evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: MolDX: Proteomics Testing (A59636)
A test is not considered a proteomics test if:The clinical validity of the test rests with the analytes measured directly and not the interactions of analytes measured as an output of the informatic approach;Is better defined as a genomics test, with DNA and RNA components as the majority or essential analytes measured;The protein analytes measured are not necessary for the clinical validity of the resultProteomics tests as defined above must be billed with an appropriate CPT code. These may be found in the Multianalyte CPT code set or may utilize the NOC code 81599; or may be defined by a relevant PLA code.Given the complexity of these tests and the ambiguity of services rendered, all proteomics tests in MolDX jurisdictions must register with the DEXDiagnostics Exchange Registry and obtain a Z-Codeidentifier. To determine if the submitted tests are compliant with relevant policy requirements, these tests will undergo Technical Assessment by Palmetto GBA as part of the MolDX program. This is effective 1/31/2024.To report a proteomics test service, please submit the following claim information:Select 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 codeNOTE:When entering the DEX Z-Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: MolDX: Proteomics Testing (A59641)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manuals, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Diagnostic Tests (MDT) L35160.Proteins are common analytes and a staple of clinical laboratory testing. Tests measuring proteins are typically found across all CPT Pathology and Laboratory code sets, except for Molecular Pathology (CPT 81105-81408), which is the general scope of the MolDX program.With advances in laboratory testing, more complex services utilizing proteins have developed. Many of these tests are multianalyte tests that seek to measure more than the presence or absence of expression of any given protein or groups of proteins. The term proteomics is commonly used for such tests.Proteomics tests are hereby defined by this contractor as those tests that seek to measure the structure, function, interactions, and compositions of proteins for the sake of understanding cellular interactions of the patient in relation to disease or therapeutic interventions. These services may include the measurement of other, non-protein analytes as part of this process. Of note, it is the interaction of proteins and other analytes that is the essential component of a proteomics test, and not the presence, structure or expression of individual proteins.To be considered a proteomics test, a test must:Be a multianalyte test that includes proteins as the major or essential analytes;Measure the interactions between analytes, including proteins;Require the use of informatics (nomograms, rubrics, or algorithms) to yield a result;Demonstrate the clinical validity of the assay as a function of the interaction of analytes measured
Article - Billing and Coding: MolDX: Proteomics Testing (A59641)
A test is not considered a proteomics test if:The clinical validity of the test rests with the analytes measured directly and not the interactions of analytes measured as an output of the informatic approach;Is better defined as a genomics test, with DNA and RNA components as the majority or essential analytes measured;The protein analytes measured are not necessary for the clinical validity of the resultProteomics tests as defined above must be billed with an appropriate CPT code. These may be found in the Multianalyte CPT code set or may utilize the NOC code 81599; or may be defined by a relevant PLA code.Given the complexity of these tests and the ambiguity of services rendered, all proteomics tests in MolDX jurisdictions must register with the DEXDiagnostics Exchange Registry and obtain a Z-Codeidentifier. To determine if the submitted tests are compliant with relevant policy requirements, these tests will undergo Technical Assessment by Palmetto GBA as part of the MolDX program. This is effective 1/31/2024.To report a proteomics test service, please submit the following claim information:Select 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 837PItem 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 codeNOTE:When entering the DEX Z-Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: MolDX: Proteomics Testing (A59642)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manuals, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Diagnostic Tests (MDT) L36256.Proteins are common analytes and a staple of clinical laboratory testing. Tests measuring proteins are typically found across all CPT Pathology and Laboratory code sets, except for Molecular Pathology (CPT 81105-81408), which is the general scope of the MolDX program.With advances in laboratory testing, more complex services utilizing proteins have developed. Many of these tests are multianalyte tests that seek to measure more than the presence or absence of expression of any given protein or groups of proteins. The term proteomics is commonly used for such tests.Proteomics tests are hereby defined by this contractor as those tests that seek to measure the structure, function, interactions, and compositions of proteins for the sake of understanding cellular interactions of the patient in relation to disease or therapeutic interventions. These services may include the measurement of other, non-protein analytes as part of this process. Of note, it is the interaction of proteins and other analytes that is the essential component of a proteomics test, and not the presence, structure or expression of individual proteins.To be considered a proteomics test, a test must:Be a multianalyte test that includes proteins as the major or essential analytes;Measure the interactions between analytes, including proteins;Require the use of informatics (nomograms, rubrics, or algorithms) to yield a result;Demonstrate the clinical validity of the assay as a function of the interaction of analytes measured
Article - Billing and Coding: MolDX: Proteomics Testing (A59642)
A test is not considered a proteomics test if:The clinical validity of the test rests with the analytes measured directly and not the interactions of analytes measured as an output of the informatic approach;Is better defined as a genomics test, with DNA and RNA components as the majority or essential analytes measured;The protein analytes measured are not necessary for the clinical validity of the resultProteomics tests as defined above must be billed with an appropriate CPT code. These may be found in the Multianalyte CPT code set or may utilize the NOC code 81599; or may be defined by a relevant PLA code.Given the complexity of these tests and the ambiguity of services rendered, all proteomics tests in MolDX jurisdictions must register with the DEXDiagnostics Exchange Registry and obtain a Z-Codeidentifier. To determine if the submitted tests are compliant with relevant policy requirements, these tests will undergo Technical Assessment by Palmetto GBA as part of the MolDX program. This is effective 1/31/2024.To report a proteomics test service, please submit the following claim information:Select 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 837PItem 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 codeNOTE:When entering the DEX Z-Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA57826)
CMS National Coverage PolicyN/AArticle Text&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;panel&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;Refer to the Local Coverage Determination (LCD) Facet Joint Interventions for Pain Management, 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. 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.
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA57826)
Coding GuidanceProviders should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.This policy applies only to cervical/thoracic or lumbar facet procedures and does not apply to other joint procedures (such as sacral injections, sacroiliitis, epidural or other spinal procedures).Diagnostic and Therapeutic procedures:Each facet level in the spinal region is composed of bilateral facet joints (i.e., there are two facet joints per level, one on the right side and one on the left). Unilateral or bilateral facet interventions may be performed during the facet joint procedure (a diagnostic nerve block, a therapeutic facet joint (intraarticular) injection, a medial branch block injection, or the medial branch radiofrequency ablation (neurotomy) in one session. A bilateral intervention is still considered a single level intervention.Each unilateral or bilateral intervention at any level should be reported as one unit, with bilateral intervention signified by appending the modifier -50.
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA57826)
Regions:An anatomic spinal region for paravertebral facet joint block (diagnostic or therapeutic), is defined as cervical\thoracic (CPT codes 64490, 64491, 64492) or lumbar\sacral (CPT codes 64493, 64494, 64495) per the AMA CPT Manual.Levels:64490 (cervical or thoracic) or 64493 (lumbar or sacral) reports a single level injection performed with image guidance (fluoroscopy or CT). Procedures performed under ultrasound guidance are not covered.64491 or 64494 describes a second level which should be reported separately in addition to the code for the primary procedure. 64491 should be reported in conjunction with 64490 and 64494 should be reported in conjunction with 64493.64492 or 64495 describes a third and additional levels and should be listed separately in addition to the code for the primary procedure and the second level procedure and cannot be reported more than once per day. 64492 should be reported in conjunction with 64490/64491 and 64495 should be reported in conjunction with 64493/64494.Laterality:Bilateral paravertebral facet injection procedures 64490 through 64495 should be reported with modifier 50.One to two levels, either unilateral or bilateral, are allowed per session per spine region (i.e., two (2) unilateral or to two (2) bilateral levels per session).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 line.KX modifier requirements:The KX modifier should be appended to the line for all diagnostic injections. In most cases the KX modifier will only be used for the two initial diagnostic injections. If the initial diagnostic injections do not produce a positive response as defined by the policy and are not indicative of identification of the pain generator, and it is necessary to perform additional diagnostic injections, at a different level, append the KX modifier to the line. Aberrant use of the KX modifier may trigger focused medical review.Therapeutic injections:
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA57826)
Therapeutic injections:Documentation of why patient is not a candidate for RFA must be submitted for therapeutic treatment.Chemodenervation of nerve:Codes 64633, 64634, 64635, 64636are reported per joint, not per nerve. Although two nerves innervate each facet joint, only one unit per code may be reported for each joint denervated, regardless of the number of nerves treated (AMA CPT Manual 2020).Each unilateral or bilateral intervention at any level should be reported as one unit, with bilateral intervention signified by appending the modifier -50.
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA57826)
Region:An anatomic spinal region for thermal facet joint denervation is defined as cervical/thoracic (CPT codes 64633 and 64634) or lumbar/sacral (CPT codes 64635 and 64636) per the AMA CPT Manual.For neurolytic destruction of the nerves innervating the T12-L1 paravertebral facet joint, use 64633Levels:64633 or 64635 describes a single level destruction by neurolytic agent performed with image guidance (fluoroscopy or CT)64634 or 64636 describes each additional level which should be reported separately in addition to the code for the primary procedure. 64634 should be used in conjunction with 64633 and 64636 should be used in conjunction with 64635.Laterality:For bilateral procedures report modifier 50 on each line in which the intervention was of a bilateral nature.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 line.Non-thermal facet joint denervation (including chemical, low grade thermal energy (<80 degrees Celsius or any other form of pulsed radiofrequency) should not be reported with CPT codes 64633, 64634, 64635 or 64636. These services should be reported with CPT code 64999. Code 64999 is non-covered when used to report non-thermal facet joint denervation.If facet joints are injected with biologicals or other substances not designated for this use the entire claim will deny per Benefit Policy Manual Chapter 16: Section 180.Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for facet injections 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.For RFA the use of moderate anesthesia or MAC may be considered if medically necessity is clearly established. Documentation must explain the medical necessity for sedation and frequent reporting of these services together may trigger focused medical review.
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA57826)
Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
Draft Article - Billing and Coding: Cervical Fusion (DA59645)
CMS National Coverage PolicyN/AArticle TextRefer to the draft Local Coverage Determination (LCD) DL39762 Cervical Fusion for reasonable and necessary requirements and frequency limitations.The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to theNCCI requirements.Coding GuidanceProviders should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.This policy applies only to cervical fusion and related procedures and does not apply to other joint procedures (such as facet, sacroiliitis, epidural or other spinal procedures).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.If you want to list out the modifiers for known non-covered service you could bullet that out under the notice section.ModifierWhen to Use ModifierGAWaiver of Liability StatementIssued as Required by PayerPolicy, Individual CaseReport when you issue a mandatory ABN for a service as required and keep it on file. You dont need to submit a copy of the ABN, but you must make it available on request. Usethe GA modifier when both covered and non-covered services appear on an ABN-related claim.GXNotice of Liability Issued,Voluntary Under Payer Policy
Draft Article - Billing and Coding: Cervical Fusion (DA59645)
GXNotice of Liability Issued,Voluntary Under Payer PolicyReport when you issue a voluntary ABN for a service we never cover because its statutorily excluded or isnt a Medicarebenefit. Use this modifier combined with modifier GY.GYNotice of Liability Not Issued,Not Required Under PayerPolicyReport Medicare statutorily excludes the item or service, or the item or service doesnt meet the definition of a Medicarebenefit. Use this modifier combined with modifier GXGZExpect Item or ServiceDenied as Not Reasonableand NecessaryReport when you expect well deny payment of the item or service because its medically unnecessary and you didntissue an ABN.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 operative note should include the procedure performed and any associated/additional procedures performed at the same time.The patients medical record should include, but is not limited to:The assessment of the patient by the performing provider as it relates to the complaint of the patient for that 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 to be injected into the joint at the time of surgery. The inclusion of biological and/or other non-FDA approved substances in the injectant will result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180Medicare Benefit Policy Manual (cms.gov). Amniotic and placenta derived injectants, amino acids, vitamins, and platelet rich plasma fall in this category.