evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Neoplasm of unspecified behavior of brain  D49.7  Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system  I80.8  Phlebitis and thrombophlebitis of other sites  M70.80  Other soft tissue disorders related to use, overuse and pressure of unspecified site M70.88  Other soft tissue disorders related to use, overuse and pressure other site  M70.89  Other soft tissue disorders related to use, overuse and pressure multiple sites  M79.5  Residual foreign body in soft tissue  M79.81  Nontraumatic hematoma of soft tissue  M79.89  Other specified soft tissue disorders  N60.01  Solitary cyst of right breast  N60.02  Solitary cyst of left breast  N60.11  Diffuse cystic mastopathy of right breast  N60.12  Diffuse cystic mastopathy of left breast  N60.21  Fibroadenosis of right breast  N60.22  Fibroadenosis of left breast  N60.31  Fibrosclerosis of right breast  N60.32  Fibrosclerosis of left breast  N60.41  Mammary duct ectasia of right breast  N60.42  Mammary duct ectasia of left breast  N60.81  Other benign mammary dysplasias of right breast  N60.82  Other benign mammary dysplasias of left breast  N61.0  Mastitis without abscess  N61.1  Abscess of the breast and nipple  N61.21  Granulomatous mastitis, right breast  N61.22  Granulomatous mastitis, left breast  N61.23  Granulomatous mastitis, bilateral breast  N62 Hypertrophy of breast  N63.11  Unspecified lump in right breast, upper outer quadrant  N63.12  Unspecified lump in right breast, upper inner quadrant  N63.13  Unspecified lump in right breast, lower outer quadrant  N63.14  Unspecified lump in right breast, lower inner quadrant  N63.15  Unspecified lump in right breast, overlapping quadrants  N63.21  Unspecified lump in the left breast, upper outer quadrant  N63.22  Unspecified lump in left breast, upper inner quadrant  N63.23  Unspecified lump in left breast, lower outer quadrant  N63.24  Unspecified lump in left breast, lower inner quadrant  N63.25
(Medicare Claims Processing Manual)
upper outer quadrant  N63.22  Unspecified lump in left breast, upper inner quadrant  N63.23  Unspecified lump in left breast, lower outer quadrant  N63.24  Unspecified lump in left breast, lower inner quadrant  N63.25  Unspecified lump in left breast, overlapping quadrants  N63.31  Unspecified lump in axillary tail of the right breast  N63.32  Unspecified lump in axillary tail of the left breast  N63.41  Unspecified lump in right breast, subareolar  N63.42  Unspecified lump in left breast, subareolar  N64.0  Fissure and fistula of nipple  N64.1  Fat necrosis of breast  N64.2  Atrophy of breast  N64.3  Galactorrhea not associated with childbirth  N64.4  Mastodynia  N64.51  Induration of breast  N64.52  Nipple discharge  N64.53  Retraction of nipple  N64.59  Other signs and symptoms in breast  N64.81  Ptosis of breast  N64.82  Hypoplasia of breast  N64.89  Other specified disorders of breast  N64.9  Disorder of breast, unspecified  N65.0  Deformity of reconstructed breast  N65.1  Disproportion of reconstructed breast  R59.0  Localized enlarged lymph nodes  R59.1  Generalized enlarged lymph nodes  R59.9  Enlarged lymph nodes, unspecified  R92.0  Mammographic microcalcification found on diagnostic imaging of breast  R92.1  Mammographic calcification found on diagnostic imaging of breast  R92.2  Inconclusive mammogram  R92.30  Dense breasts, unspecified  R92.311  Mammographic fatty tissue density, right breast  R92.312  Mammographic fatty tissue density, left breast  R92.313  Mammographic fatty tissue density, bilateral breasts  R92.321  Mammographic fibroglandular density, right breast  R92.322  Mammographic fibroglandular density, left breast  R92.323  Mammographic fibroglandular density, bilateral breasts  R92.331  Mammographic heterogeneous density, right breast  R92.332  Mammographic heterogeneous density, left breast  R92.333  Mammographic heterogeneous density, bilateral breasts  R92.341  Mammographic extreme density, right
(Medicare Claims Processing Manual)
density, right breast  R92.332  Mammographic heterogeneous density, left breast  R92.333  Mammographic heterogeneous density, bilateral breasts  R92.341  Mammographic extreme density, right breast  R92.342  Mammographic extreme density, left breast  R92.343  Mammographic extreme density, bilateral breasts  R92.8  Other abnormal and inconclusive findings on diagnostic imaging of breast  R93.9  Diagnostic imaging inconclusive due to excess body fat of patient  S20.01xA  Contusion of right breast, initial encounter  S20.02xA  Contusion of left breast, initial encounter  S21.011A  Laceration without foreign body of right breast, initial encounter  S21.012A  Laceration without foreign body of left breast, initial encounter  S21.021A  Laceration with foreign body of right breast, initial encounter  S21.022A  Laceration with foreign body of left breast, initial encounter  S21.031A  Puncture wound without foreign body of right breast, initial encounter  S21.032A  Puncture wound without foreign body of left breast, initial encounter  S21.041A  Puncture wound with foreign body of right breast, initial encounter  S21.042A  Puncture wound with foreign body of left breast, initial encounter  S21.051A  Open bite of right breast, initial encounter  S21.052A  Open bite of left breast, initial encounter  S28.211A  Complete traumatic amputation of right breast, initial encounter  S28.212A  Complete traumatic amputation of left breast, initial encounter  S28.221A  Partial traumatic amputation of right breast, initial encounter  S28.222A  Partial traumatic amputation of left breast, initial encounter  S29.091A  Other injury of muscle and tendon of front wall of thorax, initial encounter  S29.099A  Other injury of muscle and tendon of unspecified wall of thorax, initial encounter  S29.8xxA  Other specified injuries of thorax, initial encounter  S39.091A  Other injury of muscle, fascia and tendon of abdomen, initial encounter  S39.81xA  Other specified injuries of abdomen, initial encounter  T85.41xA  Breakdown (mechanical) of breast prosthesis and implant, initial encounter  T85.42xA  Displacement of breast prosthesis and implant, initial encounter  T85.43xA
(Medicare Claims Processing Manual)
Other specified injuries of abdomen, initial encounter  T85.41xA  Breakdown (mechanical) of breast prosthesis and implant, initial encounter  T85.42xA  Displacement of breast prosthesis and implant, initial encounter  T85.43xA  Leakage of breast prosthesis and implant, initial encounter  T85.44xA  Capsular contracture of breast implant, initial encounter  T85.49xA  Other mechanical complication of breast prosthesis and implant, initial encounter  T85.79xA  Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter  Z03.89  Encounter for observation for other suspected diseases and conditions ruled out   Z08 Encounter for follow -up examination after completed treatment for malignant neoplasm  Z77.123  Contact with and (suspected) exposure to radon and other naturally occurring radiation  Z77.128  Contact with and (suspected) exposure to other hazards in the physical environment  Z77.9  Other contact with and (suspected) exposures hazardous to health  Z85.3  Personal history of malignant neoplasm of breast  Z85.831  Personal history of malignant neoplasm of soft tissue  Z85.89  Personal history of malignant neoplasm of other organs and systems  Z86.000  Personal history of in -situ neoplasm of breast  Z91.89  Other specified personal risk factors, not elsewhere classified  Z92.89  Personal history of other medical treatment  Z98.82  Breast implant status  Z98.86  Personal history of breast implant removal
(Medicare Claims Processing Manual)
20.2.1 - Digital Breast Tomosynthesis  (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) A. Screening Breast Tomosynthesis  Effective for claims with dates of service January 1, 2017 through December 31, 2017, HCPCS code 77063, Screening Digital Breast Tomosynthesis, bilateral, must be billed in conjunction with the primary service mammogram code G0202. Effective for claims wi th dates of service January 1, 2018 and later HCPCS code 77063, Screening Digital Breast Tomosynthesis, bilateral, must be billed in conjunction with the primary service mammogram code 77067.
(Medicare Claims Processing Manual)
A/B MACs (A) and (B) must assure that claims containing code 77063 also contain HCPCS code 77067* (G0202*).  A/B MACs (A) return claims containing code 77063 that do not also contain HCPCS code 77067* (G0202*)with an explanation that payment for code 77063 cannot be made when billed alone.  A/B MACs (B) deny payment for 77063 when billed without 77067* (G0202*).  NOTE:  When screening digital breast tomosynthesis, code  77063, is billed in conjunction with a screening mammography, code 77067* (G0202*), and the screening mammography 77067* (G0202*) fails the age and frequency edits in CWF, both services will be rejected by CWF.  B. Diagnostic Breast Tomosynthesis  Effective with claims with dates of service January 1, 2017 through December 31, 2017 HCPCS code G0279, Diagnostic digital breast tomosynthesis, unilateral or bilateral, must be billed in conjunction with the primary service mammogram code G0204 or G0206.  Effective with claims with dates of service January 1, 2018 and later, HCPCS code G0279, Diagnostic digital breast tomosynthesis, unilateral or bilateral, must be billed in conjunction with the primary service mammogram code 77065 or 77066.Effective f or claims with dates of service January 1, 2017 through December 31, 2017 A/B MACs (A) and (B) must assure that claims containing code G0279 also contain HCPCS code G0204 or G0206.  A/B MACs (A) or (B) deny claims containing code G0279 that do not also contain HCPCS code G0202 or G0206 with an explanation that payment for code G0279 cannot be made when billed alone.  Effective for claims with dates of service January 1, 2018 and later A/B MACs (A) and (B) must assure that claims containing code G0279 also c ontain HCPCS code 77065 or 77066.  A/B MACs (A) or
(Medicare Claims Processing Manual)
1, 2018 and later A/B MACs (A) and (B) must assure that claims containing code G0279 also c ontain HCPCS code 77065 or 77066.  A/B MACs (A) or (B) deny claims containing code G0279 that do not also contain HCPCS code 77065 or 77066 with an explanation that payment for code G0279 cannot be made when billed alone.   Claims for diagnostic breast tomosynthesis, HCPCS code G0279, submitted with a revenue code other than 0401, 096X, 097X, or 098X will be return to providers.   Claims for diagnostic breast tomosynthesis, HCPCS code G0279, submitted with a TOB other than 12X, 13X, 22X, 23X, or 85X will be return to providers.
(Medicare Claims Processing Manual)
20.2.2 - Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18)  When denying claim lines for HCPCS code 77063 that are not submitted with the diagnosis code V76.11 or V76.12, the contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CAR C/RARC combination is compliant with CAQH CORE Business Scenario Three.   CARC: 167  RARC: N386  MSN: 14.9 Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is received with a GA modifier indicating a signed ABN is on file).  Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file). When denying claim lines for HCPCS code G0279 that are not submitted with HCPCS 77066 or 77065   20.3 - Payment  (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) There is no Part B deductible or coinsurance for screening mammographies.  The anti -markup payment limitation on physician billing for diagnostic tests does not apply to these services.  Following are three categories of billing for mammography services:   Professional component of mammography services (that is the physicians interpretation of the results of the examination);   Technical component (all other services); or    Both professional and technical components (global).  However, global billing is not permitted for services furnished in provider outpatient departments, except for CAHs electing the optional method of payment for mammography services furnished on or after  January 1, 2002.
(Medicare Claims Processing Manual)
20.3.1 - Payment for Screening Mammography Services Provided On and After January 1, 2002  (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) The payment limitation methodology does not apply to claims with dates of service on or after January 1, 2002.  A/B MAC (A) Claims  For claims with dates of service on or after January 1, 2002, 104 of the Benefits Improvement and Protection Act (BIPA) 2000, provides for payment of screening mammography under the Medicare physician fee schedule (MPFS) when furnished in hospitals, skill ed nursing facilities (SNFs), and CAHs not electing the optional method of payment for outpatient services.  However, payment under the physician fee schedule is not applicable to hospitals subject to the Outpatient Prospective Payment System (OPPS) until April 1, 2002.  The payment for code 77067* is equal to the lower of:   The actual charge or    Locality specific technical component payment amount under the MPFS.  Part B deductible and coinsurance does not apply.  This is a final payment.  A/B MACs (A) use the benefit -pricing file provided by CMS to pay mammography codes.  Payment for the add- on code 76085 is made under the Medicare Physician Fee Schedule.  Deductible does not apply, however, coinsurance is applicable.  *For  claims with dates of service prior to January 1, 2007, providers report CPT code 76092.  For claims with dates of service January 1, 2007 and later, providers report CPT code 77057.  A/B MACs (B) Claims  Physicians and suppliers are paid by the A/B MACs (B) for all mammography tests (including screening mammography) under the MPFS.  Separate prices for the technical component, the professional component and the global service are included on the MPFS.  The Medicare allowed charge is the lower of:   The actual charge, or
(Medicare Claims Processing Manual)
The Medicare allowed charge is the lower of:   The actual charge, or    The MPFS amount for the service billed. The Medicare payment for the service is 80 percent of the allowed charge.  Coinsurance is 20 percent of the lower of the actual charge or the MPFS amount.  Part B deductible is waived and does not apply to screening mammography. As with other MPFS services, the nonparticipating provider reduction and the limiting charge provisions apply to all mammography tests (including screening mammography).   20.3.1.1 - Outpatient Hospital Mammography Payment Table  (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) Payment for screening mammography in the Hospital Outpatient Setting (Revenue code 403) is the lesser of charge, or TC of MPFS for code 77067* (G0202*). Neither  deductible nor a coinsurance applies.   Payment for diagnostic mammography, bilateral in the Hospital Outpatient Setting (Revenue code 401) is the lesser of charge, or TC of MPFS for code 77066* (G0204*).   Payment for diagnostic mammography, unilateral in the Hospital Outpatient Setting (Revenue code 401) is the lesser of charge, or TC of MPFS for code 77065* (G0206*).  Deductible and coinsurance apply.  Beginning January 1, 2005, Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, 644, Public Law 108- 173 has changed the way Medicare pays for diagnostic mammography.  Medicare payment will be based on the MPFS.  Payment will no longer be made under the OPPS.
(Medicare Claims Processing Manual)
20.3.1.2 - Critical Access Hospital Payment  (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) Payment to a CAH for screening mammography is not subject to applicable Part B deductible, but coinsurance does apply.  Any deductible or coinsurance collected is deducted from the payment. A.  Under the Optional (All Inclusive) Method Section 403(d) of the BBRA amended 1834(g)  of the Act to permit a CAH to elect an optional method of payment for outpatient services.  This option is effective for cost reporting periods beginning on or after October 1, 2001.  A CAH may elect to be paid for outpatient services by reasonable costs for facility services and 202 of BIPA allows an amount equal to 115 percent of the allowed amount for professional component.  (Costs related to professional services are excluded from the cost payment.)  CAHs electing the optional method of reimbursement bill the A/B MAC (A) with type of bill 85X, revenue code 0403 and HCPCS code 77067* (G0202*).  They also include the professional component on a separate line, with revenue code 96X, 97X, or 98X and HCPCS code 77067* (G0202*).  B. Under the Standard Method CAHs reimbursed on the standard method of payment bill the technical component of a screening mammography to the A/B MAC (A) on type of bill 85X, revenue code 0403 and HCPCS code 77067* (G0202*).  Professional services are billed to the A/B MAC (B) and paid based on the fee schedule by the A/B MAC (B).  For claims with dates of service on or after January 1, 2002, 104 of the Benefits Improvement and Protection Act (BIPA) 2000, provides for payment of screening mammographies under the Medicare physician fee schedule (MPFS) in CAHs not electing the optiona l method of payment for outpatient services.  20.3.1.2.1 - CAH Screening Mammography Payment Table  (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01-
(Medicare Claims Processing Manual)
payment for outpatient services.  20.3.1.2.1 - CAH Screening Mammography Payment Table  (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) Payment for Screening Mammography in the Critical Access Hospital Outpatient Setting  Method 1 (Standard)
(Medicare Claims Processing Manual)
TOB  Rev Code  HCPCS  Payment  Services on or after January 1 2002 Technical Component  Deductible does not apply. Coinsurance based on charge.  85X 403 77067* (G0202)*  A/B MAC (A) payment is 80% of the lower of the charge or the fee schedule amount. Professional Component  Deductible does not apply. Coinsurance based on lower of MPFS or charge.     77067* (G0202)*  A/B MACs (B) payment is 80% of the lower of the charge or MPFS amount for the technical component.  The new A3 states payment for 76092 is lower of charge or locality specific TECHNICAL component amount under MPFS.   Method 2 (Optional Method) -  Option available with cost reporting periods starting on or after October 1, 2001 and dates of service on or after July 1, 2001.   TOB  Rev Code  HCPCS  Payment  Services on or after January 1 2002 Technical Component  Deductible does not apply. Coinsurance based on charge.  85X 403 77067* (G0202)*  A/B MAC (A) payment is 80% of the lower of the charge or the fee schedule amount. Professional Component  Deductible does not apply. Coinsurance based on lower of MPFS or charge.  85X 96X, 97X, or 98X  77067* (G0202*)  A/B MAC (A) pays 115% of 80% (that is 92%) of the lower of the charge or the MPFS amount.  20.3.1.3 - SNF Mammography Payment
(Medicare Claims Processing Manual)
20.3.1.3 - SNF Mammography Payment   (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) Payment for screening mammography in a SNF is equal to the lower of:  charge, or TC of MPFS for code 77067.   No deductible, coinsurance applies.   Payment for diagnostic mammography, bilateral in a SNF is equal to the lower of: charge, or TC of MPFS for code 77066* (G0204*).   Deductible and coinsurance apply.  Payment for diagnostic mammography, unilateral in a SNF is equal to the lower of: charge, or TC of MPFS for code 77065* (G0206*).   Deductible and coinsurance apply.   20.3.1.4 - Independent Diagnostic Testing Facility (IDTF) Mammography Payment  (Rev. 4071, Issued: 06- 08-18, Issued: 07- 09-18, Implementation: 07- 09-18)  If an IDTF furnishes any type of mammography service (Screening or  diagnostic), it must have a Food and Drug Administration (FDA) certification to perform such services. An entity that only performs diagnostic mammography service should not be enrolled as an IDTF.  Screening mammographies (including those that are self -referred) are payable by Medicare when performed in and by an IDTF entity.  For additional information, refer to 100- 04  Medicare Claims Processing Manual, Chapter 35 Independent Diagnostic Testing Facility, Section 10.2  Claims Processing.
(Medicare Claims Processing Manual)
20.4 - Billing Requirements - A/B MAC (A)  Claims (Rev.  3844, Issued: 08- 18-17, Effective: 01 -01-18, Implementation: 01- 02-18) A/B MACs use the weekly -updated MQSA file to verify that the billing facility is certified by the FDA to perform mammography services, and has the appropriate certification to perform the type of mammogram billed (film and/or digital).  (See 20.1.)  A/B M ACs (A) use the provider number submitted on the claim to identify the facility and use the MQSA data file to verify the facilitys certification(s).  A/B MAC (A) complete the following activities in processing mammography claims:   If the provider number on the claim does not correspond with a certified mammography facility on the MQSA file, then A/B MACs (A) deny the claim.    When a film mammography HCPCS code is on a claim, the claim is checked for a 1 film indicator.    If a film mammography HCPCS code comes in on a claim and the facility is certified for film mammography, the claim is paid if all other relevant Medicare criteria are met.    If a film mammography HCPCS code is on a claim and the facility is certified for digital mammography only, the claim is denied.   When a digital mammography HCPCS code is on a claim, the claim is checked for 2 digital indicator.    If a digital mammography HCPCS code is on a claim and the facility is certified for digital mammography, the claim is paid if all other relevant Medicare criteria are met.    If a digital mammography HCPCS code is on a claim and the facility is certified for film mammography only, the claim is denied.