evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
RARC N386 -  This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.  MSN 15.20  The following policy was used when we made this decision:  NCD 210.14.  Spanish Version  Las siguientes polticas fueron utilizadas cuando se tom esta decisin: NCD 210.14.   Contractors processing institutional claims shall use the following MSN message in addition to MSN 15.20:   MSN 15.19 -  Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1- 800-MEDICAR E (1-800-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto. Un LCD se us para su reclamacin. Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si piensa que puede cambiar nuestra decisin. Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).  NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.   Group Code: CO assigning financial liability to the provider (if a claim is received with a GZ modifier indicating no signed ABN is on file).    NOTE:  For modifier GZ, use CARC 50 and MSN 8.81.         220.5  Common Working File (CWF) Edits  (Rev. 11388, Issued:04- 29, 22; (Effective:02 -10-22; Implementation:10 -03-22)
(Medicare Claims Processing Manual)
220.5  Common Working File (CWF) Edits  (Rev. 11388, Issued:04- 29, 22; (Effective:02 -10-22; Implementation:10 -03-22)   The common working file (CWF) shall apply the following limitations to lung cancer screening with LDCT:   Allow one HCPCS code 71271 per annum. At least 11 full months must elapse from the date of the last screening. NOTE:   This edit shall be overridable.   Reject HCPCS codes G0296 and 71271 claims lines for beneficiaries that are not between the ages of 50 and 77 (55 and 77 for DOS prior to February 10, 2022).  NOTE : Effective December 31, 2020, HCPCS code G0297 is end- dated and replaced with 71271.  230  Screening for Hepatitis B Virus (HBV)  (Rev. 3831, Issued: 08- 04-17, Effective: 09 -28-16, Implementation: 10 - 02- 17, October 2, 2017 - analysis and design; January 2, 2018 -  testing and implementation)   Effective for services furnished on or after September 28, 2016, an initial screening for hepatitis B virus infection (HBV) is covered for asymptomatic, non -pregnant adolescents and adults at high risk for HBV infection. High risk is defined as persons born in countries and regions with high prevalence of HBV infection (i.e.,  2%), US -born persons not vaccinated as infants whose parents were born in regions with a very high prevalence of HBV infection (i.e.,  8%), HIV -positive persons, men who have sex with men, injection drug users, household contacts or sexual partners of persons with HBV infection.
(Medicare Claims Processing Manual)
In addition, CMS has determined that repeated screening would be appropriate annually only for beneficiaries with continued high risk (men who have sex with men, injection drug users, household contacts or sexual partners of persons with HBV infection) who do not receive hepatitis B vaccination.   A screening test at the first prenatal visit is covered for pregnant women and then rescreening at time of delivery for those with new or continuing risk factors. In addition, CMS has determined that screening during the first prenatal visit would be appropriate for each pregnancy, regardless of previous hepatitis B vaccination or previous negative hepatitis B surface antigen (HBsAg) test results. See section 170 of this chapter for coverage and billing instructions for pregnant beneficiaries.   Effective for claims with dates of service on or after September 28, 2016, the claims processing instructions for payment of screening for hepatitis B virus will apply to the following HCPCS and CPT codes:    HBV screening for asymptomatic, non- pregnant adolescents and adults at high risk -  code G0499    HBV screening for pregnant women  CPT codes 86704, 86706, 87340 and 87341  A. Frequency   HBV screening for asymptomatic, non -pregnant adolescents and adults at high risk (HCPCS code G0499)    A single, one -time screening test is covered for asymptomatic, non pregnant adolescents and adults who do meet the high risk definition above.    Repeat screening for high risk persons is covered annually only for persons who have continued high risk who do not receive hepatitis B vaccination .    Note: Annual means a full 11 months must elapse following the month in which the previous negative screening took place.   Note for ESRD:  Effective for claims with dates of service on or after September 28, 2016 submitted with G0499  HepB screen high risk indiv, for asymptomatic non- pregnant beneficiaries and ICD -10 diagnosis code N18.6, End Stage Renal Disease, all of the  preceding requirements shall be bypassed and the claim shall be allowed to pay, no matter what other ICD -10 diagnosis codes may appear on the claim.    HBV screening for pregnant women (CPT codes 86704, 86706, 87340 and 87341)
(Medicare Claims Processing Manual)
HBV screening for pregnant women (CPT codes 86704, 86706, 87340 and 87341)    One occurrence per pregnancy of screening for HBV in pregnant women, and   One additional occurrence per pregnancy of screening for HBV in pregnant women who are at continued risk  B. Determination of High Risk for Hepatitis B Disease   The determination of high risk for HBV is identified by the primary care physician or practitioner who assesses the patients history, which is part of any complete medical history, typically part of an annual wellness visit, and considered in the development of a comprehensive prevention plan.  The medical record should be a reflection of the service provided.   Note: See Pub. 100- 03, Medicare National Coverage Determinations (NCD) Manual 210.6 for complete coverage guidelines.   230.1  Institutional Billing Requirements  (Rev. 3831, Issued: 08- 04-17, Effective: 09 -28-16, Implementation: 10-  02- 17, October 2, 2017 - analysis and design; January 2, 2018 -  testing and implementation)   Effective for claims with dates of service on or after September 28, 2016, providers may use the following types of bill (TOBs) when submitting claims for HBV screening, HCPCS G0499, 86704, 86706, 87340, and 87341: 13X, 14X, 72X, and 85X.  Deductible and c oinsurance do not apply. Service line -items on other TOBs shall be denied.  The service shall be paid on the basis shown below:
(Medicare Claims Processing Manual)
 Outpatient hospitals  TOB 13X -  based on Outpatient Prospective Payment System   Non-patient laboratory specimen  TOB 14X  based on laboratory fee schedule   End Stage Renal Disease facilities (ESRDs)  TOB 72X  based on ESRD PPS when submitted with code G0499 and diagnosis code N18.6. HBV is not separately payable for (ESRD TOB 72X)  unless reported with Modifier AY.   Critical Access Hospitals (CAHs) -  TOB 85X  based on reasonable cost when the revenue code is not 096X, 097X, and 098X  Note: For outpatient hospital settings, as in any other setting, services covered under this NCD must be provided by a primary care provider.  NOTE : Beneficiary coinsurance and deductibles do not apply to claim lines containing HCPCS G0499, and CPT codes 86704, 86706, 87340, and 87341. NOTE:   Medicare Administrative Contractors shall contractor -price HBV screening claims, HCPCS G0499, with dates of service September 28, 2016 through December 31, 2017.   230.2  Professional Billing Requirements  (Rev. 3831, Issued: 08- 04-17, Effective: 09 -28-16, Implementation: 10-  02- 17, October 2, 2017 - analysis and design; January 2, 2018 -  testing and implementation)   For claims with dates of service on or after September 28, 2016, CMS will allow coverage for HBV screening, CPT codes 86704, 86706, 87340, 87341, and HCPCS G0499, only when services are ordered by the following provider specialties found on the providers enrollment record:   01 - General Practice  08 - Family Practice  11 - Internal Medicine  16 - Obstetrics/Gynecology 37 - Pediatric Medicine  38 - Geriatric Medicine  42  Certified Nurse Midwife  50 - Nurse Practitioner  89 - Certified Clinical Nurse Specialist 97 - Physician Assistant   Claims ordered by providers other than the specialty types noted above will be denied.
(Medicare Claims Processing Manual)
Claims ordered by providers other than the specialty types noted above will be denied.   For claims with dates of service on or after September 28, 2016, CMS will allow coverage for HBV screening, 86704, 86706, 87340, 87341, and  G0499, only when submitted with one of the following place of service (POS) codes:   11  Physicians Office  19- Off Campus Outpatient Hospital  22  On Campus Outpatient Hospital  49  Independent Clinic  71  State or Local Public Health Clinic  81-Independent Laboratory Claims submitted without one of the POS codes noted above will be denied.   NOTE : Beneficiary coinsurance and deductibles do not apply to claim lines containing CPT codes 86704, 86706, 87340, 87341, and HCPCS G0499.   NOTE:   Medicare Administrative Contractors shall contractor -price HBV screening claims, HCPCS G0499, with dates of service September 28, 2016 through December 31, 2017.   230.3  Diagnosis Code Reporting Requirements  (Rev.11035, Issued:10 -13-21, Effective: 11-17-21; Implementation:  11-17-21) For claims with dates of service on or after September 28, 2016, CMS will allow  coverage for HBV screening, HCPCS G0499, only when services are reported with both of  the following diagnosis codes denoting high risk:  Z11.59 Encounter  for screening  for other  viral  disease,  and, Z72.89 Other  Problems  related  to life style   For claims with dates of service on or after September 28, 2016, CMS will allow  coverage for HBV  screening,  HCPCS  G0499, for subsequent  visits  only when  services  are reported with the  following diagnosis codes:   Z11.59, and,  one of the high risk diagnosis  codes  below:
(Medicare Claims Processing Manual)
F11.10  Opioid  abuse,  uncomplicated  F11.11  Opioid abuse,  in remission  F11.120  Opioid abuse  with intoxication, uncomplicated  F11.121  Opioid abuse  with intoxication delirium  F11.122  Opioid abuse  with intoxication with  perceptual  disturbance  F11.13  Opioid abuse  with withdrawal  F11.14  Opioid abuse  with opioid -induced mood disorder  F11.150  Opioid abuse  with opioid -induced psychotic  disorder with delusions  F11.151  Opioid abuse  with opioid -induced psychotic  disorder  with hallucinations  F11.181  Opioid abuse  with opioid -induced sexual  dysfunction F11.182  Opioid abuse  with opioid- induced sleep  disorder  F11.188  Opioid abuse  with other  opioid- induced disorder  F11.20  Opioid dependence,  uncomplicated  F11.21  Opioid dependence,  in remission  F11.220  Opioid dependence with intoxication, uncomplicated  F11.221  Opioid  dependence  with intoxication delirium   F11.222  Opioid  dependence  with  intoxication  with  perceptual  disturbance  F11.23  Opioid  dependence  with  withdrawal  F11.24  Opioid  dependence  with  opioid -induced mood  disorder  F11.250  Opioid  dependence  with  opioid -induced psychotic disorder  with  delusions  F11.251  Opioid  dependence  with  opioid -induced psychotic disorder  with  hallucinations  F11.259  Opioid  dependence  with  opioid -induced  psychotic disorder,  unspecified  F11.281  Opioid  dependence  with  opioid -induced  sexual  dysfunction  F11.282  Opioid  dependence  with  opioid -induced  sleep disorder  F11.288  Opioid  dependence  with  other  opioid -induced  disorder  F11.90  Opioid  use, unspecified,  uncomplicated  F11.920  Opioid  use, unspecified  with  intoxication,  uncomplicated  F11.921  Opioid  use, unspecified  with  intoxication  delirium  F11.922  Opioid  use, unspecified  with  intoxication  with  perceptual  disturbance  F11.929  Opioid  use, unspecified  with  intoxication,  unspecified  F11.93  Opioid  use, unspecified with  withdrawal
(Medicare Claims Processing Manual)
F11.922  Opioid  use, unspecified  with  intoxication  with  perceptual  disturbance  F11.929  Opioid  use, unspecified  with  intoxication,  unspecified  F11.93  Opioid  use, unspecified with  withdrawal  F11.94  Opioid  use, unspecified with  opioid -induced  mood  disorder  F11.950  Opioid  use, unspecified  with  opioid -induced  psychotic  disorder  with  delusions  F11.951  Opioid  use, unspecified  with  opioid -induced  psychotic  disorder  with  hallucinations  F11.959  Opioid  use, unspecified  with  opioid -induced  psychotic  disorder,  unspecified  F11.981  Opioid  use, unspecified  with  opioid -induced  sexual  dysfunction  F11.982  Opioid  use, unspecified  with  opioid -induced  sleep  disorder  F11.988  Opioid  use, unspecified with  other  opioid -induced  disorder  F13.10  Sedative,  hypnotic  or anxiolytic  abuse, uncomplicated  F13.11  Sedative,  hypnotic  or anxiolytic  abuse,  in remission  F13.120  Sedative,  hypnotic  or anxiolytic  abuse  with  intoxication,  uncomplicated  F13.121  Sedative,  hypnotic  or anxiolytic  abuse  with intoxication  delirium  F13.129  Sedative,  hypnotic  or anxiolytic  abuse  with intoxication,  unspecified  F13.130  Sedative,  hypnotic  or anxiolytic  abuse  with  withdrawal,  uncomplicated  F13.131  Sedative,  hypnotic  or anxiolytic  abuse  with  withdrawal  delirium  F13.132  Sedative,  hypnotic  or anxiolytic  abuse  with  withdrawal  with  perceptual  disturbance  F13.14  Sedative,  hypnotic  or anxiolytic  abuse  with  sedative,  hypnotic  or anxiolytic -induced  mood  disord  F13.150  Sedative,  hypnotic  or anxiolytic  abuse  with  sedative,  hypnotic  or anxiolytic -induced  psychotic  dis F13.151  Sedative,  hypnotic  or anxiolytic  abuse  with  sedative,  hypnotic  or anxiolytic -induced  psychotic  dis F13.159  Sedative,  hypnotic  or anxiolytic  abuse  with  sedative,  hypnotic  or anxiolytic -induced  psychotic  dis F13.180  Sedative,  hypnotic  or anxiolytic
(Medicare Claims Processing Manual)
-induced  psychotic  dis F13.159  Sedative,  hypnotic  or anxiolytic  abuse  with  sedative,  hypnotic  or anxiolytic -induced  psychotic  dis F13.180  Sedative,  hypnotic  or anxiolytic  abuse  with  sedative,  hypnotic  or anxiolytic -induced  anxiety  disor  F13.181  Sedative,  hypnotic  or anxiolytic  abuse  with  sedative,  hypnotic  or anxiolytic -induced  sexual  dysfu  F13.182  Sedative,  hypnotic  or anxiolytic  abuse  with  sedative,  hypnotic  or anxiolytic -induced  sleep  disord  F13.188  Sedative,  hypnotic  or anxiolytic  abuse  with  other  sedative, hypnotic  or anxiolytic -induced  disord  F13.20  Sedative,  hypnotic  or anxiolytic  dependence,  uncomplicated  F13.21  Sedative,  hypnotic  or anxiolytic  dependence,  in remission  F13.220  Sedative,  hypnotic  or anxiolytic  dependence  with  intoxication,  uncomplicated  F13.221  Sedative,  hypnotic  or anxiolytic  dependence  with intoxication  delirium
(Medicare Claims Processing Manual)
F13.229  Sedative,  hypnotic  or anxiolytic  dependence  with  intoxication,  unspecified  F13.230  Sedative,  hypnotic  or anxiolytic  dependence  with  withdrawal,  uncomplicated  F13.231  Sedative,  hypnotic  or anxiolytic  dependence  with  withdrawal  delirium  F13.232  Sedative,  hypnotic  or anxiolytic  dependence  with  withdrawal  with  perceptual disturbance  F13.239  Sedative,  hypnotic  or anxiolytic  dependence  with withdrawal,  unspecified  F13.24  Sedative,  hypnotic  or anxiolytic  dependence  with  sedative,  hypnotic  or anxiolytic -induced  mood  F13.250  Sedative,  hypnotic  or anxiolytic  dependence  with  sedative,  hypnotic  or anxiolytic -induced  psycho
(Medicare Claims Processing Manual)
F13.251  Sedative,  hypnotic  or anxiolytic  dependence  with  sedative,  hypnotic  or anxiolytic -induced  psycho  hallucinations  F13.259  Sedative,  hypnotic  or anxiolytic  dependence  with  sedative,  hypnotic  or anxiolytic -induced  psycho  F13.26  Sedative,  hypnotic  or anxiolytic  dependence  with  sedative,  hypnotic  or anxiolytic -induced  persist  F13.27  Sedative,  hypnotic  or anxiolytic  dependence  with  sedative,  hypnotic  or anxiolytic -induced  persist  F13.280  Sedative,  hypnotic  or anxiolytic  dependence  with  sedative,  hypnotic  or anxiolytic -induced  anxiet  F13.281  Sedative,  hypnotic  or anxiolytic  dependence  with  sedative,  hypnotic  or anxiolytic -induced  sexual  F13.282  Sedative,  hypnotic  or anxiolytic  dependence  with  sedative,  hypnotic  or anxiolytic -induced  sleep  d F13.288  Sedative,  hypnotic  or anxiolytic  dependence  with  other  sedative,  hypnotic  or anxiolytic -induced  d F13.90  Sedative,  hypnotic,  or anxiolytic  use, unspecified,  uncomplicated  F13.920  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  intoxication,  uncomplicated  F13.921  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  intoxication  delirium  F13.929  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  intoxication,  unspecified  F13.930  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  withdrawal,  uncomplicated  F13.931  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  withdrawal  delirium  F13.932  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  withdrawal  with  perceptual  disturbances  F13.939  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  withdrawal,  unspecified  F13.94  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  sedative,  hypnotic  or anxiolytic -induced  mo  F13.950  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  sedative,  hypnotic  or anxiolytic -induced  ps delusions
(Medicare Claims Processing Manual)
F13.950  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  sedative,  hypnotic  or anxiolytic -induced  ps delusions   F13.951  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  sedative,  hypnotic  or anxiolytic -induced  ps hallucinations  F13.959  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  sedative,  hypnotic  or anxiolytic -induced  ps F13.96  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  sedative,  hypnotic  or anxiolytic -induced  pe F13.97  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  sedative,  hypnotic  or anxiolytic -induced  pe F13.980  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  sedative,  hypnotic  or anxiolytic -induced  an F13.981  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  sedative,  hypnotic  or anxiolytic -induced  se F13.982  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  sedative,  hypnotic  or anxiolytic -induced  sle F13.988  Sedative,  hypnotic  or anxiolytic  use, unspecified  with  other  sedative,  hypnotic  or anxiolytic -induc  F14.10  Cocaine  abuse,  uncomplicated  F14.11  Cocaine  abuse, in remission  F14.120  Cocaine  abuse  with  intoxication,  uncomplicated  F14.121  Cocaine  abuse  with  intoxication with  delirium  F14.122  Cocaine  abuse  with  intoxication with  perceptual  disturbance  F14.129  Cocaine  abuse  with  intoxication, unspecified  F14.13  Cocaine  abuse,  unspecified  with withdrawal  F14.14  Cocaine  abuse  with cocaine -induced  mood disorder
(Medicare Claims Processing Manual)
F14.150  Cocaine  abuse  with cocaine -induced  psychotic  disorder with  delusions  F14.151  Cocaine  abuse  with cocaine -induced  psychotic  disorder with  hallucinations  F14.159  Cocaine  abuse  with cocaine -induced  psychotic  disorder,  unspecified  F14.180  Cocaine  abuse  with cocaine -induced  anxiety  disorder  F14.181  Cocaine  abuse  with cocaine -induced  sexual dysfunction  F14.182  Cocaine  abuse  with cocaine -induced  sleep  disorder  F14.188  Cocaine  abuse  with other  cocaine -induced disorder  F14.20  Cocaine  dependence,  uncomplicated  F14.21  Cocaine  dependence,  in remission  F14.220  Cocaine  dependence  with intoxication,  uncomplicated  F14.221  Cocaine  dependence  with intoxication delirium  F14.222  Cocaine  dependence  with intoxication with  perceptual  disturbance  F14.229  Cocaine  dependence  with intoxication, unspecified  F14.23  Cocaine  dependence  with withdrawal  F14.24  Cocaine  dependence  with cocaine -induced  mood  disorder  F14.250  Cocaine  dependence  with cocaine -induced  psychotic  disorder with  delusions  F14.251  Cocaine  dependence  with cocaine -induced  psychotic  disorder with  hallucinations  F14.259  Cocaine  dependence  with cocaine -induced psychotic  disorder,  unspecified  F14.280  Cocaine  dependence  with cocaine -induced  anxiety  disorder  F14.281  Cocaine  dependence  with cocaine -induced  sexual dysfunction  F14.282  Cocaine  dependence  with cocaine -induced  sleep  disorder  F14.288  Cocaine  dependence  with other  cocaine -induced  disorder  F14.90  Cocaine  use, unspecified,  uncomplicated  F14.920  Cocaine  use, unspecified  with intoxication,  uncomplicated  F14.921  Cocaine  use, unspecified  with intoxication  delirium  F14.922  Cocaine  use, unspecified  with intoxication  with perceptual  disturbance  F14.929  Cocaine  use, unspecified  with intoxication,  unspecified  F14.93  Cocaine  use, unspecified with withdrawal  F14.94  Cocaine  use, unspecified  with cocaine -induced  mood  disorder  F14.950  Cocaine  use, unspecified  with cocaine -induced  psychotic  disorder  with delusions  F14.951  Cocaine  use, unspecified  with cocaine -induced  psychotic  disorder  with hallucinations  F14.959  Cocaine  use, unspecified with  cocaine -induced  psychotic  disorder,  unspecified  F14.980  Cocaine  use, unspecified  with cocaine -induced  anxiety  disorder  F14.981  Cocaine  use, unspecified  with cocaine -induced  sexual  dysfunction  F14.982  Cocaine  use, unspecified  with cocaine -induced  sleep  disorder  F14.988  Cocaine  use, unspecified  with other  cocaine -induced  disorder