evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Urine Drug Testing (A56818)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 - A/B MAC (B) Contacts with Independent Clinical LaboratoriesArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD L36029 Urine Drug Testing.A qualitative/presumptive drug screen is used to detect the presence of a drug in the body. A blood, urine, or oral fluid sample may be used. However, urine is the best specimen for broad screening, as blood is relatively insensitive for many common drugs, including psychotropic agents, opioids, and stimulants.Common methods of drug analysis include chromatography, immunoassay, chemical ("spot") tests, and spectrometry.Coding GuidelinesOne presumptive drug testing code may be billed once per patient per day as indicated by the code description and should only be billed at one unit regardless of the provider.One definitive drug testing code may be billed once per patient per day as indicated by the code description and should only be billed at one unit regardless of the provider.The documentation should support the medical necessity of the drug testing ordered and should support the clinical indicators that led to ordering the test.Documentation RequirementsAll documentation must be maintained in the patients medical record and 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 record must include the identity of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record should support the use of the selected diagnosis code(s). The submitted CPT/HCPCS code should describe the service performed.Medical record documentation (e.g., history and physical, progress notes) maintained by the ordering physician/treating physician must indicate the medical necessity for performing a drug test. All tests must be ordered in writing by the treating provider and all drugs/drug classes to be tested must be indicated in the order.
Article - Billing and Coding: Urine Drug Testing (A56818)
If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of the lab results, along with copies of the ordering/referring physicians order for the drug test. The physician must include the clinical indication/medical necessity in the order for the drug test.This LCD does not apply to acute inpatient claims.Claims for drug screening services are payable under Medicare Part B in the following places of service: office (11), urgent care (20), independent clinic (49), federally qualified health center (freestanding) (50), rural health clinic (freestanding) (72), and independent laboratory (81).All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.All coverage criteria must be met before Medicare can reimburse this service.Billing for these services in a non-covered situation (e.g., does not meet indications of the LCD) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered.Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item, or procedure may not be covered by Medicare.The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category, or is rendered for screening purposes.
Article - Billing and Coding: Percutaneous Coronary Intervention (A56823)
CMS National Coverage PolicyN/AArticle TextThis article contains and other guidelinesthat complement the Local Coverage Determination (LCD) for Percutaneous Coronary Intervention.National Coverage Provisions:Effective January 1, 2013, all PCI codes 92920-92944include the work of accessing and selectively catheterizing the vessel, traversing the lesion, radiological supervision and interpretation directly related to the intervention(s) performed, closure of the arteriotomy when performed through the access sheath, and imaging performed to document completion of the intervention. These codes include angioplasty (eg, balloon, cutting balloon, wired balloons, cryoplasty), atherectomy (eg, directional, rotational, laser), and stenting (eg, balloon expandable, self-expanding, bare metal, drug eluting, covered.) (AMA CPT 2013, Professional Edition).If a single lesion extends from one target vessel (major coronary artery, coronary artery bypass graft, or coronary artery branch) into another target vessel, but can be revascularized with a single intervention bridging the two vessels, this PCI should be reported with a single code despite treating more than one vessel. For example, if a left main coronary artery and a single stent is placed to treat the entire lesion, this PCI should be reported as a single vessel stent (92928). (AMA CPT 2013, Professional Edition).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: Percutaneous Coronary Intervention (A56823)
Specific Coding Guidelines:The major coronary arteries are the left main (LM), left anterior descending (LD), left circumflex (LC), right (RC), and ramus intermedius (RI) arteries.Claims for percutaneous coronary intervention must report the appropriate modifier(s).All PCI procedures performed in all segments (proximal, mid, distal) of a single major coronary artery through the native coronary circulation are reported with one code. When one segment of a major coronary is treated through the native circulation and treatment of another segment of the same artery requires access through a coronary artery bypass graft, the intervention through the bypass graft is reported separately. (AMA CPT 2013, Professional Edition).Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included withinthe relatedLCD. (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. Claims submitted without ICD-10-CM codes will be returned.Documentation must be in the format of a procedure note. The indications and any unusual clinical circumstances must be stated. Details and results of the intervention must be stated. Angiographic documentation (film or digital) as well as intravascular sonographic recording must be maintained and available on request.The medical record must include documentation of the need for repeat diagnostic angiography when previously performed, in the absence of any new clinical symptoms or signs of disease progression, within the preceding three months.Documentation must be available to Medicare upon request.
Article - Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (A56825)
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) for Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) L34431.SCODI (92133, 92134) and fundus photography (92250) are mutually exclusive codes. However, there may be a limited number of clinical situations in which it is necessary to perform both techniques in order to evaluate and treat the patient. In these situations, both CPT codes may be reported appending modifier 59 to indicate a distinct procedural service. Documentation supportive of the need to perform both techniques should be clear in the medical record.
Article - Billing and Coding: B-type Natriuretic Peptide (BNP) Testing (A56826)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for B-type Natriuretic Peptide (BNP) TestingCoding 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 withinthe related 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. Claims submitted without ICD-10-CM codes will be returned. Documentation must be available to Medicare upon request.Utilization Guidelines:Frequency of testing should be guided by the clinical circumstances and evidence-based literature.
Article - Billing and Coding: Proton Beam Therapy (A56827)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Proton Beam Therapy.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 related 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.Documentation in the patient medical record must:Support one or more medical necessity requirement(s) as provided under the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy.Include a treatment prescription that defines the goals of the treatment plan- including specific dose-volume parameters for the target and nearby critical structures- as well as pertinent details of beam delivery, such as method of beam modulation, field arrangement, and expected positional and range uncertainties.Include a treatment plan, signed by a physician, which meets the prescribed dose-volume parameters for the clinical target volume (CTV) and surrounding organs at risk (OARs) in the presence of expected uncertainties.Describe the target setup verification methodology, including patient positioning, immobilization and use of image guidance.Include verification of planned dose distribution via independent dose calculation or physical measurement.
Article - Billing and Coding: Mohs Micrographic Surgery (A56836)
CMS National Coverage PolicyN/AArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L34195 Mohs Micrographic Surgery.General Guidelines for Claims submitted to Part A or Part B MAC: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: Mohs Micrographic Surgery (A56836)
Advance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.
Article - Billing and Coding: Mohs Micrographic Surgery (A56836)
The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)For claims submitted to the Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC to process their claims.
Article - Billing and Coding: Reduction Mammaplasty (A56837)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Reduction Mammaplasty.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 related 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. Claims submitted without ICD-10-CM codes will be returned.Documentation must be available to Medicare upon request.
Article - Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains (A56838)
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, 60.1.1 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 Lab: Special Histochemical Stains and Immunohistochemical Stains L35922.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: Vitamin D; 25 hydroxy, includes fraction(s), if performed (A56841)
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) L33771 Vitamin D; 25 hydroxy, includes fraction(s), if performed. 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.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.The results of the Vitamin D testing and the resulting treatment regimen must be documented in the patients medical record. This information includes, but is not limited to relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures usually found in hospital/office progress notes and written laboratory reports.
Article - Billing and Coding: RAST Type Tests (A56844)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for RAST Type Tests.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 withinthe relatedLCD. (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. Claims submitted without ICD-10-CM codes will be returned.Documentation must be available to Medicare upon request.Utilization Guidelines:It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.