evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Wound and Ulcer Care (A58567)
Use of Evaluation and Management (E/M) Codes in Conjunction with Surgical DebridementsE/M codes are not usually billed in conjunction with a debridement procedure. When providing and billing surgical debridement, the surgical debridement service is to include: the pre-debridement wound assessment, the debridement, and the post-procedure instructions provided to the patient on the date of the service. When a "reasonable and necessary" E/M service is provided and documented on the same day as a debridement service, it is payable by Medicare when the documentation clearly establishes the service as a "separately identifiable service" that was reasonable and necessary, as well as distinct, from the debridement service(s) provided.Consultation services rendered by a podiatrist in a skilled nursing facility are covered if the services are reasonable and necessary and do not come within any of the specific statutory exclusions (NCD 70.2).Low frequency, non-contact, non-thermal ultrasound (MIST Therapy)  CPT code 97610One 97610 service per day is allowable for a qualifying wound. CPT Code 97610 is not separately reportable for treatment of the same wound on the same day as other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (e.g., CPT codes 11042-11047, 97597, 97598).Debridement, Total Contact Casting and Unna boot
Article - Billing and Coding: Wound and Ulcer Care (A58567)
Debridement, Total Contact Casting and Unna bootAll supply items related to the Unna boot and Total Contact Casting (TCC) are inclusive in the reimbursement for CPT code 29580 and 29445 respectively. When both a debridement is performed and an Unna boot or TCC is applied, only the debridement may be reimbursed. If only an Unna boot or TCC is applied and the wound is not debrided, then only the Unna boot or TCC application may be eligible for reimbursement. The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services Chapter 4, section G states that casting/splinting/strapping shall not be reported separately if a service from the Musculoskeletal System section of CPT (20100-28899 and 29800-29999) is also performed for the same anatomic area. It may be appropriate to use modifier 59 with these strapping codes if performed in a separate anatomical area.Debridement including removal of foreign material at the site of an open fracture or open dislocation may be reported with CPT codes 11010-11012. Since these codes would be reported with a CPT code for treatment of the open fracture or dislocation, a casting/splinting/strapping code should not be reported separately.Documentation Requirements
Article - Billing and Coding: Wound and Ulcer Care (A58567)
All 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 patient's medical record should indicate the specific signs/symptoms and other clinical data supporting the wound care provided. It is expected that the physician will document the current status of the wound in the patient's medical record and the patient's response to the current treatment.The patient's medical record must contain clearly documented evidence of the progress of the wound's response to treatment at each physician visit. This documentation must include, at a minimum:Current wound volume (surface dimensions and depth).Presence (and extent of) or absence of obvious signs of infection.Presence (and extent of) or absence of necrotic, devitalized, or non-viable tissue.Other material in the wound that is expected to inhibit healing or promote adjacent tissue breakdown.Identification of the wound location, size, depth, and stage by description must be documented and may be supported by a drawing or photograph of the wound. Photographic documentation of wounds at initiation of treatment as well as either immediately before or immediately after debridement is recommended. This may be of particular benefit for documentation as an adjunct to written documentation of reasonable and necessary services, which require prolonged or repetitive debridement.Medical record documentation for debridement services must include the type of tissue removed during the procedure as well as the depth, size, or other characteristics of the wound and must correspond to the debridement service submitted. A pathology report substantiating depth of debridement is encouraged when billing for the debridement procedures involving deep tissue or bone.In addition, except for patients with compromised healing due to severe underlying debility or other factors, documentation in the medical record must show:
Article - Billing and Coding: Wound and Ulcer Care (A58567)
There is an expectation that the treatment will substantially affect tissue healing and viability, reduce or control tissue infection, remove necrotic tissue, or prepare the tissue for surgical management.The extent and duration of wound care treatment must correlate with the patients expected restoration potential. If wound closure is not a reasonable goal, then the expectation is to optimize recovery and establish an appropriate non-skilled maintenance program. Alternatively, palliative care of the patient and wound may be provided to diminish the probability of prolonged hospitalization, etc. If it is determined that the goal of care is not wound closure, the patient should be managed following appropriate covered palliative care standards.Service(s) must include an operative note or procedure note for the debridement service(s). This note should include the following:Medical diagnosis.Indication(s) and medical necessity for the debridement.Type of anesthesia used, if and when used.Wound characteristics such as diameter, depth, undermining or tunneling, color, presence of exudates or necrotic tissue.Level/depth of tissue debrided and a description of the types(s) of tissue involved and the tissue(s) removed.Vascular status, infection, or evidence of reduced circulation.Narrative of the procedure to include the instruments used. When debridements are reported, the debridement procedure notes must demonstrate tissue removal (i.e., skin, full or partial thickness; subcutaneous tissue; muscle and/or bone), the method used to debride (i.e., hydrostatic, sharp, abrasion, etc.) and the character of the wound (including dimensions, description of necrotic material present, description of tissue removed, degree of epithelialization, etc.) before and after debridement.Patient specific goals and/or response to treatment.Immediate post-op care and follow-up instructions.The presence or absence of necrotic, devitalized, fibrotic, or other tissue or foreign matter must be documented in the medical record when wound debridement is performed.
Article - Billing and Coding: Wound and Ulcer Care (A58567)
The medical record must include treatment goals and physician follow-up. The record must document complicating factors for wound healing as well as measures taken to control complicating factors when debridement is part of the plan. Appropriate modification of treatment plans, when necessitated by failure of wounds to heal, must be demonstrated. A wound that shows no improvement after 30 days may require a new approach. Documentation of such cases may include a physician reassessment of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound healing, or a new treatment approach.Appropriate evaluation and management of contributory medical conditions or other factors affecting the course of wound healing (such as nutritional status or other predisposing conditions) should be addressed in the medical record at intervals consistent with the nature of the condition or factor.Documentation must support the use of skilled personnel with the use of jet therapy and wound irrigation for wound debridement.Documentation for low frequency, non-contact, non-thermal ultrasound services (Mist Therapy) should include documented improvements of pain reduction, reduction in wound size, improved and increased granulation tissue, or reduction in necrotic tissue. The services should be medically necessary based on the providers documentation of a medical evaluation of the patient's condition, diagnosis, and plan.When the documentation, or lack thereof, does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.
Article - Billing and Coding: Wound and Ulcer Care (A58567)
Utilization Guidelines:In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.Wound care must be performed in accordance with accepted standards for medical and surgical treatment of wounds. The appropriate interval and frequency of debridement depends on the individual clinical characteristics of the patient and the extent of the wound. The extent and number of services provided should be medically necessary and reasonable based on the documented medical evaluation of the patient's condition, diagnosis, and plan.With the above in mind, only a minority of beneficiaries who undergo debridements for wound care appear to require more than twelve total surgical excisional debridement services involving subcutaneous tissue, muscle/fascia, or bone in a 360 day period, (five debridements of which involve removal of muscle/fascia, and/or bone) in order to accomplish the desired objective of the treatment plan of the wound. When medical necessity continues to be met and there is documented evidence of clear benefit from the debridements already provided, debridement services may be continued beyond this frequency or time frame. It is similarly unlikely that more than four debridements are needed in a month, i.e. 30 days, and again, continuance of care would depend on evidence of benefit to the patient.
Article - Billing and Coding: Cosmetic and Reconstructive Surgery (A58573)
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) L38914, Cosmetic and Reconstructive Surgery. 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 RequirementsFor all procedures:All 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.Documentation Requirements for Specified ServicesDermabrasionThe medical record must describe the beneficiarys disease process of the rhinophyma that is being treated with dermabrasion.Abdominal Lipectomy/PanniculectomyThe medical record must contain the following information:Description of the pannus and underlying skin.Documentation that the panniculus causes chronic intertrigo (dermatitis occurring on the opposed surfaces of the skin, skin irritation, infection, or chafing).Description of functional impairments (e.g., difficulty walking, exercising, or impairment in activities of daily living).Description of conservative treatment the beneficiary has received and the results of treatment.Preoperative photographs of the pannus and underlying skin are recommended.Reconstructive Breast Surgery: Removal of Breast ImplantsThe medical record must describe the condition which supports the removal of the breast implant(s) as medically reasonable and necessary.
Article - Billing and Coding: Cosmetic and Reconstructive Surgery (A58573)
Reconstructive Breast Surgery: Removal of Breast ImplantsThe medical record must describe the condition which supports the removal of the breast implant(s) as medically reasonable and necessary.Reduction MammaplastyThe beneficiary's medical record must contain the following information:Height and weight.Clinical evaluation of the signs or symptoms ascribed to the macromastia, therapies prior to reduction mammaplasty and the responses to these therapies.Mammogram report for age appropriate population.The operative report with documentation of the weight of tissue removed from each breast, obtained in the operating room.The pathology report of the tissue removed from each breast.Mastectomy for gynecomastiaGlandular breast tissue confirming true gynecomastia is documented on physical exam and/or mammography.Documentation that the gynecomastia persists, despite correction of any underlying causes.Documentation supporting that the gynecomastia is classified as Grade III or IV per the American Society of Plastic Surgeons (ASPS) classification when the procedure is performed in males.Documentation that hormonal causes, including hyperthyroidism, estrogen excess, hyperprolactinemia and hypogonadism have been excluded by appropriate laboratory testing (e.g., with levels of thyroid stimulating hormone [TSH], estradiol, prolactin, testosterone and/or luteinizing hormone [LH])Documentation supporting that gynecomastia persists after 3 to 4 months of unsuccessful medical treatment, the use of potential gynecomastia-inducing drugs and substances has been ruled out and gynecomastia persists for at least one year.RhinoplastyPhotographic documentation of the patients condition is recommended to help support medical necessity if documentation is requested.The medical record must include a description of the condition requiring the rhinoplasty.When rhinoplasty is being performed for chronic obstruction, the medical record must indicate what is causing the obstruction.Septoplasty
Article - Billing and Coding: Cosmetic and Reconstructive Surgery (A58573)
SeptoplastyThe medical record must describe the conservative medical management utilized and the length of time that the treatment was trialed for septal deviation causing nasal airway obstruction.The medical record must contain the medical and antibiotic therapy that was utilized, and the length of the time treatment was trialed for recurrent sinusitis secondary to deviated septum.The medical record must contain the medical management utilized and the length of time that the treatment was trialed for obstructed nasal breathing due to septal deformity or deviation that is interfering with the effective use of Continuous Positive Airway Pressure (CPAP) for the treatment of an obstructive sleep disorder.
Article - Billing and Coding: Respiratory Pathogen Panel Testing (A58575)
CMS National Coverage PolicyIOM Citations:CMS IOM Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 80.1 Clinical Laboratory ServicesCMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 16 Laboratory ServicesChapter 23, Section 10 Reporting ICD Diagnosis and Procedure Codes, Section 20.9 National Correct Coding Initiative (NCCI), Section 40 Clinical Diagnostic Laboratory Fee ScheduleCMS IOM Publication 100-08,Medicare Program Integrity Manual,Chapter 3, Section 3.4.1.3 Diagnosis Code RequirementsSocial 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.National Correct Coding Initiative:NCCI Policy Manual for Medicare ServicesChapter 10, Pathology and Laboratory Services (CPT Codes 80000-89999), Section K MicrobiologyArticle TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38916, Respiratory Pathogen Panel Testing. 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.A respiratory pathogen panel test is a single service with a single unit of service (UOS=1). A respiratory pathogen panel testmust not be unbundled and billed as individual componentsregardless of the fact that the panel reports multiple individual pathogens and/or targets.The term "panel" refers to all respiratory pathogens tested in the outpatient setting on a single date of service from a single biologic specimen, not ordered as a reflex test.Please note: The services addressed in this article and related LCD are not applicable to providers submitting claims on institutional claim forms.Documentation Requirements
Article - Billing and Coding: Respiratory Pathogen Panel Testing (A58575)
Please note: The services addressed in this article and related LCD are not applicable to providers submitting claims on institutional claim forms.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 medical recordMUSTsupport that the test was completed in a Part B setting that is equipped to deliver timely resultsANDfor patients where the test demonstrates that clinical management can result in an improved health outcome.
Article - Billing and Coding: Respiratory Pathogen Panel Testing (A58577)
CMS National Coverage PolicyIOM Citations:CMS IOM Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 80.1 Clinical Laboratory ServicesCMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 16 Laboratory ServicesChapter 23, Section 10 Reporting ICD Diagnosis and Procedure Codes, Section 20.9 National Correct Coding Initiative (NCCI), Section 40 Clinical Diagnostic Laboratory Fee ScheduleCMS IOM Publication 100-08,Medicare Program Integrity Manual,Chapter 3, Section 3.4.1.3 Diagnosis Code RequirementsSocial 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.National Correct Coding Initiative:NCCI Policy Manual for Medicare ServicesChapter 10, Pathology and Laboratory Services (CPT Codes 80000-89999), Section K MicrobiologyArticle TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38918, Respiratory Pathogen Panel Testing. 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.A respiratory pathogen panel test is a single service with a single unit of service (UOS=1). A respiratory pathogen panel testmust not be unbundled and billed as individual componentsregardless of the fact that the panel reports multiple individual pathogens and/or targets.The term "panel" refers to all respiratory pathogens tested in the outpatient setting on a single date of service from a single biologic specimen, not ordered as a reflex test.Please note: The services addressed in this article and related LCD are not applicable to providers submitting claims on institutional claim forms.Documentation Requirements
Article - Billing and Coding: Respiratory Pathogen Panel Testing (A58577)
Please note: The services addressed in this article and related LCD are not applicable to providers submitting claims on institutional claim forms.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 medical recordMUSTsupport that the test was completed in a Part B setting that is equipped to deliver timely resultsANDfor patients where the test demonstrates that clinical management can result in an improved health outcome.
Article - Billing and Coding: Spinraza® (nusinersen) (A58578)
CMS National Coverage PolicyN/AArticle TextNoridian has received numerous billing and coding queries regarding J2326, Nusinersen, (Brand name SPINRAZA). This code became effective 01/01/2018.This article is not a coverage determination, but rather guidance on the appropriate billing and coding when utilizing this medication.As a reminder, the Internet Only Manual (IOM), Medicare Benefit Policy Manual (Pub. 100-02), Chapter 15, Section 50.4.1 Approved Use of Drug states,"Use of the drug or biological must be safe and effective and otherwise reasonable and necessary. Drugs or biologicals approved for marketing by the Food and Drug Administration (FDA) are considered safe and effective for purposes of this requirementwhen used for indications specified on the labeling.Therefore, the programmaypay for the use of an FDA approved drug or biological, if:it was injected on or after the date of the FDA's approval;it is reasonable and necessary for the individual patient and,all other applicable coverage requirements are met."1