evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Testing in Cancer (A54795)
CPT coding Instructions:Targeted Tumor PanelsTo bill for DNA-based panels that measure specific SNVs, INDELs, CNVs or rearrangements, review CPT codes 81445 and 81450. If a DNA-based targeted panel meeting the coverage requirements is used, and MSI is also performed, 81457 can be billed. If a DNA-based targeted test meeting coverage requirements is performed that includes MSI and CNVs, 81458 can be billed.81449 or 81451 for RNA-based targeted testing may also be billed for the same specimen that received a DNA-based NGS test if complaint with the language of A57503, is non-duplicative, and performed serially to DNA testing as a separate service (with a separate order and report). If only RNA-based testing is reasonable and necessary, 81449 or 81451 may be billed alone if policy requirements are met. If two targeted panels (one for DNA and the other for RNA) are always performed together and meet policy criteria, 81479 should be used for such a service to reduce claims processing errors as this would constitute one service.The unit of service (UOS) for an NGS gene panel is one (UOS=1). Providers must also provide the approved DEX Z-Codeidentifier for the test.Effective July 1, 2017, laboratories with 2 to 4 genes on their targeted NGS panel should use CPT 81479 and one (1) UOS along with their test identifier (DEX Z-Code) to represent this service on their claims.CGPCGP code 81459, based on the inclusion of the comprehensive test components addressed in the definition above, is considered a CGP test by this contractor and may be billed when all stated components of the service have satisfied technical assessment requirements. Because this code includes both DNA-only and DNA/RNA combined services in its description, it is assumed that services that include DNA/RNA combined testing add no additional relevant genomic information beyond that provided by a DNA-only test. For CGP tests that include the use of RNA to interrogate relevant genomic information beyond that captured with DNA-based testing, billing with CPT 81479 is appropriate. Additionally, if a service meets the defintion of a CGP but NOT 81459, CPT code 81479 is appropriate.
Article - Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Testing in Cancer (A54795)
Therefore, to report a CGP service, test providers should use CPT codes 81459 or 81479, in addition to the approved DEX Z-Codefor the test. Coverage of CGPs is limited to one test per surgical specimen and precludes the use of any further molecular testing on that specimen.For NGS-based tests that do not fit under the above definitions of targeted or Comprehensive panels, billing with the Not Otherwise Classified (NOC) code 81479 along with the approved DEX Z-Codeidentifier is appropriate.Tier 1 and/or Tier 2 individual biomarker CPT codes should not be used for a single gene or any combination of genes when testing is performed as part of a NGS or other multiplexing technology panel.Refer toBilling and Coding: MolDX: Next-Generation Sequencing for Solid Tumors A57831for CPT/HCPCS codes and ICD-10 codes relevant for solid tumors.Refer toBilling and Coding: MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies A57837for CPT/HCPCS codes and ICD-10 codes relevant for myeloid malignancies.
Article - Billing and Coding: Urine Drug Testing (A54799)
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 claim.CMS 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 Urine Drug Testing L35724.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.
Article - Antibacterial Drugs (A54812)
CMS National Coverage PolicyN/AArticle TextORBACTIV(oritavancin)Orbactiv(oritavancin) is a semisynthetic lipoglycopeptide antibacterial drug. It exerts concentration-dependent bactericidal activity in vitro againstS. aureus, S. pyogenes, and E. faecalis.Orbactivis specifically indicated for the treatment of adult patients with acute bacterial skin and skin structure infections (ABSSSI) caused by susceptible isolates of the following Gram-positive microorganisms:Staphylococcus aureus (including methicillin-susceptible and methicillinresistant isolates) Streptococcus pyogenes Streptococcus agalactiae Streptococcus dysgalactiae Streptococcus anginosus group (includes S. anginosus, S. intermedius, and S. constellatus) Enterococcus faecalis (vancomycin-susceptible isolates only)Orbactivis supplied as a solution for intravenous infusion. The recommended dose is a single 1200 mg dose administered by intravenous infusion over three hours in patients 18 years and older.DALVANCE(dalbavancin)Dalvance(dalbavancin) is a lipoglycopeptide antibacterial drug proposed for the treatment of adult patients with acute bacterial skin and skin structure infections (ABSSSI) caused by susceptible isolates of the following Gram-positive microorganisms:Staphylococcus aureus (including methicillin-resistant [MRSA] isolates) Streptococcus pyogenes Streptococcus agalactiae Streptococcus anginosus group (including S. anginosus, S. intermedius, S. constellatus) Enterococcus faecalis (vancomycin-susceptible isolates only)Because of its long elimination half-life, the dosing regimen is 1000 mg on Day 1 and 500 mg on Day 8, administered intravenously (IV) over 30 minutes.VIBATIV(telavancin)
Article - Antibacterial Drugs (A54812)
Vibativ(telavancin) is a bactericidal, once-daily, injectable lipoglycopeptide antibiotic with a dual mechanism of action whereby Vibativ both inhibits bacterial cell wall synthesis and disrupts bacterial cell membrane function. Vibativis specifically indicated for the treatment of adult patients with complicated skin and skin structure infections (cSSSI) caused by susceptible isolates of the following Gram-positive microorganisms:Staphylococcus aureus (including methicillin-susceptible and -resistant isolates) Streptococcus pyogenes Streptococcus agalactiae Streptococcus anginosus group (includes S. anginosus, S. intermedius, and S. constellatus) Enterococcus faecalis(vancomycin-susceptible isolates only) Hospital-acquired and ventilator-associated bacterial pneumonia (HABP/VABP) caused by susceptible isolates ofStaphylococcus aureus.Vibativis supplied as a powder for reconstitution onto a solution designed for intravenous administration. The recommended initial dose is 10 mg/kg administered over a 60-minute period in patients >18 years of age by intravenous infusion once every 24 hours for 7 to 14 days.
Article - Antibacterial Drugs (A54812)
SIVEXTRO (tedizolid)Sivextro(tedizolid)is an oxazolidinone-class antibacterial drug indicated for the treatment of adult patients with acute bacterial skin and skin structure infections (ABSSSI) caused by susceptible isolates of the following Gram-positive microorganisms:Staphylococcus aureus (including methicillin-susceptible and methicillinresistant isolates) Streptococcus pyogenes Streptococcus agalactiae Streptococcus anginosus group (includes S. anginosus, S. intermedius, and S. constellatus) Enterococcus faecalis(vancomycin-susceptible isolates only).The recommended dosage is 200 mg administered once daily for 6 days.Sivextrocanbe given orally (with or without food) or as an intravenous (IV) infusion over 1 hour for patients 18 years of age or older.To reduce the development of drug-resistant bacteria and maintain the effectiveness of these drugs-oritavancin, dalbavancin, telavancin and tedizolid should be used only to treat infections that are proven or strongly suspected to be caused by susceptible bacteria.
Article - Billing and Coding: MolDX: Short Tandem Repeat (STR) Markers and Chimerism (CPT® codes 81265-81268) (A54830)
CMS National Coverage PolicyN/AArticle TextPlease note that CPTcodes 81265 and 81266 describe services performed for recipient/donor testing and twin zygosity. Laboratories are encouraged to register tests based on the use of the test. Through the MolDX identification process, tests registered for recipient/donor testing will be considered for payment and tests for twin zygosity will be denied as a statutorily excluded service. The following instructions outline the correct reporting of recipient/donor testing for transplant services.Chimerism analysis to identify appropriate donors and monitor engraftment success or disease reoccurrence is a covered Medicare service.Code 81265 should be reported with one unit of service (UOS). Except in rare cases, this service would only be performed once per lifetime.Code 81266, when used in bone marrow transplants to report an additional double-cord blood sample, is a covered service.Code 81267 should be used post transplantation to confirm successful engraftment or disease reoccurrence. Although the original donor specimen may be referenced, an additional 81265 should NOT be submitted in addition to the 81267 service. For labs that hold the pre-transplant specimen (81265 and/or 81266) until after the transplant occurs, use 81267 plus 81265 and 81266 if necessary.Note: Code 81267 should be reported for the findings of the pre and post-transplant comparison.Code 81268 should be used to report chimerism using a buccal or other germline tissue specimen from the recipient post-transplantation. For labs that hold the pre-transplant specimen (81265 and/or 81266) until after the transplant occurs, use 81267 plus 81265 and 81266 if necessary.MolDX would not expect to see a claim for 81265 pre-transplant and an additional 81265 and 81267 post-transplant or a claim for 81265 pre-transplant and an additional claim for 81268.
Article - Billing and Coding: MolDX: Short Tandem Repeat (STR) Markers and Chimerism (CPT® codes 81265-81268) (A54830)
MolDX would not expect to see a claim for 81265 pre-transplant and an additional 81265 and 81267 post-transplant or a claim for 81265 pre-transplant and an additional claim for 81268.EXCEPTIONS:Although the initial chimerism testing, code 81265, for engraftment is usually limited to once in a lifetime, MolDX recognizes special circumstances may require an additional service and will consider approval on a case-by-case basis through the appeal process.NOTE: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: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker (A54831)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Article TextAbstract:The National Coverage Determination (NCD) 20.8.3, Single Chamber and Dual Chamber Permanent Cardiac Pacemakers was revised with an effective date of August 13, 2013. The CMS A/B Medicare Administrative Contractors (MACs) have been instructed to implement the NCD at the local level. The following providesbillingand coding instructions for the implementation of NCD 20.8.3. (CMS policy language is initalics.) The NCD Item/Service Description and Indications and Limitations are repeated here.Item/Service DescriptionA. GeneralPermanent cardiac pacemakers refer to a group of self-contained, battery operated, implanted devices that send electrical stimulation to the heart through one or more implanted leads. They are often classified by the number of chambers of the heart that the devices stimulate (pulse or depolarize). Single chamber pacemakers typically target either the right atrium or right ventricle. Dual chamber pacemakers stimulate both the right atrium and the right ventricle.The implantation procedure is typically performed under local anesthesia and requires only a brief hospitalization. A catheter is inserted into the chest and the pacemakers leads are threaded through the catheter to the appropriate chamber(s) of the heart. The surgeon then makes a small pocket in the pad of the flesh under the skin on the upper portion of the chest wall to hold the power source. The pocket is then closed with stitches.The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to conclude that implanted permanent cardiac pacemakers, single chamber or dual chamber, are reasonable and necessary for the treatment of non-reversible symptomatic bradycardia due to sinus node dysfunction and second and/or third degree atrioventricular block. Symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute (for example: syncope, seizures, congestive heart failure, dizziness, or confusion).
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker (A54831)
Indications and Limitations of CoverageB.Nationally Covered IndicationsThe following indications are covered for implanted permanent single chamber or dual chamber cardiac pacemakers:1. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and2. Documented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block.C. Nationally Non-Covered IndicationsThe following indications are non-covered for implanted permanent single chamber or dual chamber cardiac pacemakers:1. Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and hypothermia,2. Asymptomatic first degree atrioventricular block,3. Asymptomatic sinus bradycardia,4. Asymptomatic sino-atrial block or asymptomatic sinus arrest,5. Ineffective atrial contractions (e.g., chronic atrial fibrillation or flutter, or giant left atrium) without symptomatic bradycardia,6. Asymptomatic second degree atrioventricular block of Mobitz Type I unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His Bundle (a component of the electrical conduction system of the heart),7. Syncope of undetermined cause,8. Bradycardia during sleep,9. Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) without syncope or other symptoms of intermittent atrioventricular block,10. Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-blocker drug therapy,11. Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the control of tachycardia, and12. A clinical condition in which pacing takes place only intermittently and briefly, and which is not associated with a reasonable likelihood that pacing needs will become prolonged.D. Other
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker (A54831)
D. OtherMedicare Administrative Contractors will determine coverage under section 1862(a)(1)(A) of the Social Security Act for any other indications for the implantation and use of single chamber or dual chamber cardiac pacemakers that are not specifically addressed in this national coverage determination. (This NCD last reviewed August 2013.)Please note:The Decision Memo for Cardiac Pacemakers: Single-Chamber and Dual-Chamber Permanent Cardiac Pacemaker (CAG-00063R3) states:CMS initiated this current national coverage analysis to reconsider coverage indications for single chamber and dual chamber cardiac pacemakers. The scope of this reconsideration and this decision memorandum does not address biventricular pacemakers, pacemakers that stimulate more than two heart chambers, those devices used to treat tachyarrhythmias and cardiac dyssynchrony, cardiac resynchronization therapy, cardiac pacemaker evaluation services, or self-contained pacemaker monitors.Thebilling and coding guidelines only apply to those CPT codes for the initial insertion of cardiac pacemakers:33206 Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial33207 ventricular33208 atrial and ventricularThe NCD does not address replacement of pacemaker generators. CPT codes 33227, 33228 and 32229 or 33233 are therefore not addressed in this coding article.CMS NCD Covered Conditions and Diagnosis Codes  Group IClinical Conditions:Documented non-reversible symptomatic bradycardia due to sinus node dysfunctionDocumented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular blockDiagnosis Codes (ICD-10-CM) (Attest with Modifier - KX):Atrioventricular (AV) block (I44.2)Mobitz (type II) AV block (I44.1)Other second degree AV block (I44.1)Sinoatrial node dysfunction/Sick sinus syndrome (I49.5)Congenital heart block (Q24.6)Contractor (Additional) Diagnosis Codes (ICD-10-CM) Allowed by the NCD  Group II (Attest with Modifier - KX)
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker (A54831)
Contractor (Additional) Diagnosis Codes (ICD-10-CM) Allowed by the NCD  Group II (Attest with Modifier - KX)Atrioventricular block, unspecified (Symptomatic) (I44.30)First-degree atrioventricular block (Symptomatic with PR interval more than 300 milliseconds) (I44.0)Left bundle branch block, other or unspecified (I44.7)Right bundle branch block, unspecified or other (I45.10 / I45.19)Bundle branch block, unspecified (I44.30 or I44.39)Right bundle branch block and left posterior fascicular block (I45.2)Right bundle branch block and left anterior fascicular block (I45.2)Other bilateral bundle branch block (I45.2)Bifascicular block (I45.2)Trifascicular block (I45.3)Supraventricular tachycardias in which a pacemaker is specifically for control of the tachycardia (I47.10, I47.11, I47.19)Paroxysmal supraventricular tachycardia/supraventricular tachycardia (SVT that is reproducibly terminated by pacing when catheter ablation and/or drugs fail to control the arrhythmia or produce intolerable side effects) (I47.10, I47.11, I47.19/I47.9)Atrial fibrillation/atrial fibrillation, persistent; unspecified atrial fibrillation (I48.11/I48.91) with symptomatic bradycardia due to necessary medical therapyAtrial flutter/atrial flutter, typical/atypical/unspecified (I48.3/I48.4/I48.92) with symptomatic bradycardia due to necessary medical therapyHypersensitive carotid sinus syndrome and neurocardiogenic syncope (Syncope without clear, provocative events and with a hypersensitive cardioinhibitory response of 3 seconds or longer or for significantly symptomatic neurocardiogenic syncope associated with bradycardia documented spontaneously or at the time of tilt-table testing) (G90.01)
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker (A54831)
Other Conditions Not Addressed by the NCD or by the Contractor - Group III include but are not limited to the following (Attest with Modifier - SC):Cardiac resynchronization therapyObstructive hypertrophic cardiomyopathyPacing in children, adolescents, and patients with congenital heart diseasePacemaker or generator replacementsSustained pause-dependent ventricular tachycardia, with or without QT prolongationModifier Usage:Modifier  KX (Requirements specified in the medical policy have been met) must be used as an attestation by the practitioner and/or provider of the service that documentation is on file verifying the patient has a symptomatic arrhythmia or a high potential for progression of the rhythm disturbance requiring a permanent pacemaker forGroups I and II. Bradycardia that is the consequence of essential long-term drug therapy of a type and dose for which there is no acceptable alternativedoes not excludethe use of modifier  KX.In addition, use of modifier  KX may be used in patients without symptoms in Groups I and II in the following situations:
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker (A54831)
In addition, use of modifier  KX may be used in patients without symptoms in Groups I and II in the following situations:Awake, symptomfree patients in sinus rhythm, with documented periods of asystole greater than or equal to 3.0 seconds or any escape rate less than 40 beats per minute (bpm), or with an escape rhythm that is below the AV nodeAwake, symptom-free patients with atrial fibrillation and bradycardia with one or more pauses of at least 5 seconds or longerCatheter ablation of the AV junctionPostoperative AV block that is not expected to resolve after cardiac surgeryPatients with neuromuscular diseases, e.g., myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb dystrophy, and peroneal muscular atrophy, with third-degree and advanced second-degree AV block at any anatomic levelAsymptomatic persistent third-degree AV block at any anatomic site with average awake ventricular rates of 40 bpm or faster if cardiomegaly or LV dysfunction is present or if the site of block is below the AV nodeSecond or third-degree AV block during exercise in the absence of myocardial ischemiaPersistent third-degree AV block with an escape rate greater than 40 bpm in asymptomatic adult patients without cardiomegalyAsymptomatic second-degree AV block at intra-or infra-His levels found at electrophysiological studyFirst- or second-degree AV block with symptoms similar to those of pacemaker syndrome or hemodynamic compromiseAsymptomatic type II second-degree AV block with a narrow QRS. Second-degree AV block with a wide QRS including isolated right bundle-branch blockFor medically necessary pacemaker insertion in conditions not addressed by the NCD or this article,Group III, usemodifier - SC(Medically necessary service or supply).Modifiers GA and GZ:
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker (A54831)
For medically necessary pacemaker insertion in conditions not addressed by the NCD or this article,Group III, usemodifier - SC(Medically necessary service or supply).Modifiers GA and GZ:Modifier GA (Waiver of liability statement issued as required by payer policy, individual case) should be used when the provider wants to indicate that he/she anticipates that Medicare will deny a specific service as not reasonable and necessary, an Advanced Beneficiary Notice (ABN) Form CMS-R-131 has been signed by the beneficiary and is on file. Modifier GA may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN are required.Modifier GZ should be used when the provider wants to indicate that it is expected that Medicare will deny the specific services as not reasonable and necessary and the beneficiary was not asked to sign an ABN.Claims for pacemaker claims that do not meet the criteria for modifier KX or SC should have modifier GA or GZ appended depending on the ABN status and will be denied.