evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Multimarker Serum Tests Related to Ovarian Cancer Testing (A57020)
CMS National Coverage PolicyTitle 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.Section 1862(a)(7) excludes routine physical examinations, unless otherwise covered by statute.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 Publication 100-02,Medicare Benefit Policy Manual,Chapter 16: 20 Services Not Reasonable and NecessaryArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Multimarker Serum Tests Related to Ovarian Cancer Testing.Coding Guidelines: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.CPT coding:CPT code 81500 should be reported when billing for ROMATM.CPT 81503 should be reported when billing for OVA1.CPT 0003U should be reported when billing for OVERA.
Article - Billing and Coding: Cervical Disc Replacement (A57021)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary information to process that claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Cervical Disc Replacement L38033.
Article - Billing and Coding: Autonomic Function Testing (A57024)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833 (e). This section states that no payment shall be made to any provider for any claims that lack necessary information to process the claim.Title XVIII of the Social Security Act section 1862 (a)(1)(A). This section allows coverage and payment of those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act section 1862 (a)(7). This section excludes routine physical examinations and services.CMS Manual System, Pub 100-08,Medicare Program Integrity Manual, Chapter 3, Part 3.2.3 Requesting Addition Documentation During Prepayment and Post-payment review.42 CFR Section 410.32(a) indicates diagnostic tests are payable only when the physician who is treating the beneficiary for a specific medical problem uses the results in such treatment.Article TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Autonomic Function Testing.Coding Information: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.Do not report 95922 in conjunction with 95921Documentation Requirements:Medical record documentation maintained by the performing provider must clearly support the medical necessity for ANS testing as well as the test reports and interpretation. Supportive documentation showing medically reasonable and necessary indications as outlined in this LCD are expected to be documented in the medical record and be available upon request. This documentation includes, but is not limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or procedures used to rule out more common causes of autonomic signs or symptoms.General professional standards with FDA clearance apply for all equipment used in ANS testing.Utilization Guidelines:
Article - Billing and Coding: Autonomic Function Testing (A57024)
Utilization Guidelines:Diagnostic testing may be allowed once to confirm or exclude specific autonomic disease.For patients with diagnosed autonomic disorders, repeat testing is governed by a change in clinical status or response to a therapeutic intervention. If a repeat test is needed, it is not expected to exceed once per year.Providers who perform these tests on an unusually high proportion of their patients, or at frequencies exceeding once per year may be subject to medical review.Providers who do not have tilt tables and are using the code range 95921-95924 may be subject to medical review.
Article - Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A57025)
CMS National Coverage PolicyInternet-Only Manuals (IOMs):CMS IOM Publication, 100-04,Medicare Claims Processing Manual,Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)National Correct Coding Initiative (NCCI):Medicare NCCI Policy Manual,Chapter 8, Section D. OphthalmologySocial 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) L34028 Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow. 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.Effective October 1, 2017, The Center for Medicare & Medicaid Services (CMS) revised policy may allow payment to be made for a medically necessary upper eyelid blepharoptosis when performed with (noncovered) cosmetic blepharoplasty on the same eye during the same visit.For correct coding guidelines and specific applicable code combinations prior to billing Medicare, refer to the Medicare NCCI Policy Manual, Chapter 8, Section D. Ophthalmology.Correct coding dictates that removal of malignant and benign lesions requires a different set of codes than the codes listed in this article.Removal of malignant lesions should be reported with CPT codes 11640-11646.Removal of benign lesions should be reported with CPT codes 11440-11446, 67840 or 67850.Mohs surgery should be reported with CPT codes 17311-17315.Documentation Requirements
Article - Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A57025)
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 submitted medical recordmust includeresults of pertinent diagnostic tests and operative reportsas appropriate,documentation to support the medical necessity of blepharoptosis repair, brow ptosis repair, and blepharoplasty procedures:Clinical notes, supporting a decrease in visual field (peripheral vision and/or upper field vision) demonstrating a 12 to 15 degree superior loss or 24% to 30% superior visual field impairment, near or far visual impairment, or difficulty reading.Patient complaints and physical findings, for example:Interference with vision or visual field, related to activities such as, difficulty reading due to upper eyelid drooping, looking through the eyelashes, seeing the upper eyelid skin, or brow fatigue.Chronic eyelid dermatitis due to redundant eyelid skin.Lower eyelid ectropion resulting in eye irritation and inflammation and excessive tearing.Entropion where the eyelashes are contacting the cornea resulting in discomfort, redness, tearing, and foreign body sensation.Difficulty wearing prosthesis.Margin reflex distance (MRD1) of 2 mm or less.A palpebral fissure height on down-gaze of 1 mm or less, (measured with the patient fixating on an object in downgaze with the ipsilateral brow relaxed and the contralateral lid elevated).The presence of Herings Law meeting one of the above criteria in bullets 3 or 4. Herings Law of equal innervation to both upper eyelids may be considered in the documentation to perform bilateral ptosis repair in which the position of one upper eyelid has marginal criteria and the other eyelid had good supportive documentation for ptosis surgery.Visual field testing demonstrating a 12 to 15 degree superior field loss or 24% to 30% superior visual field impairment.
Article - Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A57025)
Preoperative photographs in the form of prints or slides are required to be submitted with the medical record to support medical necessity of blepharoptosis repair, brow ptosis repair and blepharoplasty procedures if the record is not sufficient to determine medical necessity. If photographs are requested to support the documentation, photograph guidelines that support medical necessity include:The photographs must be frontal view, canthus to canthus with the head perpendicular to the plane of the camera (not tilted) to demonstrate a skin rash or position of the true lid margin or the pseudo-lid margin.For CPT codes 15820-15823 or 67901-67908: If redundant skin coexists with true lid ptosis, additional photos taken with the upper lid skin retracted to show the actual position of the true lid margin are supportive of medical necessity.Oblique photos are only needed to demonstrate redundant skin on the upper eyelashes when this is the only indication for surgery.Separate from the photographs, documentation in the medical record of the indicated distance thresholds (e.g., 2 mm or less from the central corneal reflex to the upper eyelid margin or skin that overhangs the eyelid margin [pseudoptosis]) is helpful to demonstrate medical necessity.NOTE:If both a blepharoplasty and a blepharoptosis repair are planned, both must be individually documented. The medical necessity criteria for each procedure must be met and the additional required testing criteria demonstrate visual impairment that cannot be addressed by one procedure alone. This may require two sets of photographs showing the effect of drooping of redundant skin (drooping of brows and its correction by taping), and the actual presence of blepharoptosis with drooping of the upper eyelid.
Article - Billing and Coding: Computed Tomographic (CT) Colonography for Diagnostic Uses (A57026)
CMS National Coverage PolicyLanguage quoted from 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 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 Regulations42 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).42 CFR Section 410.38, subpart B indicates the tests approved for coverage of colorectal cancer screeningCMS Publications:CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual, Chapter 1:220.1 Computed TomographyCMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15:80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic TestsCMS Publication 100-04,Medicare Claims Processing Manual, Chapter 13:10 ICD-9-CM Coding for Diagnostic Tests20 Payment Conditions for Radiology Services80 Supervision and Interpretation (S & I) Codes and Interventional RadiologyArticle Text
Article - Billing and Coding: Computed Tomographic (CT) Colonography for Diagnostic Uses (A57026)
Article TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Computed Tomographic (CT) Colonography for Diagnostic Uses.Coding Information: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.Documentation Requirements: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.Utilization Guidelines:CT colonography is reimbursable only when performed following an instrument colonoscopy which was incomplete or when a board certified or board eligible gastroenterologist or surgeon trained in endoscopy determined from an evaluation of the patient that optical colonoscopy can not be safely attempted. Tests performed without a prior incomplete instrument colonoscopy in history or documentation by a board certified or eligible gastroenterologist, a surgeon trained in endoscopy or a physician with equivalent endoscopic training indicating why an optical colonoscopy cannot be safely attempted will be denied.
Article - Billing and Coding: Ultrasound, Soft Tissues of Head and Neck (A57029)
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) L34027, Ultrasound, Soft Tissues of Head and Neck. 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 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.
Article - Billing and Coding: EEG – Ambulatory Monitoring (A57030)
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, italicized text 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 1862(a)(7) excludes routine physical examinations, unless otherwise covered by statute.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).Article Text
Article - Billing and Coding: EEG – Ambulatory Monitoring (A57030)
Article TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) forEEG -Ambulatory Monitoring.Coding Information: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.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the 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.Monitoring beyond 72 hours must be supported by written documentation for each additional 24 hours of monitoring and be made available to Medicare upon request.Utilization Guidelines:The following represent the number of 24-hour segments of recordings for testing:For diagnostic testing  Two or three days is usually sufficient when looking for seizures or interictal activityFor pre-surgical evaluation  Seven to ten days may be required to capture at least three or four seizures in order to be sure of seizure onset location reliability. Two to three days is usually sufficient for follow-up.
Article - Billing and Coding: ProMark® Risk Score (A57034)
CMS National Coverage PolicyCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesCMS 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 AllowanceTitle 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. 100-02, 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) for MolDX: ProMarkRisk ScoreL36675.To report a ProMarkassay service, please submit the following claim information: Select CPT code 81479 Enter 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 claim Enter 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 form Select ICD-10-CM code C61
Article - Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment (A57037)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claimCMS Internet-Only Manuals, 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 Online 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: Biomarkers in Cardiovascular Risk Assessment L36358.