evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: MolDX: Abbott RealTime IDH1 and IDH2 testing for Acute Myeloid Leukemia (AML) (A55695)
To report anAbbott RealTime IDH1service, please submit the following claim information:Select the CPT 81120 for claims on or after 7/20/2018.To report anAbbott RealTime IDH2service, please submit the following claim information:Select the CPT code 81121 for claimson or after 1/1/2018.Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Codeidentifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM codeNote:This MolDX coverage determination and coding guideline ONLY applies to the UNMODIFIED, IDH2 test kit by Abbott Molecular for patients with acute myeloid leukemia. If a lab modifies these tests, a MolDX Technical Assessment, outlined in the MolDx section onwww.PalmettoGBA.com/medicare, must be submitted and a determination assessed prior to claims submission.This article reflects the FDA-approved indications on article creation date. MolDX will allow future FDA approved and amended indications for these tests.
Article - Billing and Coding: Frequency of Hemodialysis (A55703)
CMS National Coverage PolicyN/AArticle TextRefer to the WPS GHA Local Coverage Determination (LCD) L37537, Frequency of Hemodialysis, for reasonable and necessary requirements and frequency limitations.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.This article outlines how to line item bill dialysis sessions for End Stage Renal Disease (ESRD) patients. This does not address line item billing for sessions associated with training or other modalities such as peritoneal dialysis. This article does not change any other billing requirements for dialysis claims.Note: This article uses the terms dialysis session and treatment interchangeably.CMS IOM Publication 100-04,Medicare Claims Processing Manual, Chapter 8, requires line item billing for all ESRD claims with dates of service on or after April 1, 2007. Each dialysis session performed should be reported on a separate line.CMS IOM Publication 100-02,Medicare Benefit Policy Manual, Chapter 11 discusses that ESRD facilities furnishing dialysis treatments in-facility or in the beneficiarys home are paid for up to 3 treatments per week. Payment for additional treatments, defined as any treatments in excess 3 treatments per week, may be considered in addition to the ESRD PPS per treatment payment amount paid for up to 3 treatments per week.For monthly claims submitted with Bill Type 72X and Revenue Codes 0821 and 0881, three approaches of billingper lineare available. Based on the Patients Plan of Care (POC), or other available medical documentation, the following scheme should be followed when billing sessions.Note: Dialysis sessions in a patients POC that are not furnished should not be billed.
Article - Billing and Coding: Frequency of Hemodialysis (A55703)
For dialysis sessions that have been furnished 3 times (3X) per week, each line should be 90999 without any modifiers appended. That is, when the hemodialysis-prescription is 3 times (3X) per week and each session is furnished, all of these sessions should be billed as 90999 (no modifier appended) and they will be paid as routine conventional dialysis up to 13/14 per month.For each dialysis sessions furnished in addition to the 3 sessions per week that do not include medical documentation supporting a reasonable and necessary determination for payment, each line for these sessions should be billed as 90999 CG. Examples of when this could occur include short, more frequent treatments furnished for the convenience of the patient or staff, etc. Additional sessions need to be billed as 90999 CG when medical documentation has not been submitted to support the extra sessions as reasonable and necessary. The CG modifier indicates that the facility attests the additional treatment is not reasonable and necessary and should not receive additional payment. Each line billed as 90999 CG will be denied. However, the use of the modifier is used for data analysis. Please refer to CR 9989, Implementation of Modifier CG for Type of Bill 72X, dated May 12, 2017.For each dialysis session furnished in addition to 3 sessions per week that includes medical documentation supporting a reasonable and necessary determination for payment, each line for these services should be billed as 90999 KX. These include medical conditions for acute and occasionally chronic conditions that have supporting documentation that the extra sessions are reasonable and necessary (e.g. through documents from recent hospital care, office visits, dialysis progress notes or MCP visits). These sessions must be reasonable and necessary for additional payment based on clinical conditions. On these claims, the 90999 lines without a modifier will be paid as 3X per week and those lines with 90999 KX will be considered for additional payments. Omission of the KX modifier will result in no additional payment for the line item. For diagnoses not listed in this article but felt to be reasonable and necessary, the KX modifier should be appended as well. A denial will occur on these lines, but the redetermination process (an appeal) will be available to submit supportive documentation for review
Article - Billing and Coding: Frequency of Hemodialysis (A55703)
The expectation is that these three scenarios will be seen on monthly claims, i.e., claims with 90999 lines only, or those with lines of 90999 mixed with 90999 CG or KX modifier appended. Ongoing data analysis may trigger provider specific requests for documentation should unusual patterns occur, i.e., claims with only lines of 90999 KX submitted.Please note medical documentation to justify any of these events will be most important and may be requested.Please seethe L37537 for instructions when clinical conditions outside those listed in the available diagnosis should occur.Please seethe L37537 for Documentation Requirements and Utilization Guidelines.
(Medicare Benefit Policy Manual)
Medicare Benefit Policy Manual  Chapter 11 - End Stage Renal Disease (ESRD)   Table of Contents  (Rev. 2 57, 03- 01-19)  Transmittals for Chapter 11
(Medicare Benefit Policy Manual)
10 - Definitions Relating to ESRD  20 - Renal Dialysis Items and Services  20.1 -  Composite Rate Items and Services  20.2 -  Laboratory Services  20.3 -  Drugs and Biologicals  20.3.1 -  Drug Designation Process  20.4 -  Equipment and Supplies  30 - Home Dialysis  30.1 -  Home Dialysis Items and Services  30.2 -  Home Dialysis Trainin g 40 - Other Services  50 - ESRD Prospective Payment System (PPS) Base Rat e 60 - ESRD PPS Case -Mix Adjustment s 70 - ESRD PPS Transition Period  80 - Bad Debt s 90 - Medicare as a Secondary Payer  10 - Definitions Relating to ESRD  20 - Renal Dialysis Items and Services  20.1 -  Composite Rate Items and Services  20.2 -  Laboratory Services  20.3 -  Drugs and B iologicals  20.3.1 -  Drug Designation Process  20.4 -  Equipment and Supplies  30 - Home Dialysis  30.1 -  Home Dialysis Items and Services  30.2 -  Home Dialysis Trainin g 40 - Other Services  50 - ESRD Prospective Payment System (PPS) Base Rat e 60 - ESRD PPS Case -Mix Adjustment s 70 - ESRD PPS Transition Period  80 - Bad Debt s 90 - Medicare as a Secondary Payer  100 -  Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury (AKI)  100.1 -  Definition of AKI  100.2 -  Payment Rate for AKI Dialysis  100.3 -  Geographic Adjustment Factor  100.4 -  Other Adjustments to the AKI Payment Ra te 100.5 -  Renal Dialysis Services Included in the AKI Payment Rate  100.6 -  Applicability of Specific ESRD PPS Policies to AKI Dialysis  100.6.1 -  Dialysis Modality  100.6.2 -  Uncompleted Dialysis Treatment  100.6.3 -  Home and Self -Dialysis  100.6.4 -  Vaccines and Their Administration  100.6.5  Telehealth  110 -  Reserved  120 -  Reserved  130 -  Reserved  Appendix A -  Composite Rate Tests for Hemodialysis, IPD, CCPD, and Hemofiltration  Appendix B -  Appendix B/Composite Rate Tests for CAPD  Appendix C -  Appendix C/Brief History of ESRD Composite Payment Ra tes for Outpatient Maintenance Dialysis  140 -  Transplantation  140.1 -  Identifying Candidates for Transplantation  140.2 -  Identifying Suitable Live Donors  140.3 -
(Medicare Benefit Policy Manual)
for CAPD  Appendix C -  Appendix C/Brief History of ESRD Composite Payment Ra tes for Outpatient Maintenance Dialysis  140 -  Transplantation  140.1 -  Identifying Candidates for Transplantation  140.2 -  Identifying Suitable Live Donors  140.3 -  Pretransplant Outpatient Services  140.4 -  Pretransplant Inpatient Services  140.5 -  Living Donor Evaluation, Patient Has Entitlement or is in Preentitlemen t Period  140.6 -  Kidney Recipient Admitted for Transplant Evaluation 140.7 -  Kidney Recipient Evaluated for Transplant During Inpatient Stay  140.8 -  Kidney Reci pient Admitted for Transplantation and Evaluation  140.9 -  Posttransplant Services Provided to Live Donor  140.10 -  Coverage After Recipient Has Exhausted Part A  140.11 -  Cadaver Kidneys  140.12 -  Services Involved  140.13 -  Tissue Typing Services for Cadaver Kidney  140.14 -  Cadaver Excision Yielding Two Kidneys  140.15 -  Provider Costs Related to Cadaver Kidney Excisions  140.16 -  Noncovered Transplant Related Items and Services  140.17 -  Other Covered Services  140.18 -  Hospitals that Excise but Do Not Transplant Kidneys
(Medicare Benefit Policy Manual)
10 - Definitions Relating to ESRD  (Rev. 224, Issued: 06- 03-16, Effective: 01- 01-16, Implementation: 09- 06-16)  End Stage Renal Disease (ESRD) occurs from the destruction of normal kidney tissues over a long period of time.  Often there are no symptoms until the kidney has lost more than half its function.  The loss of kidney function in ESRD is usually irreversible and permanent.   Dialysis services furnished to  hospital in -patients are covered under Medicare Part A and paid in accordance with applicable payment rules.   ESRD facilities must be certified by Medicare and are required to comply with the Conditions for Coverage set forth in 42 CFR Part 494.  Survey a nd certification information for ESRD facilities can be found at the following Centers for Medicare and Medicaid Services website: http://www.cms.gov/Medicare/Provider -Enrollment -and-Certification/GuidanceforLawsAndRegulations/Dialysis.html .  ESRD PPS is covered under Medicare Part B.   Medicare Part B covers the services listed below unless otherwise noted.   A.  Dialysis   Dialysis is  the process of removing waste products from the body by diffusion from one fluid compartment to another across a semi -permeable membrane.  Dialysis procedures can include hemodialysis, peritoneal dialysis, hemofiltration and ultrafiltration.  Of these typ es of dialysis procedures, two are commonly used for the treatment of ESRD: hemodialysis and peritoneal dialysis.   1.  Hemodialysis -  Blood passes through an artificial kidney machine and the waste products diffuse across a manmade membrane into a bath sol ution known as dialysate after which the cleansed blood is returned to the patients body.  Hemodialysis is accomplished usually in 3 to 5 hour sessions, 3 times a week.  See 50.A.1 of this chapter for payment information.   2.  Peritoneal -  Waste products  pass from the patients body through the peritoneal membrane into the peritoneal (abdominal) cavity where the bath solution (dialysate) is introduced and removed periodically.  See 50.A.4 of this chapter for payment information.  Peritoneal dialysis is p articularly suited for:    Patients without caregivers to assist in self -dialysis;    Children;
(Medicare Benefit Policy Manual)
Peritoneal dialysis is p articularly suited for:    Patients without caregivers to assist in self -dialysis;    Children;    Patients with no peripheral sites available for fistula or cannula placement;    Patients who have difficulty learning the more complex hemodialysis technique; and    Elderly patients with cardiovascular disease who are unable to tolerate intravascular fluid shifts associated with hemodialysis.   The three types of peritoneal dialysis are listed below:   a. Continuous Ambulatory Peritoneal Dialysis (CAPD)  - In CAPD, the patients peritoneal membrane is used as a dialyzer.  The patient connects a 2 -liter plastic bag of dialysate to a surgically implanted indwelling catheter that allows the dialysate to pour into the beneficiarys peritoneal cavity.  Every 4 to 6 hours the patient drains the fluid out into the same bag and replaces the empty bag with a new bag of fresh dialysate.  This is done several times a day.   b. Continuous Cycling Peritoneal Dialysis (CCPD)  - CCPD is a treatment modality that combines the advantages of the long dwell, continuous steady -state dialysis of CAPD, with the advantages of automation inherent in intermittent peritoneal dialysis.  The major difference between CCPD and CAPD is that the solution exchanges, which are performed manually during the day by the patient on CAPD, are moved to nighttime with CCPD and are performed automatically with a peritoneal dialysis cycler.  Generally, there are three nocturnal exchanges occurring at intervals of 2 1/2 to 3 hours.  Upon awakening, the patie nt disconnects from the cycler and leaves the last 2- liter fill inside the peritoneum to continue the daytime long dwell dialysis.  c. Intermittent Peritoneal Dialysis (IPD)  - Waste products pass from the patients body through the peritoneal membrane into th e peritoneal cavity where the dialysate is introduced and removed periodically by machine.  Peritoneal dialysis generally is required for approximately 30 hours a week, either as three 10 -hour sessions or less frequent, but longer, sessions.  See 50.A.5 of this chapter for payment information.
(Medicare Benefit Policy Manual)
3.  Hemofiltration -  Hemofiltration is an alternative to peritoneal dialysis and hemodialysis.  Hemofiltration (which is also known as diafiltration) removes fluid, electrolytes, and other low molecular weight toxic  substances from the blood by filtration through hollow artificial membranes and may be routinely performed in three weekly sessions.  In contrast to both hemodialysis and peritoneal dialysis treatments, which eliminate dissolved substances via diffusion a cross semi permeable membranes, hemofiltration mimics the filtration process of the normal kidney.  The technique requires an arteriovenous access.  Hemofiltration may be performed either in an ESRD facility or at home.  For payment information see 50 A.2  of this chapter.   4.  Ultrafiltration  Ultrafiltration is the process of removing excess fluid from the blood through a dialysis membrane by exerting pressure.  This is not a substitute for dialysis.  Ultrafiltration is used in cases where excess fluid cannot be removed easily during the regular course of hemodialysis. It is commonly done during the first hour or two of hemodialysis on patients who have refractory edema.  Occasionally, medical complications may occ ur which require that ultrafiltration be performed separately from the dialysis treatment.  See 50.A.3 of this chapter for payment information.  B.  ESRD Facility   An ESRD facility is an entity that provides outpatient maintenance dialysis services, or home dialysis training and support services, or both.  ESRD facilities are classified in Section 1881 of the Act and codified in 42 CFR 413.174 as being either hospital -based or independent facilities.  There is no distinction between the two facility types for the purposes of payment under the ESRD Prospective Payment System (PPS).  1.  Hospital -Based ESRD Facilities
(Medicare Benefit Policy Manual)
1.  Hospital -Based ESRD Facilities   As defined in 42 CFR 413.65(a) hospital -based or independent ESRD facilities are not considered part of the hospital and do not qualify as provider -based departments of a hospital.  Hospital -based ESRD facilities may be located on a hospital campus and may share certain overhead costs and administrative functions with the hospital.  However, hospital -based ESRD facilities have separate provider numbers under which they bill Medicare and are subject to unique Conditions for Coverage that differ from hospital Conditions of Participation.  Information regarding the survey and certification of ESRD facilities may be found at the following link: http://www.cms.gov/Medicare/Provider -Enrollment -and-Certification/GuidanceforLawsAndRegulations/Dialysis.html .  CMS determines that an ESRD facility is hospital- based if:    The ESRD facility and hospital are subject to the bylaws and operating decisions of a common governing board.  This governing board, which has final administrative responsibility, approves all personnel actions, appoints medical staff, and carries out simi lar management functions;    The ESRD facilitys director or administrator is under the supervision of the hospitals chief executive officer and reports through that officer to the governing board;    The ESRD facilitys personnel policies and practices conf orm to those of the hospital;    The administrative functions of the ESRD facility (for example, records, billing, laundry, housekeeping, and purchasing) are integrated with those of the hospital; and    The ESRD facility and hospital are financially integrat ed, as evidenced by the cost report, which must reflect allocation of hospital overhead to the facility through the required step- down methodology.   CMS does not consider the existence of an agreement between an ESRD facility and a hospital for the referra l of patients, a shared service arrangement between a facility and a hospital, or the physical location of a dialysis unit on the premises of a hospital, to mean that an ESRD facility is hospital -based.   2.  Independent ESRD Facility  Any facility that do es not meet the criteria of a hospital- based ESRD facility.   There are several terms used to describe independent dialysis facilities which include the following:
(Medicare Benefit Policy Manual)
2.  Independent ESRD Facility  Any facility that do es not meet the criteria of a hospital- based ESRD facility.   There are several terms used to describe independent dialysis facilities which include the following:   a.  Renal Dialysis Center - A hospital -based unit, which is approved to furnish the full spectrum of diagnostic, therapeutic, and rehabilitative services required for the care of ESRD dialysis patients (including inpatient dialysis furnished directly or under a rrangement).  A hospital need not provide renal transplantation to qualify as a renal dialysis center.  Under the ESRD PPS CMS refers to renal dialysis centers as ESRD facilities.   b.  R enal Dialysis Facility - An independent unit that is approved to furni sh outpatient maintenance dialysis services directly to ESRD patients.  Under the ESRD PPS CMS refers to renal dialysis facilities as ESRD facilities.   c.  Self -Dialysis Unit -  A dialysis unit that furnishes self -dialysis services and is part of a Medicare certified ESRD facility.   d.  Home Dialysis Training and Support ESRD Facility  A Medicare certified ESRD facility that furnishes home dialysis training and support services.  See 42 CFR 494.100 for more information regarding Medicare certification requirements.  e.  Special Purpose Renal Dialysis Facility   An ESRD facility that is approved to furnish dialysis at special locations, on a short -term basis, to a group of dialysis patients otherwise unable to obtain treatment in their geographical area.   The special locations must be either special rehabilitative (including vacation) locations serving ESRD patients temporarily residing there, or locations in need of ESRD facilities under emergency circumstances.   C.  Renal Dialysis Services   Renal dialys is services are all items and services used to furnish outpatient maintenance dialysis to individuals for the treatment of ESRD in the ESRD facility or in a patients home.   Renal dialysis services include but are not limited to:   All items and services in cluded under the composite rate as of December 31, 2010 (see 20.2.E, 20.3.F, and 70.B of this chapter for more information);    Erythropoiesis stimulating agents (ESAs) and their oral or other forms of administration (see 20.3.A of this chapter for more information);
(Medicare Benefit Policy Manual)
 Erythropoiesis stimulating agents (ESAs) and their oral or other forms of administration (see 20.3.A of this chapter for more information);    Injectable drugs and biologicals and their oral or other forms of administration (see 20.3.B, 20.3.C and 20.3.D of this chapter for more information);    Oral or other forms of non -injectable drugs and biologicals (see 20.3 of this chapter  for more information);    Diagnostic laboratory tests (see 20.2 of this chapter for more information);    Home and self -dialysis training (see 30.2 of this chapter for more information); and    All supplies, equipment, and support services necessary for the effective performance of a patients dialysis furnished in the ESRD facility or in a patients home (see 20.4 of this chapter for more information).  See 20 of this chapter for more information regarding renal dialysis items and services.  Services Provi ded Under an Arrangement   A Medicare- certified ESRD facility may enter into written arrangements with a second ESRD facility to provide certain covered outpatient dialysis items or services to patients.  When services are provided under an arrangement, the first ESRD facility retains professional and financial responsibility for those services and also for obtaining reimbursement for them.  The first ESRD facility may bill the patient for the applicable coinsurance and deductible amounts.  The second ESRD f acility is permitted to seek payment only from the first ESRD facility, and may not bill the patient or Medicare.   D.  Types of Dialysis   1.  Types of Outpatient Maintenance Dialysis  - Outpatient maintenance dialysis is furnished on an outpatient basis by a Medicare certified ESRD facility and is paid under the ESRD PPS.  Outpatient maintenance dialysis is not acute dialysis.  Medicare defines acute dialysis services as dialysis that is not covered or paid under the ESRD benefit in 42 CFR 413.174.  For bill ing and payment instructions of acute dialysis services furnished in the hospital see Pub. 100- 04, chapter 4, 200.2 and Pub. 100- 02, chapter 1, section 10.  a. In-facility Dialysis  - Dialysis furnished on an outpatient basis in a Medicare certified ESRD f acility.