evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Polysomnography and Other Sleep Studies (A57697)
CMS National Coverage PolicyWhen the documentation does not meet the criteria for the service rendered, or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.CMS Pub. 100-8,Program Integrity Manual,Chapter 13, Section 5.1CMS Publication100-03 Medicare National Coverage Determination (NCD) Manual)Chapter 1,Section 240.4.1 Sleep Testing for Obstructive sleep Apnea (OSA) (Effective March 3, 2009) andSection 240.4 Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) (Effective March 13, 2008)CMS Publication100-02 Medicare Benefit PolicyChapter 6, Section 50 Sleep Disorder ClinicsCMS Publication100-02, Medicare Benefit Policy Manual,Chapter 15, Section 70 Sleep Disorder ClinicsCMS Decision Memo for Sleep Testing for Obstructive Sleep Apnea (OSA) (CAG-00405N)CMS Decision Memo for Continuous Positive Airway Pressure Therapy for Obstructive Sleep Apnea (CAG-00093R2)Italicized font-represents CMS national NCD language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national NCD language/wording.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation RequirementsDocumentation must show that the polysomnography (95808, 95810 and 95811) was performed in a facility based sleep study laboratory and not in the home or a mobile facility.The sleep disorder clinic must have on file, in the patients record, documentation that narcolepsy symptoms are severe enough to interfere with the patients well-being and health.If more than two nights of testing are performed, documentation justifying the medical necessity for the additional test(s) must be available in the patients medical record.Documentation must show that the home sleep test (HST) (G0398, G0399 and G0400) was performed in conjunction with a comprehensive sleep evaluation and in patients with a high pretest probability of moderate to severe obstructive sleep apnea.
Article - Billing and Coding: Polysomnography and Other Sleep Studies (A57697)
The patient who undergoes a HST must receive, prior to the test, adequate instruction on how to properly apply a portable sleep monitoring device. This instruction must be provided by the provider conducting the HST.Documentation must show that the home sleep test was accomplished with a Medicare-approved device (e.g., description of channels monitored or clear indications of same included in the test report) and was performed by a physician meeting the training requirements listed in the Coverage Indications, Limitations, and/or Medical Necessity Section.Parameters monitored and documented:Start time and duration of day/night of study.Total sleep time, sleep efficiency, number/duration of awakenings.For tests involving sleep staging: time and percent time spent in each stage;For tests monitoring sleep latency or maintenance of wakefulness testing: latency to both Non-Rapid Eye Movement (NREM) and Rapid Eye Movement (REM) sleep.Individual sub-test sleep latencies, mean sleep latency and the number of REM occurrences on Multiple Sleep Latency Test (MSLT).Respiratory patterns including type (central/obstructive/periodic), number and duration, effect on oxygenation, sleep stage/body position relationship, and response to any diagnostic and /or therapeutic maneuvers.Cardiac rate/rhythm and any effect of sleep-disordered breathing on EKG.Detailed behavioral observations.EEG or EMG abnormalities.The patient is to be referred to the clinic by the attending physician. The physicians order must be kept in the medical recordUtilization GuidelinesMore than one HST per year interval would not be expected. If more than one HST session is performed for suspected OSA, persuasive medical evidence justifying the medical necessity for the additional tests will be required. Similarly, more than two PSG per year interval would not be expected. If more than two PSG sessions are performed for the diagnosis or adjustment of treatment of sleep, pervasive medical evidence justifying the medical necessity for the additional tests will be required upon request. When services are performed in excess of established parameters, they may be subject to review for medical necessity.The routine use of more than one PSG to titrate CPAP therapy would not be considered reasonable and necessary. If more than one CPAP titration PSG is claimed, persuasive medical evidence justifying the medical necessity for the additional tests may be requested.
Article - Billing and Coding: Polysomnography and Other Sleep Studies (A57697)
95805 MSLT- includes all the naps done in a single day. Only one (1) unit of service should be submitted.
Article - Billing and Coding: Polysomnography and Other Sleep Studies (A57698)
CMS National Coverage PolicyWhen the documentation does not meet the criteria for the service rendered, or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.CMS Pub. 100-8,Program Integrity Manual,Chapter 13, Section 5.1CMS Publication100-03 Medicare National Coverage Determination (NCD) Manual)Chapter 1,Section 240.4.1 Sleep Testing for Obstructive sleep Apnea (OSA) (Effective March 3, 2009) andSection 240.4 Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) (Effective March 13, 2008)CMS Publication100-02 Medicare Benefit PolicyChapter 6, Section 50 Sleep Disorder ClinicsCMS Publication100-02, Medicare Benefit Policy Manual,Chapter 15, Section 70 Sleep Disorder ClinicsCMS Decision Memo for Sleep Testing for Obstructive Sleep Apnea (OSA) (CAG-00405N)CMS Decision Memo for Continuous Positive Airway Pressure Therapy for Obstructive Sleep Apnea (CAG-00093R2)Italicized font-represents CMS national NCD language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national NCD language/wording.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation RequirementsDocumentation must show that the polysomnography (95808, 95810 and 95811) was performed in a facility based sleep study laboratory and not in the home or a mobile facility.The sleep disorder clinic must have on file, in the patients record, documentation that narcolepsy symptoms are severe enough to interfere with the patients well-being and health.If more than two nights of testing are performed, documentation justifying the medical necessity for the additional test(s) must be available in the patients medical record.Documentation must show that the home sleep test (HST) (G0398, G0399 and G0400) was performed in conjunction with a comprehensive sleep evaluation and in patients with a high pretest probability of moderate to severe obstructive sleep apnea.
Article - Billing and Coding: Polysomnography and Other Sleep Studies (A57698)
The patient who undergoes a HST must receive, prior to the test, adequate instruction on how to properly apply a portable sleep monitoring device. This instruction must be provided by the provider conducting the HST.Documentation must show that the home sleep test was accomplished with a Medicare-approved device (e.g., description of channels monitored or clear indications of same included in the test report) and was performed by a physician meeting the training requirements listed in the Coverage Indications, Limitations, and/or Medical Necessity Section.Parameters monitored and documented:Start time and duration of day/night of study.Total sleep time, sleep efficiency, number/duration of awakenings.For tests involving sleep staging: time and percent time spent in each stage;For tests monitoring sleep latency or maintenance of wakefulness testing: latency to both Non-Rapid Eye Movement (NREM) and Rapid Eye Movement (REM) sleep.Individual sub-test sleep latencies, mean sleep latency and the number of REM occurrences on Multiple Sleep Latency Test (MSLT).Respiratory patterns including type (central/obstructive/periodic), number and duration, effect on oxygenation, sleep stage/body position relationship, and response to any diagnostic and /or therapeutic maneuvers.Cardiac rate/rhythm and any effect of sleep-disordered breathing on EKG.Detailed behavioral observations.EEG or EMG abnormalities.The patient is to be referred to the clinic by the attending physician. The physicians order must be kept in the medical recordUtilization GuidelinesMore than one HST per year interval would not be expected. If more than one HST session is performed for suspected OSA, persuasive medical evidence justifying the medical necessity for the additional tests will be required. Similarly, more than two PSG per year interval would not be expected. If more than two PSG sessions are performed for the diagnosis or adjustment of treatment of sleep, pervasive medical evidence justifying the medical necessity for the additional tests will be required upon request. When services are performed in excess of established parameters, they may be subject to review for medical necessity.The routine use of more than one PSG to titrate CPAP therapy would not be considered reasonable and necessary. If more than one CPAP titration PSG is claimed, persuasive medical evidence justifying the medical necessity for the additional tests may be requested.
Article - Billing and Coding: Polysomnography and Other Sleep Studies (A57698)
95805 MSLT- includes all the naps done in a single day. Only one (1) unit of service should be submitted.
Article - Billing and Coding: Computerized Corneal Topography (A57699)
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) L33810 Computerized Corneal Topography. Please refer to the LCD for reasonable and necessary requirements and limitations.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: Trigger Point Injections (TPI) (A57701)
CMS National Coverage PolicyN/AArticle TextRefer to the draft Local Coverage Determination (LCD) L34211-Trigger Point Injections (TPI) 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 trigger point injections and does not apply to dry needling or acupuncture.Modifier 50- bilateral should not be reported with CPT codes 20552 or 20553.Utilization ParametersNo more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed.CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle.MedicationThe drug used for the injection must be on the same claim as the trigger point administration.The medication used with the injection is reported with a HCPCS Drug code J-code or a revenue code.Unclassified drugs billed with J3490, J3590, J9999 or C9399* must also include name of drug and dosage to Box 19 of the CMS-1500 paper form or electronic equivalent.*C3999 should only be used for ASC outpatient facility claims.Documentation Requirements
Article - Billing and Coding: Trigger Point Injections (TPI) (A57701)
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.The procedural report should clearly document the indications and medical necessity for the injections, the name, and units of the injectant used, the location of the TPIs, along with the pre and post percent (%) pain relief achieved immediately post injection.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 visit.Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Documentation to support the medical necessity of the procedure(s).When documenting the TPI procedure, there must be specific information to indicate the location of trigger points treated, the muscles injected, medication injected, amount of medications used, and the post-procedure plan.Use of BiologicalsThere are currently no FDA approved biologicals for use as trigger point injectable agents. The inclusion of biological and/or other non-FDA approved substances in the injectant may 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, and platelet rich plasma and vitamins fall in this category.Use of AnesthesiaNo anesthesia codes should be billed in conjunction with 20552 or 20553.
Article - Billing and Coding: Trigger Point Injections (TPI) (A57702)
CMS National Coverage PolicyN/AArticle TextRefer to the draft Local Coverage Determination (LCD) L36859-Trigger Point Injections (TPI) 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 trigger point injections and does not apply to dry needling or acupuncture.Modifier 50- bilateral should not be reported with CPT codes 20552 or 20553.Utilization ParametersNo more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed.CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle.MedicationThe drug used for the injection must be on the same claim as the trigger point administration.The medication used with the injection is reported with a HCPCS Drug code J-code or a revenue code.Unclassified drugs billed with J3490, J3590, J9999 or C9399* must also include name of drug and dosage to Box 19 of the CMS-1500 paper form or electronic equivalent.*C3999 should only be used for ASC outpatient facility claims.Documentation Requirements
Article - Billing and Coding: Trigger Point Injections (TPI) (A57702)
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.The procedural report should clearly document the indications and medical necessity for the injections, the name, and units of the injectant used, the location of the TPIs, along with the pre and post percent (%) pain relief achieved immediately post injection.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 visit.Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Documentation to support the medical necessity of the procedure(s).When documenting the TPI procedure, there must be specific information to indicate the location of trigger points treated, the muscles injected, medication injected, amount of medications used, and the post-procedure plan.Use of BiologicalsThere are currently no FDA approved biologicals for use as trigger point injectable agents. The inclusion of biological and/or other non-FDA approved substances in the injectant may 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, and platelet rich plasma and vitamins fall in this category.Use of AnesthesiaNo anesthesia codes should be billed in conjunction with 20552 or 20553.
Article - Billing and Coding: Treatment of Varicose Veins of the Lower Extremities (A57706)
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 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, 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.CMS Manual System, Pub 100-08,Medicare Program Integrity Manual,Chapter 13, 13.5.1 indicates services will be considered medically reasonable and necessary only if ordered and furnished by appropriately trained personnel.This training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty or must reflect extensive continued medical education activities. If these skills have been acquired by way of continued medical education, the courses must be comprehensive, offered or sponsored or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States, and designated by the American Medical Association (AMA) as Category 1 Credit.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.1. Each claim must be submitted with an ICD-10-CM code(s) that reflects the condition of the patient and indicates the reason(s) for which the service was performed.2. The patient's medical record must contain a history and physical examination supporting the diagnosis of symptomatic varicose veins, and the failure of an adequate (at least 3 months) trial of conservative management.3. The medical record must document the performance of appropriate tests, if medically necessary, to confirm the pathology of the vascular anatomy.
Article - Billing and Coding: Treatment of Varicose Veins of the Lower Extremities (A57706)
3. The medical record must document the performance of appropriate tests, if medically necessary, to confirm the pathology of the vascular anatomy.4. This documentation must be made available to Medicare upon request.5. 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.6. 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.