evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) (A57071)
H44.633, H44.641, H44.642, H44.643, H44.651, H44.652, H44.653, H44.691, H44.692, H44.693, H44.701, H44.702, H44.703, H44.711, H44.712, H44.713, H44.721, H44.722, H44.723, H44.731, H44.732, H44.733, H44.741, H44.742, H44.743, H44.751, H44.752, H44.753, H44.791, H44.792, H44.793, H44.811, H44.812, H44.813, H44.821, H44.822, H44.823, H44.89, H44.9, Q15.0
Article - Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) (A57071)
Other Comments:
Article - Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) (A57071)
For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC. to process their claims.Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.
Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) in the Treatment of Adults with Major Depressive Disorder (A57072)
CMS National Coverage PolicyInternet-Only Manuals (IOMs):CMS IOM Publication 100-08,Medicare Program Integrity Manual,Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCDSocial 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.Title XVIII of the Social Security Act, Section 1862(a)(1)(D) prohibits the payment for any expenses incurred for items or services that are investigational or experimental.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L34998 Transcranial Magnetic Stimulation (TMS) in the Treatment of Adults with Major Depressive Disorder. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceThe ordering provider name and NPI must be included on the claim in the following locations:For Part A claims: Block 78/79 of the UB-04OR2420B for EMCFor Part B claims: Block 17 A and B for paper claims; 2310AOR2420F for EMCNotice: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.Utilization ParametersIt is expected that CPT code 90867 be reported only once per patient for the episode (for the initial planning) and NOT in conjunction with CPT codes 90868 or 90869.CPT code 90867 should not be reported more than once within a 6-week period of time.Do not report CPT code 90869 (motor threshold determination) in conjunction with 90867 or 90868.Documentation Requirements
Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) in the Treatment of Adults with Major Depressive Disorder (A57072)
Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.The medical record documentation must support that the attending physician has met with the patient face to face for the initial assessment and for subsequent delivery and management when there is a change in the individuals mental status and/or other significant change in clinical status.The medical record documentation must include evidence of clinical judgment of the treating physician in evaluation of the absolute and relative contraindications in the pre-procedure record for the present episode of care.
Article - Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing (A57077)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L36393 Controlled Substance Monitoring and Drugs of Abuse Testing. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Documentation RequirementsNote: Refer to the LCD for documentation requirements, in the patients medical record, of medical necessity for testing ordered on an individual patient basis by the clinician.All 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.
Article - Billing and Coding: Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma (A57079)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Manual System, Pub. 100-03,Medicare National Coverage Determinations Manual,Chapter 1, Part 2, 150.7.Article TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.Injection therapies for Morton's neuroma do not involve the structures described by CPT code 20550 and 20551 or direct injection into other peripheral nerves but rather the focal injection of tissue surrounding a specific focus of inflammation on the foot. These therapies are not to be coded using 20550, 20551, 64450, 64640 or other assigned CPT codes. Rather, the provider of these therapies must bill with CPT code 64455 or 64632 Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, Morton's neuroma) as the correct CPT code for the service.Injections for plantar fasciitis are addressed by 20550 and ICD-10-CM M72.2. Injections for other tendon origin/insertions by 20551. Injections to include both the plantar fascia and the area around a calcaneal spur are to be reported using a single 20551.The clinical record should include the elements leading to the diagnosis and treatment decision to use injection. If the number of injections exceeds three to the same site or local area in a six month period, the record must justify these added injections since the presumed need for further injections should raise the issues of correct diagnosis or correct choice of therapy as well as concerns for adverse side effects. Records must be made available upon request.The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.
Article - Billing and Coding: Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma (A57079)
When 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.The Section titled "Does the 'CPT 30% Rule' apply" needs clarification. This rule comes from the AMA (American Medical Association), the organization that holds the copyrights for all CPT codes. The rule states that if, in a given section (e.g., surgery) or subsection (e.g., surgery, integumentary) of the CPT Manual, more than 30% of the codes are listed in the LCD, then the short descriptors must be used rather than the long descriptors found in the CPT Manual.This policy is subject to the reasonable and necessary guidelines and the limitation of liability provision.This medical policy consolidates and replaces all previous policies and publications on this subject by Noridian and its predecessors for Medicare A/B.
Article - Billing and Coding: B-type Natriuretic Peptide (BNP) Testing (A57083)
CMS National Coverage PolicyLanguage quoted from the 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 a NCD. See 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):Title XVIII of the Social Security Act, 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.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1862(a)(7) excludes routine physical examinations (screening).Code of Federal Regulations:42 CFR Sections 410.32(a) & 410.32(a)(3) require that clinical laboratory services be orderedand usedpromptly by the physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who is treating the beneficiary.42CFR411.15 excludes from coverage examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury with specific legislative enactments as the only exceptions.CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, 20.4.4 and 20.4.5.CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 9, 100 General Billing RequirementsCMS Manual System, Pub 100-20, One Time Notification, Transmittal 477, dated April 24, 2009, Change Request 6338.Article Text
Article - Billing and Coding: B-type Natriuretic Peptide (BNP) Testing (A57083)
CMS Manual System, Pub 100-20, One Time Notification, Transmittal 477, dated April 24, 2009, Change Request 6338.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation supporting medical necessity should be legible, maintained in the patient's record, and must be made available to the A/B MAC upon request.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.
Article - Billing and Coding: B-type Natriuretic Peptide (BNP) Testing (A57084)
CMS National Coverage PolicyLanguage quoted from the 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 a NCD. See 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Title XVIII of the Social Security Act, 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.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1862(a)(7) excludes routine physical examinations (screening).Code of Federal Regulations:42 CFR Sections 410.32(a) & 410.32(a)(3) require that clinical laboratory services be ordered and used promptly by the physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who is treating the beneficiary.42CFR411.15 excludes from coverage examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury with specific legislative enactments as the only exceptions.CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, 20.4.4 and 20.4.5.CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 9, 100 General Billing Requirements.CMS Manual System, Pub 100-20, One Time Notification, Transmittal 477, dated April 24, 2009, Change Request 6338.Article Text
Article - Billing and Coding: B-type Natriuretic Peptide (BNP) Testing (A57084)
CMS Manual System, Pub 100-20, One Time Notification, Transmittal 477, dated April 24, 2009, Change Request 6338.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation supporting medical necessity must be legible, maintained in the patient's record, and made available to the A/B MAC upon request.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.
Article - Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea (A57092)
CMS National Coverage PolicyN/AArticle TextRefer to the Proposed Local Coverage Determination (LCD) L38387, Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, for reasonable and necessary requirements.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.Coding GuidelinesEffective for dates of service on or after 01/01/2022,the following CPT codes should be used to report insertion, replacement and removal of hypoglossal nerve neurostimulator:CPT code 64582should be reported for insertion of hypoglossal nerve neurostimulator electrode, generator and breathing sensor electrodeCPT code 64583should be used to report revision or replacement of hypoglossal nerve neurostimulator electrode and breathing sensor electrode with connection to existing generatorReduced services-Use modifier 52 for revision or replacement of either the hypoglossal nerve stimulator electrode array or distal respiratory sensor, and bill at a reduced rate.CPT code 64854should be used to report removal of hypoglossal nerve neurostimulator electrode and generator and breathing sensor electrodeReduced services- Use modifier 52 for removal of one or two components of the hypoglossal nerve stimulator electrode array, pulse generator, or distal respiratory sensor, and bill at a reduced rate.For dates of service prior to 01/01/2022:Implantationof a Hypoglossal Nerve Stimulator (HSN) for treatment of OSA utilizes 2 CPT codes:CPT code 64568- Incision for implantation of cranial nerve (eg: vagus nerve) neurostimulator electrode array and pulse generatorCPT code +0466T- Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (list separately in addition to code for primary procedure)*Note: Per AMA CPT, use 0466T in conjunction with 64568Revision or replacementof HSN for treatment of OSA is reported with:
Article - Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea (A57092)
*Note: Per AMA CPT, use 0466T in conjunction with 64568Revision or replacementof HSN for treatment of OSA is reported with:CPT code 0467T- Revision or replacement of chest wall respiratory sensor electrode or electrode array, including connection to existing pulse generatorRemovalof HSN for treatment of OSA is reported with:CPT code 0468T- Removal of chest wall respiratory sensor electrode or electrode arrayCoding InformationFor dates of service on or after 01/01/2022,CPT codes 64582, 64853 and 64584 should be used to report hypoglossal nerve neurostimulation.For dates of service prior to 01/01/2022:CPTcode64568is for both the neurostimulator and its corresponding electrode arrayCPTcodes0466T, 0467T, and 0468Tare codes for the insertion, revision or replacement, and removal respectivelyDocumentation 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 diagnosis code(s).
Article - Billing and Coding: MolDX: Repeat Germline Testing (A57100)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claimCMS Internet-Only Manual, Pub. 100-04, 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 CodesCMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) MolDX: Repeat Germline Testing.
Article - Billing and Coding: MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (A57106)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 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 CodesCMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) : MolDX: Prostate Cancer Classifier Assay for Men with Localized Disease L38433.To report a Prostate Genomic Classifier service, please submit the following claim information:Select applicable 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 837PBox 19 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 ICD-10-CM code C61
Article - Billing and Coding: MolDX: Blood Product Molecular Antigen Typing (A57110)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Blood Product Molecular Antigen Typing L38441.Blood product antigen typing is a germline test and the use of panels 0001U and 0084U will be limited to once in a beneficiary lifetime.The individual codes 0180U-0201U, 0221U, 0222Uand codes 81105-81112 are also germline tests. These will be non-covered as multiple antigens must be utilized as part of a comprehensive antigen evaluation and will be considered only as part of a panel.To report a Blood Product Molecular Antigen Typing service, please submit the following claim information:Select the appropriate CPTor PLA codeEnter 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 code