evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Excision of Malignant Skin Lesions (A57660)
CMS National Coverage PolicyN/AArticle TextThis First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33818 Excision of Malignant Skin Lesions provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.Refer to the LCD for reasonable and necessary requirements and limitations.The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.Coding GuidelinesWhen a lesion is excised that is a neoplasm of uncertain morphology (e.g., melanoma vs. dyplastic nevi), choose the correct CPT code based on the manner in which the lesion is excised rather than the final pathological diagnosis. The CPT code should reflect the knowledge, skill, time and effort that the provider invests in the excision of the lesion.For example, an ambiguous, but low-suspicion lesion might be excised with minimal surrounding, grossly normal skin/soft tissue margins, as for a benign lesion. This would be most appropriately reported using the excision of benign lesion codes 11400-11446. An ambiguous, but moderate to high suspicion lesion would be excised with moderate to wide surrounding grossly normal skin/soft tissue margins, as for a malignant lesion. This type of excision would be most appropriately reported using the excision of malignant lesion including margins codes 11600- 11646.Notice: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.Documentation Requirements
Article - Billing and Coding: Excision of Malignant Skin Lesions (A57660)
All 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.The medical record/ progress note should indicate the removal of a malignant or an ambiguous, but moderate to high suspicion lesion with a corresponding pathology report.The size and location of the lesion should be documented in the operative report.Utilization Guidelines:In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.Compliance with the provisions in LCD L33818, Excision of Malignant Skin Lesions may be monitored and addressed through post payment data analysis and subsequent medical review audits.
Article - Billing and Coding: MDS FISH (A57661)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MDS FISH L37620.Coding for FISH TestingThere are 2 sets of codes that describe in situ hybridization (ISH). Although the laboratory methods are similar, one distinguishes between the 2 sets of codes based on whether the ISH test is an adjunct to a surgical or cytopathology case, versus whether it is part of a clinical, chromosomal analysis. Specifically, the CPT codes 88271-88291 should be used when the laboratory performs ISH as an ancillary analysis to cytogenetic studies for oncologic or inherited disorders.When a pathologist performs ISH techniques as an adjunct to a surgical pathology or cytopathology case, CPT codes 88365-88377 should be used to distinguish qualitative versus quantitative analysis (computer assisted versus manual). These codes must never be used by a pathologist when ISH is performed as an ancillary analysis to cytogenetic studies.To report an MDS FISH service, please submit the following claim information:Select the appropriate CPT codeEnter 1 unit of service (UOS)Select the appropriate ICD-10-CM codeA DEX Z-Code identifier is not required for FISH testing. If submitting a DEX Z-Code identifier, please submit following the below instructions:Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:
Article - Billing and Coding: MDS FISH (A57661)
Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837Item 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim form
Article - Billing and Coding: MDS FISH (A57662)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MDS FISH L37622Coding for FISH TestingThere are 2 sets of codes that describe in situ hybridization (ISH). Although the laboratory methods are similar, one distinguishes between the 2 sets of codes based on whether the ISH test is an adjunct to a surgical or cytopathology case, versus whether it is part of a clinical, chromosomal analysis. Specifically, the CPT codes 88271-88291 should be used when the laboratory performs ISH as an ancillary analysis to cytogenetic studies for oncologic or inherited disorders.When a pathologist performs ISH techniques as an adjunct to a surgical pathology or cytopathology case, CPT codes 88365-88377 should be used to distinguish qualitative versus quantitative analysis (computer assisted versus manual). These codes must never be used by a pathologist when ISH is performed as an ancillary analysis to cytogenetic studies.To report an MDS FISH service, please submit the following claim information:Select the appropriate CPT codeEnter 1 unit of service (UOS)Select the appropriate ICD-10-CM codeA DEX Z-Code identifier is not required for FISH testing. If submitting a DEX Z-Code identifier, please submit following the below instructions:Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:
Article - Billing and Coding: MDS FISH (A57662)
Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837Item 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim form
Article - Billing and Coding: Nerve Blocks for Peripheral Neuropathy (A57663)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act, section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, section 1862 (a)(7) excludes routine physical evaluations.PUB 100-03 Medicare National Coverage Determinations (NCD) Manual- Chapter 1 Section:30.3  Acupuncture150.6 -Vitamin B12 Injections to Strengthen Tendons, Ligaments, etc of the Foot150.7 - Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing AgentsArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L35249 Nerve Blocks for Peripheral Neuropathy.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: Nerve Blocks for Peripheral Neuropathy (A57663)
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: Nerve Blocks for Peripheral Neuropathy (A57663)
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.)Utilization GuidelinesTreatment protocols utilizing multiple injections per day on multiple days per week for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases are not considered medically necessary.A peripheral nerve injection may be allowed during the reconsideration process if the medical record supports a medically necessary service.
Article - Billing and Coding: MolDX: Inivata™, InVisionFirst®, Liquid Biopsy for Patients with Lung Cancer (A57664)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts with Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2 Travel Allowance.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer L37897.To report an InvisionFirst Lung service, please submit the following claim information:Select CPTcode 81479Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: Inivata™, InVisionFirst®, Liquid Biopsy for Patients with Lung Cancer (A57665)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts with Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2 Travel Allowance.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Inivata, InVisionFirst, Liquid Biopsy for Patients with Lung Cancer L37899.To report an InvisionFirst Lung service, please submit the following claim information:Select CPTcode 81479Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: Surgical Treatment of Nails (A57666)
CMS National Coverage PolicyInternet-Only Manuals (IOMs):CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)National Correct Coding Initiative (NCCI) Citation:Medicare NCCI Policy Manual,Chapter 1, General Correct Coding Policies for Medicare National Correct Coding Initiative Policy ManualChapter 3, Surgery: Integumentary System CPT codes 10000-19999 for Medicare National Correct Coding Initiative Policy ManualSocial 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) L33833 Surgical Treatment of Nails. 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.The description of CPT codes 11730, 11732 and 11750 indicates partial or complete avulsion or excision of a nail plate. When CPT code 11730, 11732 or 11750 is reported, it represents all services performed on that nail for that date of service (DOS). When lateral and medial sides of a nail are involved, do not report a separate code for each border.Procedure code 11750 (Excision of nail and nail matrix, partial or complete, [e.g., ingrown or deformed nail] for permanent removal) requires the removal of the full length or the entire nail plate, with destruction or permanent removal of the matrix by any means.
Article - Billing and Coding: Surgical Treatment of Nails (A57666)
Reporting CPT codes 11730 or 11732 (removal of nail plate) with CPT code 11750 (removal of nail bed) and or 11765 (excision of nail fold toe) for the same digit on the same DOS is not correct coding.Reporting CPT code 11750 (removal of nail bed) with CPT code 11765 (excision of nail fold toe) for the same digit on the same DOS is not correct coding.CPT code 11765 requires an excision of a wedge of the skin of the nail fold from the involved side of the toe. Reporting CPT code 11765 for the removal of a small piece of the skin and/or the nail without local anesthesia is not correct coding.Procedure code 11730 (Avulsion of nail plate, partial or complete, simple; single) is reported when removing part of the nail plate or the entire nail plate.Claims must include the nail on which the procedure is performed using one of the modifiers listed in the Coding Information section below to identify the digit in order for payment to be considered.For services performed on different nails:If CPT procedure codes 11730, 11750, or 11765 are performed on different nails, report the procedure performed with one unit of service (UOS) and append with the appropriate identifying digit modifiers.For every subsequent avulsion, CPT 11732 is reported as the add-on code with one UOS and the appropriate identifying digit modifier appended.Utilization Parameters
Article - Billing and Coding: Surgical Treatment of Nails (A57666)
Utilization ParametersCPT codes 11730 and 11732 for nail avulsion will be denied if billed for the same finger less than 4 months (16 weeks) or the same toe less than 8 months (32 weeks) following a previous avulsion.A medically reasonable and necessary repeat avulsion of the same nail within 16 weeks (finger) or 32 weeks (toe) of a previous avulsion of the same nail, will be considered upon redetermination. The medical record must support the service, for example, there is an ingrown nail of the opposite border or a new significant pathology on the same border recently treated.CPT code 11750 for nail excision permanent removal will be denied if billed for the same finger or toe following a previous excision.For a medically reasonable and necessary repeat nail excision on the same finger or toe, report modifier KX (Requirements specified in the medical record have been met). The medical record documentation must be specific as to the indication, such as ingrown nail of the opposite border or new significant pathology on the same border previously treated.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.The following information must be clearly documented in the patients medical record:
Article - Billing and Coding: Surgical Treatment of Nails (A57666)
Complete detailed description of the pre-operative findings. Include the patients symptoms, the physical examination documenting the severity of the nail infection, injury or deformity, and the assessment and plan containing the rationale why surgical treatment is being selected over other treatment options.Method of obtaining anesthesia (if not used, the reason for not using it).A complete detailed description of the procedure performed.Identify the specific digit(s) and make note to the nail margin(s) involved on which the procedure was performed.Postoperative observation and treatment of the surgical site (e.g., minimal bleeding, sterile dressing applied).Postoperative instructions given to the patient and any follow-up care (e.g., soaks, antibiotics, follow-up appointments).