evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
ICD- 9 code Description  196.1 Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes  196.2 Secondary and unspecified malignant neoplasm of intra -abdominal lymph nodes  196.5 Secondary and unspecified malignant neoplasm of lymph nodes of inguinal region and lower limb  196.6 Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes  196.8 Secondary and unspecified malignant neoplasm of lymph nodes of multiple sites  196.9 Secondary and unspecified malignant neoplasm of lymph node site unspecified -   The spread of cancer to and establishment in the lymph nodes. 197.0 Secondary malignant neoplasm of lung  Cancer that has spread from the original (primary) tumor to the lung. The spread of cancer to the lung. This may be from a primary lung cancer, or from a cancer at a distant site.  197.7 Malignant neoplasm of liver secondary -  Cancer that has spread from the original (primary) tumor to the liver. A malignant neoplasm that has spread to the liver from another (primary) anatomic site. Such malignant neoplasms may be carcinomas (e.g., breast, colon), lymphomas, melanomas, or sarcom as. 198.0 Secondary malignant neoplasm of kidney -  The spread of the cancer to the kidney. This may be from a primary kidney cancer involving the opposite kidney, or from a cancer at a distant site.  198.1 Secondary malignant neoplasm of other urinary organs  198.5 Secondary malignant neoplasm of bone and bone marrow  Cancer that has spread from the original (primary) tumor to the bone. The spread of a malignant neoplasm from a primary site to the skeletal system.  The majority of metastatic neoplasms to the bone are carcinomas.  198.7 Secondary malignant neoplasm of adrenal gland 198.82 Secondary malignant neoplasm of genital organs   Coding for Off -Label PROVENGE Services
(Medicare Claims Processing Manual)
Coding for Off -Label PROVENGE Services   The use of PROVENGE off -label for the treatment of prostate cancer is left to the discretion of the Medicare Administrative Contractors. Claims with dates of service on and after July 1, 2011, for PROVENGE  paid off -label for the treatment of prostate ca ncer must be billed using either ICD -9 code 233.4 (carcinoma in situ of prostate), or ICD -9 code 185 (malignant neoplasm of prostate) in addition to HCPCS Q2043. Effective with the implementation date for ICD -10 codes, off -label PROVENGE services must be billed with either ICD -10 code D075(carcinoma in situ of prostate), or C61 (malignant neoplasm of prostate) in addition to HCPCS Q2043.   ICD- 10 Diagnosis Coding  Contractors shall note the appropriate ICD -10 code(s) that are listed below for future implementation.   Contractors shall track the ICD -10 codes and ensure that the updated edit is turned on as part of the ICD -10 implementation effective October 1, 2013.
(Medicare Claims Processing Manual)
ICD- 10 Description  C61 Malignant neoplasm of prostate (for on -label or off -label indications)  D075 Carcinoma in situ of prostate (for off -label indications only)  C77.1 Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes  C77.2 Secondary and unspecified malignant neoplasm of intra -abdominal lymph nodes  C77.4 Secondary and unspecified malignant neoplasm of inguinal and lower limb lymph nodes  C77.5 Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes  C77.8 Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions  C77.9 Secondary and unspecified malignant neoplasm of lymph node, unspecified  C78.00 Secondary malignant neoplasm of unspecified lung  C78.01 Secondary malignant neoplasm of right lung C78.02 Secondary malignant neoplasm of left lung C78.7 Secondary malignant neoplasm of liver  C79.00 Secondary malignant neoplasm of unspecified kidney and renal pelvis  C79.01 Secondary malignant neoplasm of right kidney and renal pelvis  C79.02 Secondary malignant neoplasm of left kidney and renal pelvis  C79.10 Secondary malignant neoplasm of unspecified urinary organs  C79.11 Secondary malignant neoplasm of bladder  C79.19 Secondary malignant neoplasm of other urinary organs  C79.51 Secondary malignant neoplasm of bone  C79.52 Secondary malignant neoplasm of bone marrow  C79.70 Secondary malignant neoplasm of unspecified adrenal gland  C79.71 Secondary malignant neoplasm of right adrenal gland  C79.72 Secondary malignant neoplasm of left adrenal gland  C79.82 Secondary malignant neoplasm of genital organs   280.3 - Types of Bill (TOB) and Revenue Codes  (Rev. 2380, Issued: 01- 06-12, Effective: 06 -30-11, Implementation: 08- 08-11)
(Medicare Claims Processing Manual)
280.3 - Types of Bill (TOB) and Revenue Codes  (Rev. 2380, Issued: 01- 06-12, Effective: 06 -30-11, Implementation: 08- 08-11)  The applicable TOBs for PROVENGE are: 12X, 13X, 22X, 23X, 71X, 77X, and 85X.    On institutional claims, TOBs 12X, 13X, 22X, 23X, and 85X, use revenue code 0636 -  drugs requiring detailed coding.  280.4 - Payment Method  (Rev. 2380, Issued: 01- 06-12, Effective: 06 -30-11, Implementation: 08 -08-11)  Payment for PROVENGE is as follows:    TOBs 12X, 13X, 22X and 23X -  based on the Average Sales Price (ASP) + 6%,   TOB 85X  based on reasonable cost,   TOBs 71X and 77X  based on all -inclusive rate.  For Medicare Part B practitioner claims, payment for PROVENGE is based on ASP + 6%.   Contractors shall not pay separately for routine costs associated with PROVENGE, HCPCS Q2043, except for the cost of administration. (Q2043 is all -inclusive and represents all routine costs except for its cost of administration).   280.5 - Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claim Adjustment Reason Codes (CARCs), and Group Codes (Rev. 2394, Issued: 01- 25-12, Effective: 06 -30-11 for -(claims with dates of service on or after 07 -01- 11 processed on or after July 02- 12, Implementation: 07- 02-12)  Contractors shall use the following messages when denying claims for the on- label indication for PROVENGE, HCPCS Q2043, submitted without ICD -9-CM diagnosis code 185 and at least one diagnosis code from the ICD -9 table in Section 280.2 above:   MSN 14.9 -  Medicare cannot pay for this service for the diagnosis shown on the claim.  Spanish Version -  Medicare no puede pagar por este servicio debido al diagnstico indicado en la reclamacin.
(Medicare Claims Processing Manual)
MSN 14.9 -  Medicare cannot pay for this service for the diagnosis shown on the claim.  Spanish Version -  Medicare no puede pagar por este servicio debido al diagnstico indicado en la reclamacin.   RARC 167 -  This (these) diagnosis (es) are not covered. Note: Refer to the 835 Healthcare Policy Identification segment (loop 2110 Service Payment Information REF), if present.   Group Code  CO (Contractual Obligation)   Contractors shall use the following messages when denying claims for the off -label indication for PROVENGE, HCPCS Q2043, submitted without ICD -9-CM diagnosis code 233.4:   MSN 14.9 -  Medicare cannot pay for this service for the diagnosis shown on the claim.  Spanish Version -  Medicare no puede pagar por este servicio debido al diagnstico indicado en la reclamacin.   RARC 167 -  This (these) diagnosis (es) are not covered. Note: Refer to the 835 Healthcare Policy Identification segment (loop 2110 Service Payment Information REF), if present.   Group Code  CO (Contractual Obligation)   For claims with dates of service on or after July 1, 2012, processed on or after July 2, 2012, when denying claims for PROVENGE, HCPCS Q2043 that exceed three (3) services in a patients lifetime, contractors shall use the following messages:  MSN 20.5 -  These services cannot be paid because your benefits are exhausted at this time.   Spanish Version -  Estos servicios no pueden ser pagados porque sus beneficios se han agotado.   RARC N362 -  The number of Days or Units of Service exceeds our acceptable maximum.  CARC 149 -  Lifetime benefit maximum has been reached for this service/benefit category.  Group Code  CO ( Contractual Obligation)       290  Transcatheter Aortic Valve Replacement (TAVR)  (Rev. 10179, Issued: 06 -10-20, Effective: 06 -21-19, Implementation: 06- 12-20)
(Medicare Claims Processing Manual)
290  Transcatheter Aortic Valve Replacement (TAVR)  (Rev. 10179, Issued: 06 -10-20, Effective: 06 -21-19, Implementation: 06- 12-20)  Transcatheter aortic valve replacement (TAVR -  also known as TAVI or transcatheter aortic valve implantation) is used in the treatment of aortic stenosis. A bioprosthetic valve is inserted percutaneously using a catheter and implanted in the orifice of the aortic valve.   The most recent reconsideration of the TAVR policy is effective for claims with dates of service on and after June 21, 2019. It makes changes to the criteria for the heart team and the hospital, and to the trial outcomes and the registry questions/criteria . Please see Publication 100-03, National Coverage Determination Manual Part 1, section 20.32, for complete national policy criteria.   HISTORICAL NOTE: CR 7897, Transmittal (TR) 2552, issued September 24, 2012, implemented the initial NCD for TAVR, effective May 1, 2012. CR 8168, TR 2628, issued January 7, 2013, implemented replacement coding to TAVR effective January 1, 2013. CR 8255, TR  2737, issued July 11, 2013, implemented clinical trial number reporting effective July 1, 2013. CR 8537, TR 2827, issued November 29, 2013, implemented replacement CPT coding effective January 1, 2013.   290.1  Coding Requirements for TAVR Furnished on or After May 1, 2012, through December 31, 2012  (Rev. 10179, Issued: 06 -10-20, Effective: 06 -21-19, Implementation: 06- 12-20)  The following are the applicable Current Procedural Terminology (CPT) codes for TAVR:   0256T: Implantation of catheter -delivered prosthetic aortic heart valve; endovascular approach   0257T: Implantation of catheter -delivered prosthetic aortic heart valve; open thoracic approach (eg, transapical, transventricular)   0258T: Transthoracic cardiac exposure (i.e. sternotomy, thoracotomy, subxiphoid) for catheter -delivered aortic valve replacement; without cardiopulmonary bypass
(Medicare Claims Processing Manual)
0258T: Transthoracic cardiac exposure (i.e. sternotomy, thoracotomy, subxiphoid) for catheter -delivered aortic valve replacement; without cardiopulmonary bypass   0259T: Transthoracic cardiac exposure (i.e. sternotomy, thoracotomy, subxiphoid) for catheter -delivered aortic valve replacement; with cardiopulmonary bypass   The following are the International Classification of Diseases (ICD) -9 procedure codes applicable for TAVR:   35.05: Endovascular replacement of aortic valve  35.06: Transapical replacement of aortic valve   The following are the ICD -10 procedure codes applicable for TAVR:   35.05: 02RF37Z, 02RF38Z. 02RF3JZ, 02RF3KZ  35.06: 02RF37H, 02RF38H, 02RF3JH, 02RF3KH   290.1.1 - Coding Requirements for TAVR Services Furnished on or After January 1, 2013  (Rev. 10179, Issued: 06 -10-20, Effective: 06 -21-19, Implementation: 06- 12-20)  Beginning January 1, 2013, the following are the applicable CPT codes for TAVR:   33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach   33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral approach   33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach   33364 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery approach   33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (e.g., median sternotomy, mediastinotomy)   0381T Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical approach (e.g., left thoracotomy)
(Medicare Claims Processing Manual)
0381T Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical approach (e.g., left thoracotomy)   Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with dates of service on and after January 1, 2014, shall instead use permanent CPT code 33366.   290.2 - Claims Processing Requirements for TAVR Services on Professional Claims (Rev. 10179, Issued: 06 -10-20, Effective: 06-21-19, Implementation: 06-12-20)  Place of Service (POS) Professional Claims   Effective for claims with dates of service on and after May 1, 2012, place of service (POS) code 21 shall be used for TAVR services. All other POS codes shall be denied.   The following messages shall be used when Medicare contractors deny TAVR claims for POS:   Claim Adjustment Reason Code (CARC) 58: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), i f present.   Remittance advice remark code (RARC) N428: Not covered when performed in this place of service. Beginning January 2, 2020, contractors shall no longer report RARC N428 for claims denied for invalid POS.  Medicare Summary Notice (MSN) 21.25: This service was denied because Medicare only covers this service in certain settings.   Spanish Version: El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones."   Professional Claims Modifier -62   For TAVR claims with dates of service on or after July 1, 2013, contractors shall pay claim lines with 33361, 33362, 33363, 33364, 33365 & 0318T only when billed with modifier -62. Claim lines billed without modifier -62 shall be returned as unprocessable.   Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with dates of service on and after January 1, 2014 shall instead use permanent CPT code 33366.
(Medicare Claims Processing Manual)
Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with dates of service on and after January 1, 2014 shall instead use permanent CPT code 33366.   The following messages shall be used when Medicare contractors return TAVR claims billed without modifier -62 as unprocessable:   CARC 4: The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N29: Missing documentation/orders/notes/summary/report/chart. Beginning January 2, 2020, contractors shall no longer report RARC N29 on remittance for claims billed without modifier -62 and returned as unprocessable.  RARC MA130: Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.   Professional Claims Modifier - Q0   For claims with dates of service on or after January 1 , 2013, contractors shall pay TAVR claim lines for 33361, 33362, 33363, 33364, 33365 & 0318T when billed with modifier-Q0. Claim lines billed without modifier -Q0 shall be returned as unprocessable.   Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with dates of service on and after January 1, 2014, shall instead use permanent CPT code 33366.   The following messages shall be used when Medicare contractors return TAVR claims billed without modifier -Q0 as unprocessable:   CARC 4: The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N29: Missing documentation/orders/notes/summary/report/chart. Beginning January 2, 2020, contractors shall no longer report RARC N29 on remittance for claims billed without modifier Q0 and returned as unprocessable.
(Medicare Claims Processing Manual)
RARC MA130: Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.   Diagnosis Coding  For claims with dates of service  on or after July 1, 2013, contractors shall pay TAVR claim lines for 33361, 33362, 33363, 33364, 33365 & 0318T when billed with diagnosis code V70.7 (ICD-10 Z00.6). Claim lines billed without diagnosis code V70.7 (ICD-10  Z00.6) shall be returned as unprocessable.   Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with dates of service on and after January 1, 2014 shall instead use permanent CPT code 33366.   The following messages shall be used when Medicare contractors return TAVR claims billed without diagnosis code V70.7 (ICD-10 Z00.6) as unprocessable:   CARC 16: Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).   RARC M76: Missing/incomplete/invalid diagnosis or condition   RARC MA130: Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.   Group Code  Contractual Obligation (CO): Beginning January 2, 2020, contractors shall no longer report Group Code CO on remittances for claims billed without ICD -10 dx Z00.6 and returned as unprocessable.  MSN 16.77: This service/item was not covered because it was not provided as part of a qualifying trial/study. Spanish version: Este servicio/articulo no fue cubierto porque no estaba incluido como parte de un ensavo clinic/studio calificado.  Beginning January 2, 2020, contractors shall no longer report MSN 16.77 on remittances for claims billed without ICD-10 diagnosis Z00.6 and returned as unprocessable.
(Medicare Claims Processing Manual)
Professional Claims 8 -digit ClinicalTrials.gov Identifier Number   For claims with dates of service on or after July 1, 2013, contractors shall pay TAVR claim lines for 33361, 33362, 33363, 33364, 33365 & 0318T when billed with the numeric, 8- digit clinicaltrials.gov identifier number preceded by the two alpha characters CT when placed in Field 19 of paper Form CMS-1500, or when entered without the CT prefix in the electronic 837P in Loop 2300REF02(REF01=P4). Claim lines billed without an 8- digit clinicaltrials.gov identifier number shall be returned as unprocessable.   Beginning January 1, 2014, temporary CPT code 0318T above is retired. TAVR claims with dates of service on and after January 1, 2014 shall instead use permanent CPT code 33366.   The following messages shall be used when Medicare contractors return TAVR claims billed without an 8-digit clinicaltrials.gov identifier number as unprocessable:   CARC 16: Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT).   RARC MA50: Missing/incomplete/invalid Investigational Device Exemption number for FDA -approved clinical trial services.   RARC MA130: Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.   NOTE: Clinicaltrials.gov identifier numbers for TAVR are listed on our website:  (http://www.cms.gov/Medicare/Coverage/Coverage- with-Evidence-Development/Transcatheter -Aortic -Valve -Replacement -TAVR -.html)   290.3 - Claims Processing Requirements for TAVR Services on Inpatient Hospital Claims (Rev. 10179, Issued: 06 -10-20, Effective: 06-21-19, Implementation: 06-12-20)
(Medicare Claims Processing Manual)
290.3 - Claims Processing Requirements for TAVR Services on Inpatient Hospital Claims (Rev. 10179, Issued: 06 -10-20, Effective: 06-21-19, Implementation: 06-12-20)  Inpatient hospitals shall bill for TAVR on an 11X TOB effective for discharges on or after May 1, 2012. Refer to Section 69 of this chapter for further guidance on billing under CED.  Inpatient hospital discharges for TAVR shall be covered when billed with:    ICD -9 V70.7 through September 30, 2015, ICD -10 Z00.6 for dates of service on or after October 1, 2015. and Condition Code 30.    An 8- digit clinicaltrials.gov identifier number listed on the CMS website (effective July 1, 2013)   Inpatient hospital discharges for TAVR shall be rejected when billed without:    ICD -9 V70.7 through September 30, 2015, ICD -10 Z00.6 for dates of service on or after October 1, 2015, and Condition Code 30.    An 8- digit clinicaltrials.gov identifier number listed on the CMS website (effective July 1, 2013)   Claims billed by hospitals not participating in the trial/registry shall be rejected with the following messages:   CARC 50: These are non -covered services because this is not deemed a medical necessity by the payer.   RARC N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.   Group Code:Contractual Obligation (CO)   MSN 16.77:  This service/item was not covered because it was not provided as part of a qualifying trial/study. Spanish version: Este servicio/artculo no fue cubierto porque no estaba incluido como parte de un ensayo clnico/estudio calificado.
(Medicare Claims Processing Manual)
290.4 - Claims Processing Requirements for TAVR Services for Medicare Advantage (MA) Plan Participants  (Rev. 3898, Issued: 10- 27-17; Effective: 04 -01- 15, Implementation: 04- 02-18)  MA plans are responsible for payment of TAVR services for MA plan participants.  Medicare coverage for TAVR is not included under section 310.1 of the NCD Manual (Routine Costs in Clinical Trials).   300  Billing Requirements for Ocular Photodynamic Therapy (OPT) with Verteporfin  (Rev. 2728, Issued: 06- 14-13-Effective: 04 -03-13, Implementation: 07- 16-13)  Ocular Photodynamic Therapy (OPT) is used in the treatment of ophthalmologic diseases; specifically, for age -related macular degeneration (AMD), a common eye disease among the elderly. OPT involves the infusion of an intravenous photosensitizing drug calle d Verteporfin, followed by exposure to a laser. For complete Medical coverage guidelines, see National Coverage Determinations (NCD) Manual (Pub 100- 03)  80.2 through 80.3.1.   300.1 - Coding Requirements for OPT with Verteporfin  (Rev. 2728, Issued: 06- 14-13, Effective: 04 -03-13, Implementation: 07- 16-13)  The following are applicable Current Procedural Terminology (CPT) codes for OPT with Verteporfin:   67221 - Destruction of localized lesion of choroid (e.g. choroidal neovascularization); photodynamic therapy (includes intravenous infusion)   67225-  Destruction of localized lesion of choroid (e.g. choroidal neovascularization); photodynamic therapy, second eye, at single session (List separately in addition to code for primary eye treatment)   The following are applicable Healthcare Common Procedure Coding System (HCPCS) code for OPT with Verteporfin:   J3396-  Injection, Verteporfin, 0.1 mg  300.2 - Claims Processing Requirements for OPT with Verteporfin Services on Professional Claims and Outpatient Facility Claims  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)