evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Intraosseous Basivertebral Nerve Ablation (A59468)
Refer to the Local Coverage Determination (LCD) L39644 Intraosseous Basivertebral Ablation, for reasonable and necessary requirements and frequency limitations.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.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.Coding Guidance:Providers should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.This determination billing and coding article applies only to ablation of the intraosseous basivertebral nerve (BVN) within the vertebral bodies L3-S1.NO coverage is offered for ablation of BVN in vertebral bodies other than those named in this LCD/ B&C Article.Coverage and reimbursement for treatment of identified BVN originated pain is contingent on documentation of Type 1 or Type 2 Modic changes within the vertebral body identified for treatment, no previous ablation of the named vertebral body BVN, and documented compliance with all other restrictions and limitations of the LCD. Compliance with this provision will be denoted on the claim by affixing the KX modifier to the covered CPT code.BVN ablation is covered once in a lifetime for vertebral bodies L3-S1, total 4 individual vertebral bodies treated once per beneficiary per lifetime.
Article - Billing and Coding: Intraosseous Basivertebral Nerve Ablation (A59468)
BVN ablation is covered once in a lifetime for vertebral bodies L3-S1, total 4 individual vertebral bodies treated once per beneficiary per lifetime.Previous BVN ablation of a named vertebral body precludes coverage for additional BVN ablation for that level vertebral body.BVN ablation is non-covered for individuals not having achieved skeletal maturity (<18 years of age) and other limitations as describe in the corresponding LCD L39644 without specific explanation of measures taken to rule out or counteract the effects of diagnoses listed for preclusion.Patients with diagnosed metabolic bone disease, osteoporosis, metastatic tumor, neurogenic claudication, or nerve impingement with radicular symptoms are non-covered for BVN ablation.No more than two vertebral levels may be treated at one session and may not be combined with any other paravertebral injection or intervention (facet or epidural). Documentation of the indication requirements must be reported for each vertebral level separately. The use of local anesthesia is considered included within the procedure code. The use of medicament or biological materials into the vertebral body or into the surrounding paravertebral tissue is considered contraindicated and will render the claim for BVN ablation non-payable.KX modifier requirements:Identification of a vertebral body with Modic 1 Or Modic 2 changes eligible for treatment by BVN ablation, and the absence of previous BVN ablation, is denoted by affixing the -KX modifier to the procedure code, signifying the requirements for treatment have been met.Documentation RequirementsThe patients medical record should include but is not limited to:
Article - Billing and Coding: Intraosseous Basivertebral Nerve Ablation (A59468)
The assessment of the patient (complete history and physical exam) by the performing provider as it relates to the complaint of the patient.Relevant medical history including concomitant disease diagnoses, prior operative procedures, allergies, prescription and non-prescription medications in use at the time of the procedure and preceding 6 months.Results of pertinent tests/procedures including date and professional interpretation of results.All aspects of the treatment provided, including medications, equipment utilized, energy levels at treatment, medication administered during treatment sessions, and imaging (films or interpretation) utilized for treatment as required by the local coverage determination (LCD).Signed and dated office visit records and operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Documentation of other requirements listed in LCD if applicable.
Draft Article - Billing and Coding: MolDX: Molecular Testing for Risk Stratification of Thyroid Nodules (DA59470)
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 claimCMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Testing for Risk Stratification of Thyroid Nodules DL39646.MolDX expects this test will be performed once per patient lifetime. Should the unlikely situation of a second, unrelated thyroid nodule with indeterminate pathology occur, coverage may be considered upon appeal with support documentation.To report a service, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Draft Article - Billing and Coding: MolDX: Gene Expression Profile Tests for Decision-Making in Castration Resistant and Metastatic Prostate Cancers (DA59472)
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 claimCMS Internet-Only Manuals, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only 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 MolDX: Gene Expression Profile Tests for Decision-Making in Castration Resistant and Metastatic Prostate Cancer DL39636.Please submit the following claim information:Select CPTcode 81479Only 1 test may be billed per patientEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM codeCode first the malignant neoplasm and then use an additional code as applicable to identify the hormone sensitivity status
Draft Article - Billing and Coding: MolDX: Molecular Testing for Risk Stratification of Thyroid Nodules (DA59474)
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 claimCMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Testing for Risk Stratification of Thyroid Nodules DL39646.MolDX expects this test will be performed once per patient lifetime. Should the unlikely situation of a second, unrelated thyroid nodule with indeterminate pathology occur, coverage may be considered upon appeal with support documentation.To report a service, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Draft Article - Billing and Coding: MolDX: Molecular Biomarkers for Risk Stratification of Indeterminate Pulmonary Nodules Following Bronchoscopy (DA59476)
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 claimCMS Internet-Only Manuals, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only 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 MolDX: Molecular Biomarkers for Risk Stratification of Indeterminate Pulmonary Nodules Following Bronchoscopy DL39654.Please submit the following claim information:Select CPTcode 81479Only 1 test may be billed per patientEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Draft Article - Billing and Coding: Trigger Point Injections (TPI) (DA59480)
CMS National Coverage PolicyN/AArticle TextRefer to the draft Local Coverage Determination (LCD) DL39656-Trigger Point Injections (TPI) reasonable and necessary requirements and frequency limitations.The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to theNCCI requirements.Coding GuidanceProviders should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.Notice: 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.This policy applies only to trigger point injections and does not apply to dry needling or acupuncture.Modifier 50- bilateral should not be reported with CPT codes 20552 or 20553.Utilization ParametersNo more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed.CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle.MedicationThe drug used for the injection must be on the same claim as the trigger point administration.The medication used with the injection is reported with a HCPCS Drug code J-code or a revenue code.Unclassified drugs billed with J3490, J3590, J9999 or C9399* must also include name of drug and dosage to Box 19 of the CMS-15000 paper form or electronic equivalent.*C3999 should only be used for ASC outpatient facility claims.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.
Draft Article - Billing and Coding: Trigger Point Injections (TPI) (DA59480)
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 procedural report should clearly document the indications and medical necessity for the injections, the name, and units of the injectant used, the location of the TPIs, along with the pre and post percent (%) pain relief achieved immediately post-The patients medical record should include, but is not limited to:The assessment of the patient by the performing 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.)Documentation to support the medical necessity of the procedure(s).When documenting the TPI procedure, there must be specific information to indicate the location of trigger points treated, the muscles injected, medication injected, amount of medications used, and the post-procedure plan.Use of BiologicalsThere are currently no FDA approved biologicals for use as trigger point injectable agents. The inclusion of biological and/or other non-FDA approved substances in the injectant may result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180Medicare Benefit Policy Manual (cms.gov). Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.Use of AnesthesiaNo anesthesia codes should be billed in conjunction with 20552 or 20553.
Article - Billing and Coding: Trigger Point Injections (TPI) (A59480)
CMS National Coverage PolicyN/AArticle TextRefer to the draft Local Coverage Determination (LCD) DL39656-Trigger Point Injections (TPI) reasonable and necessary requirements and frequency limitations.The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to theNCCI requirements.Coding GuidanceProviders should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.Notice: 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.This policy applies only to trigger point injections and does not apply to dry needling or acupuncture.Modifier 50- bilateral should not be reported with CPT codes 20552 or 20553.Utilization ParametersNo more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed.CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle.MedicationThe drug used for the injection must be on the same claim as the trigger point administration.The medication used with the injection is reported with a HCPCS Drug code J-code or a revenue code.Unclassified drugs billed with J3490, J3590, J9999 or C9399* must also include name of drug and dosage to Box 19 of the CMS-15000 paper form or electronic equivalent.*C3999 should only be used for ASC outpatient facility claims.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.
Article - Billing and Coding: Trigger Point Injections (TPI) (A59480)
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 procedural report should clearly document the indications and medical necessity for the injections, the name, and units of the injectant used, the location of the TPIs, along with the pre and post percent (%) pain relief achieved immediately post-The patients medical record should include, but is not limited to:The assessment of the patient by the performing 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.)Documentation to support the medical necessity of the procedure(s).When documenting the TPI procedure, there must be specific information to indicate the location of trigger points treated, the muscles injected, medication injected, amount of medications used, and the post-procedure plan.Use of BiologicalsThere are currently no FDA approved biologicals for use as trigger point injectable agents. The inclusion of biological and/or other non-FDA approved substances in the injectant may result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180Medicare Benefit Policy Manual (cms.gov). Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.Use of AnesthesiaNo anesthesia codes should be billed in conjunction with 20552 or 20553.
Draft Article - Billing and Coding: MolDX: Molecular Biomarkers for Risk Stratification of Indeterminate Pulmonary Nodules Following Bronchoscopy (DA59482)
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 claimCMS Internet-Only Manuals, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only 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 MolDX: Molecular Biomarkers for Risk Stratification of Indeterminate Pulmonary Nodules Following Bronchoscopy DL39658.Please submit the following claim information:Select CPTcode 81479Only 1 test may be billed per patientEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: Molecular Biomarker Testing to Guide Targeted Therapy Selection in Rheumatoid Arthritis (A59484)
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 Laboratories.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Biomarker Testing to Guide Targeted Therapy Selection in Rheumatoid Arthritis L39424.Only 1 test may be performed for a given patient.Please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code