evekhm/cms_iom_500 huggingface dataset:
(Medicare National Coverage Determinations Manual)
3796  R39NCD  06/24/2005  Cochlear Implantation - Replaced by Revision 42  07/05/2005  3796  R33NCD  04/22/2005  Percutaneous Transluminal Angioplasty (PTA  07/05/2005  3811  Rev.#  Issue Date  Subject  Impl. Date  CR R29NCD  03/04/2005  Implantable Automatic Defibrillators  04/04/2005  3604  R26NCD  12/10/2004  Electrocardiographic Services  10/10/2004  3590  R25NCD  10/15/2004  Percutaneous Transluminal Angioplasty (PTA)  10/12/2004  3489  R23NCD  10/01/2004  Treatment of Obesity  10/01/2004  3502  R16NCD  06/25/2004  Cardiac Pacemaker  04/30/2004  3369  R12NCD  04/30/2004  Cardiac Pacemakers - Replaced by Revision 16  04/30/2004  3290  R11NCD  04/16/2004  Noncoverage of Acupuncture for Fibromyalgia/Osteoarthritis  04/06/2004  3250  R10NCD  04/06/2004  Re-release of NCD Manual  N/A N/A R09NCD  04/01/2004  NCD - Ocular Photodynamic Therapy (OPT) With Verteporfin for Age -Related Macular Degeneration (AMD)  04/01/2004  3191  R06NCD  01/23/2004  Cardiac Output Monitoring by Thoracic Electrical Bioimpedance  02/23/2004  2689  R02NCD  10/17/2003  Artificial hearts and Related Devices  10/01/2003  2958  R01NCD  10/01/2003  Initial Release of Manual  N/A N/A Back to top of Chapter
Article - Billing and Coding: Low frequency, non-contact, non-thermal ultrasound (A53773)
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.Title XVIII of the Social Security Act, 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Article TextLow frequency, non-contact, non-thermal ultrasound (CPTcode 97610) describes a system employed in wound care that uses continuous low frequency ultrasonic energy to atomize a liquid and deliver continuous low frequency ultrasound to the wound bed. MIST therapy or other similar products are included in the payment for the treatment of the same wound with other active wound care management or wound debridement CPTcodes (97597, 97598, 97602, 97605, 97606).
Article - Billing and Coding: Frequency and Duration for Cardiac Rehabilitation and Intensive Cardiac Rehabilitation (A53775)
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. 100-02, Medicare Benefit Policy Manual, Chapter 15, 232 Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Services Furnished On or After January 1, 2010CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, 140 Cardiac Rehabilitation (CR) Programs, Intensive Cardiac Rehabilitation (ICR) Programs, and Pulmonary Rehabilitation (PR) Programs42 CFR 410.49 Cardiac rehabilitation program and intensive cardiac rehabilitation program: Conditions of coverageArticle TextCardiac Rehabilitation ProgramThe frequency and duration of the program is generally a total of 36 sessions over a maximum of 36 weeks.A single session must last at least 31 minutes in order to be billable. If 2 sessions are billed for a single day, then the total combined time must be at least 91 minutes (60 minutes for the first session and at least 31 minutes for the second session) in duration.No more than 2 1-hour sessions, utilizing any combination of the CPTor HCPCS codes (93798, 93797 or G0422, G0423) will be allowed per day for up to 36 sessions over a maximum of 36 weeks (Phase IIA).An additional 36 sessions may be allowed if a significant intercurrent illness or comorbidity occurred during the first 36 sessionsandthe exit criteria have not been met (Phase IIB). Inclusion of the KX modifier on the claim line(s) will be accepted as an attestation by the provider of the service that documentation is on file verifying that further treatment beyond 36 sessions of CR up to a total of 72 sessions meets the CR coverage requirements. The medical record must reflect the medical reasons for further treatment and be available to Medicare upon request.An additional series of 36 sessions may be allowed as a new series of CR initiated after an intervening event described as an indication for CR in this article. Inclusion of the KX modifier on the claim line(s) will be accepted as an attestation by the provider of the service that documentation is on file verifying that an additional series of CR meets the CR coverage requirements.Intensive Cardiac Rehabilitation Program (ICR)
Article - Billing and Coding: Frequency and Duration for Cardiac Rehabilitation and Intensive Cardiac Rehabilitation (A53775)
Abeneficiarymayswitchfrom anICRprogram to a CRprogram.The beneficiaryislimitedto a1-time switch,multiple switchesare notallowable. Oncethebeneficiaryswitches fromICRto CR, he or she will belimitedto thenumberofsessionsremaining in theprogram.Forexample,abeneficiarywhoswitchesfromICRto CRafter12sessionswillhave24sessionsof CRremaining,(i.e.,12sessionsofICR+ 24sessionsof CR = total of 36sessions).Should abeneficiary experiencemorethan 1indicationsimultaneously,he or shemay participatein a singleseriesof CR orICR sessions(i.e.,apatientwho had amyocardialinfarctionwithin12monthsandcurrently experiencesstable angina isentitledto 1seriesof CRsessions,up to 361-hoursessionswithcontractordiscretionfor anadditional36sessions;or1 seriesofICR sessions,up to 721-hoursessionsovera period up to 18weeks).Beneficiariesmaynotswitchfrom CR toICR.Uponcompletionof a CR orICR program,beneficiariesmustexperience anotherindication inorderto beeligibleforcoverageofmoreCR or ICR.Contractorsshallaccepttheinclusionof the KXmodifieron theclaim line(s)as anattestationby theproviderof theservicethatdocumentationis onfile verifyingthatfurthertreatmentbeyond36 sessions of CR up to a total of 72sessionsmeetstherequirementsof themedicalpolicyor, forICR,that anyfurthersessionsbeyond72 sessions within a 126 dayperiodcountingfrom the date of the firstsessionorforanysessionsprovidedafter126daysfrom the date of the firstsessionmeettherequirementsof the medicalpolicy.BeneficiarieswhoswitchfromICRto CRmayalso beeligiblefor up to 72combinedsessions withcontractordiscretionfor CRsessionsafter36(toinclude completedICRsessions prior toswitch).Inthesecases,andconsistentwith theinformationabove,the KXmodifiermustbeincludedon theclaimshould thebeneficiary participateinmorethan 36 CRsessionsfollowing theswitch.ICD-10-CM diagnosis codes supporting medical necessity must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.
Article - Billing and Coding: Frequency and Duration for Cardiac Rehabilitation and Intensive Cardiac Rehabilitation (A53775)
ICD-10-CM diagnosis codes supporting medical necessity must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.Any diagnosis submitted must have documentation in the patients record to support coverage and medical necessity.IF rendering CR or ICR services that involve ECG monitoring, the medical record must document performance of such monitoring. This should not be construed as a requirement for ECG monitoring for all CR or ICR services. Reported CPTcodes should accurately capture the service that was performed.
Article - Billing and Coding: Infusion, Injection and Hydration Services (A53778)
CMS National Coverage PolicyCMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, 10.4 and 230.CMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, 30.5CMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, 230 Billing and Payment for Drugs and Drug Administration and 230.2 Coding and Payment for Drug AdministrationCMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 17, 10 Payment Rules for Drugs and BiologicalsArticle TextPalmetto GBA has received inquiries related to the billing and documentation of infusions, injections and hydration fluids. Documentation, medical necessity, and code assignment are very important.Infusion TherapyFor purposes of facility coding, an infusion is required to be more than 15 minutes for safe and effective administration. Hydration therapy is always secondary to infusion/injection therapy.For example, if the initial administration infuses for 20 to 30 minutes the provider would bill one unit because the CPT(Current Procedural Terminology) /HCPCS (Healthcare Common Procedure Coding System) code states 'initial up to or first hour'. If an additional drug is administered and infused for 20 minutes no additional units would be billed, as the one hour increment has not been exceeded. The medication administration record and/or the nursing documentation should coincide with the billing based on time of initiation, time of completion, and discharge from the outpatient facility.Intravenous (IV) infusions are billed based upon the CPT/HCPCS description of the service rendered. A provider may bill for the total time of the infusion using the appropriate add-on codes (i.e. the CPT/HCPCS for each additional unit of time) if the times are documented. Providers may not bill separately for items/services that are part of the procedures (e.g., use of local anesthesia, IV start or preparation of chemotherapy agent).
Article - Billing and Coding: Infusion, Injection and Hydration Services (A53778)
The appropriate CPT/HCPCS codes for the IV infusion/administration of drugs should be used with the appropriate number of units. Upon initiation of the infusion it is expected that the start time be documented as well as the stop time. The nursing documentation and/or medication administration record should indicate this information and be signed by the appropriate clinical staff.When requested, providers should submit documentation indicating the volume, start and stop times, and infusion rate (s) of any drugs and solution provided. In the absence of the stop time the provider should be able to calculate the infusion stop time with the volume, start time, and infusion rate.Injections/IV Push TherapyAn intravenous injection (IV push) is an infusion of 15 minutes or less. If an IV push is administered the following criteria must be met:A healthcare professional administering an injection is continuously present to administer and observe the patientAn infusion is administered lasting 15 minutes or lessHydration TherapyHydration must be medically reasonable and necessary. If documentation supports a clinical condition that warrants hydration, other than one brought about by the requirements of a procedure, the hydration may be separately billable.When fluids are used solely to administer the drugs, i.e. the fluid is merely the vehicle for the drug administration, the administration of the fluid is considered incidental hydration and not separately billable.CPTinstructions require the administration of a hydration infusion of more than 30 minutes in order to allow the coding of hydration as an initial service. Hydration of less than 30 minutes is not separately billable. The charges for an administration of 30 minutes or less should be reported with an appropriate revenue code, but without a HCPCS or CPTcode. Hydration therapy of 30 minutes or more should be coded as initial, 31 minutes to one hour, and each additional hour should be listed separately in addition to the code for the primary infusion/injection.Frequently Asked QuestionsIn what order should hospitals bill infusion and injections?Consistent with the special instructions for facilities in the CPTmanual, infusion should be primary, injections/IV pushes next and hydration therapy last. Infusion>Injection>Hydration).How many initial services may be billed per day?
Article - Billing and Coding: Infusion, Injection and Hydration Services (A53778)
How many initial services may be billed per day?Only one initial code is allowed per patient encounter unless two separate IV sites are medically reasonable and necessary (use modifier 59). If the patient returns for a separate and medically reasonable and necessary visit/encounter on the same day, another initial code may be billed for that visit with CPTmodifier 59.What is the difference between an IV push and an IV infusion?AnIV push is an infusion of 15 minutes or less and requires that the health care professional administering the injection is continuously present to observe the patient.In order to bill an IV infusion, a delivery of more than 15 minutes is required for safe and effective administration.When can a sequential infusion be billed?Following the completion of the first infusion, sequential infusions may be billed for the administration of a different drug or service through the same IV access. There must be a clinical reason that justifies the sequential (rather than concurrent) infusion. Sequential infusions may also be billed only once per sequential infusion of same infusate mix.There is no concurrent code for either a chemotherapeutic IV infusion or hydration. Can a concurrent infusion be billed?Any hydration, therapeutic or chemotherapeutic infusion occurring at the same time and through the same IV access as another reportable initial or subsequent infusion is a concurrent infusion. Concurrent administration of hydration is not billable via a HCPCS code and not separately payable. In general, chemotherapeutics are not infused concurrently, however if a concurrent chemotherapy infusion were to occur, the infusion would be coded with the chemotherapeutic unlisted code.When can hydration be billed?
Article - Billing and Coding: Infusion, Injection and Hydration Services (A53778)
When can hydration be billed?Documentation must indicate that the hydration service is medically reasonable and necessary. It should not be an integral part of another service such as an operative procedure. The rate of infusion should be included in the documentation. When fluids are used solely to administer drugs or other substances, the process is considered incidental hydration and should not be billed. To code hydration as an initial service, hydration must be a medical necessity and administered for more than 30 minutes. Hydration of 30 minutes or less is not separately billable. The charges for an administration of 30 minutes or less should be reported with an appropriate revenue code but without a HCPCS or CPTcode. Each additional hour of hydration infusion requires an initial service being delivered (hydration or other infusion/injection service).If a patient is receiving an IV infusion for hydration and the stop time is not documented in the medical record, how should the service be coded?Infusion times should be documented. Hydration of 30 minutes or less is not separately billable. When requested, providers should submit documentation indicating the volume, start and stop times, and infusion rate (s) of the solution provided. In the absence of the stop time the provider should be able to calculate the infusion stop time with the volume, start time, and infusion rate and code accordingly.What are the most frequent documentation problems in the area of infusion therapy?As with other Medicare contractor reviews, problems arise with insufficient or incomplete documentation. In the area of infusion therapy, several areas are affected. Problem areas are listed below.Intravenous Infusion Hydration TherapyThe physician order for hydration fluids administered during the encounter for drug administration, chemotherapy or blood administration is missingNo distinction is made between hydration administration that is the standard of care, facility protocol and/or drug protocol for administration of hydrating fluids, pre- or post-medicationsDocumentation is insufficient and does not support medical necessity of pre-hydration, simultaneous or subsequent hydrationInfusion Services
Article - Billing and Coding: Infusion, Injection and Hydration Services (A53778)
Infusion ServicesDocumentation does not confirm administration through a separate access sitePoor documentation for the line flush between drugs makes it impossible to determine whether compatible substances or drugs were administered concurrently or sequentiallyThe inadequate documentation of the access site and/or each drug's start and stop times makes it impossible to determine whether compatible substances or drugs were mixed in the same bag or syringe or administered separatelyStart and/or stop times for each substance infused are often missingThe documentation of infusion services was started in the field by emergency medical services (EMS) and continued in the emergency department (ED)Documentation of infusion services that were initiated in the ED continued upon admission to outpatient observation statusWorking with vendors on electronic health records (EHR) to implement revisions to electronic forms in order to comply with changing documentation requirements was difficultRecommended Documentation PlanDevelop and/or revise documentation forms that conform to the coding guidelines for injections,IV pushes, and IV infusionsClinical personnel should focus on patient care and ensure accurate and complete documentation of the encounterThe pharmacist should communicate the classification of the drug, fluid or substance to aide in the correct application of procedure codesIn addition to the above, health information management (HIM) coding professionals should ensure accurate coding through review of documentation in the patient record to:Apply official coding guidelinesAssign CPT/HCPCS infusion codesApply modifiers (if indicated)Generate charges for infusion-administration servicesReview accuracy of drug codes and associated billing units
Article - Billing and Coding: Spiracur SNaP® Wound Care System (A53781)
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.Article TextEffective for dates of service on and after January 1, 2013, Palmetto GBA will reimburse Smart Negative Pressure (SNaP), a process that combines a suction device with an advanced hydrocolloid wound dressing. SNaPdelivers constant and controlled levels of negative pressure to facilitate the healing of the following types of open wounds:Stage III and IV pressure ulcerNeuropathic (diabetic) ulcerChronic (present for at least 30 days) ulcer of mixed etiologyVenous or arterial insufficiency ulcerComplications of a surgically created woundTraumatic woundPalmetto GBA expects providers to utilize all accepted wound care standards prior to using SNaP.Accepted wound care standards include the following:Patient turning and positioningAppropriate surface modalities to prevent pressure woundsAppropriate management of moisture and incontinenceConsistent application of compression garments and/or bandagesLeg elevation and ambulationAppropriate topical wound treatmentsAppropriate necrotic tissue debridementNutritional status evaluation with appropriate interventionThe patient medical record maintained by the health care professional must include the following patient-specific information:Physician order for treatmentDocumentation to substantiate standard protocols have been metWound description including specific measurements and conditionPatient-specific treatment planCoding/Billing GuidelinesCMS 1500 FormAn evaluation/management (E/M) service may be billed using the appropriate E/M CPTcode appended with the 25 modifier. The E/M service may only be submitted when a separately identifiable service is performed besides the negative pressure wound therapy. If the patient's condition warrants an additional E/M service, the medical record must document the medical necessity for the E/M service including the following:
Article - Billing and Coding: Spiracur SNaP® Wound Care System (A53781)
Wound description including specific measurements and conditionChange in patient statusA simple check of the wound does not justify an additional E/M service and will be denied as not reasonable or necessaryCPTcode:97607 (Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s) wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters), or97608 (Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s) wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters)*NOTE: CPTCodes 97607 and 97608 are not specific to the Spiracur SNaPWound Care System. These CPT codes apply to any equivalent product. If a disposable negative pressure wound therapy (NPWT) product is used that meets the same specifications as the Spiracur SNaPWound Care System, but is a different product, the product name should be entered in the Narrative field on the CMS 1500 Form.UB-04 (CMS 1450 form) - Outpatient TreatmentTo report a SNaPtreatment in the outpatient setting, submit the following:
Article - Billing and Coding: Spiracur SNaP® Wound Care System (A53781)
UB-04 (CMS 1450 form) - Outpatient TreatmentTo report a SNaPtreatment in the outpatient setting, submit the following:CPTcode:97607 (Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s) wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters), or97608 (Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s) wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters)Enter 'Spiracur SNaPdevice' in the Remarks field (field locator 80) on the UB-04 (CMS 1450 form)*NOTE: CPTCodes 97607 and 97608 are not specific to the Spiracur SNaPWound Care System. These CPT codes apply to any equivalent product. If a disposable negative pressure wound therapy (NPWT) product is used that meets the same specifications as the Spiracur SNaPWound Care System, but is a different product, the product name should be entered in the Remarks field (field locator 80) on the UB-04 (CMS 1450 form).