evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Wireless Capsule Endoscopy (A56704)
CMS National Coverage PolicyN/AArticle TextThis First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33774 Wireless Capsule Endoscopy provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.Refer to the LCD for reasonable and necessary requirements and limitations.The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.Coding GuidelinesNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.The date of service should be entered as the date of ingestion of the capsule and the date hook-up of the data recorder device was performed regardless of the number of days the recorder is worn.Wireless capsule endoscopy of the small bowel should be coded with the CPT code 91110.Wireless capsule endoscopy of the esophagus through the ileum should be coded with CPT code 91110. (If the ileum is not visualized add Modifier 52)Wireless capsule endoscopy of the esophagus should be coded with CPT code 91111. A dual diagnosis is required when billing this service.CPT codes 91110 and 91111 consist of a professional and technical component.The technical portion (TC modifier) of the service includes:provision of the capsule;hook-up of the recording equipment;downloading of the digital data with processing and creation of video images.The professional component (26 modifier) of the service includes review of the images and interpretation with report.Documentation Requirements
Article - Billing and Coding: Wireless Capsule Endoscopy (A56704)
provision of the capsule;hook-up of the recording equipment;downloading of the digital data with processing and creation of video images.The professional component (26 modifier) of the service includes review of the images and interpretation with report.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.The record must include documentation that attempts were made to identify the source of the bleeding, but the site of bleeding was not previously identified by colonoscopy, or endoscopy.The medical record must clearly reflect why the patient was not a candidate for conventional endoscopy. There must be documentation of specific co-morbidities and complicating medical conditions that lead the performing provider of the conventional endoscopy to believe that the risk/benefit ratio of a conventional endoscopy was not maintained. The medical record must also support how the capsule endoscopy would contribute to the patients care.Utilization GuidelinesIn accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.Compliance with the provisions in LCD L33774 Wireless Capsule Endoscopy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
Article - Billing and Coding: Respiratory Therapy (Respiratory Care) (A56717)
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 claimCMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 12, 30.1 Rules for Payment of CORF Services and 40.5 Respiratory Therapy ServicesFederal Register: December 31, 2002 (Volume 67, Number 251) p 79999-80000 Final rule revisions to payment policies specific to G0237-G0239Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forRespiratory Therapy (Respiratory Care) L34430.Therapeutic procedures whose principle aim is to treat a respiratory impairment should be identified using the G0237-G0239 series of HCPCS codes. CPTcodes 97000 to 97799 are not to be billed by professionals involved in treating respiratory conditions, unless these services are delivered by physical or occupational therapists and meet the other requirements for physical and occupational therapy services.
Article - Billing and Coding: Intravenous Immunoglobulin (IVIG) (A56718)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) states that no payment shall be made to any provider for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, 1842(b)(18)(C) and (p)(1), describes payment for services that may be furnished by a practitioner. Requests for payment, or bills submitted shall include the appropriate diagnosis code(s).CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, 80.6 Intravenous Immune Globulin.CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code Requirements.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Intravenous Immunoglobulin (IVIG) L34580.Note:With respect to HCPCS codes J2792 Injection, Rho D immune globulin (human), solvent detergent (WINRho) and J2791 Injection immune globulin (human), (Rhophylac), thisarticle only addresses their use intravenously.
Article - Billing and Coding: Intraoperative Neurophysiological Testing (A56722)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35003, Intraoperative Neurophysiological Testing. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.CPT Code 95940 is reported per 15 minutes of service. CPT Code 95940 requires reporting only the portion of time the monitoring professional was physically present in the operating room providing one-on-one patient monitoring, and no other cases may be monitored at the same time. Time spent in the operating room is cumulative. To determine units of service of 95940, use the total minutes monitoring in the operating room one-on-one. Monitoring may begin prior to incision (e.g., when positioning on the table is a time of risk). Report continuous intraoperative neurophysiologic monitoring in the operating room (95940) in addition to the services related to monitoring from outside the operating room (G0453), and interpret the baseline studies, and to remove electrodes at the end of the procedure.When services support the covered indications in the related LCD, reimbursement may be made for the following places of service (POS):Off Campus-Outpatient Hospital (POS 19)Inpatient Hospital (POS 21)On Campus-Outpatient Hospital (POS 22)Ambulatory Surgical Center (POS 24)
Article - Billing and Coding: Wireless Gastrointestinal Motility Monitoring Systems (A56724)
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 23, 10.1 general rules for diagnosis codes.CMS Internet-Only Manual, Publication 100-08,Medicare Program Integrity Manual,Chapter 3, 3.4.1.3 diagnosis code requirements.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Wireless Gastrointestinal Motility Monitoring Systems L33455.
Article - Billing and Coding: Intensity Modulated Radiation Therapy (IMRT) (A56725)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833 states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L36711, Intensity Modulated Radiation Therapy (IMRT). Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Article - Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) (A56726)
CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1862(a) (7) excludes routine physical examination unless otherwise covered by statute.Code of Federal Regulations:42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).CMS Publications:CMS Publication 100-04,Medicare Claims Manual, Chapter 12:40.1.A. Global surgery periodArticle TextThis article contains coding and other guidelines that complement the local coverage determination (LCD) for Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography).Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
Article - Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) (A56726)
Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed.Documentation Requirements:Fundus photographyThe patient's medical record must contain documentation that fully supports the medical necessity for fundus photography as it is covered by Medicare. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.A copy of the fundus photographs must be retained in the patient's medical records. An interpretation and report of the test must also be included, in addition to the photographs themselves.The medical record should document whether the pupil was dilated, and which drug was used.Documentation supporting the medical necessity should be legible, maintained in the patient's record, and must be available to the carrier upon request.Extended ophthalmoscopyThe patient's medical record must contain documentation that fully supports the medical necessity for extended ophthalmoscopy for each eye, as it is covered by Medicare. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Retinal drawings meeting the specifications indicated in the attached Appendix A of this article must be maintained in the patient's record.
Article - Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) (A56726)
Retinal drawings meeting the specifications indicated in the attached Appendix A of this article must be maintained in the patient's record.There must be a separate detailed sketch, minimal size of 3-4 inches.All items noted must be identified and labeled.Drawings in four (4) - six (6) standard colors are preferred. However, non-colored drawings are also acceptable, if clearly labeled.Optic nerve abnormalities should be separately drawn.An extensive scaled drawing must accurately represent normal, abnormal and common findings such as: lattice degeneration, hypertensive vascular changes, proliferative diabetic retinopathy, as well as retinal detachments, holes, tears or tumors.Documentation in the patients medical record for a diagnosis of glaucoma (ICD-10-CM codes H40.001-H40.152 Glaucoma ) must include all of the following:A separate detailed drawing of the optic nerve along with an interpretation that affects the plan of treatment,Documentation of cupping, disc rim, pallor, and slope,Documentation of any surrounding pathology around the optic nerve.Documentation specific to the method of examination (e.g., lens, scleral depression, instrument used) should be maintained in the medical record.The medical record should document whether the pupil was dilated, and which drug was used.All findings and a plan of action should be documented in notes.Although routine ophthalmoscopy and biomicroscopy are part of an ophthalmologic examination and are not separately payable, these should still be documented in the patient's medical record.Documentation supporting the medical necessity should be legible, maintained in the patient's record, and must be available to the carrier upon request.Appendices:See attachment in LCD L33567Utilization Guidelines:Patients actively being treated with intravitreal injections of medication for exudative AMD (ICD-10-CM code ranges H35.3210-H35.3213, H35.3220-H35.3223, H35.3230- H35.3233) may require up to 12 extended ophthalmoscopies per eye, per year.
Article - Billing and Coding: Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography) (A56726)
Conditions coded with other ICD-10-CM codes in the ranges A18.53; A18.54; E08.311-E08.359 Diabetes mellitus due to underlying condition with ophthalmic complications E09.311-E09.359 Drug or chemical induced diabetes mellitus with ophthalmic complications;E10.311-E10.359 Type 1 diabetes mellitus with ophthalmic complications; E11.311-E11.359 Type 2 diabetes mellitus with ophthalmic complications; E13.311-E13.359 Other specified diabetes mellitus with ophthalmic complications; H16.241-H16.249 Ophthalmia nodosa; H20.00-H21.1X1; G45.3 Diseases of the eye and adnexa may require up to six (6) extended ophthalmoscopic examinations per eye, per year.For ICD-10-CM codes C69.20-C69.42 Malignant neoplasm of eye and adnexa; C79.89-C79.9 Secondary malignant neoplasm of other and unspecified sites; D31.20-D31.32 Benign neoplasm of eye and adnexa up to four (4) extended ophthalmoscopic examinations may be required per eye, per year.Other conditions usually require no more than two (2) extended ophthalmoscopic examinations per eye, per year.Extended ophthalmoscopy is a physician service (examination of the eye) commonly occurring during the global post-operative period of ophthalmic surgery. As a physician service, it is included in the aftercare of the patient and is not separately billable.Fundus photography is usually medically necessary no more than two times per year.Fundus photography of a normal retina will be considered not medically necessary.Services exceeding these parameters will be considered not medically necessary.
Article - Billing and Coding: Wireless Capsule Endoscopy (A56727)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claimArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forWireless Capsule Endoscopy L36427.
Article - Billing and Coding: Magnetic Resonance Imaging of the Orbit, Face, and/or Neck (A56729)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(a)(2)(E) related to outpatient hospital radiology services.Title 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 Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, 40 Magnetic Resonance Imaging (MRI) ProceduresArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Magnetic Resonance Imaging of the Orbit, Face, and/or Neck L34425.
Article - Billing and Coding: Respiratory Therapy and Oximetry Services (A56730)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claimArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forRespiratory Therapy and Oximetry Services L33446.CPTcode 31720 is payable only if it is personally performed by the physician (or qualified Non-Physician Practitioner (NPP)).Note:CPTcodes 94760, 94761 and 94762 are bundled by the Correct Coding Initiative (CCI) with critical care services. Therefore, CPTcodes 94760, 94761 and 94762 cannot be paid separately when billed with critical care CPTcodes (99291 and 99292).CPTcode94762is considered medically necessary when performed for any of the following reasons:The patient has a condition for which intermittent arterial blood gas sampling is likely to miss important variations.The patient has a condition resulting in hypoxemia and there is a need to assess supplemental oxygen requirements and/or a therapeutic regimen.Payment can be allowed for CPTcode 31720 only if supporting documentation demonstrates the service was personally performed by the physician or NPP when this service falls within his scope of practice.Payment for CPTcode 31720 may be allowed, on an individual consideration basis, for respiratory treatments for 3 consecutive days or 3 identical services within a 30-day time frame. Additional payment may be allowed for respiratory therapy treatments exceeding these parameters only if medical necessity can be established by medical documentation. In the case of consecutive days of care, the medical record should indicate why the patient was not transferred to a higher level of care.
Article - Billing and Coding: Nerve Blocks and Electrostimulation for Peripheral Neuropathy (A56731)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) states that no payment shall be made to any provider for any claim which lacks the necessary information to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Nerve Blocks and Electrostimulation for Peripheral Neuropathy L37642.Use of Physical Medicine and Rehabilitation CPT/HCPCS Codes (97032, 97139, G0282, G0283) for these treatments is inappropriate.
Article - Billing and Coding: Mohs Micrographic Surgery (MMS) (A56732)
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 Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, 60 Payment for Pathology ServicesCMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Change Request 3458, Transmittal 434, Dated January 14, 2005, Addition of CLIA Edits to Certain Health Care Procedure Coding System (HCPCS) Codes for Mohs Surgery.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Mohs Micrographic Surgery (MMS) L33436.To allow separate payment for a biopsy and pathology on the same day as MMS, the 59 modifier is appropriate. Modifier 59 is also appropriate when a separate skin lesion, other than the lesion for which Mohs surgery is performed, is biopsied on the same day that the Mohs surgery is performed.If the 59 modifier is used with a skin biopsy/pathology code on the same day the MMS was performed, physician documentation should clearly indicate:That the biopsy was performed on a lesion other than the lesion on which the MMS was performed;That if the biopsy is of the same lesion on which the MMS was performed, a biopsy of that lesion had not been done within the previous 60 days; orIf a recent (within 60 days) biopsy of the same lesion that MMS was performed or had been done, the results of that biopsy were unobtainable by the Mohs surgeon using reasonable effort.At this time, all laboratory tests covered under CLIA are edited at the CLIA certificate level. The previously mentioned Mohs micrographic surgery HCPCS codes would require either a CLIA certificate of registration (certificate type code 9), a CLIA certificate of compliance (certificate type code 1), or a CLIA certificate of accreditation (certificate type code 3). A facility without a valid current CLIA certificate, with a current CLIA certificate of waiver (certificate type code 2), or with a current CLIA certificate for provider-performed microscopy procedures (certificate type code 4) must not be permitted to bill for these tests.