evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: MRI and CT Scans of the Head and Neck (A57204)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1862(a)(7) excludes routine physical examinations. This provision excludes screening examinations.Title XVIII of the Social Security Act, Section 1862(a)(1)(A) allows coverage and payment for only those services that are considered reasonable and necessary.Title 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)(D) prohibits Medicare payment for services and items that are experimental or investigational.CMS publication 100-3,Medicare National Coverage Determinations, Sections 220.1 Computerized Tomography, and 220.2-220.2.B.2d and Section 220.2.C-220.2.D Magnetic Resonance Imaging.Denies coverageof MRI for:Imaging of cortical bone and calcification;Procedures involving spatial resolution of bone or calcification;MRI is not covered for patients with metallic clips on vascular aneurysmsCMS publication 100-04Medicare ClaimsProcessing Manual Chapter 13 Section 40.Denies coverageof MRI for:Measurement of blood flow and spectroscopyArticle TextThe following coding and billing guidance is to be used with its associated Local Coverage Determination.Documentation GuidelinesDiagnostic evaluation of the head and neck (head/neck scans) performed by computerized tomography (CT) scanners is covered when the documentation supports that the scan is reasonable and necessary. Accurate coding information must be provided with claims to differentiate CT and/or MRI scans from other radiology services and to make coverage determinations. Sufficient documentation such as, history and physical notes, laboratory results, signs and symptoms of the disease to warrant the diagnostic test and to support the claim of reasonable and necessary must be included in the medical records. This information must be available to Medicare upon request.Coding GuidelinesThe HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits in addition to guidance in this LCD. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Whichever guidance is more restrictive should be adhered to.
Article - Billing and Coding: Oximetry Services (A57205)
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) L35434, Oximetry Services. 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.Overnight oximetry should be reported with CPT code 94762.
Article - Billing and Coding: Lumbar MRI (A57206)
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, 1862(a)(7) and 42 Code of Federal Regulations (CFR), 411.15 particular services excluded from coverage.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Title XVIII of the Social Security Act, 1842(p)(1)states that each claim submitted by a physician or practitioner shall include the appropriate diagnosis code (or codes)...". 1842(b)(18)(C) defines a practitioner. For services from physicians and (1842(b)(18)(C)) practitioner submitted with an ICD-10 code that is missing, invalid, or truncated, contractors must return the billed service to the provider as unprocessable in accordance with CR 1910, Transmittal 1728, dated November 1, 2001 (MCM Part 3, Claim Process 3005.4(p)).42 CFR 411.15(k) excludes specific services that are not reasonable and necessary.CMS Manual System, Pub. 100-08,Medicare Program Integrity Manual,Chapter 3, 3.4.1.3, Diagnosis Code Requirement42 CFR 410.32 and 410.33 indicates that diagnostic tests are payable only when ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in such treatment.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 15, 60, 60.1, 60.2, 60.3, 60.4, 60.4.1 and 80 indicate that the technical component of diagnostic tests is not covered as "incident to" physician healthcare services, but under a distinct coverage category and subject to supervision levels found in the Physician Fee Schedule database.
Article - Billing and Coding: Lumbar MRI (A57206)
CMS Manual System, Pub. 100-08,Medicare Program Integrity Manual,Chapter 10, 5-5.7.2 indicates that non-physician owned facilities performing primarily diagnostic tests should be enrolled as IDTFs rather than billing under physician PINs. See also 42 CFR 410.33.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 15, 80.4.1 and 250 govern payment for X-ray services supplied for patients in a Part A stay in a skilled nursing facility, or other facility, including payments under arrangement.CFR 486.100 stipulates that portable X-rays must comply with Federal, State, and local laws and regulations.CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 13, 40, 40.1.4 Magnetic Resonance Imaging (MRI) Procedures and Payment Requirements. Effective January 1, 2017 separate payment for the contrast media and the need to use the appropriate HCPCS Q code (Q9945  Q9954; Q9958-Q9964) for the contrast medium utilized in performing the service. 40 allows beneficiaries with implanted PMs or cardioverter defibrillators (ICDs) for use in an MRI environment in a Medicare approved clinical study. 40.1.4, Medicare will allow for coverage of MRI for beneficiaries with implanted pacemakers (PMs) when the PMs are used according to the Food and Drug Administration (FDA)-approved labeling for use in an MRI environment as described in section 220.2.C.1 of the NCD manual, effective July 7, 2011.CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 13, 100.1 describes how physicians should handle billing when two providers read a diagnostic radiologic procedure.
Article - Billing and Coding: Lumbar MRI (A57206)
CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 13, 100.1 describes how physicians should handle billing when two providers read a diagnostic radiologic procedure.CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 220.2; Magnetic Resonance Imaging (MRI), the contraindications section 220.2.C.1 of the NCD was revised to read that the contraindications will not apply to pacemakers when used according to the FDA-approved labeling in an MRI environment or in clinical trials.CMS publication 100-3,Medicare National Coverage Determinations,Sections 220.1 "Computerized Tomography", and 220.2-220.2.B.2d and Section 220.2.c-220.D "Magnetic Resonance Imaging".Denies Coverageof MRI for:1. Imaging of cortical bone and calcification2. Procedures involving spatial resolution of bone or calcification3. MRI is not covered for patients with metallic clips on vascular aneurysms.CMS publication 100-04 Medicare Claims Processing Manual Chapter 13 Section 40denies coverageof MRI for: Measurement of blood flow and spectroscopyArticle TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation RequirementsSupportive documentation evidencing the condition and treatment is expected to be documented in the medical record and be available upon request.The patients medical record must be legible and clearly indicate the necessity and reasonableness of the service.The documentation must clearly support the ICD-10-CM code(s) reported on the claim.An attending/treating physicians order is required for each test. The order must be properly signed and dated.Lumbar MRI abnormalities alone do not validate the need for the test without other supporting clinical rationale. Radiologists and/or ordering physicians should include sufficient clinical information in the report to justify its necessity.The clinical findings and relevant prior treatment that support the need for the MRI must be documented in the MRI report or clinical record and made available to the contractor upon request.The medical record of the referring physician must support a contemplated diagnosis or treatment change derived from the MRI findings. The contractor may request medical records from the referring physician if the radiologists documentation does not validate that the service is reasonable and necessary.
Article - Billing and Coding: Lumbar MRI (A57206)
According to national regulations, clinics which are (a) not physician owned and which are (b) billing Medicare primarily for diagnostic tests may be required to enroll as IDTFs. For example, a nonphysician owner who establishes a Magnetic Resonance Imaging clinic by leasing office space, equipment, and hiring technicians, and hires a retired ophthalmologist to provide off-site (general) supervision of diagnostic testing without treatment would be more appropriately enrolled as an IDTF rather than merely billing all services through the physician's PIN.Utilization GuidelinesNormally only one lumbar MRI is sufficient to diagnose the patient's condition. However, a second lumbar MRI, for the same patient, may be allowed providing the documentation indicates that comparative test results were needed to make a more definitive treatment decision.Payment will be allowed for multiple scans of different areas of the body performed on the same day for the same patient when reasonable and necessary.
Article - Billing and Coding: Lumbar MRI (A57207)
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, 1862(a)(7) and 42 Code of Federal Regulations (CFR), 411.15 particular services excluded from coverage.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Title XVIII of the Social Security Act, 1842(p)(1)states that each claim submitted by a physician or practitioner shall include the appropriate diagnosis code (or codes)...". 1842(b)(18)(C) defines a practitioner. For services from physicians and (1842(b)(18)(C)) practitioner submitted with an ICD-10 code that is missing, invalid, or truncated, contractors must return the billed service to the provider as unprocessable in accordance with CR 1910, Transmittal 1728, dated November 1, 2001 (MCM Part 3, Claim Process 3005.4(p)).42 CFR 411.15(k) excludes specific services that are not reasonable and necessary.CMS Manual System, Pub. 100-08,Medicare Program Integrity Manual,Chapter 3, 3.4.1.3, Diagnosis Code Requirement42 CFR 410.32 and 410.33 indicates that diagnostic tests are payable only when ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in such treatment.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 15, 60, 60.1, 60.2, 60.3, 60.4, 60.4.1 and 80 indicate that the technical component of diagnostic tests is not covered as "incident to" physician healthcare services, but under a distinct coverage category and subject to supervision levels found in the Physician Fee Schedule database.
Article - Billing and Coding: Lumbar MRI (A57207)
CMS Manual System, Pub. 100-08,Medicare Program Integrity Manual,Chapter 10, 5-5.7.2 indicates that non-physician owned facilities performing primarily diagnostic tests should be enrolled as IDTFs rather than billing under physician PINs. See also 42 CFR 410.33.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 15, 80.4.1 and 250 govern payment for X-ray services supplied for patients in a Part A stay in a skilled nursing facility, or other facility, including payments under arrangement.CFR 486.100 stipulates that portable X-rays must comply with Federal, State, and local laws and regulations.CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 13, 40, 40.1.4 Magnetic Resonance Imaging (MRI) Procedures and Payment Requirements. Effective January 1, 2017 separate payment for the contrast media and the need to use the appropriate HCPCS Q code (Q9945  Q9954; Q9958-Q9964) for the contrast medium utilized in performing the service. 40 allows beneficiaries with implanted PMs or cardioverter defibrillators (ICDs) for use in an MRI environment in a Medicare approved clinical study. 40.1.4, Medicare will allow for coverage of MRI for beneficiaries with implanted pacemakers (PMs) when the PMs are used according to the Food and Drug Administration (FDA)-approved labeling for use in an MRI environment as described in section 220.2.C.1 of the NCD manual, effective July 7, 2011.CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 13, 100.1 describes how physicians should handle billing when two providers read a diagnostic radiologic procedure.
Article - Billing and Coding: Lumbar MRI (A57207)
CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 13, 100.1 describes how physicians should handle billing when two providers read a diagnostic radiologic procedure.CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 220.2; Magnetic Resonance Imaging (MRI), the contraindications section 220.2.C.1 of the NCD was revised to read that the contraindications will not apply to pacemakers when used according to the FDA-approved labeling in an MRI environment or in clinical trials.CMS publication 100-3,Medicare National Coverage Determinations,Sections 220.1 "Computerized Tomography", and 220.2-220.2.B.2d and Section 220.2.c-220.D "Magnetic Resonance Imaging".Denies Coverageof MRI for:1. Imaging of cortical bone and calcification2. Procedures involving spatial resolution of bone or calcification3. MRI is not covered for patients with metallic clips on vascular aneurysms.CMS publication 100-04 Medicare Claims Processing Manual Chapter 13 Section 40denies coverageof MRI for: Measurement of blood flow and spectroscopyArticle TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation RequirementsSupportive documentation evidencing the condition and treatment is expected to be documented in the medical record and be available upon request.The patients medical record must be legible and clearly indicate the necessity and reasonableness of the service.The documentation must clearly support the ICD-10-CM code(s) reported on the claim.An attending/treating physicians order is required for each test. The order must be properly signed and dated.Lumbar MRI abnormalities alone do not validate the need for the test without other supporting clinical rationale. Radiologists and/or ordering physicians should include sufficient clinical information in the report to justify its necessity.The clinical findings and relevant prior treatment that support the need for the MRI must be documented in the MRI report or clinical record and made available to the contractor upon request.The medical record of the referring physician must support a contemplated diagnosis or treatment change derived from the MRI findings. The contractor may request medical records from the referring physician if the radiologists documentation does not validate that the service is reasonable and necessary.
Article - Billing and Coding: Lumbar MRI (A57207)
According to national regulations, clinics which are (a) not physician owned and which are (b) billing Medicare primarily for diagnostic tests may be required to enroll as IDTFs. For example, a nonphysician owner who establishes a Magnetic Resonance Imaging clinic by leasing office space, equipment, and hiring technicians, and hires a retired ophthalmologist to provide off-site (general) supervision of diagnostic testing without treatment would be more appropriately enrolled as an IDTF rather than merely billing all services through the physician's PIN.Utilization GuidelinesNormally only one lumbar MRI is sufficient to diagnose the patient's condition. However, a second lumbar MRI, for the same patient, may be allowed providing the documentation indicates that comparative test results were needed to make a more definitive treatment decision.Payment will be allowed for multiple scans of different areas of the body performed on the same day for the same patient when reasonable and necessary.
Article - Billing and Coding: MRI and CT Scans of the Head and Neck (A57215)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1862(a)(7) excludes routine physical examinations. This provision excludes screening examinations.Title XVIII of the Social Security Act, Section 1862(a)(1)(A) allows coverage and payment for only those services that are considered reasonable and necessary.Title 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)(D) prohibits Medicare payment for services and items that are experimental or investigational.CMS publication 100-3,Medicare National Coverage Determinations, Sections 220.1 Computerized Tomography, and 220.2-220.2.B.2d and Section 220.2.C-220.2.D Magnetic Resonance Imaging.Denies coverageof MRI for:Imaging of cortical bone and calcification;Procedures involving spatial resolution of bone or calcification;MRI is not covered for patients with metallic clips on vascular aneurysmsCMS publication 100-04Medicare ClaimsProcessing Manual Chapter 13 Section 40.Denies coverageof MRI for:Measurement of blood flow and spectroscopyArticle TextThe following coding and billing guidance is to be used with its associated Local Coverage Determination.Documentation GuidelinesDiagnostic evaluation of the head and neck (head/neck scans) performed by computerized tomography (CT) scanners is covered when the documentation supports that the scan is reasonable and necessary. Accurate coding information must be provided with claims to differentiate CT and/or MRI scans from other radiology services and to make coverage determinations. Sufficient documentation such as, history and physical notes, laboratory results, signs and symptoms of the disease to warrant the diagnostic test and to support the claim of reasonable and necessary must be included in the medical records. This information must be available to Medicare upon request.Coding GuidelinesThe HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits in addition to guidance in this LCD. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Whichever guidance is more restrictive should be adhered to.
Article - Billing and Coding: Plastic Surgery (A57221)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A). Allows coverage and payment for only those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act, 1833(e). Prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, 1862(a)(10). Coverage of cosmetic surgery is discussed.Medicare On-Line Manual System, Publication 100-02,Medicare Benefit Policy Manual,Chapter 16, 10, 120, and 180.Medicare On-Line Manual System, Publication 100-03,Medicare National Coverage Determinations Manual,Chapter 1, Part 2, 140.2 and 140.4.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Cosmetic surgery is performed to reshape normal structures of the body, for the purpose of improving the patients appearance and self-esteem. Per IOM 100-02 Chapter 16, cosmetic surgery and expenses incurred in connection with such surgery are not covered. This exclusion does not apply to surgery in connection with the treatment of severe burns, facial repair following auto trauma, or similar surgeries for therapeutic purposes or reconstruction.For Reduction Mammoplasty:1. Physicians should document the severity of the symptoms of breast hypertrophy and impact on health related quality of life as measured by an accepted breast specific questionnaire.The beneficiary's medical record must contain the following information and be made available to any authorized Medicare auditor upon request:Height and weightClinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to reduction mammoplasty and the responses to these therapies.The operative report with documentation of the weight of tissue removed fromeach breast, obtained in the operating room.The pathology report of the tissue removed fromeach breast.2. Reasons for denial include:
Article - Billing and Coding: Plastic Surgery (A57221)
2. Reasons for denial include:Surgery is deemed or later determined to be cosmetic in nature. Breast surgery for uncomplicated macromastia, pendulous breasts, or to correct otherwise uncomplicated nipple inversions will be considered cosmetic and not reasonable and necessary.Failure to clearly document persistent signs and symptoms despite a reasonable trial of conservative therapy for a reasonable length of time.Services submitted without a listed diagnosis (ICD-10-CM) code supporting medical necessity.Use of any ICD-10-CM codes not listed in the ICD-10-CM Codes That Support Medical Necessity Section below.For all procedures noted within this policy:The medical record must be made available to Medicare or a Medicare auditor upon request.The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.Services billed with a diagnosis code that is not listed in the ICD-10-CM Codes That Support Medical Necessity section may be considered at redetermination on a case-by-case basis.When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services may be denied as not reasonable and necessary.When requesting a written redetermination, providers must include all relevant documentation with the request. Failure to include such items will likely result in an unfavorable determination. While not required, high quality photographs may be useful in determining medical necessity and may be submitted when the provider feels it is appropriate to do so.