evekhm/cms_iom_500 huggingface dataset:
Article - Enteral Nutrition - Policy Article (A58833)
CODING GUIDELINESEnteral feeding supply allowances (B4034, B4035, B4036, and B4148) include all supplies, other than the feeding tube and nutrients, required for the administration of enteral nutrients to the beneficiary for one day. Only one unit of service may be billed for any one day. Codes B4034, B4035, B4036, and B4148 describe a daily supply fee rather than a specifically defined kit. The use of individual items may differ from beneficiary to beneficiary, and from day to day. Items included in these codes are not limited to pre-packaged kits bundled by manufacturers or distributors. These supply allowances include, but are not limited to, a catheter/tube anchoring device, feeding bag/container, flushing solution bag/container, administration set tubing, extension tubing, feeding/flushing syringes, gastrostomy tube holder, dressings (any type) used for gastrostomy tube site, tape (to secure tube or dressings), Y connector, adapter, gastric pressure relief valve, declogging device. These items must not be separately billed using the miscellaneous code (B9998) or using a specific code for any individual item, should a unique HCPCS code for item exist (for examples dressing, tape).B4105 (IN-LINE CARTRIDGE CONTAINING DIGESTIVE ENZYME(S) FOR ENTERAL FEEDING, EACH) is eligible for separate payment.Products that are only administered orally should be coded as A9270.Code B4149 describes formulas containing natural foods that are blenderized and packaged by a manufacturer. B4149 formulas are classified based upon this manufacturer requirement, not on the composition of the enteral formula. Code B4149 must not be used for foods that have been blenderized by the beneficiary or caregiver for administration through a tube.
Article - Enteral Nutrition - Policy Article (A58833)
The only products which may be billed using codes B4149, B4153, B4154, B4155, B4157, B4161, or B4162 are those for which a written Coding Verification Review has been made by the Pricing, Data Analysis and Coding (PDAC) Contractor and subsequently published on the Product Classification List (PCL). If a product is billed to Medicare using a HCPCS code that requires written coding verification review, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.Suppliers should refer to the enteral nutrition PCL on the PDAC Contractor web site or contact the PDAC for guidance on the correct coding for these items.
Article - Parenteral Nutrition (A58836)
CMS National Coverage PolicyN/AArticle Text
Article - Parenteral Nutrition (A58836)
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Parenteral Nutrition is covered under the Prosthetic Device benefit (Social Security Act  1861(s)(8)). In order for a beneficiarys equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are non-medical necessity coverage and payment rules, discussed below, that also must be met.TEST OF PERMANENCEAs stipulated in the MedicareBenefit Policy Manual(CMS Pub. 100-02), Chapter 15 Section 120, coverage of parenteral nutrition requires that a beneficiary must have a permanent impairment. However, this does not require a determination that there is no possibility that the beneficiarys condition may improve sometime in the future. If the medical record, including the judgment of the treating practitioner, indicates that the impairment will be of long and indefinite duration, the test of permanence is considered met.EQUIPMENT AND SUPPLIES:Only one infusion pump is covered for beneficiaries in whom parenteral nutrition is required.Additionally, only one supply kit and one administration kit is covered for each day that parenteral nutrition is administered.When parenteral nutrition is administered in an outpatient facility, the pump used for its administration and IV pole will be denied as not separately payable. The pump and pole are not considered as rentals to a single beneficiary, but rather, as items of equipment used for multiple beneficiaries.Services associated with the administration of parenteral nutrition in a beneficiarys home are not a covered benefit administered by the DME MACs.REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)
Article - Parenteral Nutrition (A58836)
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSThe beneficiarys medical record must contain sufficient documentation of the beneficiarys medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the beneficiarys diagnosis and other pertinent information including, but not limited to, duration of the beneficiarys condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc.Information describing the medical necessity for parenteral nutrition must be available upon request. In order to satisfy the test of permanence, there must be documentation to reflect that in the treating practitioners judgement, the impairment will be of long and indefinite duration.Documentation in the medical record shall reflect that the beneficiary has (a) a condition involving the small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients or (b) disease of the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients to be transported through and absorbed by the gastrointestinal (GI) system.
Article - Parenteral Nutrition (A58836)
In addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article (A55426), located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS.MISCELLANEOUS:Suppliers are required to monitor the beneficiarys medical condition to confirm that the coverage criteria for parenteral nutrition continue to be met.Parenteral nutrition provided to a beneficiary in a Part A covered stay must be billed by the SNF to the fiscal intermediary. No payment from Part B is available when parenteral nutrition services are furnished to a beneficiary in a stay covered by Part A. However, if a beneficiary is in a stay not covered by Part A, parenteral nutrition is eligible for coverage under Part B and may be billed to the DME MAC by either the SNF or an outside supplier.DME INFORMATION FORM (DIF)Providers and suppliers no longer need to submit a DME Information Form (DIF) for services rendered on or after January 1, 2023.
Article - Parenteral Nutrition (A58836)
For claims with dates of service on or after January 1, 2023  Providers and suppliers no longer need to submit CMNs or DIFs with claims. Due to electronic filing requirements, claims received with these forms attached will be rejected and returned to the provider or supplier.For claims with dates of service prior to January 1, 2023  If the CMN or DIF is required, it must be submitted with the claim, or be on file with a previous claim.For dates of service for which a DIF is required, a DIF which has been completed, signed, and dated by the supplier, must be kept on file by the supplier and made available upon request.The DIF for parenteral nutrition is CMS Form 10126. The initial claim must include an electronic copy of the DIF.For claims with dates of service prior to January 1, 2023 the following requirements for new initial and revised DIFs remain in effect:A new Initial DIF is required when parenteral nutrition services are resumed when they are not required for two consecutive months.A revised DIF must be submitted if:Change in HCPCS code for the current nutrient provided.Change (increase or decrease) in the calories prescribed for any HCPCS codes other than B4189, B4193, B4197, B4199, B5000, B5100, B5200.Change in the number of days per week of administration.Change in route of administration.When the length of need previously entered on the DIF has expired and the treating practitioner is extending the length of need for the item(s).MODIFIERSBA, GA, GY, GZ, and KX MODIFIERS:When an IV pole (E0776) is used in conjunction with parenteral nutrition, the BA modifier should be added to the code. Code E0776 is the only code with which the BA modifier may be used.Suppliers must add the KX modifier to claim lines billed for parenteral nutrition, parenteral pump, and supplies only if all of the coverage criteria in the Coverage Indications, Limitations, and/or Medical Necessity section in the related LCD have been met and evidence of such is retained in the suppliers files and available to the DME MAC upon request.
Article - Parenteral Nutrition (A58836)
If all of the criteria in the Coverage Indications, Limitations, and/or Medical Necessity section of the related LCD have not been met, the GA, GY or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN. When there is an expectation of a non-covered (no benefit) denial, suppliers must enter the GY modifier on the claim line.As of January 1, 2023, suppliers must calculate the units of service (UOS) for each parenteral product billed to Medicare, based on the treating practitioners order. When billing for medically necessary parenteral nutrition, units in excess of the treating practitioners order must not be billed with a KX (as these units are not reasonable and necessary). Instead, these excess units must be billed with a GA or GZ modifier.Claim lines billed with codes without a KX, GY, GA or GZ modifier will be rejected as missing information.CODING GUIDELINES:When homemix parenteral nutrition solutions are used, the component carbohydrates (B4164, B4180), amino acids (B4168, B4172, B4176, B4178), additives (B4216), and lipids (B4185 or B4187) are all separately billable. When premix parenteral nutrition solutions are used (B4189, B4193, B4197, B4199, B5000, B5100, B5200) there must be no separate billing for the carbohydrates, amino acids or additives (vitamins, trace elements, heparin, electrolytes). However, lipids (B4185 or B4187) are separately billable with premix solutions.
Article - Parenteral Nutrition (A58836)
For lipids, one unit of service of code B4185 or B4187 is billed for each 10 grams of lipids provided. 500 ml of 10% lipids contains 50 grams of lipids (5 units of service); 500 ml of 20% lipids contains 100 grams (10 units of service); 500 ml of 30% lipids contains 150 grams (15 units of service).For codes B4189, B4193, B4197, B4199, one unit of service represents one day's supply of protein and carbohydrate regardless of the fluid volume and/or the number of bags. For example, if 60 grams of protein are administered per day in two bags of a premix solution each containing 30 grams of amino acids, correct coding is one (1) unit of B4193, not two units of B4189.For codes B5000, B5100, B5200, one unit of service is one gram of amino acid.Parenteral nutrition solutions containing less than 10 grams of protein per day are coded using the miscellaneous code B9999.Parenteral nutrition supply allowances (HCPCS codes B4220, B4222 and B4224) describe a daily supply fee rather than a specifically defined kit and include all supplies required for the administration of parenteral nutrition to the beneficiary for one day. The use of individual items may differ from beneficiary to beneficiary, and from day to day. Daily allowances are considered all-inclusive and therefore refill requirements are not applicable to HCPCS codes B4220, B4222 and B4224. Only one unit of service may be billed for any one day.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Draft Article - Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound (DA58865)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) DL39116 Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound.
Article - Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound (A58865)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39116 Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound.
Draft Article - Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound (DA58867)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) DL39118 Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound.
Article - Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound (A58867)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39118 Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound.
Article - Billing and Coding: Tetanus Immunization (A58872)
CMS National Coverage PolicyInternet Only Manuals (IOMs)CMS IOM Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 50.4.4.2 ImmunizationsSocial 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 TextTetanus is a neurologic syndrome caused by a neurotoxin elaborated at the site of injury by Clostridium tetani. Nearly all cases of tetanus occur in nonimmunized or inadequately immunized individuals. In the absence of an injury or direct exposure to tetanus, preventative immunization is not covered.Coding GuidanceIf the provider knows the service is non-covered or is not a Medicare benefit, the GY modifier must be appended to the CPT/HCPCS code indicating the item or service is statutorily non-covered or does not meet the definition of any Medicare benefit.Documentation RequirementsAll 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 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.
Article - Billing and Coding: Tetanus Immunization (A58873)
CMS National Coverage PolicyInternet Only Manuals (IOMs)CMS IOM Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 50.4.4.2 ImmunizationsSocial 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 TextTetanus is a neurologic syndrome caused by a neurotoxin elaborated at the site of injury by Clostridium tetani. Nearly all cases of tetanus occur in nonimmunized or inadequately immunized individuals. In the absence of an injury or direct exposure to tetanus, preventative immunization is not covered.Coding GuidanceIf the provider knows the service is non-covered or is not a Medicare benefit, the GY modifier must be appended to the CPT/HCPCS code indicating the item or service is statutorily non-covered or does not meet the definition of any Medicare benefit.Documentation RequirementsAll 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 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.
Article - Billing and Coding: Treatment of Varicose Veins of the Lower Extremities (A58876)
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 23, 20.9 National Correct Coding Initiative (NCCI)CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code RequirementsArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) forTreatment of Varicose Veins of the Lower Extremities L39121.When billing for non-covered services, use the appropriate modifier.The sclerosant used in sclerotherapy procedures is included in the procedure code and is not separately reported.
Article - Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound (A58883)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 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 periodCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 30A Services Paid Under the Medicare Physicians Fee Schedule - Physicians ServicesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forAmniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-WoundL39128.
Draft Article - Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound (DA58893)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) DL39139 Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound.
Article - Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound (A58893)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39139 Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound.