evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58731)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 4, Section 280.14 Infusion PumpsCMS IOM Publication 100-04, Medicare Claims Processing Manual,Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)Social 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 Text
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58731)
This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39015-Epidural Steroid Injections for Pain Management. Please refer to the LCD for reasonable and necessary requirements.The services addressed in this article only apply to epidural injections. Other joint procedures (e.g. sacral injections, facet join) are not addressed.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.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 the NCCI requirements.An anatomic spinal region for epidurals is defined as cervical/thoracic (CPT codes 62321, 64479 and 64480) or lumbar/sacral (CPT codes 62323, 64483 and 64484).When the epidural injections (62322-62327) are used for cerebrospinal fluid flow imaging, cisternography (78630), the diagnosis code restrictions in this article do not apply. These services should be billed on the same claim.When epidural injections (62321, 62323, 64479, 64480, 64483 or 64484) are used for postoperative pain management, the diagnosis code restriction in this article do not apply.When epidural injection (62323) is used for an implantable infusion pump trail, the diagnosis code restrictions in this article do not apply.CPT codes 64479 and 64483 are used to report a single level injection performed with image guidance (fluoroscopy or CT). CPT codes 64480 and 64484 represent each additional level respectively and should be reported separately in addition to the primary procedure when applicable. 64480 and 64484 describes each additional level which should be reported separately in addition to the code for the primary procedure.A transformainal epidural steroid injection (TFESI) performed at the T12-L1 level should be reported with CPT code 64479.
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58731)
A transformainal epidural steroid injection (TFESI) performed at the T12-L1 level should be reported with CPT code 64479.When reporting CPT codes 64479 through 64484 for a unilateral procedure, use one line with one unit of service. For bilateral procedures regarding these same codes, use one line and append the modifier-50.For services performed in the ASC, physicians must continue use modifier 50. Only the ASC Facility itself must report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each lineIt is not medically reasonable and necessary to perform caudal ESIs or interlaminar ESIs bilaterally, therefore CPT 62321 and 62323 are not bilateral procedures.KX modifier requirements:A diagnostic selective nerve root block (DSNRB) is identically coded as an Epidural Injection. Therefore, when performing a DSNRB the -KX modifier should be appended to the appropriate line to distinguish the procedure from an epidural injection. Aberrant use of the -KX modifier may trigger focused medical review.Utilization ParametersOnly one spinal region may be treated per session (date of service).Consistent with the LCD, only two total levels per session are allowed for CPT codes 64479, 64480, 64483 and 64484. (Two unilateral or two bilateral levels). 64480 should be reported in conjunction with 64479 and 64484 should be reported in conjunction with 64483.Consistent with the LCD, CPT codes 62321 and 62323 may only be reported for one level per session.No more than 4 epidural injection sessions (CPT codes 62321, 62323, 64479, 64480, 64483, or 64484) may be reported per spinal region in a rolling 12-month period regardless of the number of levels involved.Documentation Requirements1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58731)
Documentation Requirements1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.2. 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.3. 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.4. Selective nerve root blocks (SNRBs) and TFESIs: The procedural report should clearly document the indications and medical necessity for the injections, along with the baseline pain score. SNRBs only: The procedural report should include the baseline pain score and percent (%) pain relief achieved immediately after the injection.5. Films that adequately document (minimum of 2 views) final needle position and contrast flow should be retained and made available upon request.6. The patients medical record should include, but is not limited to:
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58731)
The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visitRelevant 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).Use of BiologicalsThere are currently no FDA approved biologicals for use as injectable agents into the epidural space or spine. 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 180. Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and not routinely reimbursable and therefore may be denied. In exceptional circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record individual consideration may be considered on appeal.
Article - Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer (A58734)
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 Manual, 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: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer L39017.To report a service, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier 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-Codeidentifier 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 codeRegarding single-gene and panel testing of genes-Refer to Billing and Coding: MolDX: Testing of Multiple Genes A57910.Tier 1 and/or Tier 2 individual biomarker CPTcodes should not be used for a single gene or any combination of genes when testing is performed as part of a NGS or other multiplexing technology panel.
Article - Billing and Coding: Platelet Rich Plasma Injections for Non-Wound Injections (A58737)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Platelet Rich Plasma Injections for Non-Wound Injections L39023.
Article - Billing and Coding: Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ) (A58739)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Minimally invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ)L39025.Coding InformationProcedure codes may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and National Provider Identifier (NPI) of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See Indications and Limitations of Coverage section) This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Medical record documentation must be available to Medicare upon request.
Article - Billing and Coding: Respiratory Pathogen Panel Testing (A58741)
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) L39027, 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 (A58741)
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: Epidural Steroid Injections for Pain Management (A58745)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 4, Section 280.14 Infusion PumpsCMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)Social 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) Epidural Steroid Injections for Pain Management. Please refer to the LCD for reasonable and necessary requirements.The services addressed in this article only apply to epidural injections. Other joint procedures (e.g. sacral injections, facet joint injections) are not addressed.Coding Guidance
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58745)
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.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 the NCCI requirements.An anatomic spinal region for epidurals is defined as cervical/thoracic (CPT codes 62321, 64479 and 64480) or lumbar/sacral (CPT codes 62323, 64483 and 64484).When epidural injections (62322-62327) are used for cerebrospinal fluid flow imaging, cisternography (78630), the diagnosis code restrictions in this article do not apply. These services should be billed on the same claim.When epidural injections (62321, 62323, 64479, 64480, 64483 or 64484) are used for postoperative pain management, the diagnosis code restrictions in this article do not apply.When epidural injection (62323) is used for an implantable infusion pump trial, the diagnosis code restrictions in this article do not apply.CPT codes 64479 and 64483 are used to report a single level injection performed with image guidance (fluoroscopy or CT). CPT codes 64480 and 64484 represent each additional level respectively and should be reported separately in addition to the primary procedure when applicable. 64480 and 64484 describes each additional level which should be reported separately in addition to the code for the primary procedure.A transforaminal epidural steroid injection (TFESI) performed at the T12-L1 level should be reported with CPT code 64479.When reporting CPT codes 64479 through 64484 for a unilateral procedure, use one line with one unit of service. For bilateral procedures regarding these same codes, use one line and append the modifier-50.
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58745)
When reporting CPT codes 64479 through 64484 for a unilateral procedure, use one line with one unit of service. For bilateral procedures regarding these same codes, use one line and append the modifier-50.For services performed in the ASC, physicians must continue to use modifier 50. Only the ASC Facility itself must report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each line.It is not medically reasonable and necessary to perform caudal ESIs or interlaminar ESIs bilaterally, therefore CPT 62321 and 62323 are not bilateral procedures.KX modifier requirements:A diagnostic selective nerve root block (DSNRB) is identically coded as an epidural injection. Therefore, when performing a DSNRB the -KX modifier should be appended to the appropriate line to distinguish the procedure from an epidural injection. Aberrant use of the -KX modifier may trigger focused medical review.Utilization ParametersOnly one spinal region may be treated per session (date of service).Consistent with the LCD, only two total levels per session are allowed for CPT codes 64479, 64480, 64483 and 64484. (Two unilateral or two bilateral levels). 64480 should be reported in conjunction with 64479 and 64484 should be reported in conjunction with 64483.Consistent with the LCD, CPT codes 62321 and 62323 may only be reported for one level per session.No more than 4 epidural injection sessions (CPT codes 62321, 62323, 64479, 64480, 64483, or 64484) may be reported per spinal region in a rolling 12-month period regardless of the number of levels involved.Documentation Requirements1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.2. 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: Epidural Steroid Injections for Pain Management (A58745)
3. 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.4.Selective nerve root blocks (SNRBs) and TFESIs: The procedural report should clearly document the indications and medical necessity for the injections, along with the baseline pain score. SNRBs only: The procedural report should include the baseline pain score and percent (%) pain relief achieved immediately after the injection.5. Films that adequately document (minimum of 2 views) final needle position and contrast flow should be retained and made available upon request.6. The patients medical record should include, but is not limited to:
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58745)
The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visitRelevant 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).Use of BiologicalsThere are currently no FDA approved biologicals for use as injectable agents into the epidural space or spine. 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 180. Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.Use of moderate or deep sedation, general anesthesia, and monitored anesthesia care (MAC) is usually unnecessary or rarely indicated for these procedures and not routinely reimbursable and therefore may be denied. In exceptional circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record individual consideration may be considered on appeal.
Article - Billing and Coding: MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing (A58747)
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 Syndromic Panels for Infectious Disease Pathogen Identification Testing L39038.To report a service for Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing, please submit the following claim information:Select the appropriate CPTor PLA codeIf the panel being used does not have its own proprietary CPTor PLA code, select the appropriate CPTcode and follow the additional instructions for the given 'panel' in the relevant Group paragraphs below. If no specific CPTcode exists for the test submitted, bill with CPTcode 87999.