evekhm/cms_iom_500 huggingface dataset:
Draft Article - Billing and Coding: Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC) (DA59693)
The type of SRT planning that was ultimately used must be precisely documented and cannot be inferred from the equipment or technology or computerized optimization being utilized.The type of SRT that will be delivered must be precisely documented and cannot be inferred from the equipment or technology or computerized optimization being utilized.A treatment plan/prescription must be present and must define the goals and requirements of the treatment, including the specific dose constraints for the target(s) and nearby critical structures.A statement by the treating physician documenting the special advantages and genuine need for performing the specified SRT delivery type and planning type on the patient in question, especially in comparison to conventional forward treatment planning and/or delivery; the physician must address the other organs at risk (OAR) or adjacent critical structures.Review by the radiation oncologist or other qualified physician of the radiologic images of the target, if necessary, and all critical structures with representative isodose distributions that characterize the three-dimensional (3D) dose. The document containing this review must be signed with credentials and dated.Radiation oncologist or other qualified physician review of dose-volume histograms for all targets and critical structures specifically documented as reviewed or authenticated via signature with credentials and date.Description of the number and location of each treatment step/rotation or portal to accomplish the treatment plan.Documentation of dosimetric verification of treatment setup and delivery, signed by both the radiation oncologist and the medical physicist with a legible signature, credentials and date.Documentation of fluence distributions recomputed in a phantom, or an equivalent methodology consistent with patient specific treatment verification.Target verification methodology documentation to include documentation of the clinical treatment volume (CTV) and the planning target volume (PTV); documentation of immobilization/patient positioning and means of dose verification and secondary means of verification.Other procedures performed during the episode of care must have documentation that supports the professional and technical components by identifying the place of service, the date of service, the supervising physician, and proof of work provided.Required IGSRT DocumentationThe use of HRUS is limited to the initial planning of NMSC, when medically indicated, for the localization of target volume and for the suitability for SRT.
Draft Article - Billing and Coding: Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC) (DA59693)
Required IGSRT DocumentationThe use of HRUS is limited to the initial planning of NMSC, when medically indicated, for the localization of target volume and for the suitability for SRT.For high risk NMSCs, the continued change of HRUS may be reasonable and necessary if there is determined to be significant clinical change in the status of the tumor during the ongoing SRT treatments and imaging is required to adjust treatment dosing. Medical documentation should support the rationale for the additional use of HRUS.Provider Qualifications and Supervision of ServicesDiagnostic x-ray tests provided by freestanding RT centers to assist in the accurate placement of radiation fields are a covered Medicare benefit. Regulatory guidance pertinent to physician supervision of these services is provided under of the Code of Federal Regulations. Diagnostic x-ray tests may only be furnished under the supervision of a physician. Services furnished without the required level of physician supervision are not covered under Medicare.General Supervision: The procedure is furnished under the physicians overall direction and control, but the physicians presence is not required during the performance of the procedure (76950 or G6001 - Ultrasonic guidance for placement of RT fields).Direct Supervision: The use of diagnostic x-ray tests including HRUS in the freestanding center requires a physician be physically present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. Nonphysician practitioners cannot function as supervisors of diagnostic tests performed in conjunction with radiation therapy (77401- Radiation treatment delivery, superficial, per day).
Draft Article - Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) (DA59695)
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.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) DL39810.Coding InformationProcedure codes may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and National Provider Identifier (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 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.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD (SeeCoverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Medical record documentation must be available to Medicare upon request.
Draft Article - Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) (DA59697)
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.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) DL39812.Coding InformationProcedure codes may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and National Provider Identifier (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 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.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD (SeeCoverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Medical record documentation must be available to Medicare upon request.
Article - MolDX: Defining panel services in MolDX (A59698)
CMS National Coverage PolicyN/AArticle Text
Article - MolDX: Defining panel services in MolDX (A59698)
Medical testing services have become more comprehensive and complex over time. In the past, it was generally considered that any given condition could be diagnosed or defined with a single analyte test. Additionally, limits in technology meant that if any additional testing was necessary, an independent and subsequent service would need to be performed. Neither condition above is true today. First, many diseases require multiple genetic or other relevant analytes to be assessed simultaneously for either diagnosis or to inform the clinician on subsequent medical interventions; second, tests today are more comprehensive and parallelized, such that many analytes can be obtained at once, reducing waste and turnaround time while also increasing accuracy. As such, the old model of one gene/analyte for one disease must be wholly discarded for a majority of disorders known today.The National Correct Coding Initiative (NCCI), reflecting CMS policy, provides instruction with this line of thinking, as outlined in Chapter 10, particularly section F pertaining to Molecular Pathology. Effectively, if a multianalyte test is performed, it should be billed as a single service. If no specific code exists for that panel, it is not appropriate to bill for the components of that service (this constitutes unbundling) and should be billed with the NOC codes such as 81479, 81599, or 87999, depending on analytes measured.Additionally, the role of the payor is to pay for services that have demonstrated medical value (reasonable and necessary in the case of Medicare), and the role of coding with the payor is to ensure clarity on the service performed. Ensuring panels are appropriately billed as a single service greatly reduces the complexity and confusion in billing.Here, we define a distinction between the performance of a medical service as a panel or a discrete single analyte service. Of note this was similarly defined for germline panels in article A57503 in the Medicare Coverage Database.Defining criteria:A service is a panel if:1. If aclinician orders a group of molecular analytes (more than 1) marketed as a single service;2. The service contains multiple analytes (more than 1) that would result in a single result or single report or several independent services are performed that would result in a single result; OR
Article - MolDX: Defining panel services in MolDX (A59698)
2. The service contains multiple analytes (more than 1) that would result in a single result or single report or several independent services are performed that would result in a single result; OR3. The medical value of the service/s performed is only obtained if more than one analyte is measured and the analytes are generally performed together. As an example, if 2 analytes (A and B) are tested, and BOTH must be performed together to have medical value, then it is a panel because analyte A or B alone is insufficient to provide medical value even if each analyte independently provides partial medical information; OR4.If multiple analytes (more than 1) are measured in parallel, regardless of how they are performed or reportedOf note, it is not particularly relevant if the analytes are measured with different instruments or reagents. We consider these internal lab processes that are not relevant to the test ordered, the relevance of the analytes measured, and the resultant report.
Article - MolDX: Defining panel services in MolDX (A59698)
A service is NOT a panel if a single analyte is measured defined by a single CPT code, and that single analyte alone provides the necessary information for proper patient management without other analytes being measured for the same disease indication.Examples of a panel:A service of 2, 5, 10, or 500 genes for evaluating a patient with colorectal cancer, with or without RNA analysisA screening test looking for 5 commonly mutated genes in the prenatal settingA test that measures multiple alterations within a gene with one or more assays that have more than one associated CPT code, such as DMD sequence AND copy number analysisA respiratory pathogen test that includes 2 or more pathogens that must generally be tested together for relevance, for example Influenza A/B, RSV, and COVID-19
Article - MolDX: Defining panel services in MolDX (A59700)
CMS National Coverage PolicyN/AArticle TextMedical testing services have become more comprehensive and complex over time. In the past, it was generally considered that any given condition could be diagnosed or defined with a single analyte test. Additionally, limits in technology meant that if any additional testing was necessary, an independent and subsequent service would need to be performed. Neither condition above is true today. First, many diseases require multiple genetic or other relevant analytes to be assessed simultaneously for either diagnosis or to inform the clinician on subsequent medical interventions; second, tests today are more comprehensive and parallelized, such that many analytes can be obtained at once, reducing waste and turnaround time while also increasing accuracy. As such, the old model of one gene/analyte for one disease must be wholly discarded for a majority of disorders known today.The National Correct Coding Initiative (NCCI) reflecting CMS policy, provides instruction with this line of thinking, as outlined in Chapter 10, particularly section F pertaining to Molecular Pathology. Effectively, if a multianalyte test is performed, it should be billed as a single service. If no specific code exists for that panel, it is not appropriate to bill for the components of that service (this constitutes unbundling) and should be billed with the NOC codes such as 81479, 81599, or 87999, depending on analytes measured.Additionally, the role of the payor is to pay for services that have demonstrated medical value (reasonable and necessary in the case of Medicare), and the role of coding with the payor is to ensure clarity on the service performed. Ensuring panels are appropriately billed as a single service greatly reduces the complexity and confusion in billing.Here, we define a distinction between the performance of a medical service as a panel or a discrete single analyte service. Of note this was similarly defined for germline panels in article A57880 in the Medicare Coverage Database.Defining criteria:A service is a panel if:
Article - MolDX: Defining panel services in MolDX (A59700)
If a clinician orders a group of molecular analytes (more than 1) marketed as a single service;The service contains multiple analytes (more than 1) that would result in a single result or single report or several independent services are performed that would result in a single result; ORThe medical value of the service/s performed is only obtained if more than one analyte is measured and the analytes are generally performed together. As an example, if 2 analytes (A and B) are tested, and BOTH must be performed together to have medical value, then it is a panel because analyte A or B alone is insufficient to provide medical value even if each analyte independently provides partial medical information; ORIf multiple analytes (more than 1) are measured in parallel, regardless of how they are performed or reportedOf note, it is not particularly relevant if the analytes are measured with different instruments or reagents. We consider these internal lab processes that are not relevant to the test ordered, the relevance of the analytes measured, and the resultant report.A service is NOT a panel if a single analyte is measured defined by a single CPT code, and that single analyte alone provides the necessary information for proper patient management without other analytes being measured for the same disease indication.Examples of a panel:A service of 2, 5, 10, or 500 genes for evaluating a patient with colorectal cancer, with or without RNA analysisA screening test looking for 5 commonly mutated genes in the prenatal settingA test that measures multiple alterations within a gene with one or more assays that have more than one associated CPT code, such as DMD sequence AND copy number analysisA respiratory pathogen test that includes 2 or more pathogens that must generally be tested together for relevance, for example Influenza A/B, RSV, and COVID-19
(Medicare General Information, Eligibility, and Entitlement)
Medicare General Information, Eligibility, and Entitlement  Chapter 1 - General Overview   Table of Contents  (Rev. 12425; Issued: 12-21-23)   Transmittals for Chapter 1   10 - General Program Benefits  10.1 - Hospital Insurance (Part A) for Inpatient Hospital, Hospice, Home Health, and Skilled Nursing Facility (SNF) Services - A Brief Description  10.2 - Home Health Services  10.3 - Supplementary Medical Insurance (Part B) - A Brief Description  10.4 - Basis for Payment  20 - Administration of the Medicare Program - Introduction 20.1 - Financing the Program  20.2 - Discrimination Prohibited  20.3 - Fraud and Abuse - General 20.3.1 - Definition and Examples of Fraud  20.3.2 - Definition and Examples of Abuse  30 - Federal Government Administration of the Health Insurance Program  30.1 - CMS Responsibilities  30.2 - Public Health Service Responsibilities  30.3 - State Agencies  30.3.1 - Certification by State Agencies  30.3.2 - Consultation by State Agencies  30.3.3 - Coordination by State Agencies   40 - Role of A/B MACs (A) and (HHH)  40.1 - Assignment of A/B MAC (A) and (HHH)  40.2 - A/B MAC (A) and (HHH)  Service to Home Health Agencies (HHAs)  50 - Role of A/B MACs (B)  60 - Background and Responsibilities of the Peer Review Organization (PROs)  60.1 - Purpose of PRO Review for the Individual Medicare Beneficiaries  60.2 - PRO Responsibility for the Overall Approach to Health Care  60.3 - Other PRO Responsibilities  60.4 - Statutory Obligations of Practitioners and Other Persons  60.5 -  Responsibilities of Designated Agents Working With PROs; Organizations Subcontracted for Review  70 - Institutional Planning and Budgeting 80 - CMS Managed Modules for Software Programs and Pricing/Coding Files    10 - General Program Benefits  (Rev. 1, 09- 11-02)
(Medicare General Information, Eligibility, and Entitlement)
10 - General Program Benefits  (Rev. 1, 09- 11-02)  The Health Insurance for the Aged and Disabled Act (title XVIII of the Social Security Act), known as "Medicare," has made available to nearly every American 65 years of age and older a broad program of health insurance designed to assist the nation's elderly to meet hospital, medical, and other health costs.  Health insurance coverage has also been extended to persons under age 65 qualifying as disabled and those having end stage renal disease (ESRD) or Lou Gehrig's disease.  The program includes two related health insurance programs --hospital insurance (HI) (Part A) and supplementary medical insurance (SMI) (Part B).  10.1 - Hospital Insurance (Part A) for Inpatient Hospital, Hospice, Home Health and Skilled Nursing Facility (SNF) Services - A Brief Description  (Rev. 94, Issued: 10- 16-15, Effective: 11 -16-15, Implementation: 11- 16-15)  Hospital insurance is designed to help patients defray the expenses incurred by hospitalization and related care.   In addition to inpatient hospital benefits, hospital insurance covers posthospital extended care in SNFs and posthospital care furnished by a home health agency in the patient's home.  Blood clotting factors, for hemophilia patients competent to use such factors to control bleeding without medical or other supervision, and items related to the administration of such factors, are also a Part A benefit for beneficiaries in a covered Part A stay.  The purpose of these additional benefits is to provide continued treatment after hospitalization and to encourage the appropriate use of more economical alternatives to inpatient hospital care.  Program payments for services rendered to beneficiaries by providers (i.e., hospitals, SNFs, and home health agencies) are generally made to the provider.  In each benefit period, payment may be made for up to 90 inpatient hospital days, and 100 days of posthospital extended care services.
(Medicare General Information, Eligibility, and Entitlement)
Hospices also provide Part A hospital insurance services such as short -term inpatient care.  In order to be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill.  An individual is considered to be terminally ill if the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course.   The Part A benefit categories of inpatient hospital services and SNF services are each subject to separate and mutually exclusive day limits, so that the use of benefit days under one of these benefits does not affect the number of benefit days that remain available under the other.  Accordingly, the 90 days of inpatient hospital benefits (plus 60 nonrenewable lifetime reserve days -- see Pub. 100- 02, Medicare Benefit Policy Manual, chapter 5) that are available to a beneficiary in a hospital do not count against the 100 days of posthospital extended care benefits that are available in a SNF, and vice- versa.   10.2 - Home Health Services  (Rev. 28; Issued:  08- 12-05; Effective/Implementation:  09 -12-05)
(Medicare General Information, Eligibility, and Entitlement)
10.2 - Home Health Services  (Rev. 28; Issued:  08- 12-05; Effective/Implementation:  09 -12-05)  To qualify for home health benefits under either Part A or Part B of the program, a beneficiary must be confined to his/her home, under the care of a physician, and in need of skilled nursing services on an intermittent basis, physical therapy, or speech -language pathology services.  Being "confined to the home" does not mean a beneficiary can never leave the home.  See chapter 7 of the Benefit Policy publication for the definition of homebound.  A beneficiary who requires one or more of these services in the treatment of his/her illness or injury and otherwise qualifies for home health benefits is eligible to have payment made on his/her behalf for the skilled nursing, physical therapy or speech -language pathology services he needs, as well as for any of the other home health services specified in the law.  These services include occupational therapy, medical social services, the use of medical supplies and medical appliances, and the part-time or intermittent services of home health aides.  Conversely, a patient who does not require intermittent skilled nursing or physical therapy or speech- language pathology services cannot qualify to have payment made under the program for any home health services furnished him.  Excluded as home health services are the costs of housekeepers, food service arrangements, and transportation to outpatient facilities.   To be covered, the home health services must be needed for a condition for which the patient required inpatient hospital services or extended care services.  See the chapter 7 of the Benefit Policy publication for a description of services covered.  Discharge from the hospital must have occurred in a month in which the patient has attained age 65 or was entitled to health insurance benefits under the disability or chronic renal disease provisions of the law.