evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Somatosensory Testing (A57597)
Therefore, if authorized by state law Physical Therapists are allowed the technical portion of the test.Nurse practitioners, clinical nurse specialists, and physician assistants are not defined as physicians under 1861(r) of the Act. Therefore, they may not function as supervisory physicians under the diagnostic tests benefit (1861(s)(3) of the Act). However, when these practitioners personally perform diagnostic tests as provided under 1861(s)(2)(K) of the Act, 1861(s)(3) does not apply and they may perform diagnostic tests pursuant to State scope of practice laws and under the applicable State requirements for physician supervision or collaboration. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15: Section 80: Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests).CMS Publication 100-08,Program Integrity Manual, Chapter 13, Section 5.4 outlines thatreasonable and necessary services are ordered and/or furnished by qualified personnel.Provision of interpretation and/or supervision of these tests will be considered medically reasonable and necessary only if performed by appropriately trained providers. Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty, certification by a nationally recognized organization, or by an accredited post-graduate training course covering anatomy, neurophysiology and forms of electrodiagnostics (including both NCS and EMG). If this skill has been acquired as continuing medical education, the courses must be comprehensive, offered, sponsored, or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States, and designated by the American Medical Association (AMA) or the American Osteopathic Association (AOA) as Category 1 Credit. Documentation of training must be available upon request.It is expected that the training and experience would include:
Article - Billing and Coding: Somatosensory Testing (A57597)
existing knowledge of the anatomic structures and neurophysiologic events underlying the generation of evoked potentials;the influences of stimulus parameters and other experimental variables on the responses that are recorded;relevant normative data and statistics; andthe clinical significance and pathologic correlates of dysfunctional neural pathways demonstrated by evoked potential alterations.CMS long-standing policy that the concept of physician supervision does not apply (PSI of 09) to these PT-designated diagnostic services, which allows payment to be made for the PC or global code to the ABPTS-PT, excepted by regulation, as long as it is legal for the ABPTS-PT to provide the service in that state, and the TC has been either personally performed by the ABPTS-PT or the PT without the ABPTS certification has met the supervision requirements for the technical component portion of the service consistent with the applicable supervision indicator.Documentations RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within this Article and related LCD. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Medical record documentation maintained by the performing provider must clearly indicate the medical necessity of the service being billed. There should be evidence in the medical record that the test results were noted and influenced or contributed to the patients course of treatment. In addition, documentation that the service was performed must be included in the patients medical record. This documentation should include a hard copy computer generated recording of the test results along with the providers interpretation. The providers SEP report should note which nerves were tested, latencies at various testing points, and an evaluation of whether the resulting values are normal or abnormal. This information is normally found in the office/progress notes, hospital records, and/or procedure notes.If the provider of somatosensory testing is other than the ordering or referring physician or nonphysician practitioner, the provider of the service must maintain a copy of the test results and interpretation, along with copies of the ordering/referring physician/nonphysician practitioners order for the studies.Providers of interpretations, supervision, and performance of the technical portions of the studies must be capable of demonstrating documented training and experience for post-payment audit.
Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) (A57598)
CMS National Coverage PolicySocial Security Act:1862 (a) (1)(A) Medically Reasonable & Necessary.1862 (a) (1)(D) & (E) Investigational or Experimental.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 L34641 Transcranial Magnetic Stimulation (TMS).Documentation RequirementsAll documentation must be maintained in the patients medical record and available to the contractor upon request. The medical record documentation must support the medical necessity of the services as directed in this policy.The attending physician must monitor and document the patient's clinical progress during treatment. The attending physician must use evidence-based validated depression monitoring scales such as the Geriatric Depression Scale (GDS), the Personal Health Questionnaire Depression Scale (PHQ-9), the Beck DepressionInventory (BDI), Hamilton Rating Scale for Depression (HAM-D), the Montgomery Asberg Depression Rating Scale (MADRS), the Quick Inventory of Depressive Symptomatology (QIDS) or the Inventory for Depressive Symptomatology Systems Review (IDS-SR) to monitor treatment response and the achievement of remission of symptoms.Utilization GuidelinesThe treatment must be provided by use of a device approved by the FDA for the purpose of supplying TMS.It is expected that the services would be performed as indicated by current medical literature and standards of practice. Services performed in excess of established parameters may be subject to review for medical necessity.TMS is reasonable and necessary for up to 20 visits over a 4-week period followed by five visits for tapering for those in remission; for those who show at least a 25% improvement by means of the standard tests for depression, the therapy may be continued for an additional 2 weeks (an additional 10 visits) with an additional 6 visits for tapering.Retreatment may be considered for patients who met the guidelines for initial treatment and subsequently developed relapse of depressive symptoms if the patient responded to prior treatments as evidenced by a greater than 50% improvement in standard rating scale measurements for depressive symptoms or if there were a relapse after remission (e.g., GDS, PHQ-9, BDI, HAM-D, MADRS, QIDS or IDS-SR score.) A repeat treatment program is allowed as above.
Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) (A57598)
Maintenance therapy is considered experimental/investigational and therefore not medically necessary.
Article - Billing and Coding: Visual Electrophysiology Testing (A57599)
CMS National Coverage PolicyTitle XVIII of the Social Security Act Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act 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.Code of Federal Regulations 42 CFR Section 410.32 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 another qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).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 RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See Coverage Indications, Limitations, and/or Medical Necessity") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available to the MAC upon request.
Article - Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (A57600)
CMS National Coverage PolicyInternet Only Manual (IOM) Citations:CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 23 Fee Schedule Administration and Coding Requirements, Section 10 Reporting ICD Diagnosis and Procedure codes and Section 20.9 National Correct Coding Initiative (NCCI)National Correct Coding Initiative (NCCI) Citation:NCCI Policy Manual for Medicare Services,Chapter XI Medicare Evaluation and Management Services CPT Codes 90000-99999, Section G, Ophthalmology.Social 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) L35038, Scanning Computerized Ophthalmic Diagnostic Imaging. Please refer to the LCD for reasonable and necessary requirements and limitations.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.Utilization ParametersOne month is defined as 28 days. No more than one (1) exam per month will be considered medically reasonable and necessary to manage the patient with retinal conditions undergoing active treatment.CPT code 92132 and 92133 may not be reported more than two (2) times per year. Please refer to the LCD for details on reasonable and necessary guidelines.CPT code 92134 may not be reported more than one (1) time every two (2) months. Please refer to the LCD for details on reasonable and necessary guidelines.Documentation Requirements
Article - Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (A57600)
CPT code 92134 may not be reported more than one (1) time every two (2) months. Please refer to the LCD for details on reasonable and necessary guidelines.Documentation RequirementsAll 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 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: Intraoperative Neurophysiological Testing (A57604)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.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 L34623 Intraoperative Neurophysiological Testing.Documentation RequirementsAll documentation must be maintained in the patients medical record and available to the contractor upon request.Every page of the medical record must be legible and include appropriate patient identification information (e.g. complete name, dates of service). The record must include the physician or non-physician practitioner responsible for providing the care of the patient.The patients medical record should document the time spent in monitoring in correlation to the surgery performed.The submitted medical record should support the use of the selected diagnosis code(s).The submitted CPT/HCPCS code should describe the service performed.Utilization GuidelinesIntraoperative neurophysiology monitoring should not be reported by the physician performing the operative procedure since it is included in the global package for the surgery.
Article - Billing and Coding: MolDX: EndoPredict® Breast Cancer Gene Expression Test (A57607)
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, 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 Allowance.CMS 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: EndoPredict Breast Cancer Gene Expression Test.To report an EndoPredictservice, 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 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 formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: EndoPredict® Breast Cancer Gene Expression Test (A57608)
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, 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 Allowance.CMS Internet Online Manual Pub. 100-04,Medicare Claims Processing Manual, Chapter 23 (Section 10) "Reporting ICD Diagnosis and Procedure Codes".Article Texthe 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.To report an EndoPredictservice, 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 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 formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: ProMark® Risk Score (A57609)
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 claimCMS 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).To report a ProMark assay service, please submit the following claim information:Select CPT code 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 837PBox19 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 ICD-10-CM code C61
Article - Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains (A57611)
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 CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Special Histochemical Stains and Immunohistochemical Stains L36351.To report special histochemical stains and/or immunohistochemical stains services, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)
Article - Billing and Coding: Measurement of Salivary Hormones (A57612)
CMS National Coverage PolicyCode of Federal Regulations:42 CFR Sections 410.32(a) & 410.32(a)(3) require that clinical laboratory services be ordered and used promptly by the physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who is treating the beneficiary.42CFR411.15 excludes from coverage examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury with specific legislative enactments as the only exceptions.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual, Chapter 6, 20.4.4 and 20.4.5.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.If requested, chart documentation would show signs, symptoms, or clinical reasons why Cushings syndrome was being tested for.No comments were received for this draft LCD for comment period ending 12/15/2016.
Article - Billing and Coding: Measurement of Salivary Hormones (A57613)
CMS National Coverage PolicyCode of Federal Regulations:42 CFR Sections 410.32(a) & 410.32(a)(3) require that clinical laboratory services be ordered and used promptly by the physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who is treating the beneficiary.42CFR411.15 excludes from coverage examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury with specific legislative enactments as the only exceptions.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual, Chapter 6, 20.4.4 and 20.4.5.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.If requested, chart documentation would show signs, symptoms, or clinical reasons why Cushings syndrome was being tested for.No comments were received for this draft LCD for comment period ending 12/15/2016.
Article - Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains (A57614)
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 CodesArticle TextThe following coding and billing guidance is to be used with its associated Local coverage determination.To report special histochemical stains and/or immunohistochemical stains services, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)
Article - Billing and Coding: Treatment of Males with Low Testosterone (A57615)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.42 Code of Federal Regulations (CFR) 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.CMS Internet Online Manual Pub. 100-02 (Medicare Benefit Policy Manual), Chapter 15, Section 80, Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic TestsCMS 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 Allowance.CMS Internet Online Manual Pub. 100-04 (Medicare Claims Processing Manual), Chapter 23 (Section 10) Reporting ICD Diagnosis and Procedure Codes.CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 12, 30-Correct Coding PolicyArticle TextThe following coding and billing guidance is to be used with its associated Local coverage determination.