evekhm/cms_iom_500 huggingface dataset:
NCCI for Medicare | CMS
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NCCI for Medicare | CMS
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NCCI for Medicare | CMS
Physicians, Nurses and Allied Health ProfessionalsRural HealthSkilled Nursing Facilities (SNFs)/Long-Term CareSpecial Open Door forumsLook up topicsBack tomenusection title h3MedicareMedicaidCHIPAmerican Indian/Alaska Native CenterQuality of careSpecial populationsFraud & abuseStatesPrivacyHealth conditions & campaignsNew Medicare CardHIPAA Administrative SimplificationLearn MoreBack tomenusection title h3Attend eventsFind resourcesGet trainingFind tools to help you help othersGet digital mediaFind your provider typeBack tomenusection title h3Physicians & other health professionalsFacilitiesHealth & drug plansEmployers & unionsBreadcrumbMedicareCoding & billingNational Correct Coding Initiative (NCCI) editsNCCI for MedicarePages in this sectionNational Correct Coding Initiative (NCCI) editsMedicare NCCI Policy ManualMedicare Correspondence Language ManualMedicare NCCI Add-on Code EditsMedicare NCCI FAQ LibraryMedicare NCCI Medically Unlikely Edit (MUE) ArchiveMedicare NCCI Medically Unlikely Edits (MUEs)Medicare NCCI Procedure to Procedure (PTP) EditsAnnouncementsCMS is withdrawing NCCI PTP edits between Column One codes 80305, 80306, and 80307 for presumptive test(s), and Column Two codes G0480  G0483, and G0659 for definitive test(s).CMS will delete the edits with a replacement file for the 4th quarter of 2023. Any claim that was affected by the procedure-to-procedure edits, including those that did not apply an NCCI modifier, will be processed and paid as appropriate under existing payment and coverage policies. CMS posted areplacement fileon the NCCI PTP webpage.CMS will delete NCCI PTP edits between Column One codes22630, 22632, 22633 and 22634, and Column Two codes63052 and 63053. More information may be found on this pageunderReplacement Files.Effective Jan. 1, 2022, CMS implemented a new format for the Add-on Code (AOC) edit file. The format is a fixed-width text file. Review the newMedicare Add-On Code File Structure (PDF).The most recent edit files, including quarterly version update changes, are available on thePTP Coding Edit page, theMedically Unlikely Edits page, and theAdd-On Code Edits page.Medicare NCCI Manuals
NCCI for Medicare | CMS
Medicare NCCI ManualsCMS updates theNCCI Policy Manual for Medicare (ZIP)once a year. The NCCI Policy Manual should be used by Medicare Administrative Contractors (MACs) as a general reference tool that explains the rationale for NCCI edits. The most current policy manual, effective Jan. 1, 2022, was postedon Dec. 15, 2021. Additions and revisions to the manual are noted in red font. Additional prior versions of the National Correct Coding Initiative Policy Manual for Medicare Services are available in theNCCI Policy Manual Archive.The most recentMedicare NCCI Correspondence Language Manualannual revision was posted on February 28, 2023. CMS wrote the manual and maintains it for use by the MACs to answer routine correspondence inquiries about the NCCI PTP and MUE edits. The general correspondence language paragraphs explain the rationale for the edits. The section-specific examples further explain the PTP or MUE edits and are sorted by edit rationale and CPT code section (00000, 10000, 20000, etc.). Please refer to the Introduction of the manual for additional guidance about its use.Medicare National Correct Coding Initiative (NCCI) EditsNCCI ImplementationReplacement FilesContact InformationSubmitting an Appeal
NCCI for Medicare | CMS
CMS developed the NCCI program to promote national correct coding of Medicare Part B claims. CMS owns the NCCI program and is responsible for all decisions regarding its contents.CMS develops its coding policies based on coding conventions defined in the American Medical Associations Current Procedural Terminology (CPT) Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices.NCCI ImplementationThe purpose of the NCCI Procedure to Procedure (PTP) edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains one table of edits for physicians or practitioners and one table of edits for outpatient hospital services. The purpose of the NCCI Medically Unlikely Edits (MUE) program is to prevent improper payments when services are reported with incorrect units of service. Refer to theHow to Use NCCI Tools booklet (PDF)for more information.MACs implement NCCI PTP edits within their claim processing systems, and CMS incorporates PTP edits into the outpatient code editor (OCE) for the Outpatient Prospective Payment System (OPPS). These edits apply to outpatient hospital services and other facility services including, but not limited to, therapy providers (Part B Skilled nursing facilities (SNFs), comprehensive outpatient rehabilitation facilities (CORFs), outpatient physical therapy and speech-language pathology providers (OPTs), and certain claims for home health agencies (HHAs) billing under Type of Bills (TOBs) 22X, 23X, 75X, 74X, 34X. MACs similarly implement Medically Unlikely (MUE) edits and corresponding MUE edits within the Fiscal Intermediary Shared System (FISS).Replacement FilesSep 14, 2023 Replacement Files (4th quarter of 2023) CMS issued replacement files for NCCI Procedure to Procedure (PTP) edits for the October 1, 2023 files (PRA and OPH).Effective July 1, 2023, CMS implemented NCCI PTP edits between Column One codes 80305, 80306, and 80307 for presumptive test(s), and Column Two codes G0480  G0483, and G0659 for definitive test(s). CMS will withdraw these edits retroactive to July 1, 2023
NCCI for Medicare | CMS
for presumptive test(s), and Column Two codes G0480  G0483, and G0659 for definitive test(s). CMS will withdraw these edits retroactive to July 1, 2023 in a replacement file for the 4th quarter of 2023. The MACs will adjust those claims with dates of service between July 1, 2023 and October 1, 2023 to allow payment as appropriate under existing payment and coverage policies. Alternatively, a laboratory may also choose to use the MAC appeals process if it does not wish to wait for the automatic adjustment to occur, or it can wait to submit its claims until CMS implements the change.Effective July 1, 2023, CMS implemented bypassable NCCI PTP edits between Column One codes 22630, 22632, 22633 and 22634, and Column Two codes 63052 and 63053. CMS will delete these edits in the October 1, 2023 edit files. The MACs will adjust claims with dates of service between July 1, 2023 and October 1, 2023 that were denied due to lack of a modifier to allow payment. A provider may also choose to use the MAC appeals process if it does not wish to wait for the adjustment to occur, or it can wait to submit its claims until CMS implements the change.NCCI updates the PTP and MUE files on a quarterly basis. However, there may be instances in which a change is needed outside of those quarterly timeframes and a replacement file is necessary. CMS issued replacement files with the following changes:Dec. 7, 2022- Replacement Files (1st quarter of 2023) - CMS issued replacement files for NCCI Procedure to Procedure (PTP) edits and updated for the January 1, 2023 files (PRA and OPH).Contact InformationThe NCCI program may address general questions and concerns about the NCCI program and edits. You must submit claim-specific inquiries to the Medicare Administrative Contractors (MACs). This includes appeals of NCCI-related denials; see Submitting an Appeal below.The NCCI program cannot answer questions outside of our scope, or questions about other CMS programs or about other payors. For example, we cannot answer questions about Local Coverage Determinations, changes to code descriptors or status indicators, or modifiers not associated with NCCI.The NCCI webpages include edit
NCCI for Medicare | CMS
other CMS programs or about other payors. For example, we cannot answer questions about Local Coverage Determinations, changes to code descriptors or status indicators, or modifiers not associated with NCCI.The NCCI webpages include edit files, the Medicare NCCI Policy Manual, FAQs, and additional information. CMS does not provide a look-up service or a clean claims tool.You may submit inquiries about the NCCI program, including those related to NCCI (PTP, MUE, and Add-on Code) edits, in writing via email toNCCIPTPMUE@cms.hhs.gov.**NOTE**Dont submit any Personally Identifiable Information (PII) or Protected Health Information (PHI).Submitting an AppealYou must submit appeals to your responsible MAC or QIC, not the NCCI Contractor. To file an appeal, please follow the instructions on theAppeals website.The NCCI contractor cannot process specific claim appeals and cannot forward appeal submissions to the appropriate appeals contractor.Helpful Educational MaterialsHow to Use The National Correct Coding Initiative (NCCI) Tools (PDF)Revised Modification to the Medically Unlikely Edit (MUE) Program -R1421OTN (PDF)Proper Use of Modifiers 59, XE, XP, XS, and XU (PDF)Medicare NCCI Correspondence Language Manual- Posted February 28, 2023Revised Modification to the Medically Unlikely Edit (MUE) Program - MM8853 (PDF)SE1422 - Medically Unlikely Edits (MUE) and Bilateral Surgical Procedures (PDF)Related LinksThe National Correct Coding Initiative in MedicaidHCPCS - General Information
NCCI for Medicare | CMS
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Article - Billing and Coding: Foot Care (A56232)
CMS National Coverage PolicyCMS Publication, IOM 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 290  Foot CareCMS Publication IOM 100-03 Medicare National Coverage Determinations(NCD) Manual, Chapter 1, Part 1, Coverage Determinations, Section 70.2.1 Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy)42 CFR  411.15 - Particular services excluded from coverage (l) Foot careArticle TextRoutine foot care is usually performed by the beneficiary himself or herself, or by a caregiver.Generally, routine foot care is excluded from coverage. Services that normally are considered routine and not covered by Medicare can be found in Publication Number 100-02 Medicare Benefit Policy Manual, Chapter 15 Covered Medical and Other Health Services, Section 290.2 Routine Foot Care. WPS GHA would also include the shaving, paring, cutting, or removal of keratoma, tyloma, and heloma as routine foot care excluded from coverage.IndicationsRoutine foot care services are subject to national regulations, which provides definitions, indications, and limitations for Medicare payment of routine foot care services.Medicare Benefit Policy Manual (Pub. 100-02), Chapter 15, Section 290 describes exceptions to routine foot care exclusions.WPS GHA includes mycotic nails with the following exceptions to routine foot care exclusions:In the presence of systemic conditions such as metabolic, neurologic, and peripheral vascular diseases.In the absence of systemic conditions:Ambulatory patient must have marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of infected toenail plate.Non-ambulatory patient suffers from pain or secondary infection resulting from the thickening and dystrophy of infected toenail plate.
Article - Billing and Coding: Foot Care (A56232)
Systemic ConditionsFoot care services are covered in the presence of a systemic condition. Refer to the Medicare Benefit Policy Publication 100-02, Chapter 15, Section 290.4 D Systemic Conditions That Might Justify Coverage for a list of systemic conditions. For diagnosis codes designated by an asterisk (*), it is required the patient be under the active care of Doctor of Osteopathic Medicine (D.O.) or Doctor of Medicine (M.D.) The active care requirement would be considered met if the claim indicates that the patient has seen an M.D. or D.O. for treatment and/or evaluation of the complicating disease process during the 6-month period prior to the service. A list of diagnosis codes can be found in Group 1 Paragraph under ICD-10 Codes that Support Medical Necessity.Presumption of CoverageRefer to the Medicare Benefit Policy Publication 100-02, Chapter 15, Section 290.4 D. for a list of conditions with a presumption of coverage for routine services.In addition to a valid billing modifier, these services must include a systemic condition diagnosis listed in IOM 100-02, Chapter 15, Section 290 and in Group 1 of the diagnosis codes. All claims for routine foot care based on the presence of a systemic condition must have a billing modifier of Q7, Q8, or Q9 to be considered for payment.Mycotic NailsMycotic nail debridement may be a covered service:In the presence of a systemic disease with the class findings and appropriate Q modifier.In the absence of systemic disease if the patient has mycotic nails and marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of infected toenail plate.In the absence of systemic disease when a non-ambulatory patient has mycotic nails and suffers from pain or secondary infection resulting from the thickening and dystrophy of infected toenail plate.For services without systemic disease and class findings, the diagnosis in Group 2 and Group 3 of the diagnosis codes below must be documented in the medical record and submitted on the claim.The nail debridement procedure codes are considered non-covered routine foot care when these services do not meet the guidelines outlined above for mycotic nail services.Limitations