evekhm/cms_iom_500 huggingface dataset:
Draft Article - Billing and Coding: Urinary Biomarkers for Chronic Pain Management (DA59423)
General Guidelines for Claims submitted to Part A or Part B MACProcedure 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.Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines:An 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.
Draft Article - Billing and Coding: Urinary Biomarkers for Chronic Pain Management (DA59423)
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.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.To receive a denial, please submit the following claim information:
Draft Article - Billing and Coding: Urinary Biomarkers for Chronic Pain Management (DA59423)
Select appropriate CPTcode (for Foundational Pain Index use 0117U)Enter 1 unit of service (UOS)Select the appropriate ICD-10-CM codeNote: As this test is not a molecular pathology test that would fall under the MolDx program labs are not required to submit a technical assessment for this test and a DEX Z-code is not required on the claim.
Article - Billing and Coding: Urinary Biomarkers for Chronic Pain Management (A59423)
CMS National Coverage PolicyN/AArticle TextThis article gives guidance for billing, coding and other guidelines in relation to local coverage policy DL39616-Urinary Biomarkers for Chronic Pain Management.
Article - Billing and Coding: Urinary Biomarkers for Chronic Pain Management (A59423)
General Guidelines for Claims submitted to Part A or Part B MACProcedure 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.Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines:An 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.
Article - Billing and Coding: Urinary Biomarkers for Chronic Pain Management (A59423)
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.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.To receive a denial, please submit the following claim information:
Article - Billing and Coding: Urinary Biomarkers for Chronic Pain Management (A59423)
Select appropriate CPTcode (for Foundational Pain Index use 0117U)Enter 1 unit of service (UOS)Select the appropriate ICD-10-CM codeNote: As this test is not a molecular pathology test that would fall under the MolDx program labs are not required to submit a technical assessment for this test and a DEX Z-code is not required on the claim.
Draft Article - Billing and Coding: Nerve Conduction Studies and Electromyography (DA54095)
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.Medicare National Correct Coding Initiative (NCCI) Policy Manual:Chapter 11, Section L-Neurology and Neuromuscular ProceduresArticle TextThis Billing and Coding Article provides billing and coding guidance for Proposed Local Coverage Determination (LCD) DL35081 Nerve Conduction Studies and Electromyography. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Consistent with the LCD, nerve conduction studies (NCSs) without needle electromyography (NEMG) will be allowed for:Individuals being evaluated for carpal tunnel syndrome or tarsal tunnel syndrome when one of the following diagnosis codes are reported: G56.01, G56.02, G56.03, G57.51, G57.52 or G57.53.Individuals with significant lymphedema in the affected extremity when the following diagnosis code is reported in addition to the primary diagnosis: I89.0.Individuals treated with anticoagulants when one of the following diagnosis codes are reported in addition to the primary diagnosis: Z79.01 or Z79.02.NCSs and NEMG performed on the same day, for the same patient must be reported on the same claim.
Draft Article - Billing and Coding: Nerve Conduction Studies and Electromyography (DA54095)
NCSs and NEMG performed on the same day, for the same patient must be reported on the same claim.Consistent with the LCD, the following services/tests are non-covered. Therefore, when billing these services/tests report the unlisted neurological diagnostic CPT code 95999 appended with the GY modifier (item or service statutorily excluded or does not meet the definition of any Medicare benefit). When submitting claims, providers must provide a description of the service/test in the narrative/remarks field (Item 19) on the CMS-1500 claim form or the electronic equivalent. If a description is not provided in the narrative/remarks field, the claim/service will be rejected.Non-invasive electrodiagnostic (EDX) testing using portable hand-held devices or automated point of care nerve conduction monitoring systems, which are incapable of real-time waveform display and analysisPsychophysical measurements (electrical, vibratory, or thermal perceptions), even though they may involve delivery of a stimulus,are considered part of the physical examination and may not be reported as a separate servicePhysiologic recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor using wearable devices with accelerometers or gyroscopesNEMG for Surface electromyography (SEMG) or Macroelectromyography (macro-EMG)For HCPCS code G0255, refer to the CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 2, Section 160.23 Sensory Nerve Conduction Threshold Tests (sNCTs).Utilization ParametersStudies performed per day beyond the reasonable maximum number of studies recommended in the Current Procedural Terminology (CPT) Codebook, Appendix J, Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves will be denied. Additional studies may be considered on redetermination.
Draft Article - Billing and Coding: Nerve Conduction Studies and Electromyography (DA54095)
Consistent with the LCD, the following number of tests per 12-month period per diagnosis per provider for repeat EDX assessment are suitable: 1) Two studies for carpal tunnel-unilateral, carpal tunnel-bilateral, radiculopathy, mononeuropathy, polyneuropathy, myopathy, and neuromuscular junction (NMJ) disorders. 2) Three studies for motor neuron disease and plexopathy.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 patients medical records must clearly document the medical necessity for the test. The indication for ordering the test(s) and a clear diagnostic impression are required in each report. In cases where documentation is requested, a hard copy of waveforms and/or a complete written report with an interpretation of the test, sufficient to support that the test was medically reasonable and necessary must be submitted.Normal findings and abnormalities uncovered during the study should be documented with the nerves and muscles tested, the presence and type of spontaneous activity, as well as the characteristics of the voluntary unit potentials and interpretation. Expected normal value range for the specific EDX device should also be included.If a patient has had analogous testing performed in the past, documentation should also be included that references the date it was performed as well as results and subsequent management based on those findings.
Draft Article - Billing and Coding: Nerve Conduction Studies and Electromyography (DA57123)
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.Medicare National Correct Coding Initiative (NCCI) Policy Manual:Chapter 11, Section L-Neurology and Neuromuscular ProceduresArticle TextThis Billing and Coding Article provides billing and coding guidance for Proposed Local Coverage Determination (LCD) DL34859 Nerve Conduction Studies and Electromyography. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Consistent with the LCD, nerve conduction studies (NCSs) without needle electromyography (NEMG) will be allowed for:Individuals being evaluated for carpal tunnel syndrome or tarsal tunnel syndrome when one of the following diagnosis codes are reported: G56.01, G56.02, G56.03, G57.51, G57.52 or G57.53.Individuals with significant lymphedema in the affected extremity when the following diagnosis code is reported in addition to the primary diagnosis: I89.0.Individuals treated with anticoagulants when one of the following diagnosis codes are reported in addition to the primary diagnosis: Z79.01 or Z79.02.NCSs and NEMG performed on the same day, for the same patient must be reported on the same claim.
Draft Article - Billing and Coding: Nerve Conduction Studies and Electromyography (DA57123)
NCSs and NEMG performed on the same day, for the same patient must be reported on the same claim.Consistent with the LCD, the following services/tests are non-covered. Therefore, when billing these services/tests report the unlisted neurological diagnostic CPT code 95999 appended with the GY modifier (item or service statutorily excluded or does not meet the definition of any Medicare benefit). When submitting claims, providers must provide a description of the service/test in the narrative/remarks field (Item 19) on the CMS-1500 claim form or the electronic equivalent. If a description is not provided in the narrative/remarks field, the claim/service will be rejected.Non-invasive electrodiagnostic (EDX) testing using portable hand-held devices or automated point of care nerve conduction monitoring systems, which are incapable of real-time waveform display and analysisPsychophysical measurements (electrical, vibratory, or thermal perceptions), even though they may involve delivery of a stimulus,are considered part of the physical examination and may not be reported as a separate servicePhysiologic recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor using wearable devices with accelerometers or gyroscopesNEMG for Surface electromyography (SEMG) or Macroelectromyography (macro-EMG)For HCPCS code G0255, refer to the CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 2, Section 160.23 Sensory Nerve Conduction Threshold Tests (sNCTs).Utilization ParametersStudies performed per day beyond the reasonable maximum number of studies recommended in the Current Procedural Terminology (CPT) Codebook, Appendix J, Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves will be denied. Additional studies may be considered on redetermination.
Draft Article - Billing and Coding: Nerve Conduction Studies and Electromyography (DA57123)
Consistent with the LCD, the following number of tests per 12-month period per diagnosis per provider for repeat EDX assessment are suitable: 1) Two studies for carpal tunnel-unilateral, carpal tunnel-bilateral, radiculopathy, mononeuropathy, polyneuropathy, myopathy, and neuromuscular junction (NMJ) disorders. 2) Three studies for motor neuron disease and plexopathy.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 patients medical records must clearly document the medical necessity for the test. The indication for ordering the test(s) and a clear diagnostic impression are required in each report. In cases where documentation is requested, a hard copy of waveforms and/or a complete written report with an interpretation of the test, sufficient to support that the test was medically reasonable and necessary must be submitted.Normal findings and abnormalities uncovered during the study should be documented with the nerves and muscles tested, the presence and type of spontaneous activity, as well as the characteristics of the voluntary unit potentials and interpretation. Expected normal value range for the specific EDX device should also be included.If a patient has had analogous testing performed in the past, documentation should also be included that references the date it was performed as well as results and subsequent management based on those findings.
Draft Article - Billing and Coding: MolDX: Molecular Biomarker Testing for Risk Stratification of Cutaneous Squamous Cell Carcinoma (DA59429)
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 LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Biomarker Testing for Risk Stratification of Cutaneous Squamous Cell Carcinoma.To receive a denial, please submit the following claim information:Select appropriate CPT codeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Draft Article - Billing and Coding: Urine Drug Testing (DA56915)
CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD DL34645 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.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.