evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers (A58468)
Note:'Bundle' refers to multiple plasma assays.These Tables will be updated to reflect revisions and additions of newly covered tests.Coverage of tests for other cancer indications and episodes of care, and modifications to the definition of an episode of care will be evaluated as needed.Additional process requirements for coverage and billing:MolDX may make available specific forms to assist with test Technical Assessments (TAs). Please follow the instructions on the MolDX website to assist with this process. If such forms are available that pertain to the test type in question, these forms are required for successful coverage determinations.For patients with cancer, the UOS for this type of test is 1. Billing should occur at the start of the episode of testing.Regarding the use of NGS-based MRD tests (i.e., Signatera) in patients with cancer Theservicemay be performed once per patient per cancer diagnosis, unless there is clinical evidence ofa priorichange in genetic content.For patients without cancer (as defined in the policy), a second kind of test may exist wherein asingle timepointmay constitute a single test (i.e., 1 UOS for a given date of service). Testing in these patients will be accompanied by the appropriate Personal history of cancer ICD-10 code. Testing may not be performed more than once in a month; the testing schedule is set based on the validity established of the individual test for the given indication.NOTE: Prophylactic therapeutic interventions in patients with a history of cancer are excluded from the definition of a patient "with cancer".Refer to additional instructions outlined in the relevant Group sections below.Regarding NGS panels:To submit a claim for MRD analysis by NGS that measures multiple analytes, use CPT code 81479 and 1 UOS with the assigned DEX Z-Code.Billing instructions:Billing requires a Z-Code to be submitted with the claim. All tests must be registered with the DEX Diagnostic Exchange application.To report an episode of testing, please submit the following claim information:
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers (A58468)
Select the appropriate CPT code. If no specific CPT code exists for the test submitted, bill with the NOC 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 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 the appropriate ICD-10-CM codeNOTE:When entering the DEX Z-Code on the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.When submitting claims for the specific indicated use of monitoring response to ICI therapy, the ICI drug name must be included on the claim in the applicable detail line 2400 loop.
Article - Billing and Coding: Colon Capsule Endoscopy (CCE) (A58471)
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 TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD L38837 Colon Capsule Endoscopy (CCE).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.For the purposes of this Billing and Coding Article, ICD-10-CM diagnosis codeZ53.8indicates that the instrument colonoscopy has been attempted and was incomplete and ICD-10-CM diagnosis codeZ53.09indicates the procedure is contraindicated when a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training determined from an evaluation of the patient that optical colonoscopy cannot be safely attempted.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: Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease (A58473)
CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L38839 for Non-Invasive Fractional Flow Reserves (FFR) for Ischemic Heart Disease.Procedure codes may be subject to National Correct Coding Initiative edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.As this service constitutes post-procedure analysis of a previously performed study Coronary Computed Tomographic Angiography (CCTA), the name and NPI of the referring/ordering physician that submitted imaging data for FFRct review must be reported on the claim.An Advance Beneficiary Notice of Non-coverage may be used for services that are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30 for complete instructions.The patients medical record must document all of the following:The clinical findings that led to the initial performance of the CCTA, and the CCTA must be fully reviewed before the performance of FFRct. (as evidenced by the submission of the Coronary Computed Tomographic Angiography Report)Description of symptoms consistent with stable ischemic heart diseaseBody mass indexFractional Flow Reserve analysis report
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A58477)
CMS National Coverage PolicyN/AArticle TextRefer to the Local Coverage Determination (LCD) L38841 Facet Joint Interventions for Pain Management, for reasonable and necessary requirements and frequency limitations.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise, the symptoms prompting the performance of the test should be reported.Coding GuidanceProviders should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.This policy applies only to cervical/thoracic or lumbar facet procedures and does not apply to other joint procedures (such as sacral injections, sacroiliitis, epidural or other spinal procedure).Diagnostic and Therapeutic injections:Each facet level in the spinal region is composed of bilateral facet joints (i.e., there are 2 facet joints per level, 1 on the right side and 1 on the left). Unilateral or bilateral facet interventions may be performed during the facet joint procedure (a diagnostic nerve block, a therapeutic facet joint (intraarticular) injection, a medial branch block injection, or the medial branch radiofrequency ablation (neurotomy) in 1 session. A bilateral intervention is still considered a single level intervention.
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A58477)
Each unilateral or bilateral intervention at any level should be reported as 1 unit, with bilateral intervention signified by appending the modifier -50.Regions:An anatomic spinal region for paravertebral facet joint block (diagnostic or therapeutic), is defined as cervical\thoracic (CPT codes 64490, 64491, 64492) or lumbar\sacral (CPT codes 64493, 64494, 64495) per the AMA CPT Manual.Levels:64490 (cervical or thoracic) or 64493 (lumbar or sacral) reports a single level injection performed with image guidance (fluoroscopy or CT). Procedure performed under ultrasound guidance are not covered.64491 or 64494 describes a second level which should be reported separately in addition to the code for the primary procedure. 64491 should be reported in conjunction with 64490 and 64494 should be reported in conjunction with 64493.64492 or 64495 describes a third and additional levels and should be listed separately in addition to the code for the primary procedure and the second level procedure and cannot be reported more than once per day. 64492 should be reported in conjunction with 64490/64491 and 64495 should be reported in conjunction with 64493/64494.Laterality:Bilateral paravertebral facet injection procedures 64490 through 64495 should be reported with modifier 50.
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A58477)
Laterality:Bilateral paravertebral facet injection procedures 64490 through 64495 should be reported with modifier 50.One to 2 levels, either unilateral or bilateral, are allowed per session per spine region (i.e., 2 unilateral or to 2 bilateral levels per session).For services performed in the ASC, physicians must continue to use modifier 50. Only the ASC facility itself must report the applicable procedure code on 2 separate lines, with 1 unit each and append the RT and LT modifiers to each line.KX modifier requirements:The KX modifier should be appended to the line for all diagnostic injections. In most cases the KX modifier will only be used for the 2 initial diagnostic injections. If the initial diagnostic injections do not produce a positive response as defined by the policy and indicative of identification of the pain generator, and it is necessary to perform additional diagnostic injections, append the KX modifier to the line. Aberrant use of the KX modifier may trigger focus medical review.Therapeutic injections:Documentation of why patient is not a candidate for RFA must be submitted for therapeutic treatment upon request.Chemodenervation of nerve:Codes 64633, 64634, 64635, 64636 are reported per joint, not per nerve. Although 2 nerves innervate each facet joint, only 1 unit per code may be reported for each joint denervated, regardless of the number of nerves treated (AMA CPT Manual 2020).Each unilateral or bilateral intervention at any level should be reported as 1 unit, with bilateral intervention signified by appending the modifier -50.Region:An anatomic spinal region for thermal facet joint denervation is defined as cervical/thoracic (CPT codes 64633 and 64634) or lumbar/sacral (CPT codes 64635 and 64636) per the AMA CPT Manual.
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A58477)
For neurolytic destruction of the nerves innervating the T12-L1 paraveterbral facet joint, use 64633Levels:64633 or 64635 describes a single level destruction by neurolytic agent performed with image guidance (fluoroscopy or CT)64634 or 64636 describes each additional level which should be reported separately in addition to the code for the primary procedure. 64634 should be used in conjunction with 64633 and 64636 should be used in conjunction with 64635.Laterality:For bilateral procedures report modifier 50 on each line in which the intervention was of a bilateral nature.For services performed in the ASC, physicians must continue to use modifier 50. Only the ASC facility itself must report the applicable procedure code on 2 separate lines, with 1 unit each and append the RT and LT modifiers to each line.Non-thermal facet joint denervation (including chemical, low grade thermal energy (<80 degrees Celsius or any other form of pulsed radiofrequency) should not be reported with CPT codes 64633, 64634, 64635 or 64636. These services should be reported with CPT code 64999. Code 64999 is non-covered when used to report non-thermal facet joint denervation.If facet joints are injected with biologicals or other substances not designated for this use the entire claim will deny per Benefit Policy Manual Chapter 16: Section 180.Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for facet joint injection procedures and not routinely reimbursable and therefore may be denied. In exceptional circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record, individual consideration may be considered on appeal.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering 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.)
Article - Billing and Coding: Echocardiography for Myocardial Perfusion (A58503)
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 23, 30 Services Paid Under the Medicare Physicians Fee ScheduleCMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code RequirementsArticle TextThe information in this article contains billing, coding or other guidelines that complements the Local Coverage Determination (LCD) for Echocardiography for Myocardial Perfusion L38786.An echocardiogram done with an ultrasound enhancing agent (UEA) in the setting of cardiovascular disease for purposes of left ventricular opacification (LVO) is reasonable and medically necessary. It is the only FDA-approved use for UEAs in cardiovascular disease at the current time.All other applications in cardiovascular disease including those for myocardial perfusion measurement or myocardial viability are currently off-label uses. However, such use does occur regularly. Furthermore, over many decades a significant amount of data has accumulated and many studies, both single and multicenter in design, have been performed. The collective evidence in its totality regarding the use of UEAs approved for LVO purposes, specifically for myocardial perfusion evaluation is interpreted as warranting coverage despite off-label use.Per the related LCD, echocardiography with UEAs for purposes of assessing myocardial perfusion is considered reasonable and necessary when evaluating individuals with elevated cardiovascular risk factors in the setting of symptomatic angina with known or suspected underlying coronary artery disease (CAD). Assessment of myocardial perfusion via echocardiography with UAEs for purposes of determining cardiac viability is also considered reasonable and necessary for purposes of therapeutic or diagnostic decision making.Documentation:Regarding this topic, in general, certain documentation would be expected for the use of UEAs (aka contrast) in assessing myocardial perfusion with echocardiography procedures, to include the following:The condition/diagnosis necessitating the echocardiographic procedureThe condition/diagnosis necessitating the administration of an UEA
Article - Billing and Coding: Echocardiography for Myocardial Perfusion (A58503)
Documentation should be available, if requested, regarding the echocardiographic methods employed including mechanical indices utilized as well as accreditation of the lab and the certification of the echocardiographer.Medical records may be requested for determination of medical necessity. Additional letters of support and/or explanation are often useful, but do not represent enough documentation unless all specific information needed to make a medical necessity determination is included.The documentation in the patients medical record must support the use of UEAs as being medically reasonable and necessary.Based on that documentation, the determination of reasonable and necessary is currently left to the discretion of the Medicare Administrative Contractors (MACs).Billing information:When ultrasound (US) contrast enhancement is used for visualizing the ventricular chambers and endocardial border, the supply is considered separate from the procedure for reimbursement from Medicare.Diagnostic injection services are an integral part of a contrast procedure and are not separately payable.
Article - Billing and Coding: Complex Drug Administration Coding (A58527)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1861(t) states that these drugs may be paid when they are administered incident to a physicians service and determined to be medically reasonable and necessaryTitle XVIII of the Social Security Act, 1861(s)(2)(A) or (B) definition ofmedical and other health servicesTitle 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 memberCMS Internet Only-Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 50 Drugs and Biologicals and 50.3 Incident To RequirementsCMS Internet Only-Manual,Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, 30.5 Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions, Part D. Chemotherapy AdministrationCMS Internet Only-Manual,Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, 40 Discarded Drugs and BiologicalsArticle Text
Article - Billing and Coding: Complex Drug Administration Coding (A58527)
This Medicare Administrative Contractor (MAC) has determined in review of submitted claims that there is inappropriate use of CPTcodes 96401-96549 for chemotherapy and other highly complex drug or highly complex biologic agent administration.The Current Procedural Terminology (CPT) codebook contains the following information and direction for the Chemotherapy and Other Highly Complex Drug or Highly Complex Biological Agent Administration CPTcodes: Chemotherapy Administration codes 96401-96549 apply to parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of non-cancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as certain monoclonal antibody agents, and other biologic response modifiers. The highly complex infusion of chemotherapy or other drug or biologic agents requires physician or other qualified health care professional work and/or clinical staff monitoring well beyond that of therapeutic drug agents (96360-96379) because the incidence of severe adverse patient reactions are typically greater. These services can be provided by any physician or other qualified health care professional. Chemotherapy services are typically highly complex and require direct supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intraservice supervision of staff. Typically, such chemotherapy services require advanced practice training and competency for staff who provide these services; special considerations for preparation, dosage, or disposal; and commonly, these services entail significant patient risk and frequent monitoring. Examples are frequent changes in the infusion rate, prolonged presence of the nurse administering the solution for patient monitoring and infusion adjustments, and frequent conferring with the physician or other qualified health care professional about these issues. When performed to facilitate the infusion of injection, preparation of chemotherapy agent(s), highly complex agent(s), or other highly complex drugs is included and is not reported separately. To report infusions that do not require this level of complexity, see 96360-96379. Codes 96401-96402, 96409-96425, 96521-96523 are not intended to be reported by the individual physician or other qualified health care professional in the facility setting. The term chemotherapy in 96401-96549 includes other highly complex drugs or highly complex biologic agents.
Article - Billing and Coding: Complex Drug Administration Coding (A58527)
Medicare has determined under 1861(t) that these drugs may be paid when they are administered incident to a physicians service and determined to be medically reasonable and necessary. Such determination of reasonable and necessary is currently left to the discretion of the MACs. The documentation in the patients medical record must support the drugs as being medically reasonable and necessary.As stated in the CMS Internet Only-Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, 30.5 Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions, Part D. Chemotherapy Administration, A/B MACs (B) may provide additional guidance as to which drugs may be considered to be chemotherapy drugs under Medicare.Not Otherwise Classified (NOC) Drug BillingOffice/ClinicProviders submit NOC codes in the 2400/SV101-2 data element in the 5010 professional claim transaction (837P). When billing a NOC code, providers are required to provide a description in the 2400/SV101-7 data element. The 5010 TR3 Implementation Guide instructs: "Use SV101-7 to describe non-specific procedure codes." (Do not use the 2400 NTE segment to describe non-specific procedure codes with 5010.) The SV101-7 data element allows for 80 bytes (i.e., characters, including spaces) of information.In order for this A/B MACto correctly reimburse NOC drugs and biologicals, providers must indicate the following in the 2400/SV101-7 data element, or Item 19 of the CMS 1500 form: