evekhm/cms_iom_500 huggingface dataset:
Article - External Upper Limb Tremor Stimulator Therapy - Policy Article (A59680)
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).External upper limb tremor stimulators and related supplies and accessories meet the benefit requirements for Durable Medical Equipment (Social Security Act 1861(s)(6)). 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 specific statutory payment policy requirements, discussed below, that also must be met.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 prior to delivery, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn 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.
Article - External Upper Limb Tremor Stimulator Therapy - Policy Article (A59680)
POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn 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, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.The medical records must include all of the following documentation to support initial coverage of an external upper limb tremor stimulator of the peripheral nerves of the wrist (E0734) and associated supplies (A4542):
Article - External Upper Limb Tremor Stimulator Therapy - Policy Article (A59680)
The beneficiary is 18 years or older with a diagnosis of essential tremor (ET) with symptoms affecting their dominant upper limb, and has no contraindications to external upper limb tremor stimulator therapy; and,The external upper limb tremor stimulator is being prescribed to treat severe ET symptoms in the beneficiarys dominant upper limb that impairs their ability to perform upper-limb-related (i.e., eating, drinking, self-care, writing) activities of daily living (ADLs). Severe ET symptoms are indicated by a score of greater than or equal to 3 on the Bain & Findley Tremor ADL Scale (BF-ADL) for any upper-limb-related assessment item; and,If medically appropriate, tremor exacerbating medications (e.g., stimulants, beta agonists) have been reduced or eliminated; and,At least two (2) pharmacological treatment options for the management of ET symptoms have been either tried and failed at maximal tolerable treatment dosages (i.e., no or limited effect, intolerable side effects) or considered and ruled out (e.g., not appropriate in the context of the beneficiarys medical history); and,The external upper limb tremor stimulator therapy is being prescribed as an alternative to invasive and/or permanent surgical treatment options (e.g., deep brain stimulation, magnetic resonance guided focused ultrasound, radiosurgery).
Article - External Upper Limb Tremor Stimulator Therapy - Policy Article (A59680)
MODIFIERSGA, GZ, KX, LT, and RT MODIFIERS:Suppliers must add the KX modifier to claim lines billed for an external upper limb tremor stimulator, and related supplies and accessories, 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.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 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.Claim lines billed without a KX, GA, or GZ modifier will be rejected as missing information.An external upper limb tremor stimulator of the peripheral nerves of the wrist (E0734) and associated supplies (A4542) are limb-specific (i.e., right or left upper extremity). The RT (right) and LT (left) modifiers must be used when billing codes E0734 and A4542. When bilateral (left and right) upper limb tremor stimulators or supplies are billed on the same date of service, bill each item on separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line with 2 UOS. Claim lines billed without the RT and/or LT modifiers, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.CODING GUIDELINESCode E0734 describes an external upper limb tremor stimulator that delivers customized electrical stimulation transcutaneously to the nerves of the upper extremity.
Article - External Upper Limb Tremor Stimulator Therapy - Policy Article (A59680)
CODING GUIDELINESCode E0734 describes an external upper limb tremor stimulator that delivers customized electrical stimulation transcutaneously to the nerves of the upper extremity.Code A4542 describes related accessories and supplies used with an external upper limb tremor stimulator and includes, but is not limited to, the wrist band with integrated electrodes. Code A4542 is separately billed at initial issue of the external upper limb tremor stimulator of the peripheral nerves of the wrist (E0734) and can be billed every ninety (90) days thereafter.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: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) (DA59682)
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 Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) DL39802.Coding InformationProcedure codes may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and National Provider Identifier (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 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 RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD (SeeCoverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Medical record documentation must be available to Medicare upon request.
Article - MolDX: Defining panel services in MolDX (A59685)
CMS National Coverage PolicyN/AArticle Text
Article - MolDX: Defining panel services in MolDX (A59685)
Medical testing services have become more comprehensive and complex over time. In the past, it was generally considered that any given condition could be diagnosed or defined with a single analyte test. Additionally, limits in technology meant that if any additional testing was necessary, an independent and subsequent service would need to be performed. Neither condition above is true today. First, many diseases require multiple genetic or other relevant analytes to be assessed simultaneously for either diagnosis or to inform the clinician on subsequent medical interventions; second, tests today are more comprehensive and parallelized, such that many analytes can be obtained at once, reducing waste and turnaround time while also increasing accuracy. As such, the old model of one gene/analyte for one disease must be wholly discarded for a majority of disorders known today.The National Correct Coding Initiative (NCCI), reflecting CMS policy, provides instruction with this line of thinking, as outlined in Chapter 10, particularly section F pertaining to Molecular Pathology. Effectively, if a multianalyte test is performed, it should be billed as a single service. If no specific code exists for that panel, it is not appropriate to bill for the components of that service (this constitutes unbundling) and should be billed with the NOC codes such as 81479, 81599, or 87999, depending on analytes measured.Additionally, the role of the payor is to pay for services that have demonstrated medical value (reasonable and necessary in the case of Medicare), and the role of coding with the payor is to ensure clarity on the service performed. Ensuring panels are appropriately billed as a single service greatly reduces the complexity and confusion in billing.Here, we define a distinction between the performance of a medical service as a panel or a discrete single analyte service. Of note this was similarly defined for germline panels in article A57503 in the Medicare Coverage Database.Defining criteria:A service is a panel if:1. If a clinician orders a group of molecular analytes (more than 1) marketed as a single service;2. The service contains multiple analytes (more than 1) that would result in a single result or single report or several independent services are performed that would result in a single result; OR
Article - MolDX: Defining panel services in MolDX (A59685)
2. The service contains multiple analytes (more than 1) that would result in a single result or single report or several independent services are performed that would result in a single result; OR3. The medical value of the service/s performed is only obtained if more than one analyte is measured and the analytes are generally performed together. As an example, if 2 analytes (A and B) are tested, and BOTH must be performed together to have medical value, then it is a panel because analyte A or B alone is insufficient to provide medical value even if each analyte independently provides partial medical information; OR4.If multiple analytes (more than 1) are measured in parallel, regardless of how they are performed or reportedOf note, it is not particularly relevant if the analytes are measured with different instruments or reagents. We consider these internal lab processes that are not relevant to the test ordered, the relevance of the analytes measured, and the resultant report.A service is NOT a panel if a single analyte is measured defined by a single CPT code, and that single analyte alone provides the necessary information for proper patient management without other analytes being measured for the same disease indication.Examples of a panel:A service of 2, 5, 10, or 500 genes for evaluating a patient with colorectal cancer, with or without RNA analysisA screening test looking for 5 commonly mutated genes in the prenatal settingA test that measures multiple alterations within a gene with one or more assays that have more than one associated CPT code, such as DMD sequence AND copy number analysisA respiratory pathogen test that includes 2 or more pathogens that must generally be tested together for relevance, for example Influenza A/B, RSV, and COVID-19
Article - MolDX: Defining panel services in MolDX (A59687)
CMS National Coverage PolicyN/AArticle Text
Article - MolDX: Defining panel services in MolDX (A59687)
Medical testing services have become more comprehensive and complex over time. In the past, it was generally considered that any given condition could be diagnosed or defined with a single analyte test. Additionally, limits in technology meant that if any additional testing was necessary, an independent and subsequent service would need to be performed. Neither condition above is true today. First, many diseases require multiple genetic or other relevant analytes to be assessed simultaneously for either diagnosis or to inform the clinician on subsequent medical interventions; second, tests today are more comprehensive and parallelized, such that many analytes can be obtained at once, reducing waste and turnaround time while also increasing accuracy. As such, the old model of one gene/analyte for one disease must be wholly discarded for a majority of disorders known today.The National Correct Coding Initiative (NCCI), reflecting CMS policy, provides instruction with this line of thinking, as outlined in Chapter 10, particularly section F pertaining to Molecular Pathology. Effectively, if a multianalyte test is performed, it should be billed as a single service. If no specific code exists for that panel, it is not appropriate to bill for the components of that service (this constitutes unbundling) and should be billed with the NOC codes such as 81479, 81599, or 87999, depending on analytes measured.Additionally, the role of the payor is to pay for services that have demonstrated medical value (reasonable and necessary in the case of Medicare), and the role of coding with the payor is to ensure clarity on the service performed. Ensuring panels are appropriately billed as a single service greatly reduces the complexity and confusion in billing.Here, we define a distinction between the performance of a medical service as a panel or a discrete single analyte service. Of note this was similarly defined for germline panels in article A57503 in the Medicare Coverage Database.Defining criteria:A service is a panel if:1. If a clinician orders a group of molecular analytes (more than 1) marketed as a single service;2. The service contains multiple analytes (more than 1) that would result in a single result or single report or several independent services are performed that would result in a single result; OR
Article - MolDX: Defining panel services in MolDX (A59687)
2. The service contains multiple analytes (more than 1) that would result in a single result or single report or several independent services are performed that would result in a single result; OR3. The medical value of the service/s performed is only obtained if more than one analyte is measured and the analytes are generally performed together. As an example, if 2 analytes (A and B) are tested, and BOTH must be performed together to have medical value, then it is a panel because analyte A or B alone is insufficient to provide medical value even if each analyte independently provides partial medical information; OR4.If multiple analytes (more than 1) are measured in parallel, regardless of how they are performed or reportedOf note, it is not particularly relevant if the analytes are measured with different instruments or reagents. We consider these internal lab processes that are not relevant to the test ordered, the relevance of the analytes measured, and the resultant report.A service is NOT a panel if a single analyte is measured defined by a single CPT code, and that single analyte alone provides the necessary information for proper patient management without other analytes being measured for the same disease indication.Examples of a panel:A service of 2, 5, 10, or 500 genes for evaluating a patient with colorectal cancer, with or without RNA analysisA screening test looking for 5 commonly mutated genes in the prenatal settingA test that measures multiple alterations within a gene with one or more assays that have more than one associated CPT code, such as DMD sequence AND copy number analysisA respiratory pathogen test that includes 2 or more pathogens that must generally be tested together for relevance, for example Influenza A/B, RSV, and COVID-19
Draft Article - Billing and Coding: Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC) (DA59693)
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.Title XVIII of the Social Security Act, 1848(b)(11) Payment rules for certain radiation therapy services under the Medicare physician fee schedule.CMS Internet-Only Manual,Pub. 100-04, Medicare Claims Processing Manual, Chapter 13,70 Radiation Oncology (Therapeutic Radiology) and70.2Services Bundled Into Treatment Management CodesArticle Text
Draft Article - Billing and Coding: Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC) (DA59693)
CMS Internet-Only Manual,Pub. 100-04, Medicare Claims Processing Manual, Chapter 13,70 Radiation Oncology (Therapeutic Radiology) and70.2Services Bundled Into Treatment Management CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC) DL39808.Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceIt 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. For Part B, use the GY or GZ modifier.Per the Current Procedural Terminology (CPT) codebook definition, the use of the correct CPT codes for the simulation of radiation, SRTs, delivery of radiation treatments and uses of image guidance (IG) requires consistency with ASTRO and CMS guidelines for radiation services.For purposes of this LCD, SRT is only payable in a non-facility setting. As defined by Section 3(b) of the Patient Access and Medicare Protection Act (PAMPA), the following settings would be allowable: The term non-facility settings refers to freestanding radiation therapy centers, which are treated like physicians offices for Medicare payment and billing purposes and are paid under the Medicare Physician Fee Schedule (MPFS). In contrast, the term facility settings refers to hospitals, which provide radiation therapy (RT) in their hospital outpatient departments. Physician offices if allowed by their local state requirements as meeting these requirements would also fall under the rubric of a freestanding RT center for Medicare payment and billing purposes for the delivery of SRT.A course of RT usually includes a clearly defined set of services such as RT consultation, treatment planning, certain technical preparation and special services (e.g., medical radiation physics, dosimetry, treatment devices, treatment delivery, and treatment management).Pre-Treatment Documentation RequirementsDocumentation must support medical necessity for the use of SRT over other conventional treatment modalities and include the following:A statement by the provider why the patient is a nonsurgical candidate AND
Draft Article - Billing and Coding: Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC) (DA59693)
A statement by the provider why the patient is a nonsurgical candidate ANDAppropriate documentation of the discussion with the patient why SRT with or withouthigh resolution ultrasound (HRUS) is preferred for the treatment of their NMSC(s) and include a discussion of present and future risks of RT treatment(s).General Documentation RequirementsDocumentation must support medical necessity for the simulation, fractionation regimen, dosing, dosimetry, medical physics evaluation and any needed changes in ongoing treatment regimens including the possible need for HRUS.All documentation must be maintained in the patient's medical record. The documentation must support the medical necessity of the services as specified in this article and it must be 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 and credentials of the physician, non-physician practitioner, dosimetrist, physicist or radiation therapist responsible for and providing the described care for the patient.The submitted medical record must support the use of the selected ICD-10-CM diagnosis code(s). The submitted CPT/HCPCS code(s) must describe the service performed. It is the providers responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM and CPTcode books appropriate to the year in which the service is rendered for the claim(s) submitted.For all RT, the medical record must include the patients primary diagnosis for which the prescribed RT is needed, the patients history for this illness as well as active co-morbid medical conditions, the patients performance status when applicable and as required by the LCD, any relevant imaging reports, the proposed treatment plan, the number, location and size of tumor(s) that are present, the stage of disease, and the anatomic site of the radiation delivery.Medical record documentation maintained by the provider must indicate the medical necessity as outlined in the LCD and must include ALL of the following for a radiation oncology procedure which employs radiation treatment planning: