evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual Crosswalk)
The principal diagnosis code will include the use of V codes where ICD -9-CM is applicable.  Where the proper code has fewer than five digits (ICD -9-CM) or seven digits (ICD -10-CM), the hospital may not fill with zeros.  The principal diagnosis is the condition established after study to be chiefly responsible for this admission.  Even though another diagnosis may be more severe than the principal diagnosis, the hospital enters the principal diagnosis.  Entering any other diagnosis may result in incorrect assignment of a Diagnosis Related Group (DRG) and cause the hospital to be incorrectly paid under PPS.  The hospital reports the full ICD code for the diagnosis shown to be chiefly responsible for the outpatient services i n FL 67 of the bill.  It reports the diagnosis to its highest degree of certainty.  For instance, if the patient is seen on an outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom must be reported.  If during the course of the outpatient evaluation and treatment a definitive diagnosis is made (e.g., acute bronchitis), the hospital must report the definitive diagnosis.  When a patient arrives at the hospital for examination or testing without  a referring diagnosis and cannot provide a complaint, symptom, or diagnosis, the hospital should report an ICD code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations.  FLs 67A -67Q - Other Diagnosis Codes   Situational. Required when other condition(s) coexist or develop(s) subsequently during the patients treatment.   FL 68  Reserved   Not used. Data entered will be ignored.   FL 69 - Admitting Diagnosis   Required . For inpatient hospital claims subject to QIO review, the admitting diagnosis is required.  Admitting diagnosis is the condition identified by the physician at the time of the patients admission requiring hospitalization.   FL70A  70C - Patients Reason for Visit
(Medicare Claims Processing Manual Crosswalk)
FL70A  70C - Patients Reason for Visit   Situational.  It is required for Medicare institutional claims processing on Type of Bill 013x and 085x when: a) Form Locator 14 (Priority (Type) of Admission or Visit) codes 1, 2, or 5 are reported; and b) Revenue Codes 045x, 0516, or 0762 are reported.  The requirement for reporting Patients Reason for Visit is restricted to the outpatient bill types above.   If the Patients Reason for Visit is not required, it may be reported on other 013x and 085x bill types that fail to meet the criteria in a) or b) above at the senders discretion when this information substantiates the medical necessity of services.   FL71  Prospective Payment System (PPS) Code   Not used. Data entered will be ignored.   FL72 - External Cause of Injury (ECI) Codes   Not used. Data entered will be ignored.   FL 73  Reserved   Not used. Data entered will be ignored.   FL 74 - Principal Procedure Code and Date   Situational. Required on inpatient claims when a procedure was performed. Not used on outpatient claims.   FL 74A  74E - Other Procedure Codes and Dates   Situational. Required on inpatient claims when additional procedures must be reported. Not used on outpatient claims.   FL 75  Reserved   Not used. Data entered will be ignored.   FL 76 - Attending Provider Name and Identifiers (including NPI)   Situational. Required when claim/encounter contains any services other than nonscheduled transportation services. If not required, do not send.  The attending provider is the individual who has overall responsibility for the patients medical care and treatment reported in this claim/ encounter.   Secondary Identifier Qualifiers:   0B - State License Number   1G - Provider UPIN Number   G2  Provider Commercial Number   FL 77 - Operating Provider Name and Identifiers (including NPI)   Situational. Required when a surgical procedure code is listed on this claim. If not required, do not send.  The name and identification number of the individual with the primary responsibility for performing the surgical procedure(s).   Secondary Identifier Qualifiers:   0B - State License Number   1G - Provider UPIN Number   G2  Provider Commercial Number   FLs 78 and 79 - Other Provider Name and Identifiers (including NPI)
(Medicare Claims Processing Manual Crosswalk)
Secondary Identifier Qualifiers:   0B - State License Number   1G - Provider UPIN Number   G2  Provider Commercial Number   FLs 78 and 79 - Other Provider Name and Identifiers (including NPI)   Situational . The name and ID number of the individual corresponding to the qualifier category indicate d in this section of the claim.   Provider Type Qualifier Codes/Definition/Situational Usage Notes:   DN - Referring Provider. The provider who sends the patient to another provider for services. Required on an outpatient claim when the Referring Provider is different than the Attending Physician. If not required, do not send.   ZZ - Other Operating Physician.  An individual performing a secondary surgical procedure or assisting the Operating Physician.  Required when another Operating Physician is involved.  If not required, do not send.  82 - Rendering Provider.  The health care professional who delivers or completes a particular medical service or non-surgical procedure.  Report when state or federal regulatory requirements call for a combined claim, i.e., a claim that includes both facility and professional fee components (e.g., a Medicaid clinic bill or Critical Access Hospital claim).  If not required, do not send.  Secondary Identifier Qualifiers:   0B - State License Number   1G - Provider UPIN Number   G2  Provider Commercial Number   FL 80  Remarks   Situational.  For DME billings the provider shows the rental rate, cost, and anticipated months of usage so that the providers A/B MAC (A or HH H) may determine whether to approve the rental or purchase of the equipment.  Where Medicare is not the primary payer because WC, automobile medical, no-fault, liability insurer or an EGHP is primary, the provider enters special annotations.  In addition, the provider enters any remarks needed to provide information that is not shown elsewhere on the bill but which is necessary for proper payment.  For Renal Dialysis Facilities, the provider enters the first month of the 30-month period during which Medicare benefits are secondary to benefits payable under an EGHP. (See Occurrence Code 33.)   FL 81 - Code -Code Field   Situational.  To report additional codes related to a Form Locator or to report external code list approved by the NUBC for inclusion to the institutional data set.
(Medicare Claims Processing Manual Crosswalk)
FL 81 - Code -Code Field   Situational.  To report additional codes related to a Form Locator or to report external code list approved by the NUBC for inclusion to the institutional data set.   Codes used for Medicare claims are available from Medicare contractors.  Codes are also available from the NUBC (www.nubc.org) via the NUBCs Official UB-04 Data Specifications Manual.
(Medicare Claims Processing Manual Crosswalk)
80  Reserved  Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12423CP  12/20/2023  Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92  01/02/2024  13222  R10880CP  08/06/2021  Internet Only Manual Updates to Pub. 100-01, 100- 02, and 100- 04 to Implement Consolidated Appropriations Act Changes and Correct Errors and Omissions (SNF)  11/08/2021  12009 R4194CP  01/11/2019  Update to Publication (Pub.) 100- 04 Chapter 25 to Provide Language -Only Changes for the New Medicare Card Project  02/12/2019  11091 R3709CP  02/03/2017  Internet Only Manual (IOM) Chapter 25 Revision 04/04/2017  9964 R3435CP  12/31/2015  Clarification on Patients Reason for Visit Necessary to Capture HIPAA Compliant Fields  03/31/2016  9450 R2922CP  04/03/2014  Medicare Claims Processing Pub. 100- 04 Chapter 25 Update  04/18/2014  8577 R2874CP  02/06/2014  Medicare Claims Processing Pub. 100- 04 Chapter 25 Update  Rescinded and replaced by Transmittal 2922 03/07/2014  8577 R2683CP  04/05/2013  Non-systems Internet Only Manual (IOM) Changes  06/05/2013  8220 R2250CP  07/01/2011  Non-systems Internet Only Manual (IOM) Changes  08/01/2011  7437 R1973CP  05/21/2010  Internet Only Manual (IOM) Chapter 25 Revisions  09/01/2010  6907 R1946CP  04/15/2010  Billing and Processing Claims with Unlimited Occurrence Span Codes (OSCs)  07/06/2010  6777 Rev #  Issue Date  Subject  Impl Date  CR#  R1934CP  03/19/2010  Billing and Processing Claims with Unlimited Occurrence Span Codes (OSCs)  Rescinded and replaced by Transmittal 1946 07/06/2010  6777 R1932CP  03/17/2010  Dialysis Adequacy, Infection and Vascular Access Reporting  07/06/2010  6782 R1929CP  03/09/2010  Point of Origin for Admission or Visit Codes Update to the UB -04 (CMS
(Medicare Claims Processing Manual Crosswalk)
Dialysis Adequacy, Infection and Vascular Access Reporting  07/06/2010  6782 R1929CP  03/09/2010  Point of Origin for Admission or Visit Codes Update to the UB -04 (CMS -1450) Manual Code List  07/06/2010  6801 1917CP  02/05/2010  Point of Origin for Admission or Visit Codes Update to the UB -04 (CMS -1450) Manual Code List -  Rescinded and replaced by Transmittal 1929 07/06/2010  6801 R1915CP  02/05/2010  Non-systems Internet Only Manual Chapter 25 Changes  04/14/2010  6788 R1898CP  01/29/2010  Dialysis Adequacy, Infection and Vascular Access Reporting  - Rescinded and replaced by Transmittal 1932 07/06/2010  6782 R1877CP  12/18/2009  Instructions Regarding Processing Claims Rejecting for Gender/Procedure Conflict  04/05/2010  6638 R1839CP  10/28/2009  Instructions Regarding Processing Claims Rejecting for Gender/Procedure Conflict - Rescinded and replaced by Transmittal 1877 04/05/2010  6638 R1775CP  07/24/2009  Point of Origin Codes Update to the UB -04 (CMS -1450) Manual Code List  01/04/2010  6478 R1767CP  07/10/2009  IOM Chapter 25 Revenue Code 076X Description Change  08/10/2009  6561 R1718CP  04/24/2009  New Patient Discharge Status Code 21 to Define Discharges or Transfers to Court/Law Enforcement  10/05/2009  6385 Rev #  Issue Date  Subject  Impl Date  CR#  R1555CP  07/18/2008  Revision of the Requirements for Denial of Payment for New Admissions (DPNA) for Skilled Nursing Facility (SNF) Billing  01/05/2009  6116 R1496CP  05/02/2008  Medicare Shared Systems Modifications Necessary to Capture and Crossover Medicaid Drug Rebate Data Submitted on form UB -04 Paper Claims and Direct Data Entry (DDE) Claims  10/06/2008  5950 R1395CP  12/14/2007  Updated National Uniform Billing Committee (NUBC) Codes and Other Internet Only Manual Chapter 25 Revisions  01/07/2008  5850 R1361CP  11/02/2007  New Patient Status Discharge Code 70 to Define Discharges or Transfers to
(Medicare Claims Processing Manual Crosswalk)
Updated National Uniform Billing Committee (NUBC) Codes and Other Internet Only Manual Chapter 25 Revisions  01/07/2008  5850 R1361CP  11/02/2007  New Patient Status Discharge Code 70 to Define Discharges or Transfers to Other Types of Health Care Institutions not Defined Elsewhere in the UB -04 (CMS -1450) Manual Code List  04/07/2008  5764 R1254CP  05/25/2007  National Uniform Billing Committee (NUBC) Update to Chapter 25 06/11/2007  5593 R1104CP  11/03/2006  Uniform Billing (UB -04) Implementation 03/01/2007  5072 R1078CP  10/13/2006  Updating the Medicare Secondary Payer (MSP) Manual for Consistency on Instructing Part A Contactors on Handling MSP Claims with Condition Code (cc) 08  04/02/2007  5266 R1018CP  07/28/2006  Uniform Billing (UB -04) Implementation 03/01/2007  5072 R980CP  06/14/2006  Changes Conforming to CR 3648 Instructions for Therapy Services -  Replaces Rev. 941 10/02/2006  4014 R941CP  05/05/2006  Changes Conforming to CR 3648 Instructions for Therapy Services  10/02/2006  4014 Rev #  Issue Date  Subject  Impl Date  CR#  R901CP  04/07/2006  New National Uniform Billing Committee (NUBC) Codes and Other Chapter 25 Revisions  05/08/2006  4384 R529CP  04/22/2005  Update to Current National Uniform Billing Committee (NUBC) Codes.  07/05/2005  3794 R493CP  03/04/2005  Revision to Chapter 1 and Removal of Section 70 from Chapter 25 of the Medicare Claims Processing Manual  04/04/2005  3671 R368CP  11/12/2004  Instructions for Completion of Form CMS -1450 04/04/2005  3543 R311CP  10/08/2004  Relocation of Sections 20 and 30 to Chapter 24
(Medicare Claims Processing Manual Crosswalk)
Clarification of Noncovered Days, Patient Status Codes and Revenue Codes   New Condition Codes and Value Codes  1/5/2005 3417 R303CP  09/24/2004  Relocation of Sections 20 and 30 to Chapter 24  Clarification of Noncovered Days, Patient Status Codes and Revenue Codes   New Condition Codes and Value Codes  01/05/2005  3417 R199CP  06/10/2004  Rejection of Any Outpatient Claim Containing a Range of Dates in the Line Item Date of Service (LIDOS) Field  10/04/2004  3337 R167CP  4/30/2004 Replacement of Revenue Code 0910 by Revenue Code 0900 to Report Certain Psychiatric/ Psychological Treatment and Services.   Addition of Provider Range 4900- 4999 to the Applicable Provider Ranges for Community Mental Health Centers  10/04/2004  3194 Rev #  Issue Date  Subject  Impl Date  CR#  R149CP  04/23/2004  Update for New Condition Code, and to Clarify Patient Status Codes and Revenue Code 0910 10/04/2004  3183 R107CP  02/24/2004  Changes in X12N937 Institutional Edits  07/06/2004  3031 R081CP  02/06/2004  New Condition and Value Codes Approved by the National Uniform Billing Committee (NUBC) and Addition of All NUBC Approved Codes that Were Not Previously in Medicare Instructions, to Be Complaint With the HIPAA Requirements  07/06/2004  3012 R001CP  10/01/2003  Initial Publication of Manual  NA NA Back to top of chapter
Article - Billing and Coding: MolDX: NRAS Genetic Testing (A57486)
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 On-Line Manual, Publication 100-08, Medicare Benefit Policy Manual, Chapter 3,  3.4.1.3, Diagnosis Code Requirements.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.To report a NRAS Genetic Testing 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 837PItem19 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: NRAS Genetic Testing (A57487)
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 On-Line Manual, Publication 100-08, Medicare Benefit Policy Manual, Chapter 3,  3.4.1.3, Diagnosis Code Requirements.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.To report a NRAS Genetic Testing service, 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 837PItem19 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
Article - Billing and Coding: Polysomnography and Sleep Testing (A57496)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 4, Section 240.4 Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) and Section 240.4.1 Sleep Testing for Obstructive Sleep Apnea (OSA)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: Polysomnography and Sleep Testing (A57496)
Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33405, Polysomnography and Sleep Testing. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNon-attended sleep studies should be billed with the CPT/HCPCS code that most accurately describes the service.CPT code 95811 alone should be billed for split night studies as CPT code 95811 in this instance is inclusive of CPT code 95810. (Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist)For a study to be reported as polysomnography (PSG), sleep must be recorded and staged and directly attended by a qualified technologist. Report with modifier 52 if less than 6 hours of recording or in other cases of reduced services.CPT codes 95782, 95783, 95808, 95810, and 95811 include sleep staging. Medicare would not expect to see separate billings for an EEG, EOG, and/or EMG in addition to these codes.CPT code 95808 includes reimbursement for one to three additional parameters. CPT codes 95782, 95783, 95810 and 95811 include four or more additional parameters. Therefore, Medicare would not expect to see separate billings for additional parameters in addition to codes 95782, 95783, 95808, 95810, or 95811. Additional parameters of sleep include:ECGAirflowVentilation and respiratory effortGas exchange by oximetry, transcutaneous monitoring or end tidal gas analysisExtremity muscle activity and motor activity movementExtended EEG monitoringPenile tumescenceGastroesophageal refluxContinuous blood pressure monitoringSnoringBody positionsNotice: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 Requirements
Article - Billing and Coding: Polysomnography and Sleep Testing (A57496)
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.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.An order from the treating physician/nonphysician practitioner as required by CFR, Title 42, Volume 2, Chapter IV, Part 410.21 (a) Ordering diagnostic tests.When billing for a sleep disorder test, the ordering physicians NPI must be indicated on the claim form and the order kept on record.Documentation must support that the accreditation, credentialing, and training requirements as stated in the LCD were met for the clinic, technologist, and physician.
Article - Billing and Coding: Chest X-Ray Policy (A57497)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made for items or services which "are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member."Title XVIII of the Social Security Act, 1862(a)(7) and 42 Code of Federal Regulations (CFR) 411.15(a)(1), exclude routine physical examinations.Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80, Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests, sets forth the levels of physician supervision required for furnishing the technical component of diagnostic tests for a Medicare beneficiary who is not a hospital inpatient or outpatient.CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.4-80.4.4, Coverage of Portable X-Ray Services Not Under the Direct Supervision of a Physician applicability of health and safety standards apply to all suppliers of portable x-ray services and the scope of portable x-ray benefit and exclusions from coverage as portable x-ray services.CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 250, Medical and Other Health Services Furnished to Inpatients of Hospitals and Skilled Nursing Facilities including payments under arrangement.42 CFR 486.100, stipulates that portable X-rays must comply with Federal, State, and local laws and regulations.CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3, Diagnoses Code Requirement.42 Code of Federal Regulations, 410.32, addresses diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
Article - Billing and Coding: Chest X-Ray Policy (A57497)
42 Code of Federal Regulations, 410.32, addresses diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, 100 and 100.1, Interpretation of Diagnostic Tests describes how physicians should handle billing when two providers read a chest X-ray. Medicare will pay for the interpretation and report that directly contributes to the diagnosis and treatment of the individual patient.CMS Manual System, Pub, 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.6.1, Definitions.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.