evekhm/cms_iom_500 huggingface dataset:
Article - Surgical Dressings - Policy Article (A54563)
Elastic bandages are those that contain fibers of rubber (latex, neoprene), spandex, or elastane. Roll bandages that do not contain these fibers are considered non-elastic bandages even though many of them (e.g., gauze bandages) are stretchable. Codes A6442, A6443, A6444, A6445, A6446, A6447 describe roll gauze-type bandages made either of cotton or of synthetic materials such as nylon, viscose, polyester, rayon, or polyamide. These bandages are stretchable, but do not contain elastic fibers. These codes include short-stretch bandages.Codes A6448, A6449, A6450 describe ACE-type elastic bandages. Codes A6451 and A6452 describe elastic bandages that produce moderate or high compression that is sustained typically for one week. They are commonly included in multi-layer compression bandage systems. Suppliers billing these new codes must be able to provide, upon request, documentation from the manufacturer verifying that the performance characteristics specified in the code narratives have been met.When multi-layer compression bandage systems are used for the treatment of a venous stasis ulcer, each component is billed using a specific code for the component - e.g., moderate or high compression bandages (A6451, A6452), conforming bandages (A6443, A6444), self-adherent bandages (A6454), padding bandages (A6441), zinc paste impregnated bandage (A6456).For the compression stocking codes A6531 and A6532, one unit of service is generally for one stocking. However, if a manufacturer has a product consisting of two components that are designed to be worn simultaneously on the same leg, the two components must be billed as one claim line with one unit of service  e.g., a product that consists of an unzippered liner and a zippered stocking.
Article - Surgical Dressings - Policy Article (A54563)
The only products that may be billed using code A6545 (non-elastic compression wrap) are those for which a written CVR has been made by the PDAC contractor and subsequently published on the PCL. Information concerning the documentation that must be submitted to the PDAC for a Coding Verification Request can be found on the PDAC web site or by contacting the PDAC. A PCL with products that have received a coding verification can be found on the PDAC web site. If a product is billed to Medicare using a HCPCS code that requires written CVR, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.Modifiers A1-A9 have been established to indicate that a particular HCPCS code is being used as a primary or secondary dressing on a qualifying surgical or debrided wound. Modifiers A1-A9 are used to indicate the number of qualifying wounds on which a specific dressing HCPCS code is being used.The modifier number must correspond to the number of qualifying wounds on which the dressing HCPCS code is being used, not the total number of wounds treated.Modifiers A1-A9 are not used with codes A6531 and A6532.Example Scenarios:
Article - Surgical Dressings - Policy Article (A54563)
September 1 Dressing Shipment: Beneficiary has two wounds that require two different categories of dressings, A61XX (max allowance of 30 per month) and A62XX (max allowance of 12 per month)Supplier should bill:A61XX A1 UOS = 30A62XX A1 UOS = 12September 15 Dressing Shipment: Beneficiary has a new wound that requires one of the same categories of dressings as another wound (A61XX  max allowance of 30 per month)Supplier should supply and bill 15 units (to last for the next 2 weeks) and should append the A2 modifier because this dressing category is now used on 2 wounds. NOTE: The modifier number corresponds to the number of wounds on which the dressing is being used, not the total number of wounds treated.A61XX A2 UOS = 15October 1 Dressing Shipment: Beneficiary still has three wounds: two require A61XX (max allowance of 60 per month) and one requires A62XX (max allowance of 12 per month)Supplier should bill:A61XX A2 UOS = 60A62XX A1 UOS = 12
Article - Surgical Dressings - Policy Article (A54563)
If the dressing is not being used as a primary or secondary dressing on a surgical or debrided wound, do not use modifiers A1-A9. When dressings are provided in noncovered situations (e.g., use of gauze in the cleansing of a wound or intact skin), a GY modifier must be added to the code and a brief description of the reason for non-coverage included - e.g., "A6216GY - used for wound cleansing."When tape codes A4450 and A4452 are used with surgical dressings, they must be billed with the AW modifier (in addition to the appropriate A1-A9 modifier). When gradient compression stocking codes A6531 and A6532 or the gradient compression wrap code A6545 are used for an open venous stasis ulcer, the code must be billed with the AW modifier (but not an A1-A9 modifier). For this policy, codes A4450, A4452, A6531, A6532, and A6545 are the only codes for which the AW modifier may be used.The RT and/or LT modifiers must be used with codes A6531, A6532, and A6545 for gradient compression stockings and wraps. Effective for claims with dates of service (DOS) on or after 3/1/2019, when the same code for bilateral items (left and right) is billed on the same date of service, bill each item on two 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 and billed with 2 UOS. Claims billed without modifiers RT and/or LT, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.When dressing codes are billed for items covered under another benefit (e.g., gauze for a continent ostomy which is covered under the prosthetic device benefit) claims must be billed according to the documentation requirements specified in the applicable policy (see Ostomy Supplies policy for details).Suppliers should contact the PDAC contractor for guidance on the correct coding of these items.
Article - Billing and Coding: Removal of Benign Skin Lesions (A54602)
CMS National Coverage PolicyN/AArticle TextMedicare does not cover cosmetic surgery or expenses incurred in connection with such surgery (CMS publication 100-02; Medicare Benefit Policy Manual, Chapter 16, Section 20). including complications resulting from non-covered services (CMS publication IOM 100-02, Chapter 16, Section 180). This coding article provides documentation requirements and coding instructions for non-cosmetic removal of benign skin lesions.The following are examples of benign skin lesions:sebaceous (epidermoid) cystsskin tagsmilia ( keratin-filled cysts)nevi (moles)acquired hyperkeratosis (keratoderma)papillomashemangiomasviral wartsRemoval of benign skin lesions is not considered cosmetic when symptoms or signs which warrant medical intervention are present, including but not limited to:BleedingIntense itchingPainChange in physical appearance, for example, but not limited to:reddeningpigmentary changeenlargementincrease in the number of lesionsPhysical evidence of inflammation or infection, e.g., purulence, oozing, edema, erythema, etc.Lesion obstructs an orificeLesion clinically restricts eye function, for example, but not limited to:Lesion restricts eyelid functionlesion causes misdirection of eyelashes or eyelidlesion restricts lacrimal puncta and interferes with tear flow;lesion touches globe;Clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesion appearanceWart removals is not considered cosmetic when guidelines above are met or if any of the following clinical circumstances are present:Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus sheddingWarts showing evidence of spread from one body area to another, particularly in immunosuppressed patients or warts of recent origin in an immunocompromised patientsLesions are condyloma acuminata or molluscum contagiosumCervical dysplasia or pregnancy is associated with genital wartsMedicare will not pay for a separate E & M service on the same day as a minor surgical procedure unless a documented significant and separately identifiable medical service is rendered. The service must be fully and clearly documented in the patients medical record and a modifier 25 should be used.
Article - Billing and Coding: Removal of Benign Skin Lesions (A54602)
Medicare will not pay for a separate E & M service by the operating physician during the global period unless the service is for a medical problem unrelated to the surgical procedure. The service must be fully and clearly documented in the patients medical record.Coding GuidelinesFor excision of benign lesions requiring more than simple closure, i.e., requiring intermediate or complex closure, report 11400-11466 in addition to appropriate intermediate (12031-12057) or complex closure (13100-13153) codes. For reconstructive closure, see 14000-14300, 15000-15261, and 15570-15770.CPT codes 11400-11446 should be used when the excision is a full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure.Excision is defined as full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed. Each benign lesion excised should be reported separately.Code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). The margins refer to the most narrow margin required to adequately excise the lesion, based on the physician's judgment. The measurement of lesion plus margin is made prior to excision.Units of service:CPT code 11200 should be reported with one unit of service. CPT code 11201 should be reported with units equal to one for each additional group of 10 lesions or part thereof.CPT code 17000 should be reported with one unit of service for destruction of the first lesion; CPT code 17003 should be reported with the units equal to the number of additional lesions from 2 through 14; 17004 should be reported with one unit of service, representing 15 or more lesions and should not be used with 17000 or 17003.CPT code 17110 should be reported with one unit of service for removal of benign lesions other than skin tags or cutaneous vascular lesions, up to 14 lesions. CPT code 17111 is also reported with one unit of service representing 15 or more lesions.Billing for cosmetic surgery:
Article - Billing and Coding: Removal of Benign Skin Lesions (A54602)
Billing for cosmetic surgery:Claims for removal of benign skin lesions performed merely for cosmetic reasons may not necessarily need to be submitted to Medicare unless the patient requests that a formal Medicare denial is issued. If a claim is filed, ICD-9 CM code V50.1 (Other plastic surgery for unacceptable cosmetic appearance) should be used in conjunction with the appropriate CPT code.GY ModifierThe definition of the GY modifier is - Item or service statutorily excluded or does not meet the definition of any Medicare benefit.The GY modifier must be used when physicians, practitioners, or suppliers want to indicate that the item or service is statutorily non-covered or is not a Medicare benefitAdvance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by physician/provider should be billed on the same claim.Modifier 24 should be used when unrelated evaluation and management services, by the same physician, are reported during a postoperative global period.Modifier  25 should be used when separately identifiable evaluation and management services that are above and beyond the pre- and post-operative work of the procedure, by the same physician are performed on the same day as a covered minor surgical service is performed.Evaluation and management services provided on the day, or the day before a minor surgical procedure, for the purpose of making the decision to perform the procedure, are not payable. The modifier  57 cannot be used since the decision to perform the minor surgical procedure is considered a routine preoperative service and a visit or consultation should not be billed. (Modifier 57 is only applicable for major procedures that have a 90-day global period.)For claims submitted to the Part A MAC:Hospital Inpatient Claims:The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04.The principal diagnosis is the condition established after study to be chiefly responsible for this admission.
Article - Billing and Coding: Removal of Benign Skin Lesions (A54602)
Hospital Inpatient Claims:The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04.The principal diagnosis is the condition established after study to be chiefly responsible for this admission.The hospital enters ICD-9-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.)Hospital Outpatient Claims:The hospital should report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patients symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the providershould report an ICD-9-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (V70-V82).The hospital enters the full ICD-9-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.Documentation RequirementsMedical records maintained by the physician must clearly document the medical necessity for the lesion removal(s).
Article - Response to Comments for MolDX: Biomarkers in Cardiovascular Risk Assessment (A54610)
CMS National Coverage PolicyN/AArticle TextJudicious Use of BiomarkersComment:A commenter indicates there are occasions when it is necessary to accurately gauge a patients overall CV risk, and simple screening tests (lipids and CRP) are inadequate in capturing the majority of subjects at increased risk.  Specifically:
Article - Response to Comments for MolDX: Biomarkers in Cardiovascular Risk Assessment (A54610)
LDL particles  (yields the same info as apoB) - may help to persuade for more intensive lipid lowering intervention beyond traditional goals;Lipoprotein subclasses - LDL subclass - may help to persuade more intensive lipid lowering intervention beyond traditional goals;Intermediate density lipoproteins - Limit to high TG subjects.High density lipoprotein AI9LpAI and AI/AII  Occasionally apoAI or apoAII levels is helpful, particularly where HDL- c is markedly elevated and one wants to make sure there are actually increased levels of HDL particlesLipoprotein(a) - typically limited to consult patient when assessing global risk,or when patient has a thrombotic event history without an eliciting risk factor. It is undeniable that LPa elevation predicts incident increased CVD event risk incremental to traditional RF, lipid profile levels and CRP.Apolipoprotein B (Apo B), apo A-I and apo E  occasionally helpful  apoB (when TG levels are markedly elevated making LDL-c calculation less accurate) and apoAI levels are helpful.ApoE or apoE isoforms  not used in our institutionLipoprotein-associated phospholipase A2 (Lp-PLA2) - to better gauge global CVD risks and to assess level of intensity of preventive efforts.BNP - NT-proBNP presumably help identify those at increased risk for CVD incremental to traditional risk factors;helpful in heart failure subjects or subjects with complaint of SOB;to better gauge global CVD risks;as with microalbumin, helps making decision of what type of BP medication to intensify sometimes.Cystatin - elevated levels help identify increased risk for CKD development.Thrombogenic/hematologic factors - Factor V Leiden, Protein C, anti-cardiolipin Antibodies, etc - very rarely used; maybe unexplained thrombotic event.Interleukin-6 (IL-6), tissue necrosis factor- a (TNF- a) , plasminogen activator inhibitor-1 (PAI-1) and IL-6 promoter polymorphism  not usedFree fatty acids  rarely used
Article - Response to Comments for MolDX: Biomarkers in Cardiovascular Risk Assessment (A54610)
Free fatty acids  rarely usedVisfatin, angiotensin-converting enzyme 1 (ACE2) and serum amyloid A  rarely usedMicroalbumin  usedto gauge overall global CVD risks on initial consult;to assess for early evidence of renal issues;as withBNP, may help in BP medication to intensifyMyeloperoxidase (MPO)  occasionally at initial consult to gauge overall global CVD and thrombotic risks and to assess level of intensity of preventive efforts.Homocysteine and methylenetetrahydrofolate reductase (MTHFR) mutation testing - rarely usedHCys is associated with incident CVD event risk and premature atherosclerotic heart disease;HCys appropriate in patient with premature thrombotic event of unclear etiology;In subjects with CKD, elevated HCys is very strong predictor of incident CVD risks and mortality risks; when elevated, intensification of global CVD risk reduction effortsIf dramatically elevated, triggers search for specific vitamin deficiencies.Uric acid  some physicians under certain conditions use this to help identify those at increased risk for major adverse CV event risk incremental to traditional risk factors.
Article - Response to Comments for MolDX: Biomarkers in Cardiovascular Risk Assessment (A54610)
The following are not used for CV risk assessmentVitamin DWhite blood cell countLong-chain omega-3 fatty acids in red blood cell membraneGamma-glutamyltransferase (GGT)Genomic profiling including CardiaRisk angiotensin geneLeptin, ghrelin, adiponectin and adipokines, retinol binding protein 4 (RBP4) and resistinInflammatory markers including VCAM-1, P-selectin (PSEL) and E-selectin (ESEL)Cardiovascular risk panelsResponse:The commenter and others confirm that, aside from lipids and CRP, biomarker testing is specific for a specific clinical condition/disease, or as in the latter group, not clinically indicated for CV risk assessment at all.General CV risk assessment panels, consisting of various combinations of biochemical, immunologic, hematologic, and molecular tests, constitutes patient screening, and are not a  Medicare benefit.  Medicare coverage for CV risk assessment is limited to the basic lipid panel under NCD (90.1).  Under this policy, Medicare does cover the use of specific biomarkers (not as a broad risk panel) to characterize a given lipid abnormality or disease (e.g., diabetes), to determine a treatment plan or to assist with intensification of therapy.Comment:Another commenter writes we share your view that biomarkers reviewed in this LCD lack compelling data for use in aiding CV risk assessment beyond conventional measures."Response:Generally agree.Coverage ApoB and LDL Particle NumberComment:Another commenter agrees with the LCD policy which views non-traditional lipid markers as well as other non-lipid biomarkers, as investigational for use in cardiovascular (CV) risk assessment.  The commenter presents a thorough discussion for the role of LDL particle number and ApoB in high-risk populations to aidCV risk management.
Article - Response to Comments for MolDX: Biomarkers in Cardiovascular Risk Assessment (A54610)
In brief, LDL particle number (NMR LDL-P), rather than LDL size or subclass, has been shown to be significantly associated with CV risk independent of traditional lipid and established risk factors.  The American Association of Clinical Endocrinologists (AACE), the National Lipid Association (NLA), the American Diabetes Association (ADA) in conjunction with the American College of Cardiology (ACC), and the American Association of Clinical Chemistry (AACC) have developed consensus position statement on lipoprotein particle management in individuals at risk for CVD.  Due to the prevalence of discordantly elevated LDL-P despite achieving low LDL-C and non-HDL-C values, each endorses use of LDL particle number to evaluate LDL response and aid decision making regarding potential adjustment of therapy.  The 2013 AACE Comprehensive Diabetes Management Algorithm, as well as the 2015 joint AACE/American College of Endocrinology Clinical Practice Guidelines for Comprehensive Diabetes Mellitus Care, advocate specific LDL particle number goals for statin treated diabetic patients at high CV risk.  The commenter presents a summary table of recommendations from expert societies advocating use of LDL particle number measure inCV risk management, and respectfully request coverage of LDL particle number and apoB for use in high-risk populations to aid CV risk management.Response:CGS and the MolDx contractor sincerely appreciates the comprehensive review of current data to support LDL particle number and apoB for high-risk populations. CGS and the MolDX contractor recognizes the role of LDL particle number, apoB and other individual biomarkers as clinically indicated in the management and treatment of CV disease.  This policy is directed towards CV screening panels that exceed the basic lipid panel as specified in the NCD.
Article - Response to Comments for MolDX: Breast Cancer Assay: Prosigna (A54611)
CMS National Coverage PolicyN/AArticle TextResponse to Comments  DL36125  Breast Cancer Assay: ProsignaComment:Multiple commenters supported the coverage of Prosigna, an FDA approved molecular assay which can be provided in local qualified laboratories.Response:CGS and the MolDx contractor acknowledges the letters of support for coverage for this policy.Comment:A commenter asked to include Bill Types for independent laboratories.Response:Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, 13.1.3 LCDs consist of only reasonable and necessary information. All bill type and revenue codes have been removed.