evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The following codes are not subject to fee schedule limitations when submitted for payment on the same bill with charges for blood products.  Rather, assume they are to be used for blood matching and not for diagnostic purposes.   Codes: 86901, 86905, 86930- 86932, 86920- 86922, 86890, 86870, 86891, 86880- 86886, 86971, and 86930.  If no blood product is provided and billed for on the same claim, assume the codes are diagnostic and subject to the clinical laboratory fee schedule.   The shared system provides for this processing.  100.4 - Not Otherwise Classified Clinical Laboratory Tests  (Rev. 1, 10- 01-03)  The following codes for unlisted or not otherwise classified (NOC) clinical laboratory tests are not subject to the NLA:   81099 87999 84999 88299 85999 89399 86999  The NOC codes shall suspend for review and the A/B MAC (B) shall determine a price for them.   100.5 - Other Coding Issues  (Rev. 1, 10- 01-03)  100.5.1 - Tests Performed More Than Once on the Same Day  (Rev. 1, 10- 01-03) PM AB -98-7  When it is necessary to obtain multiple results in the course of treatment, the modifiers 59 or 91 are used to indicate that a test was performed more than once on the same day for the same patient.  The 91 modifier is used for laboratory tests paid under the clinical laboratory fee schedule.   These modifiers may be used to indicate that a test was performed more than once on the same day for the same patient, only when it is necessary to obtain multiple results in the course of treatment.  These modifiers may not be used when tests are rerun to confirm initial results; due to testing problems with specimens and equipment; or for any other reason when a normal, one -time, reportable result is all that is required.  These modifiers may not be used when there are standard HCPCS codes available that describe the series of results (e.g., glucose tolerance tests, evocative/suppression testing, etc.).  These modifiers may be used only for laboratory tests paid under the clinical laboratory fee schedule.
(Medicare Claims Processing Manual)
Improper use of modifiers is likely to indicate a fraudulent or abusive circumstance.  When informing laboratories of the availability of modifiers, A/B MACs (B) are to emphasize that these modifiers have very narrow application and that any evidence of excessive use will be referred to A/B MAC (A) or (B) Program Integrity Unit for further review.   100.6 - Pricing Modifiers  (Rev. 2487, Issued: 06- 08-12, Effective: 01 -01-11, Implementation: 06- 19-12)  PM A -03-033  Prior to January 1, 2011  Three pricing modifiers discretely identify the different payment situations for ESRD Automated Multi- Channel Chemistry (AMCC) tests.  The physician that orders the tests is responsible for identifying the appropriate modifier when ordering the tests.  The modifiers are in the following listing:    CD -  AMCC test has been ordered by an ESRD facility or MCP physician that is part of the composite rate and is not separately billable    CE - AMCC test has been ordered by an ESRD facility or MCP physician that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity    CF - AMCC test has been ordered by an ESRD facility or MCP physician that is not part of the composite rate and is separately billable   The ESRD clinical laboratory tests identified with modifiers CD, CE, or CF may not be billed as organ or disease panels.  Effective October 1, 2003, all ESRD clinical laboratory tests must be billed individually.   Effective January 1, 2011  With the implementation of the ESRD PPS, effective for claims with dates of service on or after January 1, 2011, all ESRD -related laboratory services are included in the ESRD PPS base rate.  If the ESRD facility needs to report a lab service that was not related to the treatment of ESRD, they must include the modifier AY to indicate the item or service is not f or the treatment of ESRD.  Modifiers CD, CE, and CF (also known as the 50/50 rule modifiers) are no longer valid for use on independent laboratory claims.
(Medicare Claims Processing Manual)
Effective January 1, 2012, A/B MACs (B) shall allow organ disease panel codes (i.e., HCPCS codes 80047, 80048, 80051, 80053, 80061, 80069, and 80076) to be billed by independent laboratories for AMCC panel tests furnished to ESRD eligible beneficiaries.   For more information regarding billing of AMCC tests for ESRD beneficiaries, see Section 40.6.1 of this manual.  110 - Coordination Between A/B MACs (B) and Other Entities  (Rev. 1, 10- 01-03) B3-5114.1  110.1 - Coordination Between A/B MACs (B)  and A/B MACs (A) /RRB  (Rev. 1, 10- 01-03)  The A/B MAC (B) furnishes copies of fees that are locally established under the fee schedules (price code = 22) to A/B MACs (A) and to the RRB Specialty MAC (S MAC).  The A/B MAC (B) must provide updates at least 30 days prior to the A/B MAC (B)s schedule d implementation of the update.  The A/B MACs (A) add these fees to system fee schedule tables to use in paying for hospital laboratory tests performed for both outpatients of the hospital and persons who are not patients of the hospital.  The RRB S MAC us es the fee schedules in paying for outpatient clinical laboratory tests.  A/B MACs (A) and the RRB may consult with A/B MACs (B) on filling gaps in fee schedules for tests where the A/B MAC (B) may not have established an amount.  If an A/B MAC (A) or the RRB S MAC has bills for payment on laboratory tests for which the A/B MAC (B) has not furnished amounts, it consults with the A/B MAC (B).  If necessary the A/B MAC (B) consults with other nearby A/B MACs (B).   110.2 - Coordination With Medicaid  (Rev. 1, 10- 01-03)
(Medicare Claims Processing Manual)
110.2 - Coordination With Medicaid  (Rev. 1, 10- 01-03)  A/B MACs (B) furnish copies of the fee schedules and the annual update (including NLAs where applicable) to State agencies (SAs).  A/B MACs (B) provide updates to SAs at least 30 days prior to the scheduled implementation.  To obtain Federal matching funds  for clinical laboratory services, State Medicaid agencies may not pay more than Medicare pays for the services and specimen collections.   Since the fee schedule provisions were implemented on a carrier wide basis, a State may have had more than one carrier servicing Medicare beneficiaries residing in the State.  A Medicaid agency for such a State may, if it deems necessary, use the fee sched ules of either one or both of the A/B MACs (B) to meet the Federal fund- matching requirement.  State Medicaid agencies may consult with ROs concerning the fee schedule, the NLAs, and specimen collection provisions.  110.3 - Coordination With A/B MACs (A)  and Providers (Rev. 1, 10- 01-03) HO- 437, A3- 3628  There may be procedures hospitals bill for outpatients that are not included in the fee schedule.  Where gaps occur, hospitals should work out procedures with the A/B MAC (A) so that the hospital can secure the missing information promptly.  Price Codes established by the A/B MAC (B) to fill gaps are valid until replaced by the earlier of permanent codes or the next annual update.   110.4 - A/B MAC (B)  Contacts With Independent Clinical Laboratories  (Rev. 1, 10- 01-03) B3-2070.1.F
(Medicare Claims Processing Manual)
110.4 - A/B MAC (B)  Contacts With Independent Clinical Laboratories  (Rev. 1, 10- 01-03) B3-2070.1.F   An important role of the A/B MAC (B) is as a communicant of necessary information to independent clinical laboratories.  Failure to inform independent laboratories of Medicare regulations and claims processing procedures may have an adverse effect on prose cution of laboratories suspected of fraudulent activities with respect to tests performed by, or billed on behalf of, independent laboratories.  United States Attorneys often must prosecute under a handicap or may refuse to prosecute cases where there is n o evidence that a laboratory has been specifically informed of Medicare regulations and claims processing procedures.  To assure that laboratories are aware of Medicare regulations and A/B MAC (B)s policy, notification must be sent to independent laboratories when any changes are made in coverage policy or claims processing procedures.  Additionally, to completely document efforts to fully inform independent laboratories of Medicare policy and the laboratorys responsibilities, previously issued newsletters should be periodically re -issued to remind laboratories of existing requirements.   Some items which should be discussed are the requirements to have the same charges for Medicare and private patients, to document fully the medical necessity for collection of specimens from a skilled nursing facility or a beneficiarys home, and, in cases  when a laboratory service is referred from one independent laboratory to another independent laboratory, to identify the laboratory actually performing the test.  Additionally, when A/B MAC (B) professional relations representatives make personal contacts with particular laboratories, they should prepare and retain reports of contact indicating dates, persons present, and issues discussed.  120 - Clinical Laboratory Services Based on the Negotiated Rulemaking  (Rev. 1, 10- 01-03) PM AB -02-129  Section 4554(b)(1) of the Balanced Budget Act (BBA), Public Law 105- 33 mandated the use of a negotiated rulemaking committee to develop national coverage and administrative policies for clinical laboratory services payable under Part B of Medicare.  The BBA required that these national policies be designed to promote program integrity and national uniformity; and to simplify administrative requirements with respect to clinical diagnostic laboratory services payable under Part B.
(Medicare Claims Processing Manual)
These changes apply to every diagnostic clinical laboratory service that is payable under Medicare Part B.  Neither the place where the service was performed, nor the type of A/B MAC (A) or (B) that will process the request for payment, has any effect on t he applicability of these policies.  A clinical laboratory service done in a hospital laboratory, independent laboratory, physician/practitioner office laboratory or other type of CLIA approved laboratory service is subject to these administrative policies .  The final rule did not affect the requirement that all physician claims must have a diagnosis.  If a physician submits a claim for a service performed in a physician office laboratory, that claim is considered a physician claim and must meet the requirements for physician claims.   120.1 - Negotiated Rulemaking Implementation  (Rev. 1769, Issued: 07- 10-09, Effective/Implementation: 07- 31-09)  The following requirements apply to service providers:    The date of service should be reported as the date of specimen collection.   The person obtaining the specimen must furnish the date of collection for the specimen to the entity billing Medicare.    For specimen collections that span more than a 24 -hour period, the date of service should be reported as the date the collection began.   For laboratory tests that require a specimen from stored collections, the date of service should be defined as the date the specimen was obtained from the archives.    If a situation occurs that does not correspond to the two situations described, the A/B MAC (A) or (B) will submit the question to the RO with the appropriate documentation.  The RO will contact the Division of Supplier Claims Processing in CMS, which will  serve as the point of contact.   Matching of Diagnosis to Procedure   During claims processing and adjudication, the A/B MAC (A) or (B) adheres to the following:    If there is a LMRP or NCD for one or more of the services included on the claim, the A/B MAC (A) or (B) reviews all of the diagnosis codes in making a determination regarding medical necessity of the service.    Even though a claim matches diagnosis to procedure in accordance with an NCD, other rules of adjudication may apply, which could result in denial.   Diagnoses are required on all claims.   Physicians Reporting Diagnosis Codes When A Diagnostic Test Is Ordered
(Medicare Claims Processing Manual)
 Diagnoses are required on all claims.   Physicians Reporting Diagnosis Codes When A Diagnostic Test Is Ordered  Section 4317 of the Balanced Budget Act of 1997 provides, with respect to diagnostic laboratory and certain other services, that if the Secretary (or A/B MAC (A) or (B) of the Secretary) requires the entity furnishing the services to provide diagnostic or  other medical information to the entity, the physician or practitioner ordering the service shall provide that information to the entity at the time the service is ordered by the physician or practitioner.  A laboratory or other provider must report on a  claim for Medicare payment the diagnostic code(s) furnished by the ordering physician.  In the absence of such coding information, the laboratory or other provider may determine the appropriate diagnostic code based on the ordering physicians narrative diagnostic statement or seek diagnostic information from the ordering physician/practitioner.  However, a laboratory or other provider may not report on a claim for Medicare payment a diagnosis code in the absence of physician -supplied diagnostic information supporting such code.  Clarification of the Use of the Term Screening or Screen"   The final rule clarifies that effective February 21, 2002, the use of the term screening or screen in CPT code descriptor does not necessarily describe a test performed in the absence of signs and symptoms of illness, disease or condition.  A/B MACs (A ) and (B) do not deny a service based solely on the presence of the term screening or screen in the descriptor.   Tests that are performed in the absence of signs, symptoms, complaints, personal history of disease, or injury are not covered except when there is a statutory provision that explicitly covers tests for screening as described.   If a person is tested to rule out or to confirm a suspected diagnosis because the patient has a sign and/or symptoms, this is considered a diagnostic test, not a screening test.  A/B MACs (A) and (B) have discretionary authority to make reasonable and nece ssary scope of benefit determinations.
(Medicare Claims Processing Manual)
120.2 - Implementation and Updates of Negotiated National Coverage Determinations (NCDs) for Clinical Diagnostic Laboratory Services  (Rev. 3014, Issued:  08- 06-14, Effective:  ICD -10:  Upon Implementation of ICD -10 ASC- X12:  01- 01-12, Implementation:  ICD -10:  Upon Implementation of ICD -10 ASC X12: 09 -08-14)  Under a negotiated rulemaking process, the Center for Medicare & Medicaid Services (CMS) developed 23 NCDs for clinical diagnostic laboratory services.  The NCDs are applicable to services billed under Part B regardless of the entity providing the services .  Thus, they are binding on A/B MACs (A and B) in processing clinical diagnostic laboratory services on an outpatient basis.  In order to ensure uniformity in the implementation of the NCDs, CMS developed the NCDs utilizing three lists of diagnosis codes.  Every diagnosis code will fall into one the three lists.  The lists included:  Codes Covered by Medicare, Codes Denied, and C odes That Do Not Support Medical Necessity.  Related software, called the laboratory edit module, is incorporated in the shared systems so that laboratory claims subject to one of the 23 NCDs are processed uniformly throughout the nation.  In addition, the NCDs are maintained through the NCD process that was announced in the " Federal Register"  on September 26, 2003 (68 FR 55634).  This process provides for public participation through a comment period at the beginning of the evaluation of the issue and includes a detailed decision document that outlines the rationale for the decision.  These documents may be viewed on the Medicare coverage homepage at cms.hhs.gov/coverage.   On a quarterly basis, CMS will update the NCD edit module as necessary for ministerial coding changes and to implement the NCD decisions described above.  CMS assures the updated software is communicated to the shared system maintainers.  The shared system  maintainers install the revised edit module after testing and distribute it to the A/B MACs (A and B) as part of their routine release.  A/B MACs (A and B) will conduct provider education to advise the laboratories of changes to the laboratory edit module  quarterly.  Exhibit 1 - List of Diagnostic Tests that are Considered End Stage Renal Disease (ESRD)  (Rev. 1769, Issued:  07- 10-09, Effective/Implementation:  07 -31-09)
(Medicare Claims Processing Manual)
Exhibit 1 - List of Diagnostic Tests that are Considered End Stage Renal Disease (ESRD)  (Rev. 1769, Issued:  07- 10-09, Effective/Implementation:  07 -31-09)  Refer to section 40.6.2.3 for guidance on the usage of this list.
(Medicare Claims Processing Manual)
71010 Chest x- ray 71015 Chest x- ray 71020 Chest x- ray 71021 Chest x- ray 71022 Chest x- ray 71030 Chest x- ray 71035 Chest x- ray 73120 X -ray hand  75710 Artery x- rays, arm/leg  75716 Artery x- rays, arm/leg  75774 Artery x- rays, arms/legs  75790 Artery x- ray, each vessel  75820 Visualize A -V shunt  75822 Vein x- ray, arm/leg  75893 Vein x- ray, arms/legs  75894 Transcath therapy, embolization 75896 X -rays, transcath therapy  75898 X -rays, transcath therapy  75901 Mechanical removal of pericath obstructive material  75902 Mechanical removal of intraluminal obstructive material  75961 Transcath retrieval of intravascular foreign body 75962 Transcath balloon angioplasty 75964 Transcath balloon angioplasty, each additional  76070 Computed tomography, bone mineral density study, axial  76075 Dual energy DEXA, bone density study, axial  76080 Radiologic exam, abscess, fistual or sinus tract study  76092 Screening mammography bilateral  76778 Ultrasound, transplanted kidney  78070 Parathyroid nuclear imaging 78351 Bone density, dual photon absorptionmetry 80048 Basic metabolic panel  80051 Electrolyte panel  80053 Comprehensive Metabolic Panel  ? 80061 Lipid panel  80069 Renal function panel  80074 Acute hepatitis panel  80076 Hepatic function panel  80197 Tacrolimus  80410 Calcitonin stim panel  81000 Urinalysis with microscopy  81001 Urinalysis, auto w/scope  81002 Urinalysis nonauto w/o scope  81003 Urinalysis, auto, w/o scope  81005 Urinalysis, qual or semi -quant  81007 Urine screen for bacteria, except by culture or dipstick 81015 Microscopic exam of urine  82009 Test for acetone/ketones,qual  82010 Acetone assay, quant  82017 Acylcarnitines, quant  82040 serum albumin 82042 albumin, urine quant or other source  82108
(Medicare Claims Processing Manual)
Test for acetone/ketones,qual  82010 Acetone assay, quant  82017 Acylcarnitines, quant  82040 serum albumin 82042 albumin, urine quant or other source  82108 Assay of aluminum  82232 Beta2microglobulin (monitor large molecular weigh solute clearance by dial  82247 Bilirubin, total  82248 Bilirubin, direct  82306 Assay of vitamin D -3 (calcifediol)  82307 Assay of vitamin D (calciferol)  82308 Assay of calcitonin 82310 Assay of calcium  82330 Assay of calcium, ionized  82374 Bicarbonate (CO2)  82379 Assay of carnitine  82435 Chloride blood (needed to determine acid/base status)  82465 cholesterol, total serum  82550 CPK, total  82565 Assay of creatinine  82570 Assay of urine creatinine  82575 urine creatinine clearance test  82607 Vit B12 82728 ferritin  82746 serum folate  82747 RBC folate  82800 Blood Ggases, ppH onlyy 82803 Blood gases: pH, pO2 & pCO2 82805 Blood gases W/02 saturation 82810 Blood gases, O2 sat only 82945 Glucose other fluid 82947 Assay, glucose, blood quant  82948 Reagent strip/blood glucose  83540 Assay of iron  83550 Iron binding test  83735 magnesium (monitored to avoid hypermagnesium)  83937 Osteocalcin  83970 parathormone (PTH)  83986 Assay of body fluid acidity 84075 alkaline phosphatase  84100 Assay of phosphorus, inorganic  84105 urine phosphorus  84132 Assay of serum potassium  84133 urine potassium  84134 Assay of prealbumin 84155 Assay of protein  84160 serum protein by refractometry  84295 Assay of serum sodium  84315 Body fluid specific gravity  84450 Transferase (AST) (SGOT)  84460 Alanine amino (ALT) (SGPT)  84466 transferrin  84520 Urea nitrogen, quantitative
(Medicare Claims Processing Manual)
of serum sodium  84315 Body fluid specific gravity  84450 Transferase (AST) (SGOT)  84460 Alanine amino (ALT) (SGPT)  84466 transferrin  84520 Urea nitrogen, quantitative  84540 Assay of urine/urea -n 84545 Urea -N clearance test  84630 zinc  85002 Bleeding time test  85004 Automated diff wbc count  85007 Bl smear w/diff wbc count  85008 Bl smear w/o diff wbc count  85009 Manual diff wbc count b- coat 85013 Spun microhematocrit  85014 Hematocrit  85018 Hemoglobin 85025 Complete CBC w/auto diff wbc  85027 Complete CBC, automated 85032 Manual cell count, each  85041 Automated RBC count  85044 Manual reticulocyte count  85045 Automated reticulocyte count  85046 Reticyte/hgb concentrate  85048 Automated leukocyte count  85049 Automated platelet count  85345 Coagulation time, Lee -White  85347 Coagulation time, activated  85348 Coagulation time, other methods  85520 Heparin assay  85610 Prothrombin time  85611 Prothrombin test,substitution  85651 sed rate  85652 automates sed rate  85730 thromboplastin time, partial (PTT)  85732 Thromboplastin time, partial, substitution  86590 Streptokinase, antibody 86644 CMV screen  86645 Cytomegalovirus antibody dfa (IgM)  86687 HTLV -I antibody 86688 HTLV -II antibody  86689 HTLV/HIV confirmatory test  86692 Hepatitis, delta agent  86701 HIV -1 86702 HIV -2 86703 HIV -1/HIV2, ,singgle assayy  86704 Hep B core antibody, total  86705 Hep b core antibody, IgM  86706 Hep B surface antibody 86707 Hep Be antibody  86709 Hep A, IgM antibody 86803 Hepatitis C ab test  86804 Hep C ab test, confirm  86812 HLA typing, A, B, or C  86813
(Medicare Claims Processing Manual)
86707 Hep Be antibody  86709 Hep A, IgM antibody 86803 Hepatitis C ab test  86804 Hep C ab test, confirm  86812 HLA typing, A, B, or C  86813 HLA typing, A, B, or C, multiple antigens  86816 HLA typing, DR/DQ  86817 HLAy tpypigng, DR/DQ, multiple antigens  86900 Blood typing, ABO  86901 Rh typing  86903 Blood typing, antigen screen  86904 Blood typing, patient serum  86905 Blood typing, RBC antigens  86906 Blood typing, Rh phenotype  87040 culture, blood 87070 Culture, bacteria, other  87071 Culture bacteri aerobic other, quant  87073 Culture bacteria anaerobic, quant  87075 Culture bacteria anaerobic, any source w/ID  87076 Culture anaerobe ident, each  87077 Culture aerobic identify 87081 Culture screen only 87084 Culture w/ colony estimation 87086 Urine culture/quant colony count  87088 Urine bacteria culture, isolation & ID  87181 Microbe susceptible, diffuse  87184 Microbe susceptible, disk 87185 Microbe susceptible, enzyme  87186 Microbe susceptible, mic  87187 Microbe susceptible, mlc  87188 Microbe suscept, macrobroth  87190 Microbe suscept, mycobacteri  87197 Bactericidal level, serum  87205 Smear, gram stain  87271 CMV, DFA  87340 HepB surface antigen 87341 HepatitisB  surface, ag, eia, neutralization  87350 HepatitisBe ag, eia  87380 Hepatitis delta ag, eia  87390 HIV -1 ag, eia  87391 HIV -2 ag, eia  87515 Hepatitis B, DNA, dir probe  87516 Hepatitis B, DNA, amp probe  87517 Hepatitis B, DNA, quant  87520 Hepatitis C, RNA, dir probe  87521 Hepatitis C, RNA, amp probe  87522 Hepatitis C, RN A, quant  87525 Hepatitis G, DNA, dir probe  87526 Hepatitis G, DNA, amp probe  87527 Hepatitis G, DNA, quant  89050 cell count, peritoneal fluid (no diff)  89051 cell count,