evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) (A57047)
Documentation Requirements1. All documentation must be maintained in the patients medical record and 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 medical record documentation must support the medical necessity of the services as directed in this policy.4. The attending physician must monitor and document the patient's clinical progress during treatment. The attending physician must use evidence-based validated depression monitoring scales such as the Geriatric Depression Scale (GDS), the Personal Health Questionnaire Depression Scale (PHQ-9), the Beck Depression Scale (BDI), Hamilton Rating Scale for Depression (HAM-D), the Montgomery Asberg Depression Rating Scale (MADRS), the Quick Inventory of Depressive Symptomatology (QIDS) or the Inventory for Depressive Symptomatology Systems Review (IDS-SR) to monitor treatment response and the achievement of remission of symptoms.Utilization GuidelinesThe treatment must be provided by use of a device approved by the FDA for the purpose of supplying Transcranial Magnetic Stimulation.It is expected that the services would be performed as indicated by current medical literature and standards of practice. Services performed in excess of established parameters may be subject to review for medical necessity.TMS is reasonable and necessary for up to 20 visits over a 4 week period followed by five visits for tapering for those in remission. For those who show at least a 25% improvement by means of the standard tests for depression, the therapy may be continued for an additional 2 weeks (an additional 10 visits) with an additional 6 visits for tapering. Further treatment of an episode of depression beyond this, for patients who have not achieved at least a 50% reduction in symptoms will be considered not medically reasonable and necessary and not subject to coverage.
Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) (A57047)
Retreatment may be considered for patients who met the guidelines for initial treatment and subsequently developed relapse of depressive symptoms if the patient responded to prior treatments as evidenced by a greater than 50% improvement in standard rating scale measurements for depressive symptoms or if there were a relapse after remission...(e.g., (GDS), PHQ-9, BDI, HAM-D, MADRS, QIDS or IDS-SR score. A repeat treatment program is allowed as above.
Article - Billing and Coding: Polysomnography and Other Sleep Studies (A57049)
CMS National Coverage PolicyWhen the documentation 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.CMS Pub. 100-8,Program Integrity Manual, Chapter 13, Section 5.1CMS Publication100-03 Medicare National Coverage Determination (NCD) Manual) Chapter 1,Section 240.4.1 Sleep Testing for Obstructive sleep Apnea (OSA) (Effective March 3, 2009) andSection 240.4 Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) (Effective March 13, 2008)CMS Publication100-02 Medicare Benefit PolicyChapter 6, Section 50 Sleep Disorder ClinicsCMS Publication100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70 Sleep Disorder ClinicsCMS Decision Memo for Sleep Testing for Obstructive Sleep Apnea (OSA) (CAG-00405N)CMS Decision Memo for Continuous Positive Airway Pressure Therapy for Obstructive Sleep Apnea (CAG-00093R2)Italicized font-represents CMS national NCD language/wording copied directly from CMS Manuals or CMS Transmittals.  Contractors are prohibited from changing national NCD language/wording.Article TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L36902-Outpatient Psychiatry and Psychology Services.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.
Article - Billing and Coding: Polysomnography and Other Sleep Studies (A57049)
Advance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.
Article - Billing and Coding: Polysomnography and Other Sleep Studies (A57049)
The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering 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 must show that the polysomnography (95808, 95810 and 95811) was performed in a facility based sleep study laboratory and not in the home or a mobile facility.The sleep disorder clinic must have on file, in the patients record, documentation that narcolepsy symptoms are severe enough to interfere with the patients well-being and health.If more than two nights of testing are performed, documentation justifying the medical necessity for the additional test(s) must be available in the patients medical record.Documentation must show that the home sleep test (HST) (G0398, G0399 and G0400) were performed in conjunction with a comprehensive sleep evaluation and in patients with a high pretest probability of moderate to severe obstructive sleep apnea.The patient who undergoes a HST must receive, prior to the test, adequate instruction on how to properly apply a portable sleep monitoring device. This instruction must be provided by the provider conducting the HST.Documentation must show that the home sleep test was accomplished with a Medicare-approved device (e.g., description of channels monitored or clear indications of same included in the test report) and was performed by a physician meeting the training requirements listed in the Coverage Indications, Limitations, and/or Medical Necessity Section.Parameters monitored and documented:Start time and duration of day/night of study.
Article - Billing and Coding: Polysomnography and Other Sleep Studies (A57049)
Parameters monitored and documented:Start time and duration of day/night of study.Total sleep time, sleep efficiency, number/duration of awakenings.For tests involving sleep staging: time and percent time spent in each stage.For tests monitoring sleep latency or maintenance of wakefulness testing:latency to both Non-Rapid Eye Movement (NREM) and Rapid Eye Movement (REM) sleep.Individual sub-test sleep latencies, mean sleep latency and the number of REM occurrences on Multiple Sleep Latency Test (MSLT).Respiratory patterns including type (central/obstructive/periodic), number and duration, effect on oxygenation, sleep stage/body position relationship, and response to any diagnostic and/or therapeutic maneuvers.Cardiac rate/rhythm and any effect of sleep-disordered breathing on EKG.Detailed behavioral observations.EEG or EMG abnormalities.The patient is to be referred to the clinic by the attending physician. The physicians order must be kept in the medical record.Utilization GuidelinesMore than one HST per year interval would not be expected. If more than one HST session is performed for suspected OSA, persuasive medical evidence justifying the medical necessity for the additional tests will be required. Similarly, more than two PSG per year interval would not be expected. If more than two PSG sessions are performed for the diagnosis or adjustment of treatment of sleep, pervasive medical evidence justifying the medical necessity for the additional tests will be required upon request. When services are performed in excess of established parameters, they may be subject to review for medical necessity.The routine use of more than one PSG to titrate CPAP therapy would not be considered reasonable and necessary. If more than one CPAP titration PSG is claimed, persuasive medical evidence justifying the medical necessity for the additional tests may be requested.95805 MSLT- includes all the naps done in a single day. Only one (1) unit of service should be submitted.
Article - Billing and Coding: Post-Void Residual Urine and/or Bladder Capacity by Ultrasound (A57050)
CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy.  NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred 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.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Code of Federal Regulations:42 CFR, Section 410.32, indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).CMS Publications:CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 12:70 Payment conditions for radiology servicesCMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 13:20 Payment conditions for radiology services90 Services of portable X-Ray suppliersCMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 23:20.9Standards of medical surgical practice and the correct coding initiative (CCI).Article Text
Article - Billing and Coding: Post-Void Residual Urine and/or Bladder Capacity by Ultrasound (A57050)
This article gives guidance for billing, coding, and other guidelines in relation to local coverage policyL34085-Post-Void Residual Urine and/or Bladder Capacity by Ultrasound.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.Advance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.
Article - Billing and Coding: Post-Void Residual Urine and/or Bladder Capacity by Ultrasound (A57050)
Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:
Article - Billing and Coding: Post-Void Residual Urine and/or Bladder Capacity by Ultrasound (A57050)
The assessment of the patient by the ordering 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.)The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.The patient's clinical record should indicate the plan of treatment and any changes/alterations in medications prescribed for the treatment of the patient's condition. There must be an attending/treating physician's order for each test documented in the patient's medical/clinical record.The medical record should include the results of the test including documentation that the measurement was done immediately post-void, along with the date of the test, and identification of the person performing the test.Utilization ParametersCPT code 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging) should not be performed more than once per day.Services that exceed this parameter will be considered not medically necessary.
Article - Billing and Coding: Psychiatric Inpatient Hospitalization (A57052)
CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy.  NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following Centers for Medicare and Medicaid Services (CMS) sources:Title XVIII of the Social Security Act (SSA):Section 1812(a)(1) Inpatient hospital services defined.Section 1812(b)(3) Lifetime limit of 190 days for inpatient psychiatric benefit days.Section 1814(4) Medical Records document that services were furnished while the individual was receiving intensive treatment, admission and related services for a diagnostic study, or equivalent services requirement.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1835(a) Physician certification as a requirement.Section 1861(a), 1861(c), and 1861(f) "Spell of illness", "inpatient psychiatric hospital services",  "psychiatric hospital", "medical and other health services" defined.Section 1862(a)(1)(A) excludes expenses incurred 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.Code of Federal Regulations:42 CFR Section 409.62 describes the lifetime maximum on inpatient psychiatric care.42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).42 CFR Section 411.4(a) states that the Medicare Program does not pay for services if the beneficiary has no legal obligation to pay.42 CFR Section 411.8(a) states that the Medicare Program does not pay for services if the services are paid for directly or indirectly by a governmental entity.CMS Publications:
Article - Billing and Coding: Psychiatric Inpatient Hospitalization (A57052)
CMS Publication 100-01,Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4:10 Certification and Recertification by Physicians for Hospital Services - General10.1 Failure to Certify or Recertify for Hospital Services10.2 Who May Sign Certification or Recertification10.4 Inpatient Hospital Services Certification and Recertification10.5 Selection by Hospital of Format and Method for Obtaining Statement10.9 Inpatient Psychiatric Facility Hospital Services Certification and Recertification10.20.2 Timing for Certification and Recertification for a Beneficiary Admitted Before EntitlementCMS Publication 100-01,Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5:20.3 Psychiatric Hospital20.4 Certification of Parts of Institutions as a Psychiatric Hospital20.5 Part of a Psychiatric Institution as a Psychiatric Hospital20.6 General Hospital Facility of Psychiatric Hospital20.7 Part of a General Hospital as a Psychiatric HospitalCMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 210 Inpatient Psychiatric Facility Services10.1 Background10.2 Statutory Requirements10.3 Affected Medicare Providers20 Admission Requirements30 Medical Records Requirements30.1 Development of Assessment/Diagnostic Data30.2 Psychiatric Evaluation30.2.1 Certification and Recertification Requirements30.2.1.1 Certification30.2.1.2 Recertification30.2.2 Active Treatment30.2.2.1 Principles for Evaluating a Period of Active Treatment30.2.3 Services Supervised and Evaluated by a Physician30.3 Treatment Plan30.3.1 Individualized Treatment or Diagnostic Plan30.3.2 Services Expected to Improve the Condition or for Purpose of Diagnosis30.4 Recording Progress30.5 Discharge Planning and Discharge Summary40 Personnel Requirements40.1 Director of Inpatient Psychiatric Services; Medical Staff40.2 Nursing Services50 Psychological Services60 Social Services70 Therapeutic Activities80 Benefit Application90 Benefits ExhaustCMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 4:10 Inpatient Psychiatric Benefit Days Reduction10.1 Patient Status on Day of Entitlement10.2 Institution's Status in Determining Days Deducted20 Days of Admission, Discharge, and Leave30 Reduction for Psychiatric Services in General Hospitals40 Determining Days Available50 Inpatient Psychiatric Hospital Services  Lifetime LimitationCMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 16:50.3.1Application of Exclusion to State and Local Government