evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58993)
This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39240-Epidural Steroid Injections for Pain Management. Please refer to the LCD for reasonable and necessary requirements.The services addressed in this article only apply to epidural injections. Other joint procedures (e.g. sacral injections, facet joint) are not addressed.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.The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to the NCCI requirements.An anatomic spinal region for epidurals is defined as cervical/thoracic (CPT codes 62321, 64479 and 64480) or lumbar/sacral (CPT codes 62323, 64483 and 64484).When the epidural injections (62322-62327) are used for cerebrospinal fluid flow imaging, cisternography (78630), the diagnosis code restrictions in this article do not apply. These services should be billed on the same claim.When epidural injections (62321, 62323, 64479, 64480, 64483 or 64484) are used for postoperative pain management, the diagnosis code restriction in this article do not apply.When epidural injection (62323) is used for an implantable infusion pump trail, the diagnosis code restrictions in this article do not apply.CPT codes 64479 and 64483 are used to report a single level injection performed with image guidance (fluoroscopy or CT). CPT codes 64480 and 64484 represent each additional level respectively and should be reported separately in addition to the primary procedure when applicable.A transforaminal epidural steroid injection (TFESI) performed at the T12-L1 level should be reported with CPT code 64479.
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58993)
A transforaminal epidural steroid injection (TFESI) performed at the T12-L1 level should be reported with CPT code 64479.When reporting CPT codes 64479 through 64484 for a unilateral procedure, use one line with one unit of service. For bilateral procedures regarding these same codes, use one line and append the modifier-50.For services performed in the ASC, physicians must continue to use modifier 50. Only the ASC Facility itself must report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each line.It is not medically reasonable and necessary to perform caudal ESIs or interlaminar ESIs bilaterally, therefore CPT 62321 and 62323 are not bilateral procedures.KX modifier requirements:A diagnostic selective nerve root block (DSNRB) is identically coded as an Epidural Injection. Therefore, when performing a DSNRB the -KX modifier should be appended to the appropriate line to distinguish the procedure from an epidural injection. Aberrant use of the -KX modifier may trigger focused medical review.Utilization ParametersOnly one spinal region may be treated per session (date of service).Consistent with the LCD, only two total levels per session are allowed for CPT codes 64479, 64480, 64483 and 64484. (Two unilateral or two bilateral levels). 64480 should be reported in conjunction with 64479 and 64484 should be reported in conjunction with 64483.Consistent with the LCD, CPT codes 62321 and 62323 may only be reported for one level per session.No more than 4 epidural injection sessions (CPT codes 62321, 62323, 64479, 64480, 64483, or 64484) may be reported per region in a rolling 12-month period regardless of the number of levels involved.Documentation Requirements1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58993)
Documentation Requirements1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.2. 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.3. 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.4. The procedural report should clearly document the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief achieved immediately post-injection.5. Films that adequately document (minimum of 2 views) final needle position and contrast flow should be retained and made available upon request.6. The patients medical record should include, but is not limited to:
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58993)
The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visitRelevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Documentation to support the medical necessity of the procedure(s).Use of BiologicalsThere are currently no FDA approved biologicals for use as injectable agents into the epidural space or spine. The inclusion of biological and/or other non-FDA approved substances in the injectant may result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180. Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and not routinely reimbursable and therefore may be denied. In exceptional circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record individual consideration may be considered on appeal.
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58995)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 4, Section 280.14 Infusion PumpsCMS IOM Publication 100-04, Medicare Claims Processing Manual,Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)Social 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 Text
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58995)
This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39242-Epidural Steroid Injections for Pain Management. Please refer to the LCD for reasonable and necessary requirements.The services addressed in this article only apply to epidural injections. Other joint procedures (e.g. sacral injections, facet joint) are not addressed.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.The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to the NCCI requirements.An anatomic spinal region for epidurals is defined as cervical/thoracic (CPT codes 62321, 64479 and 64480) or lumbar/sacral (CPT codes 62323, 64483 and 64484).When the epidural injections (62322-62327) are used for cerebrospinal fluid flow imaging, cisternography (78630), the diagnosis code restrictions in this article do not apply. These services should be billed on the same claim.When epidural injections (62321, 62323, 64479, 64480, 64483 or 64484) are used for postoperative pain management, the diagnosis code restriction in this article do not apply.When epidural injection (62323) is used for an implantable infusion pump trail, the diagnosis code restrictions in this article do not apply.CPT codes 64479 and 64483 are used to report a single level injection performed with image guidance (fluoroscopy or CT). CPT codes 64480 and 64484 represent each additional level respectively and should be reported separately in addition to the primary procedure when applicable.A transforaminal epidural steroid injection (TFESI) performed at the T12-L1 level should be reported with CPT code 64479.
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58995)
A transforaminal epidural steroid injection (TFESI) performed at the T12-L1 level should be reported with CPT code 64479.When reporting CPT codes 64479 through 64484 for a unilateral procedure, use one line with one unit of service. For bilateral procedures regarding these same codes, use one line and append the modifier-50.For services performed in the ASC, physicians must continue to use modifier 50. Only the ASC Facility itself must report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each line.It is not medically reasonable and necessary to perform caudal ESIs or interlaminar ESIs bilaterally, therefore CPT 62321 and 62323 are not bilateral procedures.KX modifier requirements:A diagnostic selective nerve root block (DSNRB) is identically coded as an Epidural Injection. Therefore, when performing a DSNRB the -KX modifier should be appended to the appropriate line to distinguish the procedure from an epidural injection. Aberrant use of the -KX modifier may trigger focused medical review.Utilization ParametersOnly one spinal region may be treated per session (date of service).Consistent with the LCD, only two total levels per session are allowed for CPT codes 64479, 64480, 64483 and 64484. (Two unilateral or two bilateral levels). 64480 should be reported in conjunction with 64479 and 64484 should be reported in conjunction with 64483.Consistent with the LCD, CPT codes 62321 and 62323 may only be reported for one level per session.No more than 4 epidural injection sessions (CPT codes 62321, 62323, 64479, 64480, 64483, or 64484) may be reported per spinal region in a rolling 12-month period regardless of the number of levels involved.Documentation Requirements1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58995)
Documentation Requirements1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.2. 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.3. 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.4. The procedural report should clearly document the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief achieved immediately post-injection.5. Films that adequately document (minimum of 2 views) final needle position and contrast flow should be retained and made available upon request.6. The patients medical record should include, but is not limited to:
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58995)
The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visitRelevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Documentation to support the medical necessity of the procedure(s).Use of BiologicalsThere are currently no FDA approved biologicals for use as injectable agents into the epidural space or spine. The inclusion of biological and/or other non-FDA approved substances in the injectant may result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180. Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and not routinely reimbursable and therefore may be denied. In exceptional circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record individual consideration may be considered on appeal.
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers (A58996)
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.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Minimal Residual Disease Testing for Cancer L38814.A Minimal Residual Disease (MRD) test, as defined in the related policy, is aservicethat may include multiple components and/or multiple timepoints (i.e., serial assays).Testing schedules are set based on the validity established for the individual test comprising the service.Each component and timepoint of the service must be reasonable and necessary and adhere to the criteria set forth in the policy. The medical record must contain clear documentation of the medical necessity of this test, as per the conditions outlined in the policy.The following tests have met the criteria for coverage under the policyManufacturerTestIndicated Uses and LimitationsAdaptive BiotechnologiesClonoSeqNote:An episode of testing typically requires a baseline assay and multiple follow-up assays.Acute lymphoblastic leukemia (ALL), Multiple myeloma (MM), and Chronic lymphocytic leukemia (CLL),and Diffuse Large B-Cell Lymphoma (DLBCL).Refer to CPT/HCPCS Group 2 for additional instructions and select the appropriate ICD-10 code listed under ICD-10 Codes that Support Medical Necessity Group 2 Codes.
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers (A58996)
This Table will be updated to reflect revisions and additions of newly covered tests.Coverage of CLONOSEQfor other cancer indications and episodes of care, and modifications to the definition of an episode of care will be evaluated as needed.Additional process requirements for coverage and billing:MolDX may make available specific forms to assist with test Technical Assessments (TAs). Please follow the instructions on the MolDX website to assist with this process. If such forms are available that pertain to the test type in question, these forms are required for successful coverage determinations.Single-gene PCR tests:For patients with or without cancer (as defined in the policy),established standard-of-careMRD tests using single-genePCR(i.e., BCR-ABL1)may be billed on an individual basis according to testing schedules outlined in national (i.e., NCCN) or society guidelines, with 1 UOS for each date of service.Refer to CPT/HCPCS Group 3 for additional instructions and select the appropriate ICD-10 code listed under ICD-10 Codes that Support Medical Necessity Group 3 Codes.Regarding single-gene and panel testing of genes  Refer to definitions and instructions in Billing and Coding: MolDX: Testing of Multiple Genes A58120 and Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) A57526
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers (A58996)
Regarding single-gene and panel testing of genes  Refer to definitions and instructions in Billing and Coding: MolDX: Testing of Multiple Genes A58120 and Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) A57526Other tests (i.e., ClonoSeq):For patients with cancer, the unit of service for this type of test is 1. Billing should occur at the start of the episode of testing. Regarding the use of NGS-based MRD tests (i.e., ClonoSeq) in patients with cancer Theservicemay be performed once per patient per cancer diagnosis, unless there is clinical evidence ofa priorichange in genetic content.For patients without cancer (as defined in the policy), a second kind of test may exist wherein asingletimepointmay constitute a single test (i.e., 1 UOS for a given date of service). Testing in these patients will be accompanied by the appropriate Personal history of cancer ICD-10 code. Testing may not be performed more than once in a month; the testing schedule is set based on the validity established of the individual test for the given indication.Refer to additional instructions outlined in the relevant Group sections below.Regarding NGS panels:To submit a claim for MRD analysis by NGS that measures multiple analytes, use CPT 81479 and one (1) UOS with the assigned DEX Z-Code.Billing instructions:Billing requires a Z-identifier code to be submitted with the claim. All tests must be registered with the DEX Diagnostic Exchange application.To report an episode of testing, please submit the following claim information:Select the appropriate CPTcode.If no specific CPT code exists for the test submitted, bill with the NOC code 81479.Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claim
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers (A58996)
Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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:When entering the DEX Z-Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers (A58997)
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.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Minimal Residual Disease Testing for Cancer L38816.A Minimal Residual Disease (MRD) test, as defined in the related policy, is aservicethat may include multiple components and/or multiple timepoints (i.e., serial assays).Testing schedules are set based on the validity established for the individual test comprising the service.Each component and timepoint of the service must be reasonable and necessary and adhere to the criteria set forth in the policy. The medical record must contain clear documentation of the medical necessity of this test, as per the conditions outlined in the policy.The following tests have met the criteria for coverage under the policyManufacturerTestIndicated Uses and LimitationsAdaptive BiotechnologiesClonoSeqNote:An episode of testing typically requires a baseline assay and multiple follow-up assays.Acute lymphoblastic leukemia (ALL), Multiple myeloma (MM), and Chronic lymphocytic leukemia (CLL),and Diffuse Large B-Cell Lymphoma (DLBCL).Refer to CPT/HCPCS Group 2 for additional instructions and select the appropriate ICD-10 code listed under ICD-10 Codes that Support Medical Necessity Group 2 Codes.
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers (A58997)
This Table will be updated to reflect revisions and additions of newly covered tests.Coverage of CLONOSEQfor other cancer indications and episodes of care, and modifications to the definition of an episode of care will be evaluated as needed.Additional process requirements for coverage and billing:MolDX may make available specific forms to assist with test Technical Assessments (TAs). Please follow the instructions on the MolDX website to assist with this process. If such forms are available that pertain to the test type in question, these forms are required for successful coverage determinations.Single-gene PCR tests:For patients with or without cancer (as defined in the policy),established standard-of-careMRD tests using single-genePCR(i.e., BCR-ABL1)may be billed on an individual basis according to testing schedules outlined in national (i.e., NCCN) or society guidelines, with 1 UOS for each date of service.Refer to CPT/HCPCS Group 3 for additional instructions and select the appropriate ICD-10 code listed under ICD-10 Codes that Support Medical Necessity Group 3 Codes.Regarding single-gene and panel testing of genes  Refer to definitions and instructions in Billing and Coding: MolDX: Testing of Multiple Genes A58121 and Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) A57527.
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers (A58997)
Other tests (i.e., ClonoSeq):For patients with cancer, the unit of service for this type of test is 1. Billing should occur at the start of the episode of testing. Regarding the use of NGS-based MRD tests (i.e., ClonoSeq) in patients with cancer Theservicemay be performed once per patient per cancer diagnosis, unless there is clinical evidence ofa priorichange in genetic content.For patients without cancer (as defined in the policy), a second kind of test may exist wherein asingletimepointmay constitute a single test (i.e., 1 UOS for a given date of service). Testing in these patients will be accompanied by the appropriate Personal history of cancer ICD-10 code. Testing may not be performed more than once in a month; the testing schedule is set based on the validity established of the individual test for the given indication.Refer to additional instructions outlined in the relevant Group sections below.Regarding NGS panels:To submit a claim for MRD analysis by NGS that measures multiple analytes, use CPT 81479 and one (1) UOS with the assigned DEX Z-Code.Billing instructions:Billing requires a Z-identifier code to be submitted with the claim. All tests must be registered with the DEX Diagnostic Exchange application.To report an episode of testing, please submit the following claim information:Select the appropriate CPTcode.If no specific CPT code exists for the test submitted, bill with the NOC code 81479.Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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:When entering the DEX Z-Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.