evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Total Knee Arthroplasty (A57685)
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 following billing and coding guidance is to be used with its associated Local Coverage Determination.Documentation RequirementsIn order to qualify for coverage of both Medicare Part A inpatient services and Part B provider services the medical record must contain documentation that fully supports the medical necessity and justification of the procedure performed and must be made available to Noridian upon request. When the documentation does not meet the criteria for the service(s) rendered or the documentation does not establish the medical necessity for the service(s), such service(s) will be denied as not reasonable and necessary.A history and physical, discharge summary, physician progress notes and an operative report are typically in the hospital record for the procedures in this LCD.Other relevant information addressing coverage criteria related to the patients episode of care prior to the hospitalization, should be included in the hospital record (see below).Failure to include this information in the hospital record may result in denial of coverage for Part A services and trigger a review of the Part B provider claim to determine whether the Part B service rendered was reasonable and necessary.When the procedure is indicated for advanced joint disease, the following should be documented in the medical record: Arthritis of the knee supported by X-ray, MRI, or CT. The X-ray, MRI or CT, as medically necessary, should demonstrate and the provider must document one or more of the following:a) subchondral cysts,b) subchondral sclerosis,c) periarticular osteophytes,d) joint subluxation,e) the degree of joint space narrowing,f) avascular necrosis org) bone on bone articulations Pain or functional disability at the knee. Pain and/or functional disability should be described in context. For example, documented pain that interferes with ADLs (functional disability), or pain that is increased with initiation of activities or pain that increases with weight bearing.
Article - Billing and Coding: Total Knee Arthroplasty (A57685)
 Unsuccessful conservative therapy (non-surgical medical management) if appropriate. The documentation should demonstrate a history of a reasonable attempt at conservative therapy as appropriate for the patient in his/her current episode of care. For example, documented trial of NSAIDs or contraindication to such therapy and/or documented supervised physical therapy. Documentation should support that ADLs are diminished due to pain and/or disability despite non-surgical medical management. For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as THA should be appropriately addressed in the medical record.Medical record documentation for other TKR/TKA indications outlined in the LCD should include the following, when indicated: Supporting evidence (e.g., pathology reports and referral from an Oncologist for a malignancy of the joint or X-ray of a fracture). Pain at the knee when indicated as a reason for the procedure (e.g., for revision/replacement TKR/TKA). For example, documented pain that interferes with ADLs (functional disability), pain that is increased with initiation of activities or pain that increases with weight bearing. For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as TKR/TKA should be appropriately addressed in the medical record. When infection is the reason for revision TKR/TKA surgery, laboratory and/or pathology reports must be in the medical record and all documentation regarding treatment of the infection and a physician note indicating that it is appropriate to proceed with surgery should be in the medical record as well.In the instance that the patient is undergoing a bilateral knee replacement, all criteria listed above would apply to the bilateral surgery when indicated. The medical record should also support the medical necessity for performing a bilateral TKR/TKA.
Article - Billing and Coding: Total Knee Arthroplasty (A57685)
In the instance that the patient is undergoing a bilateral knee replacement, all criteria listed above would apply to the bilateral surgery when indicated. The medical record should also support the medical necessity for performing a bilateral TKR/TKA.The treating physician must discuss the significant benefit and risks with the patient. In order to meet Medicares reasonable and necessary (R&N) threshold for coverage of a procedure, the physicians documentation for the case should clearly support both the diagnostic criteria for the indication (standard test results and/or clinical findings as applicable) and the medical need (the procedure does not exceed the medical need and is at least as beneficial as existing alternatives & the procedure is furnished with accepted standards of medical practice in a setting appropriate for the patients medical needs and condition).Lacking compelling arguments for an exception in the supporting documentation, the hospital and physician services can be denied.If in certain circumstances the patient does not meet all of the required criteria outlined in the local coverage determination (LCD) for a procedure, but the treating physician feels that the procedure is a covered procedure given the current standards of care, then the documentation must clearly outline the patients episode of care that supports the major procedure and must clearly address the reason(s) for coverage. For example, if clinical findings (or lack of) for an indication are not consistent with the LCD criteria, it should be directly addressed in the pre-procedure documentation. For example,if certain conservative measures are not necessary or appropriate for a given patient, it should be directly noted in the pre-procedure documentation. The clinical judgment of the treating physician is always a consideration if clearly addressed in the pre-procedure record and if consistent with the episode of care for the patient as documented in patient records and claim history.Review of the medical record must indicate that inpatient hospital care was medically necessary, reasonable, and appropriate for the diagnosis and condition of the beneficiary at any time during the stay. The beneficiary must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basis.
Article - Billing and Coding: Total Knee Arthroplasty (A57686)
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 following billing and coding guidance is to be used with its associated Local Coverage Determination.Documentation RequirementsIn order to qualify for coverage of both Medicare Part A inpatient services and Part B provider services the medical record must contain documentation that fully supports the medical necessity and justification of the procedure performed and must be made available to Noridian upon request. When the documentation does not meet the criteria for the service(s) rendered or the documentation does not establish the medical necessity for the service(s), such service(s) will be denied as not reasonable and necessary.A history and physical, discharge summary, physician progress notes and an operative report are typically in the hospital record for the procedures in this LCD.Other relevant information addressing coverage criteria related to the patients episode of care prior to the hospitalization, should be included in the hospital record (see below).Failure to include this information in the hospital record may result in denial of coverage for Part A services and trigger a review of the Part B provider claim to determine whether the Part B service rendered was reasonable and necessary.When the procedure is indicated for advanced joint disease, the following should be documented in the medical record: Arthritis of the knee supported by X-ray, MRI or CT. The X-ray, MRI or CT, as medically necessary, should demonstrate and the provider must document one or more of the following:a) subchondral cysts,b) subchondral sclerosis,c) periarticular osteophytes,d) joint subluxation,e) the degree of joint space narrowing,f) avascular necrosis org) bone on bone articulations Pain or functional disability at the knee. Pain and/or functional disability should be described in context. For example, documented pain that interferes with ADLs (functional disability), or pain that is increased with initiation of activities or pain that increases with weight bearing.
Article - Billing and Coding: Total Knee Arthroplasty (A57686)
 Unsuccessful conservative therapy (non-surgical medical management) if appropriate. The documentation should demonstrate a history of a reasonable attempt at conservative therapy as appropriate for the patient in his/her current episode of care. For example, documented trial of NSAIDs or contraindication to such therapy and/or documented supervised physical therapy. Documentation should support that ADLs are diminished due to pain and/or disability despite non-surgical medical management. For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as TKF/TKA should be appropriately addressed in the medical record.Medical record documentation for other TKR/TKA indications outlined in the LCD should include the following, when indicated: Supporting evidence (e.g., pathology reports and referral from an Oncologist for a malignancy of the joint or X-ray of a fracture). Pain at the knee when indicated as a reason for the procedure (e.g., for revision/replacement TKR/TKA). For example, documented pain that interferes with ADLs (functional disability), pain that is increased with initiation of activities or pain that increases with weight bearing. For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as TKR/TKA should be appropriately addressed in the medical record. When infection is the reason for revision TKR/TKA surgery, laboratory and/or pathology reports must be in the medical record and all documentation regarding treatment of the infection and a physician note indicating that it is appropriate to proceed with surgery should be in the medical record as well.In the instance that the patient is undergoing a bilateral knee replacement, all criteria listed above would apply to the bilateral surgery when indicated. The medical record should also support the medical necessity for performing a bilateral TKR/TKA.
Article - Billing and Coding: Total Knee Arthroplasty (A57686)
In the instance that the patient is undergoing a bilateral knee replacement, all criteria listed above would apply to the bilateral surgery when indicated. The medical record should also support the medical necessity for performing a bilateral TKR/TKA.The treating physician must discuss the significant benefit and risks with the patient. In order to meet Medicares reasonable and necessary (R&N) threshold for coverage of a procedure, the physicians documentation for the case should clearly support both the diagnostic criteria for the indication (standard test results and/or clinical findings as applicable) and the medical need (the procedure does not exceed the medical need and is at least as beneficial as existing alternatives & the procedure is furnished with accepted standards of medical practice in a setting appropriate for the patients medical needs and condition).Lacking compelling arguments for an exception in the supporting documentation, the hospital and physician services can be denied.If in certain circumstances the patient does not meet all of the required criteria outlined in the local coverage determination (LCD) for a procedure, but the treating physician feels that the procedure is a covered procedure given the current standards of care, then the documentation must clearly outline the patients episode of care that supports the major procedure and must clearly address the reason(s) for coverage. For example, if clinical findings (or lack of) for an indication are not consistent with the LCD criteria, it should be directly addressed in the pre-procedure documentation. For example,if certain conservative measures are not necessary or appropriate for a given patient, it should be directly noted in the pre procedure documentation. The clinical judgment of the treating physician is always a consideration if clearly addressed in the pre procedure record and if consistent with the episode of care for the patient as documented in patient records and claim history.Review of the medical record must indicate that inpatient hospital care was medically necessary, reasonable, and appropriate for the diagnosis and condition of the beneficiary at any time during the stay. The beneficiary must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basis.
Article - Billing and Coding: Lab: Flow Cytometry (A57689)
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 IOM Pub 100-04 Ch 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS IOM Pub 100-04 Medicare Claims Processing Manual, Ch 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe following coding and billing guidance is to be used with its associated Local overage determination.Flow cytometry is a complex laboratory process to examine body fluids, including blood and cerebrospinal fluid (CSF); bone marrow; and components of the lymphoreticular system, such as lymph nodes, tonsil, and spleen. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. LCD L34215-Flow Cytometry outlines the coverage criteria for flow cytometry testing. When covered, testing is limited to no more than 24 markers without additional medical necessity documentation.Flow cytometry for the detection and/or identification or enumeration of bacteria or viruses in patients with chronic rhinosinusitis with or without polyps is investigational/experimental and is not a Medicare benefit.To report a Flow Cytometry service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Select the appropriate ICD-10-CM code
Article - Billing and Coding: Lab: Flow Cytometry (A57690)
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 IOM Pub 100-04 Ch 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS IOM Pub 100-04 Medicare Claims Processing Manual, Ch 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe following coding and billing guidance is to be used with its associated Local overage determination.Flow cytometry is a complex laboratory process to examine body fluids, including blood and cerebrospinal fluid (CSF); bone marrow; and components of the lymphoreticular system, such as lymph nodes, tonsil, and spleen. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. LCD L36094-Flow Cytometry outlines the coverage criteria for flow cytometry testing. When covered, testing is limited to no more than 24 markers without additional medical necessity documentation.Flow cytometry for the detection and/or identification or enumeration of bacteria or viruses in patients with chronic rhinosinusitis with or without polyps is investigational/experimental and is not a Medicare benefit.To report a Flow Cytometry service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Select the appropriate ICD-10-CM code
Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) (A57692)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act (SSA) 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physician examinations.Title XVIII of the Social Security Act (SSA) 1862(a)(1)(D), and (E). Investigational or Experimental.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD L37086 Transcranial Magnetic Stimulation (TMS).Documentation RequirementsAll documentation must be maintained in the patients medical record and available to the contractor upon request. The medical record documentation must support the medical necessity of the services as directed in this policy as well as include sufficient detail to determine services rendered.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 attending physician must monitor and document the patient's clinical progress during treatment. The attending physician must use evidence-based validated depression monitoring scales such as the Geriatric Depression Scale (GDS), the Personal Health Questionnaire Depression Scale (PHQ-9), the Beck Depression Scale (BDI), Hamilton Rating Scale for Depression (HAM-D), the Montgomery Asberg Depression Rating Scale (MADRS), the Quick Inventory of Depressive Symptomatology (QIDS) or the Inventory for Depressive Symptomatology Systems Review (IDS-SR) to monitor treatment response and the achievement of remission of symptoms.Utilization GuidelinesThe treatment must be provided by use of a device approved by the FDA for the purpose of supplying Transcranial Magnetic Stimulation.It is expected that the services would be performed as indicated by current medical literature and standards of practice. Services performed in excess of established parameters may be subject to review for medical necessity.
Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) (A57692)
It is expected that the services would be performed as indicated by current medical literature and standards of practice. Services performed in excess of established parameters may be subject to review for medical necessity.TMS is reasonable and necessary for up to 20 visits over a 4-week period followed by five visits for tapering for those in remission. For those who show at least 25% improvement by means of the standard tests for depression, the therapy may be continued for an additional 2 weeks (an additional 10 visits) with an additional 6 visits for tapering.Retreatment may be considered for patients who met the guidelines for initial treatment and subsequently developed relapse of depressive symptoms if the patient responded to prior treatments as evidenced by a greater than 50% improvement in standard rating scale measurements for depressive symptoms or if there was a relapse after remission (e.g., (GDS), PHQ-9, BDI, HAM-D, MADRS, QIDS or IDS-SR score). A repeat treatment program is allowed as above.Maintenance therapy is considered experimental/investigational and therefore non-covered as not medically reasonable and necessary.
Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) (A57693)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act (SSA) 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physician examinations.Title XVIII of the Social Security Act (SSA) 1862(a)(1)(D), and (E). Investigational or Experimental.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD L37088 Transcranial Magnetic Stimulation (TMS).Documentation RequirementsAll documentation must be maintained in the patients medical record and available to the contractor upon request. The medical record documentation must support the medical necessity of the services as directed in this policy as well as include sufficient detail to determine services rendered.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 attending physician must monitor and document the patient's clinical progress during treatment. The attending physician must use evidence-based validated depression monitoring scales such as the Geriatric Depression Scale (GDS), the Personal Health Questionnaire Depression Scale (PHQ-9), the Beck Depression Scale (BDI), Hamilton Rating Scale for Depression (HAM-D), the Montgomery Asberg Depression Rating Scale (MADRS), the Quick Inventory of Depressive Symptomatology (QIDS) or the Inventory for Depressive Symptomatology Systems Review (IDS-SR) to monitor treatment response and the achievement of remission of symptoms.Utilization GuidelinesThe treatment must be provided by use of a device approved by the FDA for the purpose of supplying Transcranial Magnetic Stimulation.It is expected that the services would be performed as indicated by current medical literature and standards of practice. Services performed in excess of established parameters may be subject to review for medical necessity.
Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) (A57693)
It is expected that the services would be performed as indicated by current medical literature and standards of practice. Services performed in excess of established parameters may be subject to review for medical necessity.TMS is reasonable and necessary for up to 20 visits over a 4-week period followed by five visits for tapering for those in remission. For those who show at least 25% improvement by means of the standard tests for depression, the therapy may be continued for an additional 2 weeks (an additional 10 visits) with an additional 6 visits for tapering.Retreatment may be considered for patients who met the guidelines for initial treatment and subsequently developed relapse of depressive symptoms if the patient responded to prior treatments as evidenced by a greater than 50% improvement in standard rating scale measurements for depressive symptoms or if there was a relapse after remission (e.g., (GDS), PHQ-9, BDI, HAM-D, MADRS, QIDS or IDS-SR score). A repeat treatment program is allowed as above.Maintenance therapy is considered experimental/investigational and therefore non-covered as not medically reasonable and necessary.