evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto. Un LCD se us para su reclamacin. Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si piensa que puede cambiar nuestra decisin. Para obtener una copia del LCD, llame al 1-800- MEDICARE (1 -800-633-4227).  NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.    Group Code: CO (Contractual Obligation) assigning financial liability to the provider        A/B MACs (Part A) shall deny for any covered dx audiology/therapy services related to cochlear implantation with the following messages:  Use the following messages when denying services on claims:   Submitted on a TOB other than 11X, 12X (except surgical procedures), 13X or 85X (Part A only), or  submitted without diagnostic code Z00.6  submitted without one of the CPT/HCPCs listed (92521-92524, 92507, 92601- 92604, L7510, L8614, L8619, 69930)  CARC 50 - These are non -covered services because this is not deemed a medical necessity by the payer  RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp . If you do not have web access, you may contact the contractor to request a copy of the NCD.  MSN 15.20 = The following policies were used when we made this decision: NCD 50. 3   Spanish translation: Las siguientes polticas fueron utilizadas cuando se tom esta decisin: NCD 50.3)  Contractors processing institutional claims shall use the following MSN message in addition to MSN 15.20:
(Medicare Claims Processing Manual)
Contractors processing institutional claims shall use the following MSN message in addition to MSN 15.20:  MSN 15.19 - Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICAR E (1-800-633-4227) for a copy of the LCD.  Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto. Un LCD se us para su reclamacin. Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si piensa que puede cambiar nuestra decisin. Para obtener una copia del LCD, llame al 1-800- MEDICARE (1 -800-633-4227).  NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.    Group Code: CO (Contractual Obligation) assigning financial liability to the provider         A/B/MACs (Part B) shall deny claims for evaluation and therapeutic services related to cochlear implantation. NOTE: Modifiers - Q0/-Q1 do not need to be applied to these services (92601 92604, 92521-92524 or any applicable audiology codes).
(Medicare Claims Processing Manual)
Use the following messages when denying services on claims:   Submitted without one of the CPT/HCPCs listed (92521-92524, 92507, 92601- 92604).   CARC 50 - These are non -covered services because this is not deemed a medical necessity by the payer  RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp . If you do not have web access, you may contact the contractor to request a copy of the NCD.  MSN 15.20 - The following policies were used when we made this decision: NCD 50. 3   Spanish translation: Las siguientes polticas fueron utilizadas cuando se tom esta decisin: NCD 50.3)  Group Code - CO (Contractual Obligation) assigning financial liability to the provider        110  Coverage and Billing for Ultrasound Stimulation for Nonunion Fracture Healing  (Rev. 597, Issued: 06-24-05, Effective: 04-27-05, Implementation: 08-01-05)  An ultrasonic osteogenic stimulator is a non- invasive device that emits low intensity, pulsed ultrasound.  This device is applied to the surface of the skin at the fracture site and ultrasound waves are emitted via a conductive coupling gel to stimulate fracture healing.  The ultrasonic osteogenic stimulators are not to be used concurrently with other non- invasive osteogenic devices.   110.1  Coverage Requirements  (Rev. 597, Issued: 06-24-05, Effective: 04-27-05, Implementation: 08-01-05)  Effective for dates of service on and after April 27, 2005, ultrasonic osteogenic stimulators are covered as medically reasonable and necessary for the treatment of nonunion bone fractures prior to surgical intervention.  In demonstrating nonunion fracture s, CMS expects:
(Medicare Claims Processing Manual)
 A minimum of 2 sets of radiographs, obtained prior to starting treatment with the osteogenic stimulator, separated by a minimum of 90 days.  Each radiograph set must include multiple views of the fracture site accompanied with a written interpretation by a  physician stating that there has been no clinically significant evidence of fracture healing between the 2 sets of radiographs.   For further coverage information, please refer to the National Coverage Determinations Manual, Pub. 100-03, chapter 1, section 150.2.  110.2  Intermediary Billing Requirements (Rev. 597, Issued: 06-24-05, Effective: 04-27-05, Implementation: 08-01-05)  The RHHIs will pay for ultrasonic osteogenic stimulators only when services are submitted on type of bills (TOBs) listed under Pub. 100- 04, Medicare Claims Processing Manual, chapter 32, section 100.3.   Fiscal intermediaries (FIs) must educate hospitals that there are no covered services for Ultrasonic Osteogenic Stimulation for which hospitals can be paid by the FI.   NOTE: Hospitals can not bill for Ultrasonic Osteogenic Stimulators.   110.3  Bill Types (Rev. 597, Issued: 06- 24-05, Effective: 04 -27-05, Implementation: 08- 01-05)  Only the following TOBs can bill for Ultrasonic Osteogenic Stimulators: 32X, 33X, 34X, which is payable under the DMEPOS Fee Schedule.   NOTE:   Ultrasonic Osteogenic Stimulators must be in the patients home health plan of care if billed on TOBs 32X or 33X.   110.4  Carrier and Intermediary Billing Instructions  (Rev. 597, Issued: 06- 24-05, Effective: 04 -27-05, Implementation: 08- 01-05)  Effective for dates of service on or after April 27, 2005, contractors shall allow payment for ultrasonic osteogenic stimulators with the following current procedural terminology (CPT) code:    20979 -  Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)   110.5  DMERC Billing Instructions  (Rev. 816, Issued: 01- 20-06, Effective: 04 -27-05, Implementation: 04- 03-06)
(Medicare Claims Processing Manual)
110.5  DMERC Billing Instructions  (Rev. 816, Issued: 01- 20-06, Effective: 04 -27-05, Implementation: 04- 03-06)  Effective for dates of service on or after April 27, 2005, DMERCs shall allow payment for ultrasonic osteogenic stimulators with the following HCPCS codes:   E0760 for low intensity ultrasound (include modifier KF), or;  E1399 for other ultrasound stimulation (include modifier KF)   120 - Presbyopia- Correcting (P -C IOLS) and Astigmatism -Correcting Intraocular Lenses (A -C IOLs) (General Policy Information)  (Rev. 1228; Issued:  04- 27-07; Effective:  01 -22-07; Implementation:  05 -29-07)  Per CMS Ruling 05- 01, issued May 3, 2005, Medicare will allow beneficiaries to pay additional charges associated with insertion of a P -C IOL following cataract surgery.    Presbyopia is a type of age -associated refractive error that results in progressive loss of the focusing power of the lens of the eye, causing difficulty seeing objects at near distance, or close -up.  Presbyopia occurs as the natural lens of the eye becomes thicker and less flexible with age.    A presbyopia -correcting IOL is indicated for primary implantation in the capsular bag of the eye for the visual correction of aphakia (absence of the lens of the eye) following cataract extraction that is intended to provide near, intermediate and distance vision without the need for eyeglasses or contact lenses.   Per CMS -1536- Ruling, effective for services on and after January 22, 2007, Medicare will allow beneficiaries to pay additional charges (which are non- covered by Medicare as these additional charges are not part of a Medicare benefit category) for insertion  of an A- C IOL.    Regular astigmatism is a visual condition where part of an image is blurred due to uneven corneal curvature.  A normal cornea has the same curvature at all axes, whereas the curvature of an astigmatic cornea differs in two primary axes, resulting in vision  that is distorted at all distances.
(Medicare Claims Processing Manual)
 The A -C IOL is intended to provide what is otherwise achieved by two separate items; an implantable conventional IOL (one that is not astigmatism- correcting) that is covered by Medicare, and the surgical correction, eyeglasses or contact lenses that are no t covered by Medicare.  A list of A -C IOLs and P- C IOLs can be accessed online at  http://www.cms.hhs.gov/HospitalOutpatientPPS/01_overview.asp  120.1 - Payment for Services and Supplies  (Rev. 1430; Issued:  02-01- 08; Effective:  01 -01-08; Implementation:  03 -03-08)  For an IOL inserted following removal of a cataract in a hospital, on either an outpatient or inpatient basis, that is paid under the hospital Outpatient Prospective Payment System (OPPS) or the Inpatient Prospective Payment System (IPPS), respectively; or in a Medicare -approved ambulatory surgical center (ASC) that is paid under the ASC fee schedule:   Medicare does not make separate payment to the hospital or ASC for an IOL inserted subsequent to extraction of a cataract.  Payment for the IOL is packaged into the payment for the surgical cataract extraction/lens replacement procedure.    Any person or ASC, who presents or causes to be presented a bill or request for payment for an IOL inserted during or subsequent to cataract surgery for which payment is made under the ASC fee schedule, is subject to a civil money penalty.   For a P -C IOL or A -C IOL inserted subsequent to removal of a cataract in a hospital, on either an outpatient or inpatient basis, that is paid under the OPPS or the IPPS, respectively; or in a Medicare-approved ASC that is paid under the ASC fee schedule:
(Medicare Claims Processing Manual)
 The facility shall bill for the removal of a cataract with insertion of a conventional IOL, regardless of whether a conventional, P -C IOL, or A -C IOL is inserted.  When a beneficiary receives a P -C or A -C IOL following removal of a cataract, hospitals and ASCs shall report the same CPT code that is used to report removal of a cataract with insertion of a conventional IOL.  Physicians, hospitals and ASCs may also report an additional HCPCS code, V2788, to indicate any additional charges that accrue when a P -C IOL or A -C IOL is inserted in lieu of a conventional IOL until January 1, 2008.  Effective for A -C IOL insertion services on or after January 1, 2008, physicians, hospitals and ASCs should use V2787 to report any additional charges that accrue. On or after January 1, 2008, physicians, hospitals, and ASCs should continue to report HCPCS code V2788 to indicate any additional charges that accrue for insertion of a P-C IOL.  See Section 120.2 for coding guidelines.   There is no Medicare benefit category that allows payment of facility charges for services and supplies required to insert and adjust a P- C or A -C IOL following removal of a cataract that exceed the facility charges for services and supplies required for the insertion and adjustment of a conventional IOL.   There is no Medicare benefit category that allows payment of facility charges for subsequent treatments, services and supplies required to examine and monitor the beneficiary who receives a P -C or A-C IOL following removal of a cataract that exceeds the fa cility charges for subsequent treatments, services and supplies required to examine and monitor a beneficiary after cataract surgery followed by insertion of a conventional IOL.    A - For a P -C IOL or A -C IOL inserted in a physician's office    -  A physician shall bill for a conventional IOL, regardless of a whether a conventional, P -C IOL, or A -C IOL is inserted (see section 120.2, General Billing Requirements)
(Medicare Claims Processing Manual)
-  A physician shall bill for a conventional IOL, regardless of a whether a conventional, P -C IOL, or A -C IOL is inserted (see section 120.2, General Billing Requirements)    -  There is no Medicare benefit category that allows payment of physician charges for services and supplies required to insert and adjust a  P -C or A -C IOL following removal of a cataract that exceed the physician charges for services and supplies for the  insertion and adjustment of a conventional IOL.    -  There is no Medicare benefit category that allows payment of physician charges for subsequent treatments, service and supplies required to examine and monitor a beneficiary following removal of a cataract with insertion of a P -C or A -C IOL that exceed physician charges for services and supplies to examine and monitor a beneficiary following removal of a cataract with insertion of a conventional IOL.    B - For a P -C IOL or A -C IOL inserted in a hospital    -  A physician may not bill Medicare for a P -C or A -C IOL inserted during a cataract procedure performed in a hospital setting because the payment for the lens is included in the payment made to the facility for the surgical procedure.    -  There is no Medicare benefit category that allows payment of physician  charges for services and supplies required to insert and adjust a P -C or A -C IOL following removal of a cataract that exceed the physician charges for services and supplies require d for the insertion of a conventional IOL.    C - For a P -C IOL or A -C IOL inserted in an Ambulatory Surgical Center    -  Refer to Chapter 14, Section 40.3 for complete guidance on payment for P -C IOL or A -C IOL in Ambulatory Surgical Centers.  120.2 - Coding and General Billing Requirements  (Rev. 1430; Issued:  02- 01-08; Effective:  01 -01-08; Implementation:  03 -03-08)
(Medicare Claims Processing Manual)
Physicians and hospitals must report one of the following Current Procedural Terminology (CPT) codes on the claim:   66982 -  Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexi s) or performed on patients in the amblyogenic development stage.   66983 -  Intracapsular cataract with insertion of intraocular lens prosthesis (one stage procedure)    66984 -  Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification)    66985 -  Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract extraction    66986 -  Exchange of intraocular lens   In addition, physicians inserting a P -C IOL or A -C IOL in an office setting may bill code V2632 (posterior chamber intraocular lens) for the IOL. Medicare will make payment for the lens based on reasonable cost for a conventional IOL.  Place of Service (PO S) = 11.   Effective for dates of service on and after January 1, 2006, physician, hospitals and ASCs may also bill the non-covered charges related to the P -C function of the IOL using HCPCS code V2788.  Effective for dates of service on and after January 22, 2007 through January 1, 2008, non- covered charges related to A -C function of the IOL can be billed using HCPCS code V2788. The type of service indicator for the non -covered billed charges is Q.  (The type of service is applied by the Medicare carrier and not the provider).  Effective for A -C IOL insertion services on or after January 1, 2008, physicians, hospitals and ASCs should use V2787 rather than V2788 to report any additional charges that accrue.
(Medicare Claims Processing Manual)
When denying the non- payable charges submitted with V2787 or V2788, contractors shall use an appropriate Medical Summary Notice (MSN) such as 16.10 (Medicare does not pay for this item or service) and an appropriate claim adjustment reason code such as 96 (non- covered charges) for claims submitted with the non-payable charges.   Hospitals and physicians may use the proper CPT code(s) to bill Medicare for evaluation and management services usually associated with services following cataract extraction surgery, if appropriate.    A - Applicable Bill Types    The hospital applicable bill types are 12X, 13X, 83X and 85X.    B - Other Special Requirements for Hospitals   Hospitals shall continue to pay CAHs method 2 claims under current payment methodologies for conditional IOLs.   120.3 - Provider Notification Requirements  (Rev. 1228; Issued:  04- 27-07; Effective:  01 -22-07; Implementation:  05 -29-07)  When a beneficiary requests insertion of a P -C or A -C IOL instead of a conventional IOL following removal of a cataract:    Prior to the procedure to remove a cataractous lens and insert a P -C or A -C lens, the facility and the physician must inform the beneficiary that Medicare will not make payment for services that are specific to the insertion, adjustment or other subsequent treatments related to the  P-C or A -C functionality of the IOL.    The P -C or A -C functionality of a P -C or A -C IOL does not fall into a Medicare benefit category, and, therefore, is not covered.  Therefore, the facility and physician are not required to provide an Advanced Beneficiary Notice to beneficiaries who request a P -C or A -C IOL.    Although not required, CMS strongly encourages facilities and physicians to issue a Notice of Exclusion from Medicare Benefits to beneficiaries in order to clearly identify the non- payable aspects of a P -C or A -C IOL insertion.  This notice may be found in English at http:\\cms.hhs.gov/medicare/bni/20007_English.pdf   Spanish language at:   http://cms.hhs.gov/medicare/bni/20007_Spanish.pdf .
(Medicare Claims Processing Manual)
 Spanish language at:   http://cms.hhs.gov/medicare/bni/20007_Spanish.pdf .  120.4 - Beneficiary Liability  (Rev. 1228; Issued:  04-27- 07; Effective:  01 -22-07; Implementation:  05 -29-07)  When a beneficiary requests insertion of a P -C or A -C IOL instead of a conventional IOL following removal of a cataract and that procedure is performed, the beneficiary is responsible for payment of facility and physician charges for services and supplies attributable to the P -C or A -C functionality of the P- C or A -C IOL:    In determining the beneficiary's liability, the facility and  physician may take into account any additional work and resources required for insertion, fitting, vision acuity testing, and monitoring of the P -C or A -C IOL that exceed the work and resources attributable to insertion of a conventional IOL.   The physician and the facility may not charge for cataract extraction with insertion of a P- C or A -C IOL unless the beneficiary requests this service.   o The physician and the facility may not require the beneficiary to request a P- C or A -C IOL as a condition of performing a cataract extraction with IOL insertion.  130 - External Counterpulsation (ECP) Therapy  (Rev. 898, Issued:  03- 31-06; Effective/Implementation Dates:  03 -31-06)  Commonly referred to as enhanced external counterpulsation, is a non- invasive outpatient treatment for coronary artery disease refractory medical and/or surgical therapy.  Effective for dates of service July 1, 1999, and after, Medicare will cover ECP when its use is in patients with stable angina (Class III or Class IV, Canadian Cardiovascular Society Classification or equivalent classification) who, in the opinion of a cardiologist or cardiothoracic surgeon, are not readily amenable to surgical intervention, such as PTCA or cardiac bypass, becaus e:   Their condition is inoperable, or at high risk of operative complications or post- operative failure;    Their coronary anatomy is not readily amenable to such procedures; or   They have co -morbid states that create excessive risk.
(Medicare Claims Processing Manual)
 Their condition is inoperable, or at high risk of operative complications or post- operative failure;    Their coronary anatomy is not readily amenable to such procedures; or   They have co -morbid states that create excessive risk.   (Refer to Publication 100-03, section 20.20 for further coverage criteria.)  130.1 - Billing and Payment Requirements  (Rev. 12109; Issued:06-29- 23; Effective: 10 -02-23; Implementation: 10-02-23)   Effective for dates of service on or after January 1, 2000, use HCPCS code G0166 (External counterpulsation, per session) to report ECP services. The codes for external cardiac assist (92971), ECG rhythm strip and report (93040 or 93041), pulse oximetry (94760 or 94761) and plethysmography (93922 or 93923) or other monitoring tests for examining the effects of this treatment are not clinically necessary with this service and should not be paid on the same day, unless they occur in a clinical setting not connected with the delivery of the ECP. Daily evaluation and management service, e.g., 99201-  99205, 99211- 99215, 99217- 99220, 99241-99245, and G0463 cannot be billed with the ECP treatments. Any evaluation and management service must be justified with adequate documentation of the medical necessity of the visit. Deductible and coinsurance apply.   Note: Please note that effective December 31, 2020 evaluation and management service code 99201 is end-dated. Effective December 31, 2022 codes 99217,99218,99219,99220 and 99241 are end dated.  For Part A, remove CPT codes 99202- 99215, 99242- 99245 and repl ace with G0463 (the OPPS equivalent of E/M codes) effective retroactive to 10/1/2015.     130.2 - Special Intermediary Billing and Payment Requirements  (Rev. 898, Issued:  03- 31-06; Effective/Implementation Dates:  03 -31-06)