evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Guardant360® (A58214)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, 80.0, 80.1.1, 80.2. Clinical Laboratory servicesCMS Internet-Only Manual Publication 100-04,Medicare Claims Processing Manual, Chapter 23, 10 "Reporting ICD Diagnosis and Procedure Codes"Article TextCoverage will continue on a case by case basis utilizing the following criteria until such time a more comprehensive non-proprietary local coverage determination can be developed.Guardant360remains covered for patients with non-CNS originated solid tumors who meet the criteria of NCD 90.2 when the following conditions are met:Patient has been diagnosed with a recurrent, relapsed, refractory, metastatic, or advanced solid tumor that did not originate from the central nervous system. Patients who would meet all of the indications on the FDA label for larotrectinib if they are found to have an NTRK mutation may be considered to have advanced cancer,andPatient has not previously been tested with the Guardant360 test for the same primary cancer. For a patient who has been tested previously using Guardant360 for a cancer, that patient may only be tested again when the patient has a new primary cancer diagnosis. In a patient with previously tested primary cancer, who has evidence of new malignant growth, that growth may be considered to be a different primary cancer if it does not originate from the same cell line or it is physiologically different enough that it responds differently to treatment than the previously tested cancer,andPatient is untreated for the primary cancer being tested or the patient is not responding to treatment (e.g. progression or new lesions on treatment),andThe patient has decided to seek further cancer treatment with the following conditions:The patient is a candidate for further treatment with a drug that is either FDA-approved for that patients cancer, or has an NCCN 1 or NCCN 2A recommendation for that patients cancer,andThe FDA-approved indication or NCCN recommendation is based upon information about the presence or absence of a genetic biomarker tested for in the Guardant360 assay,and
Article - Billing and Coding: Guardant360® (A58214)
Tissue-based CGP is infeasible (i.e., quantity not sufficient for tissue-based CGP or invasive biopsy is medically contraindicated)orspecifically in NSLC Tissue-based CGP has shown no actionable mutations.If no alteration is detected by Guardant360 or if ctDNA is insufficient/not detected, tissue-based genotyping should be considered.
Article - Billing and Coding: Screening for Cervical Cancer with Human Papillomavirus (HPV) (A58216)
CMS National Coverage PolicyIOM Citations:CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 4, Section 210.2.1 Screening for Cervical Cancer with Human Papillomavirus (HPV) Testing (Effective July 9, 2015)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 TextIt has come to our attention that services submitted for screening for cervical cancer with Human Papillomavirus (HPV) Testing have been reported incorrectly. This Billing and Coding Article provides billing and coding guidance for these services.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered as if they are covered. When billing for non-covered services, use the appropriate modifier.Consistent with National Coverage Determination (NCD) 210.2.1 screening HPV services are to be billed with Healthcare Common Procedure Coding System (HCPCS) code G0476. These services require dual diagnosis codes. The primary International Statistical Classification of Diseases and Related Health Problems, 10threvision, (ICD-10) code Z11.51 must be reported along with one of the following secondary ICD-10-CM diagnosis codes: Z01.411 or Z01.419.It is incorrect to report these screening services with Current Procedural Terminology (CPT) code 87624 [Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types].Please refer to NCD 210.2.1 for complete information on screening for cervical cancer with Human Papillomavirus (HPV).
Article - Billing and Coding: Computed Tomography Cerebral Perfusion Analysis (CTP) (A58218)
CMS National Coverage PolicyN/AArticle TextDocumentation RequirementsThe patients medical record should include but is not limited to: The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit, Relevant medical history Results of pertinent tests/procedures Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.) Performance of the study in a stoke centerEffective 12/12/2021 please append computed tomography cerebral perfusion analysis identified with CPT 0042T with the KX modifier to attest the CTP analysis was performed in a certified stroke center.If the service is provided in the emergency room (POS 23) the ER must be part of the certified stroke center to qualify for coverage.The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes willbe returned.The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, the reason for the tests, an interpretive report and copies of images. The computerized image reconstruction data should also be maintained.Documentation must be available to Medicare upon request.
Article - Billing and Coding: Computed Tomography Cerebral Perfusion Analysis (CTP) (A58223)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Computed Tomography Cerebral Perfusion Analysis (CTP).Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Documentation Requirements:The patients medical record should include but is not limited to: The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit, Relevant medical history Results of pertinent tests/procedures Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.) Performance of the study in a stoke centerThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the attached LCD. (See "Indications and Limitations of Coverage" of the LCD.) This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be denied.The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, the reason for the tests, an interpretive report and copies of images. The computerized image reconstruction data should also be maintained.
Article - Billing and Coding: Computed Tomography Cerebral Perfusion Analysis (CTP) (A58225)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Computed Tomography Cerebral Perfusion Analysis (CTP).Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Documentation Requirements:The patients medical record should include but is not limited to: The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit, Relevant medical history Results of pertinent tests/procedures Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.) Performance of the study in a stoke centerThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the attached LCD. (See "Indications and Limitations of Coverage" of the LCD.) This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be denied.The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, the reason for the tests, an interpretive report and copies of images. The computerized image reconstruction data should also be maintained.
Article - Billing and Coding: Transurethral Waterjet Ablation of the Prostate (A58227)
CMS National Coverage PolicySocial 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 TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38705 Transurethral Waterjet Ablation of the Prostate. Please refer to the LCD for reasonable and necessary requirements.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.Documentation RequirementsAll documentation must be maintained in the patient's 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: Transurethral Waterjet Ablation of the Prostate (A58229)
CMS National Coverage PolicySocial 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 TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38707 Transurethral Waterjet Ablation of the Prostate. Please refer to the LCD for reasonable and necessary requirements.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.Documentation RequirementsAll documentation must be maintained in the patient's 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: Screening for Cervical Cancer with Human Papillomavirus (HPV) (A58232)
CMS National Coverage PolicyCMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 4, Section 210.2.1 Screening for Cervical Cancer with Human Papillomavirus (HPV) Testing (Effective July 9, 2015)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 TextIt has come to our attention that services submitted for screening for cervical cancer with Human Papillomavirus (HPV) Testing have been reported incorrectly. This Billing and Coding Article provides billing and coding guidance for these services.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered as if they are covered. When billing for non-covered services, use the appropriate modifier.Consistent with National Coverage Determination (NCD) 210.2.1 screening HPV services are to be billed with Healthcare Common Procedure Coding System (HCPCS) code G0476. These services require dual diagnosis codes. The primary International Statistical Classification of Diseases and Related Health Problems, 10th revision, (ICD-10) code Z11.51 must be reported along with one of the following secondary ICD-10-CM diagnosis codes: Z01.411 or Z01.419.It is incorrect to report these screening services with Current Procedural Terminology (CPT) code 87624 [Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types].Please refer to NCD 210.2.1 for complete information on screening for cervical cancer with Human Papillomavirus (HPV).
Article - Billing and Coding: Transurethral Waterjet Ablation of the Prostate (A58243)
CMS National Coverage PolicySocial 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 TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38712, Transurethral Waterjet Ablation of the Prostate. Please refer to the LCD for reasonable and necessary requirements.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.Documentation RequirementsAll documentation must be maintained in the patient's 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 Chronic Venous Insufficiency of the Lower Extremities (A58250)
CMS National Coverage PolicyInternet Only Manual (IOM) Citations:CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 23, Section 20.9 National Correct Coding Initiative (CCI)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.National Correct Coding Initiative:NCCI Policy Manual for Medicare ServicesChapter 1 General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services.Chapter 5 Surgery: Respiratory, Cardiovascular, Hemic and Lymphatic Systems (CPT Codes 30000-39999), Section D Cardiovascular System.Chapter 9 Radiology Services (CPT codes 70000-79999), Section D Interventional/Invasive Diagnostic Imaging, Section G Medically Unlikely Edits (MUEs), and Section H General Policy Statements.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38720 Treatment of Chronic Venous Insufficiency of the Lower Extremities. Please refer to the LCD for reasonable and necessary requirements.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 sclerosant used in sclerotherapy procedures is included in the procedure code and is not separately reported.Liquid sclerotherapy is reported using CPT codes 36468, 36470, and 36471.Non-compounded foam (NCF) sclerotherapy, for treatment of incompetent extremity truncal veins, is reported using CPT codes 36465 and 36466.Non-compounded foam (NCF) sclerotherapy, for treatment of other incompetent extremity veins, is reported using CPT codes 36470 and 36471.
Article - Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities (A58250)
Non-compounded foam (NCF) sclerotherapy, for treatment of other incompetent extremity veins, is reported using CPT codes 36470 and 36471.Physician-compounded foam (PCF) sclerotherapy, for treatment of incompetent extremity truncal veins and other incompetent extremity veins, is reported using CPT codes 36470 and 36471.The Curent Procedural Terminology (CPT) Professional edition code book states that when performed in the office setting, all required supplies and equipment are included in 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, and 36483 and may not be separately reported. In addition, application of compression dressing(s) (e.g., compression bandages/stockings) is included and may not be separately reported.According to the CPT Professional edition code book, CPT codes 37241-37244 are used to describe vascular embolization and occlusion procedures excluding the ablation/sclerotherapy procedures for venous insufficiency/telangiectasia of the extremities/skin, which are reported using 36468, 36470, and 36471. For sclerosis of veins or endovenous ablation of incompetent extremity veins, see 36468-36479. CPT code 37241 is not appropriate for reporting of vein ablation for the treatment of chronic venous insufficiency of the lower extremities and is incorrect coding.Per the NCCI Policy Manual for Medicare Services, Chapter 5, Section D., Subsection 43, Ligation procedures of the lower extremity (e.g., CPT codes 37700-37785) include application of a compression dressing, if performed. CPT code 29581 (application of multi-layer compression system) shall not be reported separately.Utilization Parameters
Article - Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities (A58250)
Utilization ParametersCPT code 36468 should be reported for the treatment of symptomatic spider veins/telangiectasia in the lower extremities by injection of sclerosing agents. According to the CPT Professional edition code book, it may only be reported once per extremity per session, regardless of the number of injections performed.Per the CPT Professional edition code book, codes 36474, 36476, 36479, and 36483 for subsequent vein(s) treated in the same extremity may only be reported once per extremity, regardless of the number of additional vein(s) treated.Documentation RequirementsAll documentation must be maintained in the patient's 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.Documentation must include a plan of care, for a 90 day episode of care, that supports the evaluation of the patient including a history, physical examination, CEAP clinical classification, VCSS and a formal venous duplex scan.