evekhm/cms_iom_500 huggingface dataset:
Draft Article - Billing and Coding: Transesophageal Echocardiography (TEE) (DA52868)
Use procedure code 93314 or 93317 where the provider is reporting the actual manipulation of the probe to obtain images and to provide an interpretation and report. Code 93317 is reserved for congenital anomalies only.CPT code 93318 (C8927 for OPPS billing when contrast is used) (intraoperative monitoring) is considered part of an anesthesia service and should not be billed separately by the anesthesiologist.CPT codes 76376 and 76377 and 93319 (3D echocardiography) should be billed in conjunction with the base code for the imaging procedure. For the purposes of this LCD, the base codes for CPT 76376 and 76377 are 93312, 93314, C8925, 93315, C8926, and 93317 and the base codes for CPT 93319 are 93312, 93314, 93315, C8926, and 93317.Diagnosis codingICD-10-CM code R93.1 or R93.8 should be reported when a TEE (CPT codes 93312, 93313, and 93314) is performed because of inadequate visualization of cardiac anatomy on TTE, for structures normally visualized by TTE and for which TEE is not usually indicated. ICD-10-CM code R93.1 or R93.8 should be reported as the primary diagnosis and the cardiac abnormality should be coded as a secondary diagnosis.ICD-10-CM code Z01.89 should be reported when a TEE is performed during an open chest procedure. ICD-10-CM code Z01.89 should be reported as the primary diagnosis and the reason for the surgical procedure should be coded as the secondary diagnosis.For add-on CPT codes 93319, 93320, 93321 and 93325, the ICD-10-CM codes reported should be the same as those reported for the base codes to which they are attached.Bundled servicesProcedure 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.
Draft Article - Billing and Coding: Transesophageal Echocardiography (TEE) (DA52868)
Bundled servicesProcedure 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.CPT codes 93312-93318 include conscious sedation. Therefore sedation should not be billed separately, and if it is, will be bundled into the primary procedure code.For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.For claims submitted to the Part A MAC:The OPPS does not apply to claims for every type of bill submitted by Medicare-certified providers. The following guidelines pertain to claims for bill types that are subject to the OPPS:Hospitals are required to include HCPCS codes for all services paid under the OPPS.HCPCS codes C8925, C8926, and C8927 should be used to report transesophageal echocardiography services by OPPS hospitals when contrast is used. If the transesophageal echocardiography services are performedwithoutcontrast, OPPS hospitals should report CPT codes from the 9xxxx series, as appropriate.
Draft Article - Billing and Coding: Transesophageal Echocardiography (TEE) (DA52868)
Every effort should be made to report all services performed on the same day on the same claim to assure proper payment under the OPPS. Claims submitted for the same date of service will be returned to the provider (except duplicates or those containing condition code 20 or 21) with a notification that an adjustment bill should be submitted (CMS Program Memorandum, Transmittal No. A-00-36, Change Request #1229, June 2000).Documentation Requirements:A covered service must include a complete interpretation/report by the performing physician, and must be available if requested.The patient's medical record must contain documentation that fully supports the medical necessity for services included within the attached 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, as well as reasons for repeat testing.In those instances in which repeat tests were denied, the physician must document a good faith effort was made to identify them and to request copies of them from previous providers, in order for NGS to consider reimbursement for such tests on appeal.Each service requires a formal written report with interpretation. This report should be kept on file with copies of image documentation (paper or tape) for review if requested. All appropriate measurements should be included in the report.A Doppler interrogation should state the modes used and should give both qualitative and quantitative information.Documentation of the qualifications of personnel performing tests, as described in the Indications section of the LCD, should be available on request.All documentation must be submitted upon request.Utilization Guidelines:
Draft Article - Billing and Coding: Transesophageal Echocardiography (TEE) (DA52868)
TEE services will be covered twice per year for all conditions except endocarditis (ICD-10 code I39), for which four (4) services per year will be covered.TEE may be repeated in patients with repeat episodes of atrial fibrillation/flutter prior to cardioversion.Services exceeding this parameter will be considered not medically necessary, unless there is documentation that the tests were performed for clinical indications reflecting a change in the patients status or underlying cardiac condition, or documentation of a new unrelated condition, sign or symptom.In those instances in which repeat tests were denied and a physician has documented a good faith effort to identify them and to request copies of them from previous providers, then NGS could reimburse such tests on appeal.These guidelines do not apply to tests performed on hospital inpatients.
Draft Article - Billing and Coding: MolDX: Gene Expression Profile Tests for Decision-Making in Castration Resistant and Metastatic Prostate Cancers (DA59462)
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: Intraosseous Basivertebral Nerve Ablation (DA59466)
CMS National Coverage PolicyN/AArticle Text
Draft Article - Billing and Coding: Intraosseous Basivertebral Nerve Ablation (DA59466)
Refer to the Local Coverage Determination (LCD) DL39642 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 identification of Type 1 or Type 2 Modic changes within the vertebral body identified for treatment. 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.Previous BVN ablation of a named vertebral body precludes coverage for additional BVN ablation for that level vertebral body.
Draft Article - Billing and Coding: Intraosseous Basivertebral Nerve Ablation (DA59466)
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 DL39642without 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 one vertebral level may be treated at one session and may not be combined with any other paravertebral injection or intervention (facet or epidural). 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 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:
Draft Article - Billing and Coding: Intraosseous Basivertebral Nerve Ablation (DA59466)
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, allergies and medications utilized at the time of the procedure and preceding 6 months.Results of pertinent tests/procedures including date and professional interpretation of results.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.
Article - Billing and Coding: Intraosseous Basivertebral Nerve Ablation (A59466)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Intraosseous Basivertebral Nerve Ablation (A59466)
Refer to the Local Coverage Determination (LCD) L39642 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 (A59466)
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 described in the corresponding LCD L39642 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 (A59466)
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: Intraosseous Basivertebral Nerve Ablation (DA59468)
CMS National Coverage PolicyN/AArticle Text
Draft Article - Billing and Coding: Intraosseous Basivertebral Nerve Ablation (DA59468)
Refer to the Local Coverage Determination (LCD) DL39644 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 identification of Type 1 or Type 2 Modic changes within the vertebral body identified for treatment. 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.Previous BVN ablation of a named vertebral body precludes coverage for additional BVN ablation for that level vertebral body.
Draft Article - Billing and Coding: Intraosseous Basivertebral Nerve Ablation (DA59468)
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 DL39644 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 one vertebral level may be treated at one session and may not be combined with any other paravertebral injection or intervention (facet or epidural). 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 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:
Draft Article - Billing and Coding: Intraosseous Basivertebral Nerve Ablation (DA59468)
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, allergies and medications utilized at the time of the procedure and preceding 6 months.Results of pertinent tests/procedures including date and professional interpretation of results.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.
Article - Billing and Coding: Intraosseous Basivertebral Nerve Ablation (A59468)
CMS National Coverage PolicyN/AArticle Text