evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Routine Foot Care (A56680)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) states that no payment shall be made to any provider 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, 290 Foot CareArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Routine Foot Care L37643.Coding for Mycotic NailsAlthough CPTcoding does not exclusively apply CPTcodes 11720 and 11721 to mycotic nails or to the feet, Medicare assumes these are the CPTcodes usually used to code for services related to debriding mycotic nails.Assuming services are being provided based on this indication, and the above requirements are documented, the claim should be coded withICD-10-CM code B35.1 as a primary code AND L02.611- L02.612, L03.031-L03.032, L03.041-L03.042, M79.671- M79.672, M79.674-M79.675 or R26.2as a secondary code. Systemic condition modifiers are not necessary for services performed for this indication with these diagnosis codes.The nail debridement procedure codes (11720-11721) are considered noncovered routine foot care when these services do not meet the guidelines outlined above for mycotic nail services or are not based on the presence of a systemic condition. If the nail debridement procedures are performed in the absence of mycotic nails and as part of foot care, they must meet the same criteria as all other routine foot care services to be considered for payment.Coding for Systemic ConditionsFoot care services are covered in the presence of certain conditions described in the CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 290 identified by the following ICD-10-CM codes:Diabetes mellitus*E08.00-E13.9Arteriosclerosis obliterans(A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)
Article - Billing and Coding: Routine Foot Care (A56680)
E08.00-E13.9Arteriosclerosis obliterans(A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)I70.201-I70.92I73.00-I73.01I73.9Buergers disease (thromboangiitis obliterans)I73.1Chronic thrombophlebitis*I80.00-I80.3Peripheral neuropathies involving the feet:Associated with malnutrition and vitamin deficiency*E56.9 and G63Malnutrition (general, pellagra)*E46, E52, or E64.0 and G63Alcoholism*G62.1Malabsorption (celiac disease, tropical sprue)*K90.0 or K90.1 and G63Pernicious Anemia*D51.0 and G63Associated with carcinoma*G13.0Associated with diabetes mellitus*E08.40E08.42E09.40E09.42E10.40E10.42E11.40E11.42E13.40E13.42Associated with drugs and toxins*G62.0G62.2G62.82Associated with multiple sclerosis*G35 and G63Associated with uremia (chronic renal disease)*N18.1-N18.9 and G63Associated with traumatic injury
Article - Billing and Coding: Routine Foot Care (A56680)
Associated with multiple sclerosis*G35 and G63Associated with uremia (chronic renal disease)*N18.1-N18.9 and G63Associated with traumatic injuryS86.001A-S86.009SS86.091A-S86.109SS86.191A-S86.201SS86.209A-S86.209SS86.291A-S86.309SS86.391A-S86.809SS86.891A-S86.909SS86.991A-S86.999SS89.80XA-S89.92XSS96.001A-S96.009SS96.091A-S96.109SS96.191A-S96.209SS96.291A-S96.809SS96.891A-S96.909SS96.991A-S96.999SS99.811A-S99.929Sand G63Associated with leprosy or neurosyphilisA30.0-A30.9 and G63A52.10-A52.3 and G63Associated with hereditary disordersG60.0-G60.9Heredity sensory radicular neuropathyG60.0Angiokeratoma corporis diffusum (Fabry's)E75.21 and G63Amyloid neuropathyE85.0-E85.9 and G63
Article - Billing and Coding: Routine Foot Care (A56680)
G60.0Angiokeratoma corporis diffusum (Fabry's)E75.21 and G63Amyloid neuropathyE85.0-E85.9 and G63When the patients condition is 1 of those designated by an asterisk (*) above, routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition. This must be indicated by the name and national provider identifier (NPI) of the attending physician in block 17 and 17B of the CMS-1500 or the equivalent electronic claim format. The date the patient was last seen (DPLS) by the attending physician should be billed in block 19. Claims for such routine services should show the complicating systemic disease in block 21 of the CMS-1500.A presumption of coverage will be applied when the physician rendering the routine foot care has identified:1 Class A finding using modifier Q7;2 Class B findings using modifier Q8; or1 Class B and 2 Class C findings using modifier Q9.In addition to a valid billing indicator, these services must include a systemic condition diagnosis listed above. All claims for routine foot care based on the presence of a systemic condition should have a billing indicator of Q7, Q8 or Q9 to be considered for payment.Claims without a systemic diagnosis listed will be denied as non-covered routine-type foot care services.Services not meeting the instructions and criteria in this statement of national coverage will be denied as statutory non-covered services. For ICD-10-CM codes designated by an asterisk (*), we will require the DPLS and the NPI of the doctor of medicine or osteopathy.
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A56681)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-02,Medicare Benefit Policy Manual,Chapter 16, Section 180 Services Related to and Required as a Result of Services Which Are Not Covered Under MedicareCMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 4, Section 280.14 Infusion PumpsCMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)Social Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L36920, Epidural Steroid Injections for Pain Management. Please refer to the LCD for reasonable and necessary requirements.The services addressed in this article only apply to epidural injections. Other joint procedures (e.g., sacral injections, facet joint) are not addressed.Coding GuidanceNotice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to the NCCI requirements.An anatomic spinal region for epidurals is defined as cervical/thoracic (CPT codes 62321, 64479 and 64480) or lumbar/sacral (CPT codes 62323, 64483 and 64484).
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A56681)
When CPT codes 62321, 62323, 64479, 64480, 64483 or 64484 are used to report postoperative pain management, the diagnosis code restrictions in this article do not apply when reporting these codes with ICD-10 codes G89.12 (acute post-thoracotomy pain) or G89.18 (other acute postprocedural pain).If epidural injection (CPT code 62323) is used for an implantable infusion pump trial for severe spasticity, the restrictions in this article do not apply as coverage is determined by NCD 280.14 Infusion Pumps.When the epidural injection (CPT code 62323) is used for cerebrospinal fluid flow imaging, cisternography (CPT code 78630), the diagnosis code restrictions in this article do not apply. These services should be billed on the same claim.Consistent with the LCD, it is not medically reasonable and necessary to perform caudal ESIs or interlaminar ESIs bilaterally, therefore CPT codes 62321 and 62323 are not bilateral procedures.CPT codes 64479 and 64483 are used to report a single level injection. CPT codes 64480 and 64484 represent each additional level, respectively and should be reported separately in addition to the primary procedure when applicable.A transforaminal epidural steroid injection (TFESI) performed at the T12-L1 level should be reported with CPT code 64479.When reporting CPT codes 64479 through 64484 for a unilateral procedure, use one line with one unit of service. For bilateral procedures regarding these same codes, use one line and append the modifier-50.For services performed in the ASC, modifier -50 should not be utilized. Report the applicable procedure code on two separate lines, with one unit of service each and append the -RT and -LT modifiers to each line.KX Modifier Requirements
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A56681)
KX Modifier RequirementsA diagnostic selective nerve root block (DSNRB) is identically coded as an epidural injection. Therefore, when performing a DSNRB, the -KX modifier should be appended to the appropriate line to distinguish the procedure from an epidural injection. This applies to TFESI CPT codes 64479, 64480, 64483, and 64484. Aberrant use of the -KX modifier may trigger focused medical review.Use of BiologicalsThere are currently no U.S. Food and Drug Administration (FDA) approved biologicals for use as an injectable agent into the epidural space or spine. The inclusion of a biological and/or other non-FDA approved substance in the injectant may result in denial of the entire claim based on the CMS IOM Publication 100-02,Medicare Benefit Policy Manual, Chapter 16, Section 180. Amniotic and placenta derived injectants, platelet rich plasma, and vitamins fall into this category.Utilization ParametersOnly one spinal region may be treated per session (date of service).Consistent with the LCD, only two total levels per session are allowed for CPT codes 64479, 64480, 64483 and 64484 (two unilateral or two bilateral levels). CPT code 64480 should be reported in conjunction with CPT code 64479 and CPT code 64484 should be reported in conjunction with CPT code 64483.Consistent with the LCD, CPT codes 62321 and 62323 may only be reported for one level per session.No more than 4 epidural injection sessions (CPT codes 62321, 62323, 64479, 64480, 64483, or 64484) may be reported per anatomic region in a rolling 12-month period regardless of the number of levels involved.Documentation Requirements
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A56681)
Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.SNRBs and TESIs:The procedural report should clearly document the indications and medical necessity for the injections, along with the baseline pain score.SNRBs only:The procedural report should include the baseline pain score and percent (%) pain relief achieved immediately after the injection.Films that adequately document (minimum of two views) final needle position and contrast flow should be retained and made available upon request.The patients medical record should include, but is not limited to:The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit.Relevant medical history.Results of pertinent tests/procedures.Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed).Documentation to support the medical necessity of the procedure(s).
Article - Billing and Coding: Diagnostic Abdominal Aortography and Renal Angiography (A56682)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35092, Diagnostic Abdominal Aortography and Renal Angiography. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.CMS issued HCPCS code G0278 for femoral or iliac angiography when done at the time of coronary angiography.Documentation RequirementsAll documentation must be maintained in the patients medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
Article - Billing and Coding: Intraoperative Radiation Therapy (A56684)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary information to process that claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forIntraoperative Radiation Therapy L37779.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: Partial Hospitalization Programs (A56685)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) states that no payment shall be made to any provider for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, 260.1 Special Partial Hospitalization Billing Requirements for Hospitals, Community Mental Health Centers, and Critical Access HospitalsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forPartial Hospitalization Programs L37633.LimitationsNoncovered-Reasonable and Necessary DenialsCPTcodes 90875 and 90876
Article - Billing and Coding: HbA1c (A56686)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 120.2 Implementation and Updates of Negotiated National Coverage Determinations (NCDs) for Clinical Diagnostic Laboratory ServicesCMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code Requirements42 CFR 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: ConditionsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for HbA1c L33431.
Article - Billing and Coding: Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor (A56690)
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 Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor DL37761.
Article - Billing and Coding: Cardiac Computed Tomography & Angiography (CCTA) (A56691)
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) forCardiac Computed Tomography & Angiography (CCTA) L33423.Refer to the Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease L38278 LCD and related billing and coding article A58406 for more information regarding the use of add-on analysis of CCTA.
Article - Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (A56692)
CMS National Coverage PolicyN/AArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) L34061.General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Article - Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (A56692)
Advance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.
Article - Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (A56692)
The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Not applicableUtilization GuidelinesOptic Nerve Damage - CPT code 92133SCODI will be considered medically necessary usually only for one (1) or two (2) tests per year per patient.SCODI would rarely be necessary or beneficial with patients who have advanced optic nerve damage.Retinal Damage - CPT code 92134It is expected that no more than one exam per eye every two months would be required to manage the patient whose primary ophthalmological condition is related to a retinal disease.Patients with retinal conditions undergoing active intravitreal drug treatment may be allowed one scan per month per eye. These conditions include age-related macular degeneration (wet), choroidal neovascularization, macular edema, diabetic retinopathy (proliferative and nonproliferative), branch retinal vein occlusion, central retinal vein occlusion, and cystoid macular edema.
Article - Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (A56692)
In addition, other conditions which may undergo rapid clinical changes monthly requiring aggressive therapy and frequent follow-up, such as macular hole and traction retinal detachment, may also require monthly scans.
Article - Billing and Coding: Implantable Infusion Pump (A56695)
CMS National Coverage PolicyTitle XVIII Social Security Act, 1833(e)prohibits Medicare payment for any claim lacking the necessary information to process that claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, 10-70.1.2 Drugs and BiologicalsCMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3,3.4.1.3 Diagnosis Code RequirementArticle Text