evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Mohs Micrographic Surgery (A57477)
Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L35494 Mohs Micrographic Surgery.The medical records should clearly show that Mohs surgery was chosen because of the complexity, size and/or location of the lesion and why other approaches are not medically necessary and reasonable. The operative notes and pathology documentation in the patients medical record must clearly show that Mohs micrographic surgery was performed using accepted Mohs technique, with the same physician performing both the surgical and pathology services. The notes should also contain the location, number, and size of the lesion(s), the number of stages performed, and the number of specimens per stage. Denied claims may be appealed and providers can submit documentation to support the service.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. Refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.CPT codes 17311-17315 are reserved for the surgeon who removes a lesion, prepares, and interprets the slides. Select skin biopsy/excision services and pathology services are part of the MOHS surgery and bundled into 17311-17315. Refer to the NCCI Manual and CPT manual for additional information.MOHS surgery includes the pathologic examination of the specimen performed by the surgeon and should not be reported separately. There may be instances when a MOHS surgeon submits a specimen(s) derived from the procedure for pathologic examination to another physician (i.e., pathologist) for either frozen or permanent section. In those situations, the service is not considered a MOHS service and pathology service may be reported by the performing pathologist. The surgeon should report for excision and repair using appropriate codes (Reference American Medical Association [AMA] CPT Professional Edition)
Article - Billing and Coding: Mohs Micrographic Surgery (A57477)
It isNOTappropriate to report modifier -59 when the biopsy and MOHS surgery are performed on the same lesion, in the same operative session and on the same date of service. However, if a suspected skin cancer is biopsied for pathologic diagnosis prior to proceeding to MOHS micrographic surgery, the biopsy and frozen section pathology may be reported separately using modifier -59 to distinguish the diagnostic biopsy from the definitive MOHS surgery Refer to the NCCI Manual and CPT manual for additional information.Modifier -59 shouldonlybe appended to the pathology codes, by the MOHS surgeon, if a biopsy is performed on a completely separate lesion that does not involve the MOHS surgery; however, MOHS surgery and pathology service may be reported when tissue separate from the tissue examined during the MOHS surgery is submitted for subsequent formalin-fixed processing and histopathologic examination (i.e., the submitted specimen originates from the same operative site or from a different operative site but is not the same tissue processed during the MOHS surgery). Refer to the NCCI Manual and CPT manual for additional information.There may be rare instances where a biopsy and pathology must occur on the same date as a MOHS procedure. In these instances, skin biopsy CPT codes and the pathology CPT codes may be reported with the -59 modifier appended if:The lesion for which MOHS is planned has not been biopsied within the previous 60 days, orIf the surgeon cannot obtain a pathology report from the referring physician with a reasonable effort, orThe biopsy is performed on a lesion that is not associated with the MOHS surgery. For example: If a biopsy is performed prior to the MOHS surgery for a diagnostic purpose, the biopsy can also be performed. Modifier -59 or -58 would be appended to distinguish the diagnostic biopsy from the definitive MOHS surgery Refer to the NCCI Manual and CPT manual for additional information.When it is appropriate to report modifier -59, the modifier should be reported on the same line as the biopsy procedure codes. It shouldNOTbe reported on the same line as the MOHS procedure.
Article - Billing and Coding: Mohs Micrographic Surgery (A57477)
When it is appropriate to report modifier -59, the modifier should be reported on the same line as the biopsy procedure codes. It shouldNOTbe reported on the same line as the MOHS procedure.The appropriate MOHS surgery code should be reported with the appropriate quantities for the specimens mapped in the days/units field.CPT code 17312 should be reported for additional stages with the first stage code 17311.CPT code 17314 should be reported for additional stages with the first stage code 17313.CPT code 17315 may be used to report each block after the first 5 blocks for any single stage.All surgical procedures performed in the same operative session should be reported on the same claim.Multiple instances of CPT codes 17312 and 17314 should not be reported on separate claim lines. The services should be totaled and entered as a single item with the appropriate number of units of service.Please note that these codes refer to the number of blocks, not number of slides.If a MOHS procedure is performed on acompletely separate lesionon the same date of service, each first stage (CPT code 17311 or 17313) code should be reported on a separate claim line with a -59 modifier signifying a separate and distinct lesion. If additional stages are required on the additional lesion, report the second stage codes (CPT code 17312 or 17314) on separate claim lines with a -59 modifier (Reference NCCI Initiative Modifiers: Modifier 59 Fact Sheet).Documentation Requirements
Article - Billing and Coding: Mohs Micrographic Surgery (A57477)
All documentation must be maintained in the patients medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The 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. The medical record documentation must support the medical necessity of the services as stated in this policy.Procedures that exceed the medical need are not reasonable and necessary (not a Medicare covered service), therefore, documentation (pre-procedure E/M note and/or post-procedure operative notes) must address (a) why the lesion will not be (was not) managed by standard excision or destruction technique and (when applicable) (b) why (when utilized or referred to a plastic surgeon) procedures for complex repair, adjacent tissue transfer or rearrangement, flap, or graft codes are employed.The physician must document in the patients medical record that the diagnosis is appropriate for MMS and that MMS is an appropriate choice as the treatment of the particular lesion. The options for care (both the primary procedure options and repair options) must be discussed with the patient and clearly noted in the pre-procedure (or post procedure as appropriate) documentation. In summary, the minimal medical record documentation entails that the beneficiary was informed of their treatment options and explained the risks/benefits of the MMS technique and associated repair.Though complexity of the lesion (poorly defined borders, suspected deep invasion, recurrent lesion, prior radiation), lesion size/location, and maximum conservation of healthy tissue are to be addressed in the preoperative medical record, the surgeon must document why the lesion will not be (was not) managed by excision or destruction technique.Operative notes and pathology documentation in the patients medical record should clearly document that MMS was performed using accepted MMS technique, in which the physician acts in two integrated and distinct capacities: surgeon and pathologist (therefore confirming that the procedure meets the definition of the CPT code[s]).
Article - Billing and Coding: Mohs Micrographic Surgery (A57477)
Operative documentation should note: location, number, and size of the lesion(s); number of stages performed; number of specimens per stage.Histology documentation must include the following:First stage: if tumor present, depth of invasion; pathological pattern of the tumor; cell morphology; if present, note perineural invasion of scar tissue.Subsequent stages: if the tumor characteristics are the same as in the first stage, note this fact only. If the tumor characteristics are different from the first stage, describe the differences.
Article - Billing and Coding: Mohs Micrographic Surgery (A57477)
Measurement of the primary lesion necessitating MMS and measurements in support of repair or related procedures (such as but not limited to adjacent tissue transfer/rearrangements, grafts/flaps) completing the MMS procedure and confirming the primary defect measurement or other relevant measurements should be verifiable. Documentation of the clinical tumor border definition may be accomplished by:Preoperative photography with the skin stretched to delineate the visible clinical borders with or without debulking curettage (using a centimeter ruler or relation of size by another anatomic structure).Postoperative photography to document the defect may also be considered, especially for small lesions that have a significant subepithelial component (i.e., tip of the iceberg phenomenon).It is understood that photographic documentation may not be possible in a small percentage of cases because of technical difficulties.When the surgical defect created by MMS requires reconstruction, it should be clear in the documentation that the reconstructive technique performed was an appropriate choice to preserve functional capabilities and to restore physical appearance.
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A57478)
CMS National Coverage PolicyCode of Federal Regulations:42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who uses the results in the management of the beneficiary's specific medical problem.Federal Register:Federal Register Vol. 62, 59047, Supervision of Diagnostic Tests, describes the degree of physician supervision required for diagnostic tests.CMS Publications:CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2:160.23 Sensory Nerve Conduction Threshold Tests (sNCTs)Program Memorandum Carriers Transmittal B-01-28 Change Request 850, describes tests that may be performed by PTs with ABPTS certificationCMS Publication 100-2.Medicare Benefit Policy Manual, Chapter 15, Section 80: Requirements for Diagnostic Tests.Transmittal 2663 Change Request 8169 April Update to the CY 2013 Medicare Physician Fee Schedule Database (MPFSDB)Italicized font-represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated Local Coverage Determination (LCD) L34594 Nerve Conduction Studies and Electromyography.I. Coding GuidelinesA. Evaluation/Management (E/M)Usually an E&M service is included in the exam performed just prior to and during nerve conduction studies and/or electromyography. If the E&M service is a separate and identifiable service, the medical record must document medical necessity and the CPT code must be bill with a modifier 25.A clinical history from the referral source must indicate the need for testing. Such data containing pertinent clinical information must be attainable for review in instances where the need for a test may come under scrutiny. Absolute inclusive or exclusive criteria for performance of a diagnostic test are difficult to enumerate.B. Nerve Conduction Studies
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A57478)
B. Nerve Conduction StudiesThe table below provides a reasonable maximum number of studies per diagnostic category necessary for a provider to arrive at a diagnosis in 90% of patients with that final diagnosis.The appropriate number of studies to be performed is left to the judgment of the provider performing the evaluation; however, in the small number of cases, which require testing in excess of the numbers listed in the table, the provider should be able to provide supplementary documentation to justify the additional testing.In some situations, it may be necessary to test an asymptomatic contralateral limb to establish normative values for an individual patient. Documentation must support the medical necessity of the additional test.Codes 95907-95913 describe one or more nerve conduction studies. A single conduction test is defined as a sensory conduction test, a motor conduction test with or without an F wave test, or an H-reflex test. Each type of study (sensory, motor with or without F wave, H reflex) for each nerve is counted as a distinct study when determining the number of studies billed.Each type of study is counted only once when multiple sites on the same nerve are stimulated and recorded. The number of tests (sensory, motor with or without F wave, H reflex) per nerve should be added to determine the code to be billed.Nerve conduction codes 95907-95913 had their Physician Supervision of Diagnostic Procedures Indicators adjusted to 7A effective 01/01/2013 (CR 8169). Therefore, if authorized by state law Physical Therapists are allowed the technical portion and professional component of the test according to the description of 7A.7A = Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.77 = Procedure must be performed by a PT with ABPTS certification (TC & PC) or by a PT without certification under direct supervision of a physician (TC only; PC always physician).These changes are effective January 1, 2013.Appendix J from CPT codebookIndicationsLimbs Studied by Needle EMG95860-95864,95867-95870,95885-95887Nerve Conduction StudiesTotal nerves studied95907-95913Neuromuscular junctiontesting (Repetitivesimulation 95937)
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A57478)
Carpal Tunnel unilateral17_Carpal Tunnel bilateral210_Radiculopathy27_Mononeuropathy18_Polyneuropathy/ Mononeuropathy Multiplex310_Myopathy242Motor Neuropathy (e.g., ALS)462Plexopathy212_Neuromuscular Junction243Tarsal Tunnel Syndrome (unilateral)18_Tarsal Tunnel Syndrome (bilateral)211_Weakness, fatigue, cramps, or twitching (local)272Weakness, fatigue, cramps, or twitching (general)482Pain, numbness, or tingling (unilateral)19_Pain, numbness, or tingling (bilateral)212_C. ElectromyographyUse EMG codes 95860-95864 and 95867-95870 when no nerve conduction studies (95907-95913) are performed on that day.Use 95885, 95886, and 95887 for EMG services when nerve conduction studies (95907-95913) are performed on the same day.To bill these codes, extremity muscles innervated by three nerves (for example, radial, ulnar, median, tibial, peroneal, femoral, not sub branches) or four spinal levels must be evaluated; a minimum of five muscles must have been studied.CPT Code 95869 - Needle electromyography; thoracic paraspinal musclesCPT code 95869 should be used to bill a limited EMG study of specific muscles. Examinations confined to distal muscles only, such as intrinsic foot or hand muscles, will be reimbursed as Code 95869 and not as 95860-95866.Use CPT Code 96869 to study thoracic paraspinal muscles between T3 and T11.One unit can be billed, despite the number of levels studied or whether unilateral or bilateral.CPT Code 95870 Needle electromyography, other than paraspinal
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A57478)
CPT Code 95870 Needle electromyography, other than paraspinalCPT code 95870 is used for limited testing of specific muscles during an examination. This code should be used only when the muscles tested do not fit more appropriately under another CPT code.CPT code 95870 can be billed at one unit per extremity (one limb, arm or leg), when fewer than five muscles are examined.It can also be used for examining non-limb (axial) muscles (e.g., intercostal, abdominal wall, cervical and lumbar paraspinal muscles (unilateral or bilateral) regardless of the number of levels tested. However, it should not be billed when the paraspinal muscles corresponding to extremity are tested, and when the extremity codes 95860, 95861, 95863, or 95864 are reported.CPT Code 95933 - Blink ReflexesRecordings should be made bilaterally with both ipsilateral and contralateral stimulation.The report of this study should include the presence or absence of the R1 and R2 components.CPT Code 95937 - Neuromuscular Junction StudiesRepetitive stimulation studies are used to identify and to differentiate disorders of the NMJ. This test consists of recording muscle responses to a series of nerve stimulus (at variable rates), both before, and at various intervals after, exercise or transmission of high-frequency stimuli.These codes may be used in association with motor and sensory NCSs of the same nerves and are reimbursed separately.When this study is performed, the providers report should note characteristics of the test, including the rate of repetition of stimulations, and any significant incremental or decremental response.II. Reasons for Denial in addition to those stated in LCD
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A57478)
II. Reasons for Denial in addition to those stated in LCDThe report(s) did not include the required numerical data specifically, the amplitude, latency, and velocity gathered during nerve conduction studies.Descriptions of F-wave without reference to a corresponding motor conduction data; pattern-setting unilateral H-reflex measurements; separate E/M charges without documentation requested from the referral source.Surface and macro EMGs will not be paid.Failure to submit, upon request or when request an informal review, a clinical history indicating the need for testing.Absence of a clinical history, preferable written by the referral source, indicating the need for the test.Absence of documentation to support repeated testing on the same beneficiary.Testing every beneficiary referred for pain.Needle electromyographic (EMG) codes 95860- 95870, and 95885-95887 have the designation of 6A for the technical portion of the test. Therefore, if authorized by state law Physical Therapists are allowed the technical portion of the test according to the description of 6A. Definition below:6A = Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.Needle electromyographic (EMG) code 95872 has the designation of 66 for the technical portion of the test. Definition below:66 = May be personally performed by a physician or by a physical therapist with ABPTS certification and certification in this specific procedure.CMS long-standing policy that the concept of physician supervision does not apply (PSI of 09) to these PT-designated diagnostic services, which allows payment to be made for the PC or global code to the ABPTS-PT, excepted by regulation, as long as it is legal for the ABPTS-PT to provide the service in that state, and the TC has been either personally performed by the ABPTS-PT or the PT without the ABPTS certification has met the supervision requirements for the technical component portion of the service consistent with the applicable supervision indicator.III. Comments
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A57478)
Certain less than optimal practices are discouraged, and may invite review. They include: exclusive testing of intrinsic foot muscles in the diagnosis of proximal lesions; definitive diagnostic conclusions based on paraspinal EMG in regions bearing scar of past surgeries (e.g., previous laminectomies); pattern-setting limited limb muscle examinations, without paraspinal muscle testing for diagnosis of radiculopathies, narrative reports without data, and premature EMG testing after trauma when EMG changes may not have taken place.There are situations in which EMG and nerve conduction studies can be valuable in a relatively acute situation with or without trauma, even though full-blown EMG changes may not yet have taken place. An example is, to assess the presence of pre-existing injury or disease after trauma or in the evaluation of some non-traumatic conditions, such as suspected Guillain-Barre syndrome.Frequency of testing is a difficult issue to answer. Clinical justification, rather than an algorithm, should be the determinant in these instances. While this removes any recipe-style limits, it also calls for clear responsible and evidence-based documentation for any repeat study. Such a guideline applies to all studies including those for patients(s) under medical, surgical or rehabilitative treatment, (ii) for neuropathy and (iii) for patients with chronic renal failure and/or dialysis.
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A57478)
Physical Therapists Performing EMGsProgram Memorandum Transmittal B-01-28/Change Request 850 sets forth revised levels of physician supervision required for diagnostic tests payable under the Medicare Physician Fee Schedule. Effective July 1, 2001, certain codes in the range of CPT 95860-95937 were assigned new supervision levels (21, 22, 6a, 66, 77 or 77a). This implementation date would make it possible for physical therapists to acquire the certification required to perform these services without supervision. A physical therapist who is presently certified by the American Board of Physical Therapy Specialties can perform procedures assigned level of 21, 22, 66, 6a, 77, or 77a without supervision. These numeric levels assigned to the CPT codes are listed in the Medicare Physician Fee Schedule Database (MFSDB).Physical therapists who do not possess the ABPTS (American Board of Physical Therapy Specialties) certification by July 1, 2001, may continue to furnish those tests that require the certification if they have been furnishing such diagnostic tests prior to May 1, 2001.Payment will be based on the Medicare Physician Fee Schedule level of supervision designation.Nerve conduction code 95905 does not have one of the above designations and is therefore not allowed by Physical Therapists.Nerve conduction codes 95907-95913 had their Physician Supervision of Diagnostic Procedures Indicators adjusted to 7A effective 01/01/2013 (CR 8169). Therefore, if authorized by state law Physical Therapists are allowed the technical portion and professional component of the test according to the description of 7A which is included in this Billing and Coding Article.