evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Diagnostic and Therapeutic Colonoscopy (A57342)
Article TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.Coding GuidelinesDo not report a colonoscopy procedure code for an endoscopy performed with a sigmoidoscope on a patient with a normal length colon, even if the sigmoidoscope reaches proximal to the splenic flexure. A sigmoidoscope (an endoscope typically 65 centimeters in length) may be used for a colonoscopy only if the bowel is sufficiently short so that the entire colon may be examined, and such should be clearly documented in the clinical record.Payment for a colonoscopy performed in the office is subject to recovery when colonoscope information is not available to the contractor.An incomplete colonoscopy is defined by CMS in the IOM at 100-4, Chapter 12, Section 30.1.B;Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121).An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier -53. (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. An incomplete colonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.When the colonoscopy procedure is unusual or difficult, modifier 22 (unusual procedural services) may be reported.The most specific ICD-10-CM code must be chosen and billed to its highest level of specificity. Submit this as the line diagnosis (linked to the procedure) on the claim.LimitationsThe requirements for coverage havenotbeen met if:
Article - Billing and Coding: Diagnostic and Therapeutic Colonoscopy (A57342)
Only a sigmoidoscope is used.An office-based colonoscopy is not validated with the appropriate equipment information.Chronic abdominal pain unresponsive to medical therapy is used to justify the service but lacks appropriate clinical documentation.Documentation RequirementSupportive clinical documentation evidencing the condition and treatment is expected to be documented in the clinical notes or procedure note and be made available upon request from the MAC or other authorized CMS auditor.Medical records need not be submitted with the claim unless modifier 22 is used; however, they must be furnished to Medicare upon request.The medical records must support the medical reasonableness, necessity, and frequency of each diagnostic service supplied.The medical record must substantiate the diagnosis listed on the claim form.The colonoscopy report must describe the following:The maximum depth of penetration;A description of any abnormal findings; andAny procedures performed as the result of such findings (e.g., biopsy).
Article - Billing and Coding: Diagnostic and Therapeutic Colonoscopy (A57343)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1862(a)(1)(A) states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1862(a)(7) and 42 Code of Federal Regulations, 411.15 et seq. exclude routine physical examinations.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Title XVIII of the Social Security Act, 1862(a)(1)(H) and Balanced Budget Act 97, Chapter V, Subtitle B, 4104 provides coverage for colorectal cancer screening tests.CMS Manual System, Publication 100-04,Medicare Claims Processing Manual,Chapter 12, 30.1B, addresses incomplete colonoscopies.Article Text
Article - Billing and Coding: Diagnostic and Therapeutic Colonoscopy (A57343)
Article TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.Coding GuidelinesDo not report a colonoscopy procedure code for an endoscopy performed with a sigmoidoscope on a patient with a normal length colon, even if the sigmoidoscope reaches proximal to the splenic flexure. A sigmoidoscope (an endoscope typically 65 centimeters in length) may be used for a colonoscopy only if the bowel is sufficiently short so that the entire colon may be examined, and such should be clearly documented in the clinical record.Payment for a colonoscopy performed in the office is subject to recovery when colonoscope information is not available to the contractor.An incomplete colonoscopy is defined by CMS in the IOM at 100-4, Chapter 12, Section 30.1.B;Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121).An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier -53. (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. An incomplete colonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.When the colonoscopy procedure is unusual or difficult, modifier 22 (unusual procedural services) may be reported.The most specific ICD-10-CM code must be chosen and billed to its highest level of specificity. Submit this as the line diagnosis (linked to the procedure) on the claim.LimitationsThe requirements for coverage havenotbeen met if:
Article - Billing and Coding: Diagnostic and Therapeutic Colonoscopy (A57343)
Only a sigmoidoscope is used.An office-based colonoscopy is not validated with the appropriate equipment information.Chronic abdominal pain unresponsive to medical therapy is used to justify the service but lacks appropriate clinical documentation.Documentation RequirementSupportive clinical documentation evidencing the condition and treatment is expected to be documented in the clinical notes or procedure note and be made available upon request from the MAC or other authorized CMS auditor.Medical records need not be submitted with the claim unless modifier 22 is used; however, they must be furnished to Medicare upon request.The medical records must support the medical reasonableness, necessity, and frequency of each diagnostic service supplied.The medical record must substantiate the diagnosis listed on the claim form.The colonoscopy report must describe the following:The maximum depth of penetration;A description of any abnormal findings; andAny procedures performed as the result of such findings (e.g., biopsy).
Article - Billing and Coding: BDX-XL2 (A57356)
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. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims,60.1.2 Independent Laboratory Specimen Drawing, and60.2 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 BDX-XL2 L37054.
Article - Billing and Coding: BDX-XL2 (A57357)
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 Manuals, Pub.100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, and 60.2 Travel AllowanceCMS Internet-Only Manuals, Pub.100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesCMS Internet-Only Manuals, Pub.100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesArticle TextThe following coding and billing guidance is to be used with its associated Local Coverage Determination BDX-XL2 L37062.
Article - Billing and Coding: Monitored Anesthesia Care (A57361)
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) L35049 Monitored Anesthesia Care. 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.Anesthesia procedures listed in the CPT/HCPCS Codes section of this article are examples of those that are usually provided by the attending surgeon and are included in the global fee and are not separately billable. In certain instances, however, MAC provided by anesthesia personnel may be necessary for these procedures if the patient has one or more of the conditions or situations found in the ICD-10-CM Codes That Support Medical Necessity section of this article. The use of anesthesia modifiers, when the CPT code is not fully descriptive, isrequiredas follows:
Article - Billing and Coding: Monitored Anesthesia Care (A57361)
G8 anesthesia modifier used to indicate certain deep, complex, complicated or markedly invasive surgical procedures. This modifier is to be applied to the following anesthesia codes only: 00100, 00300, 00400, 00160, 00532 and 00920.G9 anesthesia modifier represents a history of severe cardiopulmonary disease and should be utilized whenever the proceduralist feels the need for MAC due to a history of advanced cardiopulmonary disease. The documentation of this clinical decision-making process and the need for additional monitoring must be clearly documented in the medical record.Anesthesia codes utilized to indicate the clinical condition of the patient receiving MAC:P1 healthy individual with minimal anesthesia risk,P2 mild systemic disease,P3 severe systemic disease with intermittent threat of morbidity or mortality,P4 severe systemic illness with ongoing threat of morbidity or mortality,P5 premorbid condition with high risk of demise unless procedural intervention is performed.Special conditions or criteria must be supported by documentation in the medical record.Conditions listed under the Diagnoses that Support Medical Necessity section of this article, if matched with anesthesia procedures in the CPT/HCPCS Codes section of the article, could support the need for MAC. Other disease states can also be considered if medical justification is demonstrated.Diagnoses that Support Medical NecessityAdditional diagnoses that do not have a fully descriptive ICD-10-CM code are listed below. By using the diagnosis code(s) listed, the medical records must reflect the conditions as described.For combative patients, use ICD-10-CM code F91.9.For patients with low pain thresholds or who suffer severe pain, use ICD-10-CM code G97.81.For intraoperative expansion of procedure, use ICD-10-CM code T81.9XXA.For any condition in a pediatric patient, Medicare eligible and younger than 18 years of age, use ICD-10-CM code T88.8XXA.For patients with mental retardation (patients who are uncooperative due to a lack of understanding caused by their mental disability), use ICD-10-CM code F79.
Article - Billing and Coding: Monitored Anesthesia Care (A57361)
If MAC is used for these reasons, clinical records must be available upon request that justify the need for MAC.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.
Article - Billing and Coding: MolDX: Breast Cancer Assay: Prosigna® (A57363)
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 Manuals, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS 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 CodesArticle TextThe following coding and billing guidance is to be used with its associated Local coverage determination.To report a Prosigna service, please submit the following claim information:Select CPT code 81520Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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: MolDX: Breast Cancer Assay: Prosigna® (A57364)
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 Manuals, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS 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 CodesArticle TextThe following coding and billing guidance is to be used with its associated Local coverage determination.To report a Prosigna service, please submit the following claim information:Select CPTcode 81520Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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: MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (A57372)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.s.CMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure Codes.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease.To report a Prostate Genomic Classifier service, please submit the following claim information:Select applicable 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 837PItem 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 ICD-10-CM code C61
Article - Billing and Coding: MolDX: Blood Product Molecular Antigen Typing (A57376)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Blood Product Molecular Antigen Typing.Blood product antigen typing is a germline test and the use of panels 0001U and 0084U will be limited to once in a beneficiary lifetime.The individual codes 0180U-0201U, 0221U and 0222U and codes 81105-81112 are also germline tests. These will be noncovered as multiple antigens must be utilized as part of a comprehensive antigen evaluation and will be considered only as part of a panel.To report a Blood Product Molecular Antigen Typing service, please submit the following claim information:Select the appropriate CPTor PLA codeEnter 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 837PItem 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: MolDX: Pharmacogenomics Testing (A57384)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Pharmacogenomics Testing L38335Relevant National Coverage Determinations (NCDs):NCD 90.1: Testing for CYP2C9 and VKORC1 for Warfarin dosage must adhere to the requirements set forth in this NCD.Relevant Articles:Billing and Coding: MolDX: Testing of Multiple Genes A58120Billing and Coding: MolDX: Repeat Germline Testing A57331Additional documentation requirements for coverage and billing:Performing providers are required to acquire and retain records of the drugs under consideration for use or in use by the ordering physician that necessitate the use of ordered test.MolDX may make available specific forms to assist with test Technical Assessments (TAs). Please follow the instructions on the MolDX website to assist with this process. If such forms are available that pertain to the test type in question, these forms are required for successful coverage determinations.Billing instructions:To report a pharmacogenomics testing service, please submit the following claim information:Select the appropriate CPT code or PLA 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 837PItem 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: MolDX: Pharmacogenomics Testing (A57384)
Select the appropriate ICD-10-CM codeFor part B claims, the drug or drugs in consideration for use that require the use of the pharmacogenomics (PGx) test must be submitted in the applicable detail line 2400 loop. The character maximum for loop 2400 is 80. To prevent denials/rejects when indicating more than 80 characters, please indicate the required drug names first. If multiple drugs are being used/considered for the specified beneficiary on the claim, they should be added to the comment line separated by a "/" (example Drug 1/Drug 2). Do not list the same drug more than once. The use of the generic name is strongly preferred.For Part B paper claims, the drug or drugs in consideration for use that require the use of the pharmacogenomics (PGx) test must be submitted in Item 19 field.Only one test may be performed per date of service; the test should be the most likely to identify the necessary alleles/variants for the drug/drugs in question. This applies to both single gene tests and multigene panels.The medical necessity for the additional testing and the clinical decision making for the additional testing must be documented in the medical record. The CPT code set relevant to this policy is listed in the table below. If no CPT code is available for the gene being tested, the NOC code 81479 may be used. The identification of the proper recommended billing code is established as part of the test application process.Gene/CPT coding/Drug informationTable 1 represents relevant gene/drug associations related to metabolizing enzymes from CPIC and FDA sources.Table 1.This table represents metabolism gene/drug associations from CPIC and FDA sources.GeneCPT Code(s)Generic NameTrade Name(s)Intended use for Drug(s)GuidanceABCG281479rosuvastatinCrestorAntihyperlipidemicCPICBCHE81479mivacurium, succinylcholineMivacurium chloride, AnectineNeuromuscular blocking agentFDACYP2B681479efavirenzSustivaAntiretroviral; HIVCPIC/FDACYP2B681479sertralineZoloftAntidepressant-Selective Serotonin Reuptake Inhibitor (SSRI)CPIC/FDACYP2C19