evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer (A57112)
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.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic TestsCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesCMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer L38443.The following tests are covered in accordance with the LCD: MolDX: Predictive Classifiers for Early Stage Non-Small Cell Lung Cancer.To report a Service, please submit the following claim information:Select the appropriate CPT codeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: Removal of Benign Skin Lesions (A57113)
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) L34938, Removal of Benign Skin Lesions. 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.According to the Current Procedural Terminology (CPT) Manual, appropriate code selection for lesion removal is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision. Please refer to the current CPT manual for further information.Measurement is made prior to excision. Lesion compared to margin plus lesion should not differ significantly.Do not report shave removal codes (11300  11313) when a tangential (shave) biopsy of the lesion is performed. Shave removal codes (11300  11313) include removal of tissue that may be submitted for pathological examination, biopsy code(s) should not be reported separately with these codes. Histopathologic examination of the lesion may be reported separately, see 88304-88305. When shave removal is performed with the sole intent of obtaining pathologic diagnosis, tangential biopsy CPT code(s) 11102-11103, should be reported.Documentation RequirementsAll documentation must be maintained in the patients medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
Article - Billing and Coding: Injection of Trigger Points (A57114)
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) L33912, Injection of Trigger Points. Please refer to the LCD for reasonable and necessary requirements.Coding GuidelinesNotice: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.The medical record must clearly indicate the number of injections given per session and the site(s) injected. Furthermore, the medical record must clearly document the medical necessity for repeated injections of trigger point(s). When frequent injections are required, the medical record must reflect the reason for repeated injections.
Article - Billing and Coding: Noninvasive Ear or Pulse Oximetry For Oxygen Saturation (A57115)
CMS National Coverage PolicyN/AArticle TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33923, Noninvasive Ear or Pulse Oximetry For Oxygen Saturation. 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.Procedure codes 94760 and 94761 represent services that have a T-status indicator. Therefore, if any other services payable under the physician fee schedule are billed on the same date by the same provider, this service is bundled into the physician services for which payment is made.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.Medical record documentation maintained by the ordering/referring physician (e.g., office/progress notes) must indicate the medical necessity for performing ear or pulse oximetry studies. Additionally, a copy of the study results should be maintained in the medical records.If the provider of oximetry studies is other than the ordering/referring physician, that provider must maintain hard copy documentation of test results and interpretation along with copies of the ordering/referring physician's order for the study. The ordering/referring physician must state the clinical indication/medical necessity for the oximetry study in the order for the test.
Article - Billing and Coding: Vestibular Function Tests (A57118)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Vestibular Function Tests (A57118)
This First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33966 Vestibular Function Tests provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.Refer to the LCD for reasonable and necessary requirements and limitations.The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.Coding GuidelinesFor CPT code 92546 (Sinusoidal vertical axis rotational testing), Auto Head Rotation Tests, sometimes referred to as Active-Head Rotation Tests, should not be billed with this code.The physician ordering the vestibular test must appear on the audiologist claim.For procedure code 92537: Goggles are placed over the patients eyes and adjusted firmly on the patients face. Video cameras are positioned so that the pupils are in the field of the camera, and contrast and sensitivity are adjusted so that the pupil can be differentiated and tracked during testing. Caloric vestibular test is performed by irrigating the ear canal with either water or air for a period of 30 to 60 seconds and recording the movement response (nystagmus) for approximately two minutes following the irrigation. Sufficient time is given (Typically 5 minutes) before the opposite ear is irrigated. Based on standard practice, procedure code 92537 is intended to report a complete caloric vestibular testing procedure that includes bilateral performance of bithermal irrigation (ie, one warm and one cool irrigation for each each). Fewer irrigation procedures require a different method of reporting according to what was done. Three irrigations (ie, irrigation of both ears using monothermal irrigation of one ear and bithermal irrigation of the contralateral ear), code 92537 is reported with modifier 52 appended.For procedure code 92538: Monothermal irrigation (ie; irrigation of both ears with either cool or warm irrigation) is reported once with procedure code 92538. If a single ear is irrigated with a single method of irrigation (cool or warm), procedure code 92538 is reported once with modifier 52 appended.
Article - Billing and Coding: Vestibular Function Tests (A57118)
It is not expected to see 92540, 92541, 92542 or 92544, 92545 or 92546 billed more than once during a session.Procedure codes 92540-952546 have a professional and technical component. It would be appropriate to bill a 26 and TC modifier if necessary.Do not report 92540 in conjunction with 92541, 92542, 92544 or 92545.Notice: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 Requirements
Article - Billing and Coding: Vestibular Function Tests (A57118)
All 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.An order from the treating physician/nonphysician practitioner as required by CFR, Title 42, Volume 2, Chapter IV, Part 410.32(a) Ordering diagnostic tests.The services require a recording be obtained at the time the service is rendered. These recordings must be maintained in the patients medical record and be made available upon request. The procedure report by itself is not enough to show that the services being billed are medically reasonable and necessary. Documentation of the medical necessity of the service is typically found in the office note when the service is performed in an office setting or the physician's progress note(s) when the service is performed in a facility setting.The medical record must contain a detailed history and physical exam including a complete medication review. The medical record must support that other physiological/psychological, medication or other systemic reasons that could cause the balance problems were ruled out and that it is medically necessary to proceed with diagnostic testing of the vestibular system. The medical record must also contain the name and serial number of the equipment used to perform the vestibular tests.Utilization GuidelinesIn accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.Compliance with the provisions in LCD L33966, Vestibular Function Tests may be monitored and addressed through post payment data analysis and subsequent medical review audits.
Article - Billing and Coding: Ionized Calcium (A57120)
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) L34011 Ionized Calcium. 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.Renal dialysis facilities should report a diagnosis code of N18.6 for submission of claims.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.The medical records maintained in the patients file must document the medical necessity of the test including the test results. This information is usually found in the office/progress notes, hospital notes, and/or laboratory results.
Article - Billing and Coding: Parathormone (Parathyroid Hormone) (A57122)
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) L34018 Parathormone (Parathyroid Hormone). Please refer to the LCD for reasonable and necessary requirements and limitations.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.Renal dialysis facilities should report a diagnosis code of N18.6 for submission of claims.CPT 83970 should not be billed with more than one (1) unit of service per day.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.If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physicians order for the studies. The physician must state the clinical indication/medical necessity for the study in his order for the test.
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A57123)
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.Medicare National Correct Coding Initiative (NCCI) Policy Manual:Chapter 11, Section L-Neurology and Neuromuscular ProceduresArticle TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L34859 Nerve Conduction Studies and Electromyography. 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.Consistent with the LCD, nerve conduction studies (NCSs) without needle electromyography (NEMG) will be allowed for:Individuals being evaluated for carpal tunnel syndrome or tarsal tunnel syndrome when one of the following diagnosis codes are reported: G56.01, G56.02, G56.03, G57.51, G57.52 or G57.53.Individuals with significant lymphedema in the affected extremity when the following diagnosis code is reported in addition to the primary diagnosis: I89.0.Individuals treated with anticoagulants when one of the following diagnosis codes are reported in addition to the primary diagnosis: Z79.01 or Z79.02.NCSs and NEMG performed on the same day, for the same patient must be reported on the same claim.Consistent with the LCD, the following services/tests are non-covered. Therefore, when billing these services/tests report the unlisted neurological diagnostic CPT code 95999. When submitting claims, providers must provide a description of the service/test in block 80 (Part A for the UBO4 claim), box 19 (Part B for a paper claim) or electronic equivalent of the claim. Failure to include this information on the claim will result in Part A claims being returned to the provider and Part B claims being rejected.
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A57123)
Non-invasive electrodiagnostic (EDX) testing using portable hand-held devices or automated point of care nerve conduction monitoring systems, which are incapable of real-time waveform display and analysisPsychophysical measurements (electrical, vibratory, or thermal perceptions), even though they may involve delivery of a stimulus,are considered part of the physical examination and may not be reported as a separate servicePhysiologic recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor using wearable devices with accelerometers or gyroscopesNEMG for Surface electromyography (SEMG) or Macroelectromyography (macro-EMG)For HCPCS code G0255, refer to the CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 2, Section 160.23 Sensory Nerve Conduction Threshold Tests (sNCTs).Utilization ParametersStudies performed per day beyond the reasonable maximum number of studies recommended in the Current Procedural Terminology (CPT) Codebook, Appendix J, Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves will be denied. Additional studies may be considered on redetermination.Consistent with the LCD, the following number of tests per 12-month period per diagnosis per provider for repeat EDX assessment are suitable: 1) Two studies for carpal tunnel-unilateral, carpal tunnel-bilateral, radiculopathy, mononeuropathy, polyneuropathy, myopathy, and neuromuscular junction (NMJ) disorders. 2) Three studies for motor neuron disease and plexopathy.Documentation Requirements
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A57123)
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.The patients medical records must clearly document the medical necessity for the test. The indication for ordering the test(s) and a clear diagnostic impression are required in each report. In cases where documentation is requested, a hard copy of waveforms and/or a complete written report with an interpretation of the test, sufficient to support that the test was medically reasonable and necessary must be submitted.Normal findings and abnormalities uncovered during the study should be documented with the nerves and muscles tested, the presence and type of spontaneous activity, as well as the characteristics of the voluntary unit potentials and interpretation. Expected normal value range for the specific EDX device should also be included.If a patient has had analogous testing performed in the past, documentation should also be included that references the date it was performed as well as results and subsequent management based on those findings.