evekhm/cms_iom_3000 huggingface dataset:
Article - Billing and Coding: MolDX: Prometheus IBD sgi Diagnostic Policy (A57517)

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 Manuals, Publication 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 Online Manual Pub. 100-04 (Medicare Claims Processing Manual), Chapter 23 (Section 10) "Reporting ICD Diagnosis and Procedure Codes"Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.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 UB 04
Article - Billing and Coding: MolDX: Immunohistochemistry (IHC) Indications for Breast Pathology (A57523)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Article TextBased on recommendations from the College of American Pathologists, the American Society of Clinical Oncologists (ASCO), and the National Comprehensive Cancer Network (NCCN), hormone receptor assays, estrogen receptor (ER), progesterone receptor (PR), and Her-2/neu are the only current biomarkers that demonstrate standardized value in breast cancer pathology evaluation. Although other biomarkers, such as Ki-67, PI3K, and gene expression assays, have been studied, no proven standardized value has been established. Therefore, MolDX will allow ER, PR, and Her2 testing by IHC for patients with primary invasive breast cancers and recurrent or metastatic cancers.To report an IHC service for an ER, PR, Her2, submit the following claim information:CPT CodeSpecimenUOS88342First single/multiplex stain188341Each additional2To report morphometric analysis,select oneof the following codes based on the type of morphometric analysis:CPT CodeService TypeUOS88360Manual388361Computer-assisted3Note: a unit of service applies to a single separately identifiable specimen.
Article - Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) (A57526)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1 Clinical Laboratory ServicesCMS 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) for MolDX: Molecular Diagnostic Tests (MDT) L35160.To report a Molecular Diagnostic Test service, please submit the following claim information:Select appropriate CPTcodeEnter 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 837PItem 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 formNOTE:When entering the DEX Z- Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) (A57527)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1 Clinical Laboratory ServicesCMS 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) for MolDX: Molecular Diagnostic Tests (MDT) L36256.To report a Molecular Diagnostic Test service, please submit the following claim information:Select appropriate CPT codeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier 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-Code identifier 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 formNOTE:When entering the DEX Z- Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: Allergy Testing (A57531)

CMS National Coverage PolicyInternet-Only Manuals (IOMs):CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 12, Section 200 Allergy Testing and ImmunotherapySocial 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) L33261 Allergy 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.Consistent with the related LCD, CPT code 82785 Gammaglobulin [immunoglobulin]; IgE is not appropriate in most general allergy testing. Please refer to the LCD for details on medically reasonable and necessary guidelines.It is not usually necessary to report CPT code 86003 Allergen specific IgE; quantitative or semiquantitative, crude allergen extract (in vitro testing) in addition to skin testing. Please see the related LCD for medically reasonable and necessary guidelines.Documentation Requirements:All 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 medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.Prior to performance of allergy testing, there must be evidence in the medical record that a history has been obtained, indicating the possible presence of allergy.This history should support that attempts to narrow the area of investigation were taken so that the minimal number of necessary skin tests might deliver a diagnosis.The history should support that the selection of antigens was based on the patient specific history and physician examination.The medical record must indicate which allergy test(s) were used, the interpretation(s), and measurement (in mm) of reaction size of both wheal and erythema response or a standardized grading system in vivo testing (as applicable).
Article - Billing and Coding: Autonomic Function Testing (A57551)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833 (e). This section states that no payment shall be made to any provider for any claims that lack necessary information to process the claim.Title XVIII of the Social Security Act section 1862 (a)(1)(A). This section allows coverage and payment of those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act section 1862 (a)(7). This section excludes routine physical examinations and services.CMS Manual System, Pub 100-08,Medicare Program Integrity Manual, Chapter 3, Part 3.2.3 Requesting Addition Documentation During Prepayment and Post-payment review.42 CFR Section 410.32(a) indicates diagnostic tests are payable only when the physician who is treating the beneficiary for a specific medical problem uses the results in such treatment.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD.Documentation RequirementsMedical record documentation maintained by the performing provider must clearly support the medical necessity for ANS testing as well as the test reports and interpretation. Supportive documentation showing medically reasonable and necessary indications as outlined in this LCD are expected to be documented in the medical record and be available upon request. This documentation includes, but is not limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or procedures used to rule out more common causes of autonomic signs or symptoms.General professional standards with FDA clearance apply for all equipment used in ANS testing.Utilization GuidelinesDiagnostic testing may be allowed once to confirm or exclude specific autonomic disease. For patients with diagnosed autonomic disorders, repeat testing is governed by a change in clinical status or response to a therapeutic intervention. If a repeat test is needed, it is not expected to exceed once per year.Providers who perform these tests on an unusually high proportion of their patients, or at frequencies exceeding once per year may be subject to medical review.Providers who do not have tilt tables and are using the code range 95921-95924 may be subject to medical review.
Article - Billing and Coding: Coronary Computed Tomography Angiography (CCTA) (A57552)

CMS National Coverage PolicyItalicized font represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording.Title XVIII of the Social Security Act (SSA):Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1862 (a)(7) excludes routine physical examinations.Code of Federal Regulations: 42 CFR Section 410.32  Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostics tests: Conditions. This indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary.CMS Publications:CMS Publication 100-03,National Coverage Determination Manual, Chapter 1- Coverage Determinations Part 4, 220.1 Computed Tomography (CT)CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 13  Radiology Services and Other Diagnostic Procedures, 20 Payment Conditions for Radiology ServicesArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD Coronary Computed Tomography Angiography (CCTA).
Article - Billing and Coding: Immune Globulins (A57554)

CMS National Coverage PolicyCMS Pub 100-02 Medicare Benefit Policy Manual, Chapter 15  Covered Medical and Other Health Services, Section 50.6  Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency Diseases in the Home.CMS Pub 100-03 Medicare National Coverage Determination (NCD) Manual, Chapter 1, Part 4, Section 250.3  Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases.CMS Pub 100-04 Medicare Claims Processing Manual, Chapter 17  Drugs and Biologicals, Section 80.6  Intravenous Immune Globulin (Change Requests 2149, 3745, 4244, 5635, 5643, and 5981).Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD.Documentation RequirementsMedical records must include the indications to support using IVIG. For those indications stating routine use is not indicated, the medical record must document the interventions that were unsuccessful or the reason they were not tolerated.Documentation must support objective response for continued coverage. Medical Records must be made available to the Contractor upon request.
Article - Billing and Coding: BDX-XL2 (A57558)

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 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, and 60.2 Travel Allowance.CMS Internet-Only Manuals, Pub 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesCMS Internet-Only Manuals, 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 L37216.
Article - Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment (A57559)

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 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 Allowance.CMS 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 L36523.
Article - Billing and Coding: MolDX: Breast Cancer Assay: Prosigna® (A57560)

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 Manuals, 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-Online 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: Prosigna L36811.To report a Prosigna service, please submit the following claim information:Select CPT code 81520Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier 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 formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: Decision Dx-UM (Uveal Melanoma) (A57566)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833(e) prohibits Medicare payment for any claim that lacks the necessary information 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 Laboratories.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 Allowance.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23 10 Reporting ICD Diagnosis and Procedure Codes.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L37210, MolDX: Decision Dx-UM (Uveal Melanoma).To report a DecisionDx-UM (Uveal Melanoma) service, please submit the following claim information: Select CPT code 81552 Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier 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 837P Box 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types: Line SV202-7 for 837I electronic claim Block 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: EndoPredict® Breast Cancer Gene Expression Test (A57567)

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 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: EndoPredict Breast Cancer Gene Expression Test L37663.To report an EndoPredict service, please submit the following claim information:Select CPT code 81522Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier 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 formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: Envisia™, Veracyte™, Idiopathic Pulmonary Fibrosis Diagnostic Test (A57568)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.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 Manuals, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.12 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS Internet Online Manual Pub. 100-04 (Medicare Claims Processing Manual), Chapter 23 (Section 10) Reporting ICD Diagnosis and Procedure Codes.Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test (L37919).To report an Envisia Genomic Classifier service, please submit the following claim information:Select CPT code 81554Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier 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 formSelect the appropriate ICD-10-CM code