evekhm/cms_iom_500 huggingface dataset:
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA58364)
Regions:An anatomic spinal region for paravertebral facet joint block (diagnostic or therapeutic), is defined as cervical\thoracic (CPT codes 64490, 64491, 64492) or lumbar\sacral (CPT codes 64493, 64494, 64495) per the AMA CPT Manual.Levels:64490 (cervical or thoracic) or 64493 (lumbar or sacral) reports a single level injection performed with image guidance (fluoroscopy or CT). Procedures performed under ultrasound guidance are not covered.64491 or 64494 describes a second level which should be reported separately in addition to the code for the primary procedure. 64491 should be reported in conjunction with 64490 and 64494 should be reported in conjunction with 64493.64492 or 64495 describes a third and additional levels and should be listed separately in addition to the code for the primary procedure and the second level procedure and cannot be reported more than once per day. 64492 should be reported in conjunction with 64490/64491 and 64495 should be reported in conjunction with 64493/64494.Laterality:Bilateral paravertebral facet injection procedures 64490 through 64495 should be reported with modifier 50.One to two levels, either unilateral or bilateral, are allowed per session per spine region (i.e., two (2) unilateral or to two (2) bilateral levels per session).For services performed in the ASC, physicians must continue use modifier 50. Only the ASC Facility itself must report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each line.KX modifier requirements:The KX modifier should be appended to the line for all diagnostic injections. In most cases the KX modifier will only be used for the two initial diagnostic injections. If the initial diagnostic injections do not produce a positive response as defined by the policy and are not indicative of identification of the pain generator, and it is necessary to perform additional diagnostic injections, at a different level, append the KX modifier to the line. Aberrant use of the KX modifier may trigger focused medical review.Therapeutic injections:
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA58364)
Therapeutic injections:Documentation of why patient is not a candidate for RFA must be submitted for therapeutic treatment.Chemodenervation of nerve:Codes 64633, 64634, 64635, 64636are reported per joint, not per nerve. Although two nerves innervate each facet joint, only one unit per code may be reported for each joint denervated, regardless of the number of nerves treated (AMA CPT Manual 2020).Each unilateral or bilateral intervention at any level should be reported as one unit, with bilateral intervention signified by appending the modifier -50.
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA58364)
Region:An anatomic spinal region for thermal facet joint denervation is defined as cervical/thoracic (CPT codes 64633 and 64634) or lumbar/sacral (CPT codes 64635 and 64636) per the AMA CPT Manual.For neurolytic destruction of the nerves innervating the T12-L1 paravertebral facet joint, use 64633Levels:64633 or 64635 describes a single level destruction by neurolytic agent performed with image guidance (fluoroscopy or CT)64634 or 64636 describes each additional level which should be reported separately in addition to the code for the primary procedure. 64634 should be used in conjunction with 64633 and 64636 should be used in conjunction with 64635.Laterality:For bilateral procedures report modifier 50 on each line in which the intervention was of a bilateral nature.For services performed in the ASC, physicians must continue use modifier 50. Only the ASC Facility itself must report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each line.Non-thermal facet joint denervation (including chemical, low grade thermal energy (<80 degrees Celsius or any other form of pulsed radiofrequency) should not be reported with CPT codes 64633, 64634, 64635 or 64636. These services should be reported with CPT code 64999. Code 64999 is non-covered when used to report non-thermal facet joint denervation.If facet joints are injected with biologicals or other substances not designated for this use the entire claim will deny per Benefit Policy Manual Chapter 16: Section 180.Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for facet injections and not routinely reimbursable and therefore may be denied. In exceptional circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record individual consideration may be considered on appeal.For RFA the use of moderate anesthesia or MAC may be considered if medically necessity is clearly established. Documentation must explain the medical necessity for sedation and frequent reporting of these services together may trigger focused medical review.
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA58364)
Documentation RequirementsThe 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 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.)
Draft Article - Billing and Coding: Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Essential Tremor (DA56690)
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.
Draft Article - Billing and Coding: KidneyIntelX and KidneyIntelX.dkd Testing (DA59595)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for KidneyInteX and KidneyIntelX.dkd testing.Coding Information: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.Specific Coding InformationThe KidneylntelX or KidneyIntelX.dkd test is considered reasonable and necessaryonce in a lifetimewhen all criteria in the LCD's Indications of Coverage section are met.Please report PLA code 0105U for services rendered on or after 9/1/2023 through 12/31/2023.Please report PLS code 0407U for services rendered on or after 1/1/2024.
Draft Article - Billing and Coding: Computed Tomography Cerebral Perfusion Analysis (CTP) (DA58354)
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 13, 20 Payment Conditions for Radiology ServicesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 20.9 National Correct Coding Initiative (NCCI) and 30 Services Paid Under the Medicare Physicians Fee ScheduleArticle TextThe information in this article contains billing, coding or other guidelines that complements the Local Coverage Determination (LCD) for Computed Tomography Cerebral Perfusion Analysis (CTP) DL38769.Documentation Requirements:The 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. The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, the reason for the tests, an interpretive report and copies of images. The computerized image reconstruction data should also be maintained.
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA58350)
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 that lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, 180 Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, 10.1 Billing Part B Radiology Services and Other Diagnostic Procedures and 20 Payment Conditions for Radiology Services.Article Text
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA58350)
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forFacet Joint Interventions for Pain Management DL38765.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to NCCI edits or Hospital 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 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.Coding Guidance:Providers should refer to the applicable American Medical Association (AMA) CPTManual to assist with proper reporting of these services.This article applies only to cervical/thoracic or lumbar facet procedures and does not apply to other joint procedures (such as sacral injections, sacroiliitis, epidural or other spinal procedures).Diagnostic and Therapeutic Procedures:Each facet level in the spinal region is composed of bilateral facet joints (i.e., there are 2 facet joints per level, 1 on the right side and 1 on the left). Unilateral or bilateral facet interventions may be performed during the facet joint procedure (a diagnostic nerve block, a therapeutic facet joint (intra-articular) injection, a medial branch block injection, or the medial branch radiofrequency ablation (neurotomy)) in 1 session. A bilateral intervention is still considered a single level intervention.Each unilateral or bilateral intervention at any level should be reported as 1 unit, with bilateral intervention signified by appending the modifier -50.
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA58350)
Each unilateral or bilateral intervention at any level should be reported as 1 unit, with bilateral intervention signified by appending the modifier -50.One medial branch block is counted as 2 facet joint injections.Regions:An anatomic spinal region for paravertebral facet joint block (diagnostic or therapeutic), is defined as cervical\thoracic (CPTcodes 64490, 64491, 64492) or lumbar\sacral (CPTcodes 64493, 64494, 64495) per the AMA CPTManual.Levels:64490 (cervical or thoracic) or 64493 (lumbar or sacral) reports a single level injection performed with image guidance (fluoroscopy or computed tomography [CT]). Procedures performed under ultrasound guidance are not covered.64491 or 64494 describes a second level which should be reported separately in addition to the code for the primary procedure. 64491 should be reported in conjunction with 64490 and 64494 should be reported in conjunction with 64493.64492 or 64495 describes a third and additional levels and should be listed separately in addition to the code for the primary procedure and the second level procedure and cannot be reported more than once per day. 64492 should be reported in conjunction with 64490/64491 and 64495 should be reported in conjunction with 64493/64494.Laterality:Bilateral paravertebral facet injection procedures 64490 through 64495 should be reported with modifier 50.One to 2 levels, either unilateral or bilateral, are allowed per session per spine region (i.e., 2 unilateral or 2 bilateral levels per session).For services performed in the Ambulatory Surgery Center (ASC), physicians must continue using modifier 50. Only the ASC facility itself must report the applicable procedure code on 2 separate lines, with 1 unit each and append the -RT and -LT modifiers to each line.KX modifier requirements:
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA58350)
KX modifier requirements:The KX modifier should be appended to the line for all diagnostic injections. In most cases the KX modifier will only be used for the 2 initial diagnostic injections. If the initial diagnostic injections do not produce a positive response as defined by the related LCD and indicative of identification of the pain generator, and it is necessary to perform additional diagnostic injections, append the KX modifier to the line. Aberrant use of the KX modifier may trigger focused medical review.Therapeutic injections:Documentation of why patient is not a candidate for radiofrequency ablation (RFA) must be submitted for therapeutic treatment.Chemodenervation of nerve:Codes 64633, 64634, 64635, 64636 are reported per joint, not per nerve. Although 2 nerves innervate each facet joint, only 1 unit per code may be reported for each joint denervated, regardless of the number of nerves treated (AMA CPTManual 2020).Each unilateral or bilateral intervention at any level should be reported as 1 unit, with bilateral intervention signified by appending the modifier -50.Region:An anatomic spinal region for thermal facet joint denervation is defined as cervical/thoracic (CPTcodes 64633 and 64634) or lumbar/sacral (CPTcodes 64635 and 64636) per the AMA CPTManual.For neurolytic destruction of the nerves innervating the T12-L1 paravertebral facet joint, use 64633.Levels:64633 or 64635 describes a single level destruction by neurolytic agent performed with image guidance (fluoroscopy or CT).64634 or 64636 describes each additional level which should be reported separately in addition to the code for the primary procedure. 64634 should be used in conjunction with 64633 and 64636 should be used in conjunction with 64635.Laterality:For bilateral procedures report modifier 50 on each line in which the intervention was of a bilateral nature.
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA58350)
Laterality:For bilateral procedures report modifier 50 on each line in which the intervention was of a bilateral nature.For services performed in the ASC, physicians must continue using modifier 50. Only the ASC facility itself must report the applicable procedure code on 2 separate lines, with 1 unit each and append the -RT and -LT modifiers to each line.Non-thermal facet joint denervation (including chemical, low-grade thermal energy (<80 degrees Celsius or any other form of pulsed radiofrequency) should not be reported with CPTcodes 64633, 64634, 64635 or 64636. These services should be reported with CPTcode 64999. Code 64999 is non-covered when used to report non-thermal facet joint denervation.If facet joints are injected with biologicals or other substances not designated for this use the entire claim will deny per Medicare Benefit Policy Manual, Chapter 16, 180.Use of moderate or deep sedation, general anesthesia, and monitored anesthesia care (MAC) is usually unnecessary or rarely indicated for facet injections and not routinely reimbursable and, therefore, may be denied. In exceptional circumstances, if the medical necessity of sedation is unequivocal and clearly documented in the medical record, individual consideration may be considered on appeal.For RFA, the use of moderate anesthesia or MAC may be considered if medical necessity is clearly established. Documentation must explain the medical necessity for sedation, and frequent reporting of these services together may trigger focused medical review.Documentation RequirementsThe patients medical record should include, but is not limited to:
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA58350)
The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visitRelevant 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.)
Draft Article - Billing and Coding: Cervical Fusion (DA59608)
CMS National Coverage PolicyN/AArticle TextRefer to the draft Local Coverage Determination (LCD) DL39738 Cervical Fusion for reasonable and necessary requirements and frequency limitations.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 theNCCI requirements.Coding GuidanceProviders should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.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.This policy applies only to cervical fusion and related procedures and does not apply to other joint procedures (such as facet, sacroiliitis, epidural or other spinal procedures).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.If you want to list out the modifiers for known non-covered service you could bullet that out under the notice section.ModifierWhen to Use ModifierGAWaiver of Liability StatementIssued as Required by PayerPolicy, Individual CaseReport when you issue a mandatory ABN for a service as required and keep it on file. You dont need to submit a copy of the ABN, but you must make it available on request. Usethe GA modifier when both covered and non-covered services appear on an ABN-related claim.GXNotice of Liability Issued,Voluntary Under Payer Policy
Draft Article - Billing and Coding: Cervical Fusion (DA59608)
GXNotice of Liability Issued,Voluntary Under Payer PolicyReport when you issue a voluntary ABN for a service we never cover because its statutorily excluded or isnt a Medicarebenefit. Use this modifier combined with modifier GY.GYNotice of Liability Not Issued,Not Required Under PayerPolicyReport Medicare statutorily excludes the item or service, or the item or service doesnt meet the definition of a Medicarebenefit. Use this modifier combined with modifier GXGZExpect Item or ServiceDenied as Not Reasonableand NecessaryReport when you expect well deny payment of the item or service because its medically unnecessary and you didntissue an ABN.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 operative note should include the procedure performed and any associated/additional procedures performed at the same time.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 visitRelevant 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.)Documentation to support the medical necessity of the procedure(s).Use of BiologicalsThere are currently no FDA approved biologicals to be injected into the joint at the time of surgery. The inclusion of biological and/or other non-FDA approved substances in the injectant will result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180Medicare Benefit Policy Manual (cms.gov). Amniotic and placenta derived injectants, amino acids, vitamins, and platelet rich plasma fall in this category.