evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Erythropoiesis Stimulating Agents (ESA) (A56462)
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.)Effective February 23, 2013, Omontys  (HCPCS code J0890) has been recalled by the FDA and will no longer be covered by CGS. The effective date of this non-coverage is February 23, 2013. More information regarding this recall is available on the FDA website.Other Comments:Bill type codes for Home Health services are not listed in the LCD for Erythropoiesis Stimulating Agents (ESAs) because "drugs and biologicals are specifically excluded from coverage by the statute section 1861(m)(5) of the Act.The administration of an ESA may be a qualifying service for Home Health services. The beneficiary must be receiving the ESA for a covered indication, as specified in this LCD.For claims submitted to the Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC to process their claims.Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73x. For dates of service on or after April 1, 2010, bill type 77x should be used to report FQHC services.
Article - Billing and Coding: Erythropoiesis Stimulating Agents (ESA) (A56462)
For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73x. For dates of service on or after April 1, 2010, bill type 77x should be used to report FQHC services.Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.
Article - Billing and Coding: Flow Cytometry (A56464)
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 TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy for L34037-Flow Cytometry.General Guidelines for Claims submitted to Part A or Part B MAC:General Guidelines for claims submitted to Part A or Part B MAC:Code 88182 applies to the physician professional and facility technical components of DNA ploidy and S-phase analysis of tumor by flow cytometric technique. Use codes 88184 (first marker) and 88185 (each additional marker, beyond the first) to report the facility technical component of flow cytometric immunophenotyping for the assessment of potential hematolymphoid neoplasia.Flow cytometry interpretation should be reported using CPT codes 88187-88189. Only one code should be reported for all flow cytometry performed on a specimen. Since Medicare does not pay for duplicate testing, do not report flow cytometry on multiple specimens on the same date of service unless the morphology or other clinical factors suggest differing results on the different specimens. There is no CPT code for interpretation of one marker. The provider should not bill for interpretation of a single marker using another CPT code.
Article - Billing and Coding: Flow Cytometry (A56464)
Quantitative cell counts performed by flow cytometry are billed using CPT codes 86355, 86356, 86357, 86359, 86360, 86361 and 86367. These codes should not be reported with the flow cytometry interpretation CPT codes 88187-88189 since there is no interpretative service for these quantitative cell counts. Do not report code 88184 or 88185 together with a code in the 86355-86367 series in conjunction with the same laboratory analysis.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.
Article - Billing and Coding: Flow Cytometry (A56464)
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: Flow Cytometry (A56464)
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.)For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.Claims for Flow Cytometry services are payable under Medicare Part B in the following places of service:For CPT codes 86355, 86356, 86357, 86359, 86360 and 86361: office (11), independent clinic (49), federally qualified health center (50), rural health clinic (72), and independent laboratory (81);For CPT code 88182, (global service) office (11), independent clinic (49), and independent laboratory (81);For CPT codes 88182-TC, 88184 and 88185 (technical services), office (11), independent clinic (49), federally qualified health center (50), rural health clinic (72), and independent laboratory (81);For CPT codes 88182-26, 88187, 88188 and 88189 (professional services) office (11), inpatient hospital (21), outpatient hospital (22), independent clinic (49), and independent laboratory (81).For CPT code 92025 (global/technical) POS 15 (mobile unit) is payable under Medicare Part B.
Article - Billing and Coding: GlycoMark® Testing for Glycemic Control (A56465)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e). Prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manuals, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.12 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet Online Manual Pub. 100-04 (Medicare Claims Processing Manual), Chapter 23 (Section 10) "Reporting ICD Diagnosis and Procedure Codes"Article TextThe information in this article contains billing, coding or other guidelines that complement the local coverage policy forL36906-GlycoMarkTesting for Glycemic Control.To receive a GlycoMark test denial, please submit the following claim information:CPT code 84378 or 84999An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierGeneral Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Article - Billing and Coding: GlycoMark® Testing for Glycemic Control (A56465)
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: GlycoMark® Testing for Glycemic Control (A56465)
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: Laser Ablation of the Prostate (A56467)
CMS National Coverage PolicyN/AArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L34090-Laser Ablation of the Prostate.The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCDL34090-Laser Ablation of the Prostate.(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.The medical record/progress notes must document the duration of BPH, AUA symptoms index, and the urodynamics studies and/or post-void residual volume results if performed.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.
Article - Billing and Coding: Laser Ablation of the Prostate (A56467)
Documentation must be available to Medicare upon request.General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.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.
Article - Billing and Coding: Laser Ablation of the Prostate (A56467)
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.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: Laser Ablation of the Prostate (A56467)
Other Comments:For claims submitted to the Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC to process their claims.Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.Limitation of liability and refund requirements apply when denials are based on medical necessity. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be considered medically necessary by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)
Article - Billing and Coding: Ambulance Services (A56468)
CMS National Coverage Policy
Article - Billing and Coding: Ambulance Services (A56468)
Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claimTitle XVIII of the Social Security Act 1861(s)(7) defines ambulance service where the use of other methods of transportation is contraindicated by the individual's condition, but only to the extent provided in regulationsTitle XVIII of the Social Security Act 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member42 CFR 410.40 addresses the coverage of ambulance servicesCMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 10, 10 Ambulance Service, 10.2.2 Reasonableness of the Ambulance Trip, 10.2.6 Effect of Beneficiary Death on Medicare Payment for Ground Ambulance Transports, 10.3 The Destination, 10.3.1 Institution of Beneficiary's Home, 10.3.2 Institution of Institution, 10.3.3 Separately Payable Ambulance Transport Under Part B Versus Patient Transportation that is Covered Under a Packaged Institutional Service, 10.3.4 Transports to and from Medical Services for Beneficiaries who are not Inpatients, 10.3.7 Partial Payment, 10.3.8 Ambulance Service to Physician's Office, 10.3.9 Transportation Requested by Home Health Agency, 10.3.10 Multiple Patient Ambulance Transport, 10.4 Air Ambulance Services, 10.1.1 Coverage Requirements, 10.4.4 Hospital to Hospital Transport, 10.4.5 Special Coverage Rule, 10.4.6 Special Payment Limitations, 10.4.8 Air Ambulance Transports Canceled Due to Weather or Other Circumstances Beyond the Pilot's Control, 10.4.9 Effect of Beneficiary Death on Program Payment for Air Ambulance Transports, 10.5 Joint Responses, and 20 Coverage Guidelines for Ambulance Service ClaimsCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 15, 10.2 Summary of the Benefit, 10.4 Additional Introductory Guidelines, 20 Payment Rules, 20.1 Payment Under the Ambulance Fee Schedule, 20.1.1
Article - Billing and Coding: Ambulance Services (A56468)
Medicare Claims Processing Manual, Chapter 15, 10.2 Summary of the Benefit, 10.4 Additional Introductory Guidelines, 20 Payment Rules, 20.1 Payment Under the Ambulance Fee Schedule, 20.1.1 General, 20.1.3 Services Provided, 20.1.4 Components of the Ambulance Fee Schedule, 20.3 Air Ambulance, 20.6 Payment for Non-Emergency BLS Trips to/from ESRD Facilities, 30 General Billing Guidelines, 30.1 Multi-Carrier System (MCS) Guidelines, 30.1.1 MCS Coding Requirements for Suppliers, 30.1.2 Coding Instructions for Paper and Electronic Claim Forms, 30.1.3 Coding Instructions for Form CMS-1491, 30.2 Fiscal Intermediary Shared System (FISS) Guidelines, 30.2.1 A/B MAC (A) Bill Processing Guidelines Effective April 1, 2002, as a Result of Fee Schedule Implementation, 30.2.2 SNF Billing, 30.2.3 Indian Health Services/Tribal Billing, and 30.2.4 Non-covered Charges on Institutional Ambulance Claims