evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Non-pressure chronic ulcer of left calf with necrosis of muscle  L97.224  Non-pressure chronic ulcer of left calf with necrosis of bone  L97.225  Non-pressure chronic ulcer of left calf with muscle involvement without evidence of necros  L97.226  Non-pressure chronic ulcer of left calf with bone involvement without evidence of necrosis  L97.228  Non-pressure chronic ulcer of left calf with other specified severity  L97.315  Non-pressure chronic ulcer of right ankle with muscle involvement without evidence of  necrosis  L97.316  Non-pressure chronic ulcer of right ankle with bone involvement without evidence of  necrosis  L97.318  Non-pressure chronic ulcer of right ankle with other specified severity  L97.321  Non-pressure chronic ulcer of left ankle limited to breakdown of skin L97.322  Non-pressure chronic ulcer of left ankle with fat layer exposed  L97.323  Non-pressure chronic ulcer of left ankle with necrosis of muscle  L97.324  Non-pressure chronic ulcer of left ankle with necrosis of bone  L97.325  Non-pressure chronic ulcer of left ankle with muscle involvement without evidence of  necrosis  L97.326  Non-pressure chronic ulcer of left ankle with bone involvement without evidence of  necrosis  L97.328  Non-pressure chronic ulcer of left ankle with other specified severity  L97.411  Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin  L97.412  Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed  L97.413  Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle  L97.414  Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone  L97.415  Non-pressure chronic ulcer of right heel and midfoot with muscle involvement without  evidence of necrosis  L97.416  Non-pressure chronic ulcer of right heel and midfoot with bone involvement without  evidence of necrosis  L97.418  Non-pressure chronic ulcer of right heel and midfoot with other specified severity  L97.421  Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin  L97.422  Non-pressure chronic ulcer of left heel and midfoot with fat layer exposed
(Medicare Claims Processing Manual)
and midfoot with other specified severity  L97.421  Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin  L97.422  Non-pressure chronic ulcer of left heel and midfoot with fat layer exposed  L97.423  Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle  L97.424  Non-pressure chronic ulcer of left heel and midfoot with necrosis of bone  L97.425  Non-pressure chronic ulcer of left heel and midfoot with muscle involvement  without evidence of necrosis  L97.426  Non-pressure chronic ulcer of left heel and midfoot with bone involvement  without evidence of necrosis  L97.428  Non-pressure chronic ulcer of left heel and midfoot with other specified severity  L98.411  Non-pressure chronic ulcer of buttock limited to breakdown of skin  L98.412  Non-pressure chronic ulcer of buttock with fat layer exposed  L98.413  Non-pressure chronic ulcer of buttock with necrosis of muscle  L98.414  Non-pressure chronic ulcer of buttock with necrosis of bone  L98.415  Non-pressure chronic ulcer of buttock with muscle involvement without evidence of necros  L98.416  Non-pressure chronic ulcer of buttock with bone involvement without evidence of necrosis  L98.418  Non-pressure chronic ulcer of buttock with other specified severity  L98.421  Non-pressure chronic ulcer of back limited to breakdown of skin  L98.422  Non-pressure chronic ulcer of back with fat layer exposed  L98.423  Non-pressure chronic ulcer of back with necrosis of muscle  L98.424  Non-pressure chronic ulcer of back with necrosis of bone  L98.425  Non-pressure chronic ulcer of back with muscle involvement without evidence of necrosis  L98.426  Non-pressure chronic ulcer of back with bone involvement without evidence of necrosis  L98.428  Non-pressure chronic ulcer of back with other specified severity  L98.491  Non-pressure chronic ulcer of skin of other sites limited to breakdown of skin  L98.492  Non-pressure chronic ulcer of skin of other sites with fat layer exposed  L98.493  Non-pressure chronic ulcer of
(Medicare Claims Processing Manual)
Non-pressure chronic ulcer of skin of other sites limited to breakdown of skin  L98.492  Non-pressure chronic ulcer of skin of other sites with fat layer exposed  L98.493  Non-pressure chronic ulcer of skin of other sites with necrosis of muscle  L98.494  Non-pressure chronic ulcer of skin of other sites with necrosis of bone
(Medicare Claims Processing Manual)
Frequency Requirements:   Effective for claims with dates of service on and after April 13, 2021, contractors shall cover PRP services for chronic non- healing diabetic wounds, G0465, for a maximum of 20 weeks beginning with the first week of treatment.   Effective for claims with dates of services on or after April 13, 2021, the local MACs shall have discretion to pay PRP services for chronic non- healing diabetic wounds, G0465, that are performed more than 20 weeks after the date of the first PRP service w hen the -KX modifier is reported on the claim.  Effective for claims with dates of service on and after April 13, 2021, contractors shall have discretion to cover, and determine frequency for, PRP services for chronic non- healing non-diabetic wounds, G0460.   11.3.3  Types of Bill (TOB)  (Rev. 11214, Issued: 01- 20-22, Effective:04 -13-21, Implementation: 01- 03-22 Shared Systems Contractors, 02- 14-22 MACs)    11.3.4  Payment Method  (Rev. 11214, Issued: 01- 20-22, Effective:04 -13-21, Implementation: 01- 03-22 Shared Systems Contractors, 02- 14-22 MACs)   Payment for PRP services is as follows:    Hospital outpatient departments TOBs 12X and 13X  based on the Outpatient Prospective Payment System   Skilled Nursing Facility TOBs 22X and 23X  based on the Medicare Physician Fee Schedule (MPFS)   TOB  71X  based on the all -inclusive rate   TOB 75X  based on the MPFS   TOB 77X  based on the all -inclusive rate   TOB 85X  based on reasonable cost   Critical Access Hospitals TOB 85X and revenue codes 096X, 097X, or 098X  based on the MPFS   Local MACs shall pay for PRP services for hospitals in Maryland under the jurisdiction of the Health Services Cost Review Commission on an outpatient basis, TOB 13X, in accordance with the terms of the Maryland waiver.
(Medicare Claims Processing Manual)
Local MACs shall pay for PRP services for hospitals in Maryland under the jurisdiction of the Health Services Cost Review Commission on an outpatient basis, TOB 13X, in accordance with the terms of the Maryland waiver.   11.3.5 - Place of Service (POS) for Professional Claims  (Rev. 11214, Issued: 01- 20-22, Effective:04 -13-21, Implementation: 01- 03-22 Shared Systems Contractors, 02- 14-22 MACs)   Effective for claims with dates of service on or after August 2, 2012, place of service (POS) codes 11, 22, and 49 shall be used for PRP services.  Effective for claims with dates of service on or after April 13, 2021, POS codes 11, 19, 22, and 49 shall be used for PRP services.   11.3.6  Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claim Adjustment Reason Codes (CARCs) and Group Codes (Rev. 11214, Issued: 01- 20-22, Effective:04 -13-21, Implementation: 01- 03-22 Shared Systems Contractors, 02- 14-22 MACs)   Contractors shall deny claims for PRP services when provided on other than TOBs 12X, 13X, 22X, 23X, 71X, 75X, 77X, and 85X using:   MSN 21.25 -  This service was denied because Medicare only covers this service in certain settings.   Spanish Version -  El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones.   CARC 58 -  Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. NOTE: Refer to the 832 Healthcare Policy Identification Segment (loop 2110 Service payment Information REF), if present.   RARC N428 -  Service/procedure not covered when performed in this place of service.   Group Code -  CO (Contractual Obligation)    Contractors shall reject claims for PRP services for the treatment of chronic non -healing diabetic wounds, G0465, that are performed more than 20 weeks after the date of the first PRP service when the --KX modifier is NOT included on the claim using the following messages:   CARC 119  Benefit Maximum for this time period or occurrence has been reached.
(Medicare Claims Processing Manual)
CARC 119  Benefit Maximum for this time period or occurrence has been reached.   RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.  Medicare Summary Notice (MSN) 20.5  These services cannot be paid because your benefits are exhausted at this time.   Spanish Version: Estos servicios no pueden ser pagados porque sus beneficios se han agotado.  Group Code  CO (Contractual Obligation)  Contractors shall deny/reject claims for PRP services for the treatment of chronic non-healing diabetic wounds, G0465, that dont contain the appropriate diagnosis codes as noted above and use the following messages:  Claim Adjustment Reason Code (CARC) 50 - These are non -covered services because this is not deemed a 'medical necessity' by the payer. Remittance Advice Remark Code (RARC) N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at: www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD. Medicare Summary Notice (MSN) 15.19 - We used a Local Coverage Determination (LCD) to decide coverage for your claim. To appeal, get a copy of the LCD at www.cms.gov/medicare- coverage- database
(Medicare Claims Processing Manual)
(use the MSN Billing Code for the CPT/HCPCS Code) and send with information from your doctor." Spanish Version - Usamos una Determinacin de Cobertura Local (LCD) para decidir la cobertura de su reclamo. Para apelar, obtenga una copia del LCD en www.cms.gov/medicare-coverage- database ( use el cdigo de facturacin de MSN para el cdigo "CPT/HCPCS") y envela con la informacin de su mdico.  MSN  15.20 - The following polices were used when we made this decision: NCD 270.3. Spanish Version  Las siguientes polticas fueron utilizadas cuando se tom esta decisin: NCD 270.3. NOTE: Due to system requirement, the Fiscal Intermediary Shared System (FISS) has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.  Group Code  Contractual Obligation (CO).   12 - Counseling to Prevent Tobacco Use  (Rev.3848, Issued: 08-  25-17, Effective: 09 -26-17, Implementation: 09-  26-17)  Background: Effective for services furnished on or after March 22, 2005, a National Coverage Determination (NCD) provided for coverage of smoking and tobacco- use cessation counseling services located at Medicare National Coverage Determinations Manual, Publication 100- 03 section 210.4.  CMS established a related policy entitled Counseling to Prevent Tobaccos Use at NCD Manual 210.4.1 effective August 25, 2010.  However, effective September 30, 2016, the conditions of Medicare Part A and Medicare Part B cove rage for smoking and tobacco- use cessation counseling services (210.4) were deleted.  The remaining NCD entitled Counseling to Prevent Tobacco Use (210.4.1), remains in effect, along with HCPCS codes 99406 and 99407, specifically payable for counseling to prevent tobacco use effective October 1, 2016.   12.1 - Counseling to Prevent Tobacco Use HCPCS and Diagnosis Coding  (Rev. 4237, Issued: 02- 08- 19, Effective: 03 -12- 19, Implementation: 03- 12-19)
(Medicare Claims Processing Manual)
12.1 - Counseling to Prevent Tobacco Use HCPCS and Diagnosis Coding  (Rev. 4237, Issued: 02- 08- 19, Effective: 03 -12- 19, Implementation: 03- 12-19)  The following HCPCS codes should be reported when billing for counseling to prevent tobacco use services:   99406 -  Smoking and tobacco- use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes   99407 -  Smoking and tobacco- use cessation counseling visit; intensive, greater than 10 minutes   Note the above codes were effective for dates of service on or after January 1, 2008, and specifically effective for counseling to prevent tobacco use claims on or after October 1, 2016.    Contractors shall allow payment for a medically necessary E/M service on the same day as the counseling to prevent tobacco use service when it is clinically appropriate.  Physicians and qualified non- physician practitioners shall use an appropriate HCPCS c ode, such as HCPCS 99201 99215, to report an E/M service with modifier 25 to indicate that the E/M service is a separately identifiable service from 99406 or 99407.  Contractors shall only pay for 8 counseling to prevent tobacco use sessions in a 12- month period.  The beneficiary may receive another 8 sessions during a second or subsequent year after 11 full months have passed since the first Medicare covered counselin g session was performed.  To start the count for the second or subsequent 12- month period, begin with the month after the month in which the first Medicare covered counseling session was performed and count until 11 full months have elapsed.   Claims for counseling to prevent tobacco use services shall be submitted with an appropriate diagnosis code.   NOTE:   This decision does not modify existing coverage for minimal cessation counseling (defined as 3 minutes or less in duration) which is already considered to be covered as part of each Evaluation and Management (E/M) visit and is not separately billable.   Claims for counseling to prevent tobacco use services shall be submitted with an applicable diagnosis code:   ICD- 9-CM (prior to October 1, 2015)  V15.82, personal history of tobacco use, or  305.1, non- dependent tobacco use disorder  989.84, toxic effect of tobacco
(Medicare Claims Processing Manual)
ICD- 9-CM (prior to October 1, 2015)  V15.82, personal history of tobacco use, or  305.1, non- dependent tobacco use disorder  989.84, toxic effect of tobacco   ICD- 10-CM (effective October 1, 2015)  F17.210, nicotine dependence, cigarettes, uncomplicated,  F17.211, nicotine dependence, cigarettes, in remission, F17.213 Nicotine dependence, cigarettes, with withdrawal  F17.218 Nicotine dependence, cigarettes, with other nicotine -induced disorders   F17.219 Nicotine dependence, cigarettes, with unspecified nicotine -induced disorders   F17.220, nicotine dependence, chewing tobacco, uncomplicated,  F17.221, nicotine dependence, chewing tobacco, in remission, F17.223 Nicotine dependence, chewing tobacco, with withdrawal  F17.228 Nicotine dependence, chewing tobacco, with other nicotine -induced disorders   F17.229 Nicotine dependence, chewing tobacco, with unspecified nicotine -induced disorders   F17.290, nicotine dependence, other tobacco product, uncomplicated,  F17.291, nicotine dependence, other tobacco product, in remission, or  F17.293 Nicotine dependence, other tobacco product, with withdrawal  F17.298 Nicotine dependence, other tobacco product, with other nicotine -induced disorders   F17.299 Nicotine dependence, other tobacco product, with unspecified nicotine -induced disorders
(Medicare Claims Processing Manual)
F17.298 Nicotine dependence, other tobacco product, with other nicotine -induced disorders   F17.299 Nicotine dependence, other tobacco product, with unspecified nicotine -induced disorders   Z87.891, personal history of nicotine dependence, unspecified, uncomplicated.  T65.211A, Toxic effect of chewing tobacco, accidental (unintentional), initial encounter  T65.212A, Toxic effect of chewing tobacco, intentional self -harm, initial encounter  T65.213A, Toxic effect of chewing tobacco, assault, initial encounter  T65.214A, Toxic effect of chewing tobacco, undetermined, initial encounter  T65.221A, Toxic effect of tobacco cigarettes, accidental (unintentional), initial encounter  T65.222A, Toxic effect of tobacco cigarettes, intentional self -harm, initial encounter  T65.223A, Toxic effect of tobacco cigarettes, assault, initial encounter  T65.224A, Toxic effect of tobacco cigarettes, undetermined, initial encounter  T65.291A, Toxic effect of other tobacco and nicotine, accidental (unintentional), initial encounter  T65.292A, Toxic effect of other tobacco and nicotine, intentional self -harm, initial encounter  T65.293A, Toxic effect of other tobacco and nicotine, assault, initial encounter  T65.294A, Toxic effect of other tobacco and nicotine, undetermined, initial encounter   12.2 - Counseling to Prevent Tobacco Use A/B MAC (B) Billing Requirements  (Rev.3848, Issued: 08-  25-17, Effective: 09 -26-17, Implementation: 09-  26-17)  A/B MACs (B) shall pay for counseling to prevent tobacco use services billed with codes 99406 and 99407 for dates of service on or after October 1, 2016 A/B MACs (B) shall pay for counseling services billed with codes G0436 and G0437 for dates of service on and after August 25, 2010, through September 30, 2016.  The type of service (TOS) for each of the new codes is 1.
(Medicare Claims Processing Manual)
A/B MACs (B) pay for these services billed based on the Medicare Physician Fee Schedule (MPFS).  Deductible and coinsurance are waived.  Claims from physicians or other providers where assignment was not taken are subject to the Medicare limiting charge, w hich means that charges to the beneficiary may be no more than 115% of the allowed amount.  Physicians or qualified non- physician practitioners shall bill the A/B MAC (B) for counseling to prevent tobacco use services using the ASC X12 837 professional claim format or the Form CMS -1500.  12.3 - A/B MAC (A) Billing Requirements  (Rev.3848, Issued: 08-  25-17, Effective: 09 -26-17, Implementation: 09-  26-17)  The A/B MACs (A) shall pay for counseling to prevent tobacco use services with codes 99406 and 99407 for dates of service on or after October 1, 2016.  A/B MACs (A) shall pay for counseling services billed with codes G0436 and G0437 for dates of service on or after August 25, 2010, through September 30, 2016. Deductible and coinsurance are waived.   A. Claims for counseling to prevent tobacco use services should be submitted using the ASC X12 837 institutional claim format or Form CMS -1450.  The applicable bill types are 12X, 13X, 22X, 23X, 34X, 71X, 77X, 83X, and 85X. Effective April 1, 2006, type of bill 14X is for non- patient laboratory specimens and is no longer applicable for counseling to prevent tobacco use services.   Applicable revenue codes are as follows:   Provider Type  Revenue Code  Rural Health Centers (RHCs)/Federally Qualified Health Centers (FQHCs)  052X  Indian Health Services (IHS)  0510  Critical Access Hospitals (CAHs) Method II  096X, 097X, 098X  All Other Providers  0942   NOTE:  When these services are provided by a clinical nurse specialist in the RHC/FQHC setting, they are considered incident to and do not constitute a billable visit.   Payment for outpatient services is as follows:
(Medicare Claims Processing Manual)
NOTE:  When these services are provided by a clinical nurse specialist in the RHC/FQHC setting, they are considered incident to and do not constitute a billable visit.   Payment for outpatient services is as follows:   Type of Facility  Method of Payment  Rural Health Centers (RHCs)  All-inclusive rate (AIR) for the encounter  Federally Qualified Health Centers (FQHCs)  FQHC Prospective Payment System (PPS) for the encounter  Indian Health Service (IHS)/Tribally owned or operated hospitals and hospital - based facilities  AIR IHS/Tribally owned or operated non-hospital -based facilities  Medicare Physician Fee Schedule (MPFS)  IHS/Tribally owned or operated Critical Access Hospitals (CAHs)  Facility Specific Visit Rate  Hospitals subject to the Outpatient Prospective Payment System (OPPS)  Ambulatory Payment Classification (APC)  Hospitals not subject to OPPS  Payment is made under current methodologies  Skilled Nursing Facilities (SNFs)   NOTE:   Included in Part A PPS for skilled patients.  MPFS  Home Health Agencies (HHAs)  MPFS  Critical Access Hospitals (CAHs)  Method I: Technical services are paid at 101% of reasonable cost. Method II: technical services are paid at 101% of reasonable cost, and Professional services are paid at 115% of the MPFS Data Base  Maryland Hospitals  Payment is based according to the Health Services Cost Review Commission (HSCRC). That is 94% of submitted charges subject to any unmet deductible, coinsurance, and non- covered charges policies.   NOTE: Inpatient claims submitted with counseling to prevent tobacco use services are processed under the current payment methodologies. In addition, payment is not allowed for inpatients whose primary diagnosis is counseling to prevent tobacco use.   12.4 - Remittance Advice (RA) Notices  (Rev.3848, Issued: 08-  25-17, Effective: 09 -26-17, Implementation: 09-  26-17) Contractors shall use the appropriate claim RA(s) when denying payment for counseling to prevent tobacco use services.   The following messages are used where applicable:    If the counseling services were furnished before August 25, 2010, use an appropriate RA claim adjustment reason code (CARC), such as, 26, Expenses incurred prior to coverage.
(Medicare Claims Processing Manual)
The following messages are used where applicable:    If the counseling services were furnished before August 25, 2010, use an appropriate RA claim adjustment reason code (CARC), such as, 26, Expenses incurred prior to coverage.    If the claim for counseling services is being denied because the coverage criteria are not met, use an appropriate CARC, such as, 272, Coverage/program guidelines were not met.    If the claim for counseling services is being denied because the maximum benefit has been reached, use an appropriate CARC, such as, 119, Benefit maximum for this time period or occurrence has been reached.   12.5 - Medicare Summary Notices (MSNs)  (Rev.3848, Issued: 08-  25-17, Effective: 09 -26-17, Implementation: 09-  26-17)  (When denying claims for counseling to prevent tobacco use services that were performed prior to the effective date of coverage, contractors shall use an appropriate MSN, such as, MSN 21.11, This service was not covered by Medicare at the time you received it.   When denying claims for counseling services on the basis that the coverage criteria were not met, use an appropriate MSN, such as MSN 21.21, This service was denied because Medicare only covers this service under certain circumstances.   When denying claims for counseling services that have dates of service exceeding the maximum benefit allowed, use an appropriate MSN, such as MSN 17.8, Payment is denied because the maximum benefit allowance has been reached.   12.6 - Post-Payment Review for Smoking and Tobacco- Use Cessation Counseling Services  (Rev.3848, Issued: 08-  25-17, Effective: 09 -26-17, Implementation: 09-  26-17)  As with any claim, Medicare may decide to conduct post -payment reviews to determine that the services provided are consistent with coverage instructions.  Providers must keep patient record information on file for each Medicare patient for whom a counseling claim is made.  These medical records can be used in any post -payment reviews and must include standard information along with sufficient patient histories to allow determination that the steps required in the coverage instructions were followed.  12.7 - Common Working File (CWF) Inquiry  (Rev. 4203, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)