evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (A57949)
CMS National Coverage PolicyN/AArticle TextRefer to the Local Coverage Determination (LCD) L38312, Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, for reasonable and necessary requirements.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.Coding GuidelinesImplantationof a Hypoglossal Nerve Stimulator (HSN) for treatment of OSA CPT code:CPT code 64582- Open implantation of hypoglossal nerve neurostimulator array, pulse generator and distal respiratory sensor electrode or electrode array.Revision or replacementof HSN for treatment of OSA is reported with:CPT code 64583-Revision or replacement of hypoglossal nerve neurostimulator array and distal respiratory sensor electrode or electrode array, including connection to existing pulse generator.Reduced Services -Use modifier 52 for revision or replacement of either the hypoglossal nerve stimulator electrode array or distal respiratory sensor, and bill at a reduced rate.Removalof HSN for treatment of OSA is reported with:CPT code 64584-Removal of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array.Reduced Services -Use modifier 52 for removal of one or two components of the hypoglossal nerve stimulator electrode array, pulse generator, or distal respiratory sensor, and bill at a reduced rateCoding GuidanceDo notbill CPT code64582in conjunction with64583 or 64584Do notbill CPT code64583in conjunction with64582 or 64584Do notbill CPT code64584in conjunction with64582 or 64583Documentation Requirements
Article - Billing and Coding: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (A57949)
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 diagnosis code(s).
Article - Billing and Coding: Routine Foot Care (A57954)
CMS National Coverage PolicyCMS Internet Only Manual, Benefit Policy Manual, Pub 100-02 Chapter 15, Section 290 - Foot CareTitle 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.Article TextBelow is a summary of the expected coding and billing to be used when billing for routine foot care that meets the criteria as established in the CMS Internet Only Manual,Benefit Policy Manual, Pub 100-02 Chapter 15, Section 290 linked in the Associated Documents section below.Please note the clinical documentation must clearly show that the patients condition warrants a provider rendering these services in accordance with the above instruction and failure to provide such professional services would be hazardous to the beneficiary due to their underlying medical condition(s). Failure to properly document the reasoning for the care rendered may result in denial of the claim.In addition, the beneficiary may have complicating diagnosis(es) that require them to be under the care of a primary physician for the disease that is causing the beneficiary to seek provider based routine foot care. For the asterisked conditions, the name of the primary physician (must be a D.O. or M.D.) who made the diagnosis, and the approximate date of the last visit should be included in the record and entered on the appropriate claim forms or electronic equivalent when billing Medicare per the Benefit Policy Manual noted above. Please refer to the CMS website for instructions for billingPart AandPart Bclaims. There is also information on Noridians website for JEPart Bclaims.Routine foot care services are not restricted to podiatrists. These services may be used by any certified physician or non-physician (NPP) specialty, in keeping with State licensure, if applicable, to provide proper care in either a Part A facility or physicians office.
Article - Billing and Coding: Routine Foot Care (A57957)
CMS National Coverage PolicyCMS Internet Only Manual, Benefit Policy Manual, Pub 100-02 Chapter 15, Section 290 - Foot CareTitle 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.Article TextBelow is a summary of the expected coding and billing to be used when billing for routine foot care that meets the criteria as established in the CMS Internet Only Manual,Benefit Policy Manual, Pub 100-02 Chapter 15, Section 290 linked in the Associated Documents section below.Please note the clinical documentation must clearly show that the patients condition warrants a provider rendering these services in accordance with the above instruction and failure to provide such professional services would be hazardous to the beneficiary due to their underlying medical condition(s). Failure to properly document the reasoning for the care rendered may result in denial of the claim.In addition, the beneficiary may have complicating diagnosis(es) that require them to be under the care of a primary physician for the disease that is causing the beneficiary to seek provider based routine foot care. For the asterisked conditions, the name of the primary physician (must be a D.O. or M.D.) who made the diagnosis, and the approximate date of the last visit should be included in the record and entered on the appropriate claim forms or electronic equivalent when billing Medicare per the Benefit Policy Manual noted above. Please refer to the CMS website for instructions for billingPart AandPart Bclaims. There is also information on Noridians website for JFPart Bclaims.Routine foot care services are not restricted to podiatrists. These services may be used by any certified physician or non-physician (NPP) specialty, in keeping with State licensure, if applicable, to provide proper care in either a Part A facility or physicians office.
Article - Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility (A57970)
CMS National Coverage PolicyCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Inpatient Hospital Billing, Chapter 3, Section 90 Billing Transplant ServicesTitle 42 CFR 412 Prospective Payment Systems for Inpatient Hospital ServicesArticle Text
Article - Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility (A57970)
Article TextMedicare covers the following solid organ transplants: kidney, heart, lung, heart/lung, liver, pancreas, pancreas/kidney, and intestinal/multi-visceral. Medicare also covers stem cell transplants for certain conditions.Claims for CPTcodes used to describe Human Leukocyte Antigen (HLA) testing used for transplant histocompatibility testing will be denied. See below for further explanation on correct billing for these services. This does not refer to HLA testing for non-transplant services.HLA testing for histocompatibility testing as part of transplantation are part of solid organ acquisition services.Services for organ transplants must be billed as described in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Inpatient Hospital Billing, Chapter 3 Section 90 and as described in the Electronic Code of Federal Regulations, Title 42, Public Health, Part 412 Prospective Payment Systems for Inpatient Hospital Services. The acquisition costs of hearts, kidneys, livers, lungs, pancreas, and intestines (or multivisceral organs) incurred by approved transplantation centers are paid on a reasonable cost basis by approved transplant centers; they are not billed as stand-alone laboratory services.HLA typing is a component of the acquisition services for an allogeneic stem cell transplant as well. Payment for these acquisition services is included in the MS-DRG payment for the allogeneic stem cell transplant when the transplant occurs in the inpatient setting and in the OPPS APC payment for the allogeneic stem cell transplant when the transplant occurs in the outpatient setting. The Medicare contractor does not make separate payment for these acquisition services, because hospitals may bill and receive payment only for services provided to the Medicare beneficiary who is the recipient of the stem cell transplant and whose illness is being treated with the stem cell transplant. Unlike the acquisition costs of solid organs for transplant (e.g., hearts and kidneys), which are paid on a reasonable cost basis, acquisition costs for allogeneic stem cells are included in prospective payment.Acquisition charges do not apply to autologous transplants.HLA CPTcodesunrelated to transplant testinghave coverage as outlined in the following Local Coverage Determinations (LCDs):
Article - Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility (A57970)
CPT81381-The MolDX: Pharmacogenomics Testing L38335 LCD addresses limited coverage for gene-drug interactions.CPT81383 - The MolDX: HLA-DQB1*06:02 Testing for Narcolepsy L36551 LCD addresses non-coverage of HLA-DQB1*06:02 typing for the diagnosis or management of narcolepsy.
Article - Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility (A57972)
CMS National Coverage PolicyCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Inpatient Hospital Billing, Chapter 3, Section 90 Billing Transplant ServicesTitle 42 CFR 412 Prospective Payment Systems for Inpatient Hospital ServicesArticle Text
Article - Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility (A57972)
Article TextMedicare covers the following solid organ transplants: kidney, heart, lung, heart/lung, liver, pancreas, pancreas/kidney, and intestinal/multi-visceral. Medicare also covers stem cell transplants for certain conditions.Claims for CPTcodes used to describe Human Leukocyte Antigen (HLA) testing used for transplant histocompatibility testing will be denied. See below for further explanation on correct billing for these services. This does not refer to HLA testing for non-transplant services.HLA testing for histocompatibility testing as part of transplantation are part of solid organ acquisition services.Services for organ transplants must be billed as described in the Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Inpatient Hospital Billing, Chapter 3 Section 90 and as described in the Electronic Code of Federal Regulations, Title 42, Public Health, Part 412 Prospective Payment Systems for Inpatient Hospital Services. The acquisition costs of hearts, kidneys, livers, lungs, pancreas, and intestines (or multivisceral organs) incurred by approved transplantation centers are paid on a reasonable cost basis by approved transplant centers; they are not billed as stand-alone laboratory services.HLA typing is a component of the acquisition services for an allogeneic stem cell transplant as well. Payment for these acquisition services is included in the MS-DRG payment for the allogeneic stem cell transplant when the transplant occurs in the inpatient setting and in the OPPS APC payment for the allogeneic stem cell transplant when the transplant occurs in the outpatient setting. The Medicare contractor does not make separate payment for these acquisition services, because hospitals may bill and receive payment only for services provided to the Medicare beneficiary who is the recipient of the stem cell transplant and whose illness is being treated with the stem cell transplant. Unlike the acquisition costs of solid organs for transplant (e.g., hearts and kidneys), which are paid on a reasonable cost basis, acquisition costs for allogeneic stem cells are included in prospective payment.Acquisition charges do not apply to autologous transplants.HLA CPTcodesunrelated to transplant testinghave coverage as outlined in the following Local Coverage Determinations (LCDs):
Article - Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility (A57972)
CPT81381- The MolDX: Pharmacogenomics Testing L38337 LCD addresses limited coverage for gene-drug interactions.CPT81383 - The MolDX: HLA-DQB1*06:02 Testing for Narcolepsy L36544 LCD addresses non-coverage of HLA-DQB1*06:02 typing for the diagnosis or management of narcolepsy.
Article - Billing and Coding: MolDX: Pigmented Lesion Assay (A57983)
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. 100-04, Medicare Claims Processing Manual, Chapter 16, Sections:50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel Allowance.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, Section10 Reporting ICD Diagnosis and Procedure Codes.CMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Pigmented Lesion Assay L38178.To report a service, please submit the following claim information:Select the appropriate CPT codeEnter 1 unit of service (UOS)Enter the app 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 837PBox 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 formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: Implantable Automatic Defibrillators (A57994)
CMS National Coverage PolicyN/AArticle TextThe National Coverage Determination (NCD) 20.4, Implantable Automatic Defibrillators was revised with an effective date of February 15, 2018. The CMS A/B Medicare Administrative Contractors (MACs) have been instructed to implement the NCD at the local level. The following provides coding and billing instructions for the implementation of NCD 20.4. (CMS policy language is initalics.) The NCD Item/Service Description and Indications and Limitations are repeated here.This article does not alter previous CMS A/B Medicare Administrative Contractors (MACs) instructions for coding and billing of NCD 20.8.3 (National Coverage Determination (NCD) for Cardiac Pacemakers: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers) nor does it alter MAC Local Coverage for Cardiac Resynchronization Therapy.Item/Service DescriptionA. GeneralAn ICD is an electronic device designed to diagnose and treat life-threatening ventricular tachyarrhythmias.Indications and Limitations of CoverageB. Nationally Covered IndicationsEffective for services performed on or after February 15, 2018, CMS has determined that the evidence is sufficient to conclude that the use of ICDs, (also referred to as defibrillators) is reasonable and necessary:1. Patients with a personal history of sustained Ventricular Tachyarrhythmia (VT) or cardiac arrest due to Ventricular Fibrillation (VF). Patients must have demonstrated:An episode of sustained VT, either spontaneous or induced by an Electrophysiology (EP) study, not associated with an acute Myocardial Infarction (MI) and not due to a transient or reversible cause; orAn episode of cardiac arrest due to VF, not due to a transient or reversible cause.ICD-10-CM codes which describe the above: I46.2, I46.9, I47.21, I47.29, I49.01, I49.02, I49.3, I49.9, I5A, Z45.02 or Z86.74.2. Patients with a prior MI and a measured Left Ventricular Ejection Fraction (LVEF)  0.30. Patients must not have:
Article - Billing and Coding: Implantable Automatic Defibrillators (A57994)
New York Heart Association (NYHA) classification IV heart failure; or,Had a Coronary Artery Bypass Graft (CABG), or Percutaneous Coronary Intervention (PCI) with angioplasty and/or stenting, within the past three (3) months; or,Had an MI within the past 40 days; or,Clinical symptoms and findings that would make them a candidate for coronary revascularization.For these patients identified in B2, a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1) of the Social Security Act (the Act)) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in 1861(aa)(5) of the Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision making encounter may occur at a separate visit.ICD-10-CM code I25.2 must be billed with one of the following ICD-10-CM codes which describe the above: I50.21, I50.22, I50.23, I50.41, I50.42 or I50.43.3. Patients who have severe, ischemic, dilated cardiomyopathy but no personal history of sustained VT or cardiac arrest due to VF, and have NYHA Class II or III heart failure, LVEF  35%. Additionally, patients must not have:Had a CABG, or PCI with angioplasty and/or stenting, within the past three (3) months; or,Had an MI within the past 40 days; or,Clinical symptoms and findings that would make them a candidate for coronary revascularization.
Article - Billing and Coding: Implantable Automatic Defibrillators (A57994)
For these patients identified in B3, a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1) of the Act) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in 1861(aa)(5) of the Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision making encounter may occur at a separate visit.ICD-10-CM code I25.5 must be billed with one of the following ICD-10-CM codes which describe the above: I50.21, I50.22, I50.23, I50.41, I50.42 or I50.43.4. Patients who have severe, non-ischemic, dilated cardiomyopathy but no personal history of cardiac arrest or sustained VT, NYHA Class II or III heart failure, LVEF  35%, been on optimal medical therapy for at least three (3) months. Additionally, patients must not have:Had a CABG or PCI with angioplasty and/or stenting, within the past three (3) months; or,Had an MI within the past 40 days; or,Clinical symptoms and findings that would make them a candidate for coronary revascularization.
Article - Billing and Coding: Implantable Automatic Defibrillators (A57994)
For these patients identified in B4, a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1) of the Act) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in 1861(aa)(5) of the Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision making encounter may occur at a separate visit.ICD-10-CM codes codes I42.0, I42.6, I42.7 or I42.8 must be billed with one of the following ICD-10-CM codes which describe the above: I50.21, I50.22, I50.23, I50.41, I50.42 or I50.43.5. Patients with documented, familial or genetic disorders with a high risk of life-threatening tachyarrhythmias (sustained VT or VF, to include, but not limited to, long QT syndrome or hypertrophic cardiomyopathy).For these patients identified in B5, a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1) of the Act) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in 1861(aa)(5) of the Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision making encounter may occur at a separate visit.ICD-10-CM codes which describe the above: I42.1, I42.2, I45.6, I45.81 orI45.89.6. Patients with an existing ICD may receive an ICD replacement if it is required due to the end of battery life, Elective Replacement Indicator (ERI), or device/lead malfunction.For each of the six (6) covered indications above, the following additional criteria must also be met:
Article - Billing and Coding: Implantable Automatic Defibrillators (A57994)
Patients must be clinically stable (e.g., not in shock, from any etiology);LVEF must be measured by echocardiography, radionuclide (nuclear medicine) imaging, cardiac Magnetic Resonance Imaging (MRI), or catheter angiography;Patients must not have:Significant, irreversible brain damage; or,Any disease, other than cardiac disease (e.g., cancer, renal failure, liver failure) associated with a likelihood of survival less than one (1) year; or,Supraventricular tachycardia such as atrial fibrillation with a poorly controlled ventricular rate.
Article - Billing and Coding: Implantable Automatic Defibrillators (A57994)
Exceptions to waiting periods for patients that have had a CABG, or PCI with angioplasty and/or stenting, within the past three (3) months, or had an MI within the past 40 days:Cardiac Pacemakers: Patients who meet all CMS coverage requirements for cardiac pacemakers, and who meet the criteria in this national coverage determination for an ICD, may receive the combined devices in one procedure, at the time the pacemaker is clinically indicated;Replacement of ICDs: Patients with an existing ICD may receive an ICD replacement if it is required due to the end of battery life, ERI, or device/lead malfunction.ICD-10-CM codes which describe the above: T82.110A, T82.111A, T82.118A, T82.119A, T82.120A, T82.121A, T82.128A, T82.129A, T82.190A, T82.191A, T82.198A, T82.199A, T82.7XXA or Z45.02.C. Nationally Non-Covered IndicationsN/AD.OtherFor patients that are candidates for heart transplantation on the United Network for Organ Sharing (UNOS) transplant list awaiting a donor heart, coverage of ICDs, as with cardiac resynchronization therapy, as a bridge-to-transplant to prolong survival until a donor becomes available, is determined by the local Medicare Administrative Contractors (MACs).ICD-10-CM code Z76.82 must be billed with ICD-10-CM code I50.84 which describes the above.All other indications for ICDs not currently covered in accordance with this decision may be covered under Category B Investigational Device Exemption (IDE) trials (42 CFR 405.201).ICD-10-CM code which describes the above: Z00.6 with modifier Q0 appended to the HCPCS code billed.
Article - Billing and Coding: Implantable Automatic Defibrillators (A57994)
ICD-10-CM code which describes the above: Z00.6 with modifier Q0 appended to the HCPCS code billed.The coding and billing guidelines apply to the following ICD-10-Procedure codes: insertion codes: 0JH608Z, 0JH609Z, 0JH60FZ, 0JH638Z, 0JH639Z, 0JH63FZ, 0JH808Z, 0JH809Z, 0JH838Z, 0JH839Z, 02H43KZ, 02H60KZ, 02H63KZ, 02H64KZ, 02H70KZ, 02H73KZ, 02H74KZ, 02HK0KZ, 02HK3KZ, 02HK4KZ, 02HL0KZ, 02HL3KZ, 02HL4KZ and removal codes: 0JPT0FZ, 0JPT0PZ, 0JPT3FZ, 0JPT3PZ, 02PA0MZ, 02PA3MZ, 02PA4MZ and 02PAXMZ. Procedure code 02PAXMZ is no longer valid after 10/01/2021.The coding and billing guidelines also apply to the following CPT codes: 33202, 33203, 33223, 33230, 33231, 33240, 33241, 33243, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, G0448, 33215, 33216, 33217, 33218, 33220, 33224 and 33225.ICD professional services are only covered for inpatient or outpatient facilities: POS 19, 21, 22, 24, and 26.