evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Cosmetic and Reconstructive Surgery (A59299)
CMS National Coverage PolicyCMS PUB. 100-02 Medicare Benefit Policy ManualChapter 1  Inpatient Hospital Services Covered under Part A120 - Services Related to and Required as a Result of Services Which Are Not Covered Under MedicareChapter 16-General Exclusions from Coverage:120 Cosmetic Surgery180 - Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare.CMS PUB. 100-3 Medicare National Coverage Determinations ManualChapter 1, Part 2140.2 - Breast Reconstruction Following Mastectomy140.4 - Plastic Surgery to Correct "Moon Face"Chapter 1, Part 4250.4  Treatment of Actinic Keratosis250.5 - Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS)CMS PUB 100-04 Medicare Claims Processing ManualChapter 32 - Billing Requirements for Special Services260 - Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (LDS)National Coverage Determination 250.5 Dermal Injections for the Treatment of Facial Lipodystrophy SyndromeTitle XVIII of the Social Security Act (SSA): 1862 (a)(1)(A) Medically Reasonable & Necessary tests used in the diagnosis and management of illness or injury or to improve the function of a malformed body part.Title XVIII of the Social Security Act (SSA): 1862 (a)(1)(D) Investigational or Experimental.Title XVIII of the Social Security Act, Section 1862 (a)(10). This section excludes Cosmetic Surgery.Change Request 10901, Transmittal 829, Local Coverage Determinations (LCDs) October 3, 2018Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD DL39506 Cosmetic and Reconstructive Surgery.This article will support reconstructive surgery performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease. It is generally performed to improve function but may also be done to approximate a normal appearance.This article will not support cosmetic surgery performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.Coding Guidelines
Article - Billing and Coding: Cosmetic and Reconstructive Surgery (A59299)
Claimsdo nothave to be submitted for cosmetic procedures. However, if a denial of Medicare coverage is necessary, a GY modifier (items or services statutorily excluded or does not meet the definition of any Medicare benefit) can be used on a cosmetic procedure to receive a non-covered denial. Use diagnosis code:Z41.1 Encounter for cosmetic surgery.All submitted non-covered or no payment claims using condition code 21 will be processed to completion, and all services on those claims, since they are submitted as non-covered, will be denied. The default liability for payment of these claims is assigned to the beneficiary, who may then submit the denial from Medicare, as the primary payer, to subsequent payer(s) for consideration. Since a denial is a Medicare determination of payment, all services submitted on no payment claims may be appealed later if unusual circumstances so warrant. That is, all payment determinations are subject to appeal, even denials of services submitted as non-covered.Documentation RequirementsFor all procedures:All documentation must be maintained in the patients 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 medical record documentation must support the medical necessity of the services as stated in this policy.Documentation Requirements for Specific ServicesReconstructive Surgery: Removal of Breast ImplantsThe medical record must describe the condition which supports the removal of a breast implant(s) as medically reasonable and necessary.Breast ReductionThe beneficiarys medical record must contain the following information:Height and weight.Body Surface Area (BSA)Clinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to breast reduction and the responses to these therapies.The operative report with documentation of the weight of tissue removed from each breast, obtained in the operating room.The pathology report with the weight of the tissue removed from each breast.Documentation of back or neck or shoulder pain from macromastia that was unrelieved by 6 months of conservative analgesia, supportive measures (garment, etc.), and physical therapy.Mastectomy for gynecomastia
Article - Billing and Coding: Cosmetic and Reconstructive Surgery (A59299)
Mastectomy for gynecomastiaGlandular breast tissue confirming true gynecomastia is documented on physical exam and/or mammographyDocumentation that the gynecomastia persists, despite correction of any underlying causesDocumentation supporting that the gynecomastia is classified as Grade III or IV per the American Society of Plastic Surgeons classificationDocumentation that hormonal causes, including hyperthyroidism, estrogen excess, hyperprolactinemia and hypogonadism have been excluded by appropriate laboratory testing (e.g. with levels of thyroid stimulating hormone [TSH], estradiol, prolactin, testosterone and or luteinizing hormone [LH])Documentation supporting that gynecomastia persists after 6 months of unsuccessful medical treatment, the use of potential gynecomastia-inducing drugs and substances has been ruled out and gynecomastia persist for at least one year. (ASPS)Tattooingor to correct color defects of the skin must indicate the prior condition i.e. post-mastectomy, trauma necessitating the reconstruction in the progress notes.Punch graft hair transplants:pre-operative photographs must be made available upon Contractor request.RhinoplastyThe medical record must include a description of the condition requiring the rhinoplasty.When performed for chronic obstruction the medical record must indicate what is causing the obstruction.Documentation of anterior rhinoscopy, endoscopy, Cottle maneuver/modified Cottle maneuver and/or CT report is recommended to help support medical necessity if requested.The medical record should include a description of any conservative treatment that has been utilized to treat obstruction and the length of time that the conservative treatment has been trialed.Surgical/pathology report if post operativeSeptoplasty
Article - Billing and Coding: Cosmetic and Reconstructive Surgery (A59299)
SeptoplastyThe medical record must contain the medical and antibiotic therapy that was utilized and the length of time treatment was trialed for recurrent sinusitis secondary to deviated septum.When the procedure is being done for asymptomatic septal deformity to gain access to other transnasal areas during another medically necessary procedure the medical record must indicate what surgical procedure is being performed.The medical record must contain the medical management utilized and the length of time that the treatment was trialed for obstructed nasal breathing due to septal deformity or deviation that is interfering with the effective use of Continuous Positive Airway Pressure (CPAP) for the treatment of an obstructive sleep disorder.Abdominal Lipectomy/PanniculectomyThe beneficiarys medical record must contain the following information:the evaluation and management supporting the medical necessity and/or complications with decision to perform surgery,surgical operative record,description of the pannus and the underlying skin,documentation that the panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing),description of conservative treatment undertaken and its results,evidence that the individual has maintained a stable weight for at least 6 months.Rhytidectomydocumentation should include the evaluation and management note in which the decision to perform surgery was made, surgical note and any notes documenting the functional impairment.
Draft Article - Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin (DA59311)
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 3, 90.3.1 Allogeneic for Stem Cell TransplantationCMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2,110.23 Stem Cell TransplantationCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 3, 90.3.1 Allogeneic for Stem Cell TransplantationCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing, Chapter 32, 90 Stem Cell Transplantation, 90.1 General and 90.2 HCPCS and Diagnosis Coding  ICD-9-CM ApplicableArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forAllogeneic Hematopoietic Cell Transplantationfor Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell OriginDL39513.The CMS National Coverage Determination (NCD 110.23) for Stem Cell Transplantation describes nationally covered indications for stem cell transplant, the details of which will not be repeated within this article. This article describes additional locally covered indications for stem cell transplant.A pretransplant assessment, even accounting for institutional variations, should establish the extent of disease and provide information about the individual's comorbidities that are likely to impact outcomes.The pretransplant evaluation should include a significant portion of the following elements or documentation of the completion of the institutions pre-established pre-transplant protocol, demonstrating the elements of that protocol.History and physical examination which includes:Detailed historyPhysical examinationAll relevant laboratory studiesA chest radiograph, an electrocardiogram, and a study of cardiac functionPulmonary function testDisease-specific restaging studiesFurther studies may be required depending on signs and symptoms.It is expected that documentation of the pretransplant evaluation be included in the medical record that supports the transplants billing and be available on request.PRETRANSPLANT COUNSELING
Draft Article - Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin (DA59311)
Further studies may be required depending on signs and symptoms.It is expected that documentation of the pretransplant evaluation be included in the medical record that supports the transplants billing and be available on request.PRETRANSPLANT COUNSELINGThis A/B MAC suggests the following:Fertility preservation discussion, if relevantEnd-of-life and/or advance care planningAllogeneic Hematopoietic Cell Transplantation represents intense therapy for severe disease. Therefore, Palmetto GBA expects documentation relating the precise benefits and risks to a beneficiary in such a way that it is clear the discussion was tailored to the individual patient.Informed consent guidelines should show that patients have an accurate understanding of the risks of HCT. (Deeg & Sandmaier,Determining eligibility for allogeneic hematopoietic transplantation.UpToDate.2022).
Article - Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin and Non-Hodgkin Lymphoma with B-cell or T-cell Origin (A59311)
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 3, 90.3.1 Allogeneic for Stem Cell TransplantationCMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2,110.23 Stem Cell TransplantationCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 3, 90.3.1 Allogeneic for Stem Cell TransplantationCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing, Chapter 32, 90 Stem Cell Transplantation, 90.1 General and 90.2 HCPCS and Diagnosis Coding  ICD-9-CM ApplicableArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forAllogeneic Hematopoietic Cell Transplantationfor Primary Refractory or Relapsed Hodgkin and Non-Hodgkin Lymphoma with B-cell or T-cell OriginDL39513.The CMS National Coverage Determination (NCD 110.23) for Stem Cell Transplantation describes nationally covered indications for stem cell transplant, the details of which will not be repeated within this article. This article describes additional locally covered indications for stem cell transplant.A pretransplant assessment, even accounting for institutional variations, should establish the extent of disease and provide information about the individual's comorbidities that are likely to impact outcomes.The pretransplant evaluation should include a significant portion of the following elements or documentation of the completion of the institutions pre-established pre-transplant protocol, demonstrating the elements of that protocol.History and physical examination which includes:Detailed historyPhysical examinationAll relevant laboratory studiesA chest radiograph, an electrocardiogram, and a study of cardiac functionPulmonary function testDisease-specific restaging studiesFurther studies may be required depending on signs and symptoms.It is expected that documentation of the pretransplant evaluation be included in the medical record that supports the transplants billing and be available on request.PRETRANSPLANT COUNSELINGThis A/B MAC suggests the following:
Article - Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin and Non-Hodgkin Lymphoma with B-cell or T-cell Origin (A59311)
It is expected that documentation of the pretransplant evaluation be included in the medical record that supports the transplants billing and be available on request.PRETRANSPLANT COUNSELINGThis A/B MAC suggests the following:Fertility preservation discussion, if relevantEnd-of-life and/or advance care planningAllogeneic Hematopoietic Cell Transplantation represents intense therapy for severe disease. Therefore, Palmetto GBA expects documentation relating the precise benefits and risks to a beneficiary in such a way that it is clear the discussion was tailored to the individual patient.Informed consent guidelines should show that patients have an accurate understanding of the risks of HCT. (Deeg & Sandmaier,Determining eligibility for allogeneic hematopoietic transplantation.UpToDate.2022).
Draft Article - Billing and Coding: Cataract Surgery in Adults (DA57195)
CMS National Coverage PolicyTitle XVIII of the Social Security Act 1862(a)(7) excludes routine physical examinations.Title 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 member.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare Payment for any claim which lacks the necessary information to process the claim.Code of Federal Regulations 42 CFR CH.IV [411.15(b)(2)&(3)and(o)(1)&(2)] Services excluded from coverageCode of Federal Regulations 42 CFR CH. IV [416.65] Covered surgical proceduresCMS Manual System, Pub 100-03,Medicare National Coverage Determinations Manual,Chapter 1, Part 1, 80.10, Phaco-Emulsification Procedure-Cataract ExtractionCMS Manual System, Pub 100-04,Medicare Claims Processing ManualChapter 12, 40.6, 40.7, Claims for Multiple Surgeries, Claims for Bilateral SurgeriesArticle TextDocumentation Requirements:The following documentation must be present in the medical chart:For Cataract Surgery Patients:
Draft Article - Billing and Coding: Cataract Surgery in Adults (DA57195)
The patient's chief complaint which conveys the symptoms, such as blurred vision, reduced contrast sensitivity or complaints of glare which are associated with impaired functionality.A unique statement indicating the specific symptomatic (i.e., causing the patient to seek medical attention) impairment of visual function resulting in the patient's inability to function satisfactorily while performing Activities of Daily Life. Such activities would typically include, but are not limited to, reading, viewing television, driving, or meeting vocational or recreational expectations. The patients own words should be included in the statement where possible. If desired, completion of a VF-14 or VF-8R visual activities questionnaire (one for each eye) may be used.A best-corrected Snellen visual acuity at distance (and near if the primary visual impairment is at near) as determined by a careful refraction under standard testing conditions as appropriate must be recorded to establish the inability to correct the patient's visual function with a tolerable change to glasses or contact lenses. Neither uncorrected visual acuity nor corrected acuity with the patients current prescription will satisfy this requirement. The refraction may be performed by the surgeon or by suitably trained staff in the surgeons practice as permitted by law.A degree of lens opacity that correlates with the impairment of best-corrected visual acuity when cataract is the primary cause of visual compromise. A statement supported by documented symptoms and physical findings in the medical record indicating that the patient's impairment of visual function is not believed to be correctable with a tolerable change in glasses or contact lenses.When one or more concomitant ocular diseases are present that potentially affect visual function (e.g., macular degeneration or diabetic retinopathy), the statement should indicate that cataract is believed to be significantly contributing to the patients visual impairment or a statement indicating the medical condition or circumstance and the specific reason for surgical intervention (e.g., "Cataract surgery is being performed to establish clear media for the treatment [or monitoring] of diabetic retinopathy).
Draft Article - Billing and Coding: Cataract Surgery in Adults (DA57195)
A statement that the patient desires surgical correction, and that the risks, benefits, and alternatives have been explained. When the surgery is not being performed to improve vision, there should be a statement that the patient understands that the surgery is being performed to address the specified medical condition or circumstance. For example, cataract is impairing treatment and monitoring of diabetic retinopathy due to poor visualization of the retina. If vision is not expected to improve, the statement should include the patient's understanding of that fact.An appropriate preoperative ophthalmologic evaluation, which includes a comprehensive ophthalmologic exam (or its equivalent components occurring over a series of visits). Certain examination components may be appropriately excluded based on the specific condition and/or urgency of surgical intervention.Results and interpretation of specialized ophthalmic studies done for medically necessary reasons unique to the patient's situation.Results and interpretation of specialized ophthalmic studies that arenotroutinely expected to be routinely performed for routine cataract surgery with clear statements/explanation of the reasons they are needed to establish or exclude medical necessity.
Draft Article - Billing and Coding: Cataract Surgery in Adults (DA57195)
For Complex Cataract Surgery (CPT code 66982):The billing of CPT code 66982 isnotrelated to the surgeon's perception of the surgical difficulty. The use of this code is governed by the need to employ devices or techniques not generally required/utilized in routine cataract surgery. Every complex cataract surgery must have clear justification to meet the requirements of its CPT descriptor. Therefore, it is strongly recommended to include an initial supporting statement in the operative note. For example:Indication for Complex Cataract Surgery: The patient required suturing a posterior chamber intraocular lens because of insufficient capsular support.Indication for Complex Cataract Surgery: Iris hooks were required to address a severely miotic pupil.Indication for Complex Cataract Surgery: Trypan blue dye was needed to adequately visualize the lens capsule in the presence of a mature cataract.
Draft Article - Billing and Coding: Cataract Surgery in Adults (DA57195)
In general, all documentation supporting medical necessity must be legible, maintained in the patient's medical record, meet all Medicare signature requirements, and must be made available to the A/B MAC or other CMS review entity upon request.Utilization RequirementsMedicare benefits include a conventional intraocular lens (IOL) following cataract surgery, facility supplies and physician services to implant the conventional IOL and one pair of glasses or contact lenses as a prosthetic device post-operative.Ancillary tests that arenotroutinely indicated in the preoperative workup for cataract surgery (see Specialized Ophthalmic testing) will not be considered a covered benefit if performed unless medical necessity is clearly documented in the patient's record.If an optometrist or an ophthalmologist who is not the surgeon performs biometry for intraocular lens power calculation, he/she should do so in coordination with the operating surgeon so that only one procedure is necessary. If the operating surgeon repeats biometry due to inadequacy of the first study, the original eye care physician/provider should anticipate not being reimbursed for the study.When billing ICD-10 codes H26.231, H26.232, H26.233, H26.221, H26.222, H26.223, H26.211, H26.212, H26.213, E08.36, E09.36, E10.36, E11.36, E13.36, H28 note that coding guidelines require that the ICD-10 code for the underlying condition must appear and be coded first on the claim. For ICD-10 codes H26.31, H26.32, H26.33, H26.8, coding guidelines require that the causative agent be identified on the claim.
Draft Article - Billing and Coding: Cataract Surgery in Adults (DA57196)
CMS National Coverage PolicyTitle XVIII of the Social Security Act 1862(a)(7) excludes routine physical examinations.Title 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 member.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare Payment for any claim which lacks the necessary information to process the claim.Code of Federal Regulations 42 CFR CH.IV [411.15(b)(2)&(3)and(o)(1)&(2)] Services excluded from coverageCode of Federal Regulations 42 CFR CH. IV [416.65] Covered surgical proceduresCMS Manual System, Pub 100-03,Medicare National Coverage Determinations Manual,Chapter 1, Part 1, 80.10, Phaco-Emulsification Procedure-Cataract ExtractionCMS Manual System, Pub 100-04,Medicare Claims Processing ManualChapter 12, 40.6, 40.7, Claims for Multiple Surgeries, Claims for Bilateral SurgeriesArticle TextDocumentation Requirements:The following documentation must be present in the medical chart:For Cataract Surgery Patients: