evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Intravenous Immune Globulin (A56779)
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: Intravenous Immune Globulin (A56779)
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.)
Article - Billing and Coding: Transthoracic Echocardiography (TTE) (A56781)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Transthoracic Echocardiography (TTE) (A56781)
This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Transthoracic Echocardiography (TTE).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. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the 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, as well as reasons for repeat testing.Each service requires a formal written report with interpretation. This report should be kept on file with copies of image documentation (paper or tape) for review if requested. All appropriate measurements should be included in the report.At a minimum, a complete study should contain M mode and/or 2D measurements of LV end diastolic diameter, LV end systolic diameter, LV wall thickness, left atrial diameter, aortic valve excursion and a qualitative description of the LV function, whenever possible given any technical limitations in a particular case. Individual echocardiographic laboratories (providers) may choose valid substitutes for these parameters such as LV volumes, ejection fraction and mass measurements.A Doppler interrogation should state the modes used and should give both qualitative and quantitative information.Claims for contrast echocardiography services must be supported by documentation that conventional studies were inconclusive and there was a need for the contrast enhancement.The medical record should clearly document the reasons for performing multiple tests, as well as prior data which has been reviewed. If specific prior test results were requested and not received, necessitating repeat or additional testing, then this should also be noted in the records.
Article - Billing and Coding: Transthoracic Echocardiography (TTE) (A56781)
In the case of disease processes that could preclude the performance of exercise stress testing, the medical documentation should clearly describe why the patient cannot perform exercise stress testing. The documentation must include (but is not limited to) history and physical exam findings demonstrating that the patient could not reasonably be expected to perform exercise stress testing.Documentation of the qualifications of personnel performing tests, as described in the Indications section of the LCD, should be available on request.In those instances in which repeat tests were denied, the physician must document a good faith effort was made to identify them and to request copies of them from previous providers, in order for NGS to consider reimbursement for such tests on appeal.Documentation must be available to Medicare upon request.
Article - Billing and Coding: Transthoracic Echocardiography (TTE) (A56781)
Utilization Guidelines:Repeat echocardiographic studies should be guided by the clinical status of the patient. The frequency of services is guided by the circumstances outlined in the Indications and Limitations section ofthe attached LCD.Repeat studies are appropriate to monitor changes in cardiac structure or function when there are changes in the clinical status of the patient, or when disease progression is otherwise suspected.Services performed in the Emergency Room and other emergency services are excluded from any frequency limitations on coverage for repeat testing. While Emergency Room services would be identified on the claim by the place of service code (23), emergency services provided at other sites would require post-pay review of the documentation provided in the medical record.In those instances in which repeat tests were denied and a physician has documented a good faith effort to identify them and to request copies of them from previous providers, then NGS could reimburse such tests on appeal.
Article - Billing and Coding: Pulmonary Stress Testing (A56784)
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) forPulmonary Stress Testing L33444.
Article - Billing and Coding: Immune Globulin (A56786)
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) L35093 (Immune Globulin). 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 use of the JA and JB modifiers is required for drugs which have one HCPCS Level II (J or Q) code but multiple routes of administration. Drugs that fall under this category must be billed with the JA modifier for the intravenous infusion of the drug or billed with the JB modifier for the subcutaneous injection of the drug.HCPCS codes J1561 and J1569 must be billed with either modifier JA for the intravenous formulation or modifier JB for the subcutaneous formulation.Not Otherwise Classified (NOC) Drug BillingOffice/ClinicProviders submit NOC codes (e.g., J1599) in the 2400/SV101-2 data element in the 5010 professional claim transaction (837P). When billing an NOC code, providers are required to provide a description in the 2400/SV101-7 data element. The 5010 TR3 Implementation Guide instructs: "Use SV101-7 to describe non-specific procedure codes." (Do not use the 2400 NTE segment to describe non-specific procedure codes with 5010). The SV101-7 data element allows for 80 bytes (i.e., characters, including spaces) of information.In order for the A/B MAC to correctly reimburse NOC drugs and biologicals, providers must indicate the following in the 2400/SV101-7 data element, or Item 19 of the CMS 1500 form:
Article - Billing and Coding: Immune Globulin (A56786)
In order for the A/B MAC to correctly reimburse NOC drugs and biologicals, providers must indicate the following in the 2400/SV101-7 data element, or Item 19 of the CMS 1500 form:The name of the drug,The total dosage (plus strength of dosage, if appropriate), andThe method of administration.Important:Listoneunit of service in the 2400/SV1-04 data element or in item 24G of the CMS 1500 form. Do not quantity-bill NOC drugs and biologicals even if multiple units are provided. Medicare determines the proper payment of NOC drugs and biologicals by the narrative information, not the number of units billed.Claims for NOC drugs and biologicals will reject as unprocessable if any of the information listed above is missing, or if the NOC code is billed with more than one unit of service. (Note: The remittance notice will include remark code M123, "Missing/incomplete/invalid name, strength, or dosage of the drug furnished," even if the rejection is due to the number of units billed).Ambulatory Surgical Centers (ASCs) and Hospital Outpatient DepartmentsHCPCS code C9399, Unclassified drug or biological, should be used for new drugs and biologicals that are approved by the United States (U.S.) Food and Drug Administration (FDA) on or after January 1, 2004, for which a specific HCPCS code has not been assigned.Drug WastageWhen billing for Part B drugs and biologicals (except those provided under a competitive acquisition program [CAP]), the use of the JW modifier to identify unused drugs or biologicals from single use vials or single use packages that are appropriately discarded is required. The discarded amount shall be billed on a separate claim line using the JW modifier. Providers are required to document the discarded drug or biological in the patients medical record.Any amount wasted must be clearly documented in the medical record and should include the date and time, amount of medication wasted, and the reason for the wastage.The use of the JZ modifier (attesting that there were no discarded amounts) is required on claims to report there are no discarded amounts of unused drugs or biologicals from single use vials or single use packages.
Article - Billing and Coding: Immune Globulin (A56786)
The use of the JZ modifier (attesting that there were no discarded amounts) is required on claims to report there are no discarded amounts of unused drugs or biologicals from single use vials or single use packages.Claims for drugs separately payable under Medicare Part B from single-dose containers are required to report either the JW or JZ modifier, to identify any discarded amounts or to attest that there are no discarded amounts, respectively.The JW and JZ modifier policy does not apply for drugs that are not separately payable, such as packaged OPPS or ASC drugs, or drugs administered in the FQHC or RHC setting.The JW and JZ modifiers do not apply to drugs assigned status indicator N (Items and Services Packaged into APC Rates) under the OPPS. Similarly, the JW and JZ modifiers do not apply to drugs assigned payment indicator N1 (ASC).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 medical record documentation must support the medical necessity of the services as stated in the LCD.The information contained in the medical record should include all relevant diagnostic laboratory studies, prior history of bleeding, infection, disease progression, prior medical/surgical therapies, vaccination response, and any other information essential in establishing that the patient meets the coverage indications as set forth in the NCD and LCD.An accurate weight in kilograms should be documented prior to the infusion since the dosage is based on mg/kg/dosage.
Article - Billing and Coding: Nonvascular Extremity Ultrasound (A56787)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that compliment the LCD for Nonvascular Extremity Ultrasound.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. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned.A permanent record of the ultrasound and its interpretation should be kept on file in the patient's record. The record should include all of the following:Images of all appropriate areas, labeled with exam date, patient identification, and image orientation; anddocumentation of the variations from normal, accompanied by measurements;formal interpretation.Results of all testing should be shared with the referring physician. Documentation must be available to Medicare upon request.Utilization Guidelines:Services in excess of two tests per extremity in six months will be considered not medically necessary.
Article - Billing and Coding: YAG Capsulotomy (A56792)
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 claimArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for YAG Capsulotomy L37644.
Article - Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases (A56793)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases.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 Guidelines:Regarding Acute Myelogenous Leukemia (AML), Myelodysplastic Syndromes (MDS), and Myeloproliferative Neoplasms (MPN), the following guidelines apply:Targeted genomic sequence analysis panel, hematolymphoid neoplasm, DNA analysis, and RNA analysis 5-50 genes (CPT 81450 or 81451) is a useful representation of the aggregate of these gene tests, and may be used as long as the panel contains, at a minimum, 5 or more gene tests for molecular biomarkers determined to meet Medicare coverage criteria (for example, NCCN Biomarkers Compendium Evidence Category I or 2A and associated clinical utility).The specified coverage indications are in line with NCCN recommendations. Evaluation of other genes or genomic sequences not addressed by NCCN or other professional guidelines are not precluded, but their inclusion in panels recognized by this code should not be interpreted as endorsement of such testing by genomic sequencing procedures and laboratories and users of such testing are advised to adhere to traditional regulatory and institutional oversight mechanisms to assure their clinical validity and utility.
Article - Billing and Coding: Erythropoiesis Stimulating Agents (ESAs) (A56795)
CMS National Coverage PolicyCMS Pub 100-04Medicare Claim Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, Section 60.4.2 - Facility Billing Requirements for ESAsCMS Publication 100-04Medicare Claims Processing Manual, Chapter 17 - Drugs and Biologicals, Section 80.9  Required Modifiers for ESAs Administered to Non-ESRD PatientsCMS IOM Publication 100-02,Medicare Benefit Policy Manual, Chapter 11 - End Stage Renal Disease (ESRD), Section 20.3  Drugs and Biologicals.CR 11244: Discontinuing the Erythropoietin Stimulating Agent (ESA) Monitoring Policy System Edits under the End Stage Renal Dialysis Prospective Payment System (ESRD PPS). Effective 01/01/2020.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L34633.A number of chronic conditions, especially chronic renal failure, result in decreased production of or relative resistance to erythropoietin, often causing anemia. Supplementation by synthetic drugs with structures identical or similar to naturally occurring erythropoietin has been proven safe and effective in correcting anemia in certain groups of patients.General Information for Erythropoiesis Stimulating Agents (ESA) claims:
Article - Billing and Coding: Erythropoiesis Stimulating Agents (ESAs) (A56795)
No ESA should be given within the context of uncontrolled hypertension.No ESA should be used to replace red blood cell (RBC) transfusions in patients who need immediate urgent correction of anemia.With any ESA, the patients medical record should reflect the clinical reason for dose changes and hematocrit (HCT) levels outside the range of 30.0-36.0% (hemoglobin (Hb) levels 10.0-12.0g/dL). Medicare contractors may review medical records to assure appropriate dose reductions are applied and maintained and hematological target ranges are maintained.There may be instances when a patient has a chronic health condition not specifically addressed in this policy for which an ESA is useful treatment. Such scenarios would be expected to demonstrate considerable transfusion dependence and anemia-related symptoms. In the event of denials, an appeals process will allow the opportunity for the provider to substantiate a reasonable and necessary basis for ESA treatment based on medical literature, specialty organization best practice alignment, and the unique clinical circumstances for the beneficiary. Explanatory documentation within the medical record is crucial.Coding GuidanceFor coverage of all drugs and biologicals, such as erythropoiesis stimulating agents (ESAs), used for the treatment of ESRD, please refer to CMS IOM Publication 100-02,Medicare Benefit Policy Manual, Chapter 11, Section 20.3.HCPCS Drug Codes:Healthcare Common Procedure Coding System (HCPCS) codes J0881, J0885, J0888, and Q5106 are for use in patients with non-end stage renal disease (ESRD) conditions.HCPCS codes J0882, J0887, Q4081, and Q5105 are intended for use only with patients who have ESRD and are on dialysis.Modifiers:-EA, EB, ECEffective January 1, 2008, all non-ESRD claims billing HCPCS Q5106, J0881 and J0885 must begin reporting one of the following modifiers:EA: ESA, anemia, chemo-induced;EB: ESA, anemia, radio-induced;EC: ESA, anemia, non-chemo/radio.
Article - Billing and Coding: Erythropoiesis Stimulating Agents (ESAs) (A56795)
EA: ESA, anemia, chemo-induced;EB: ESA, anemia, radio-induced;EC: ESA, anemia, non-chemo/radio.-JA, JB, JERoute of administration is important information especially with drugs that can be given multiple different ways. All non-ESRD claims reporting HCPCS code J0881, J0885, J0888, or Q5106 and all ESRD claims reporting J0882, Q4081, and Q5105 must also be reported with one and only one of the following modifiers:JA-Administered intravenouslyJB-Administered subcutaneouslyJE-Administered via dialysateClaims Reporting-Hemoglobin/HematocritClaims billing for the administration of an ESA (HCPCS codes J0881, J0882, J0885, J0887, J0888, Q4081, Q5105 and Q5106) must report the most recent HCT or Hb reading. Claims not reporting this information will be returned to the provider.For institutional claims the Hb reading is reported with a value code 48 and a HCT reading is reported with the value code 49.For professional paper claims, test results are reported in item 19 of the Form CMS-1500 claim form. For electronic claims (837P), providers report the Hb or Hct readings in Loop 2400 MEA segment. The specifics are mEA01=TR (for test results), MEA02=R1 (for Hb) orR2 (for HCT), and MEA03= the test results.Documentation RequirementsThe medical record documentation for patients receiving ESA therapy must support the reasonable and necessary basis for such therapy.