation. In the case of consecutive days of care, the medical record should indicate why the patient was not transferred to a higher level of care.
Article - Billing and Coding: Nerve Blocks and Electrostimulation for Peripheral Neuropathy (A56731)

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 Nerve Blocks and Electrostimulation for Peripheral Neuropathy L37642.Use of Physical Medicine and Rehabilitation CPT/HCPCS Codes (97032, 97139, G0282, G0283) for these treatments is inappropriate.
Article - Billing and Coding: Mohs Micrographic Surgery (MMS) (A56732)

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 12, 60 Payment for Pathology ServicesCMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Change Request 3458, Transmittal 434, Dated January 14, 2005, Addition of CLIA Edits to Certain Health Care Procedure Coding System (HCPCS) Codes for Mohs Surgery.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Mohs Micrographic Surgery (MMS) L33436.To allow separate payment for a biopsy and pathology on the same day as MMS, the 59 modifier is appropriate. Modifier 59 is also appropriate when a separate skin lesion, other than the lesion for which Mohs surgery is performed, is biopsied on the same day that the Mohs surgery is performed.If the 59 modifier is used with a skin biopsy/pathology code on the same day the MMS was performed, physician documentation should clearly indicate:That the biopsy was performed on a lesion other than the lesion on which the MMS was performed;That if the biopsy is of the same lesion on which the MMS was performed, a biopsy of that lesion had not been done within the previous 60 days; orIf a recent (within 60 days) biopsy of the same lesion that MMS was performed or had been done, the results of that biopsy were unobtainable by the Mohs surgeon using reasonable effort.At this time, all laboratory tests covered under CLIA are edited at the CLIA certificate level. The previously mentioned Mohs micrographic surgery HCPCS codes would require either a CLIA certificate of registration (certificate type code 9), a CLIA certificate of compliance (certificate type code 1), or a CLIA certificate of accreditation (certificate type code 3). A facility without a valid current CLIA certificate, with a current CLIA certificate of waiver (certificate type code 2), or with a current CLIA certificate for provider-performed microscopy procedures (certificate type code 4) must not be permitted to bill for these tests.
Article - Billing and Coding: Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) (A56737)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) forCardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA).Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the attached 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.Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed.The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, the reason for the tests, an interpretive report and copies of images. The computerized image reconstruction data should also be maintained.Documentation must be available to Medicare upon request.
Article - Billing and Coding: Cardiovascular Nuclear Medicine (A56743)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Cardiovascular Nuclear 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. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within this 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.Medical records must substantiate the medical necessity of the services, including a clinical diagnosis and the specific reason for the study.All segments of the service must have a formal interpretation and report.The referral order must include the medical indication for the study, and be kept on file in the patient's medical record.When CPT code 78472 and add-on code 78496 are submitted with perfusion codes 78451-78454, the formal reports must document that simultaneous cardiac function studies using the first pass technique were performed and that the laboratories are equipped to perform such studies.When a blood pool scan is performed to assess ejection fraction prior to implantation of defibrillator or biventricular pacemaker, the record must document the intended plan for insertion and the result of the test.When billing for the purchase of radiopharmaceutical(s), a copy of the bill indicating the dosage administered, unit price per dose, name and total charge of the radiopharmaceutical must be on file in the patient's medical record and available on request.Utilization Guidelines:Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the past two years would be reimbursable; otherwise tests repeated in the absence of changes in cardiac signs or symptoms will be considered not medically necessary.
Article - Billing and Coding: Intravesical Instillation of Bacillus Calmette-Guérin (BCG) (A56754)

CMS National Coverage PolicyN/AArticle TextDue to the current shortage of Bacillus Calmette-Gurin (BCG) for intravesical instillation it may be necessary to maintain ongoing treatment for bladder cancer with this product at less than the Food and Drug Administration (FDA) label dose of 81 mg (1 vial) per instillation. In response to this situation, Centers for Medicare and Medicaid Services (CMS) has created a new HCPCS code by which to report BCG which will allow for reporting of doses less than 1 vial per instillation. HCPCS code J9030BCG live intravesical instillation, 1 mgbecomes effective 7/1/2019 and replaces HCPCS code J9031BCG intravesical per instillation. HCPCS code J9031BCG intravesical per instillationwill no longer be payable by Medicare as of 7/1/2019. HCPCS code J9030 should be reported with the number of units corresponding to the units being equal to the number of milligrams actually instilled per treatment, as the unit equals 1 mg for the new code.For updates on the current shortage of BCG live intravesical:https://www.ashp.org/Drug-Shortages/Current-Shortages
Article - Billing and Coding: Home Health - Psychiatric Care (A56756)

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 10, 40.2 HH PPS ClaimsCMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, 6.2.4 Coding and 6.2.7 Medical Review of Home Health Demand BillsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Home Health - Psychiatric Care L34561.Diagnostic CriteriaA Patient must have a diagnosis as defined in the Diagnostic and Statistical Manual of Mental Health Disorders, 5th Edition, DSM-5. This diagnosis must match the diagnosis that the ordering physician is treating and/or for which the patient was hospitalized. This diagnosis must be fully documented and available in the medical record.The DSM-5 has combined Axis III with Axes I and II. Clinicians should continue to list medical conditions that are important to the understanding or management of an individual's mental disorder as opposed to personality disorders, mental retardation, general medical conditions, psychosocial and environmental problems and global assessment of functioning.Billing When Separate Visits Were Made for Medical and Psychiatric Nursing CarePsychiatric nursing care is not separately billable from non-psychiatric nursing care. Both of these services constitute skilled nursing care and may be furnished by the psychiatric nurse, in the course of a single visit. Therefore, visits will not be covered for 1 nurse to provide psychiatric nursing care and another to provide non-psychiatric nursing care, unless the non-psychiatric nursing care is of such a highly specialized and technical nature, that the service could not be safely rendered by the psychiatric nurse (e.g., infusion therapy).
Article - Billing and Coding: Heavy Metal Testing (A56767)

CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Heavy Metal Testing.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Article - Billing and Coding: Somatosensory Testing (A56769)

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. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic TestsCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10.4 ICD Procedure Codes, 10.5 Coding for Outpatient Services and Physician Offices, 10.6 Relationship of Diagnosis Codes and Date of Service and 20 Description of Healthcare Common Procedure Coding SystemArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Somatosensory Testing L34433.
Article - Billing and Coding: Special Electroencephalography (A56771)

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) for Special Electroencephalography L33447.Ambulatory electroencephalography (EEG) should always be preceded by a routine EEG. A routine EEG is described by Current Procedural Terminology (CPT) codes 95812, 95813, 95816, 95819 or 95822 and refers to a routine EEG recording of less than a 24-hour continuous duration.A routine resting(EEG) (as described by CPTcodes 95812, 95813, 95816, 95819 or 95822) must be performed prior to performing an ambulatory continuous EEG. A claim for the routine EEG must have been submitted to Medicare with a date of service (DOS) within 1 year of the DOS of the ambulatory EEG.The CPTcodes contained in this article are the codes that describe the services covered per the LCD language. Claims billed with EEG services represented by CPTcodes not contained in this article require the submission of documentation and will be reviewed on a claim-by-claim basis. Note that the codes for these services now have separate coding for the professional and the technical components. Providers should bill only the component of the service which they have provided.