evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease (A58406)
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 claimCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 30 Financial Liability ProtectionsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease L38278.As this service constitutes post-procedure analysis of a previously performed study (CCTA), the name and National Provider Identifier (NPI) of the referring/ordering physician that submitted imaging data for FFRCTreview must be reported on the claim.An Advance Beneficiary Notice (ABN) of non-coverage may be used for services that are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 30 for complete instructions.The patients medical record must document all of the following:The clinical findings that led to the initial performance of the CCTA, and the CCTA must be fully reviewed before the performance of FFRCT(as evidenced by the submission of the Coronary Computed Tomographic Angiography Report)Description of symptoms consistent with stable ischemic heart diseaseFractional Flow Reserve analysis report
Article - Billing and Coding: Colon Capsule Endoscopy (CCE) (A58410)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states thatno 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) L38805 Colon Capsule Endoscopy (CCE). 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.For the purposes of this Billing and Coding Article, ICD-10-CM diagnosis codeZ53.8indicates that the instrument colonoscopy has been attempted and was incomplete and ICD-10-CM diagnosis codeZ53.09indicates the procedure is contraindicated when a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training determined from an evaluation of the patient that optical colonoscopy cannot be safely attempted.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: Chiropractic Services (A58412)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Sections 30.5 Chiropractors Services, 240 Chiropractic Services  General, 240.1  Coverage of Chiropractic Services, 240.1.1  Manual Manipulation, 240.1.2  Subluxation May Be Demonstrated by X-Ray or Physicians Exam, 240.1.3  Necessity for treatment, 240.1.4  Location of Subluxation, and 240.1.5  Treatment ParametersCMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 12, Section 220 Chiropractic ServicesChapter 30, Financial Liability ProtectionsSocial 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 Chiropractic Services.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered as if they are covered. When billing for non-covered services, use the appropriate modifier.When billing for Chiropractic services:Report the initial treatment or date of exacerbation.Specify the precise spinal location and level of subluxation.Report the date of X-ray if an X-ray is used to demonstrate subluxation.Report the level of subluxation using the appropriate ICD-10-CM code.In addition to reporting the ICD-10-CM code for the level of subluxation, report any other pertinent ICD-10-CM codes.All treatments must be categorized as acute subluxation, chronic subluxation or maintenance therapy. An exacerbation of a previous injury should be categorized into either "acute" or "chronic" (e.g., an identifiable re-injury would fall under acute).The following modifiers should be reported with CPT codes 98940, 98941, and98942 as is appropriate to each patient's situation:
Article - Billing and Coding: Chiropractic Services (A58412)
The following modifiers should be reported with CPT codes 98940, 98941, and98942 as is appropriate to each patient's situation:AT  Acute treatmentGA  Waiver of liability statement issued as required by payer policy, individual case. Authorization has been provided to notify the beneficiary of the likelihood that services rendered will be denied as not reasonable and medically necessary under Medicare guidelines.GZ  Item or service expected to be denied as not reasonable and necessaryFor Medicare purposes, the AT modifier shall now be used only when chiropractors bill for active/corrective treatment.Every chiropractic claim (those containing CPT codes 98940, 98941, or 98942) with a date of service on or after October 1, 2004 is to include the AT modifier if active/corrective treatment is being performed; orThe AT modifier should not be appended to the service if maintenance therapy is being performed. Contractors shall deny a chiropractic claim (containing CPT codes 98940, 98941, or 98942) with a date of service on or after October 1, 2004, that does not contain the AT modifier.The mere presence of the AT modifier does not indicate that the service(s) are medically necessary. Reasonable and necessary requirements as addressed in the Medicare Internet-Only Manuals must be met.Reasons for DenialExcluded from Medicare coverage is any service other than manual manipulation for the treatment of subluxation of the spine. The chiropractor is not required to bill excluded services. However, if the beneficiary requests Medicare be billed, the provider must bill services to Medicare in order to obtain a denial for secondary insurance purposes. The following are examples (not an all-inclusive list) of services excluded from Medicare coverage when performed by a chiropractor; the beneficiary is responsible for payment.Laboratory testsX-raysOffice visits (history and physicals)PhysiotherapyTractionSuppliesInjectionsDrugsEKGs or any diagnostic studyOrthopedic devicesNutritional supplements/counselingAny service ordered by the chiropractorDocumentation Requirements
Article - Billing and Coding: Chiropractic Services (A58412)
Laboratory testsX-raysOffice visits (history and physicals)PhysiotherapyTractionSuppliesInjectionsDrugsEKGs or any diagnostic studyOrthopedic devicesNutritional supplements/counselingAny service ordered by the chiropractorDocumentation 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: Colon Capsule Endoscopy (CCE) (A58414)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states thatno 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) L38807 Colon Capsule Endoscopy (CCE). 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.For the purposes of this Billing and Coding Article, ICD-10-CM diagnosis codeZ53.8indicates that the instrument colonoscopy has been attempted and was incomplete and ICD-10-CM diagnosis codeZ53.09indicates the procedure is contraindicated when a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training determined from an evaluation of the patient that optical colonoscopy cannot be safely attempted.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: Botulinum Toxins (A58423)
CMS National Coverage PolicyInternet Only Manual (IOM) Citations:CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 17, Drugs and BiologicalsChapter 23, Section 20.9 National Correct Coding Initiative (CCI)Social 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) L38809, Botulinum Toxins. Please refer to the LCD for reasonable and necessary requirements.According to the FDA Label indications, botulinum toxin treatment for blepharospasm and chronic migraine headaches is limited to specific muscles. The muscles that are currently FDA approved are listed below. Please refer to the LCD for complete coverage guidelines.Currently the following muscles are FDA approved for Onabotulinumtoxin A (BOTOX) injections for chronic migraine headache treatment:CorrugatorProcerusFrontalisTemporalisOccipitalisCervical paraspinalsTrapeziusCurrently the following muscles are FDA approved for Onabotulinumtoxin A (BOTOX) injections for blepharospasm treatment:Medial and lateral pre-tarsal orbicularis oculi muscle of the upper lidLateral pre-tarsal orbicularis oculi muscle of the lower lidCurrently the following muscles are FDA approved for Incobotulinumtoxin A (Xeomin) injections for blepharospasm treatment:Lateral and medial superior pre-tarsal part of the orbicularis oculi muscleLateral canthus of the orbicularis oculi muscleInferolateral portion of the orbicularis oculi muscleCorrugator muscle
Article - Billing and Coding: Botulinum Toxins (A58423)
Lateral and medial superior pre-tarsal part of the orbicularis oculi muscleLateral canthus of the orbicularis oculi muscleInferolateral portion of the orbicularis oculi muscleCorrugator muscleCoding 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.The administration/injection code should be reported on the same claim with the botulinum toxin medication. When the botulinum toxin medication is denied, the related injection code(s) will also be subject to denial.JW and JZ ModifiersWhen billing for Part B drugs and biologicals (except those provided under a competitive acquisition program [CAP]), the use of the JW modifier to identify unused drugs or biologicals from single-dose containers or single-use packages that are appropriately discarded is required. The discarded amount shall be billed on a separate claim line using the JW modifier. Providers are required to document the discarded drug or biological in the patients medical record.Any amount wasted must be clearly documented in the medical record and should include the date and time, amount of medication wasted, and the reason for the wastage.The use of the JZ modifier (attesting that there were no discarded amounts) is required on claims to report there are no discarded amounts of unused drugs or biologicals from single-dose containers or single-use packages.Claims for drugs separately payable under Medicare Part B from single-dose containers are required to report either the JW or JZ modifier to identify any discarded amounts or to attest that there are no discarded amounts respectively.The JW and JZ modifier policy does not apply for drugs that are not separately payable, such as packaged OPPS or ASC drugs, or drugs administered in the FQHC or RHC setting.The JW and JZ modifiers do not apply to drugs assigned status indicator N (Items and Services Packaged into APC Rates) under the OPPS. Similarly, the JW and JZ modifiers do not apply to drugs assigned payment indicator N1 (ASC).Documentation Requirements
Article - Billing and Coding: Botulinum Toxins (A58423)
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 provider must support the medical necessity of the services as stated in the LCD and should include the following elements in the event of a post payment review:Documentation of unsuccessful, inadequate response, or not a candidate for conventional methods of treatment, and/or other appropriate methods used to control condition as applicable (a statement outlining relevant medical history is acceptable).Results of pertinent tests/procedures.Name of botulinum toxin, total dosage, each injection site with the dosage, and frequency of injections.Support of the clinical effectiveness of the injections.Documentation of the patient's response or lack of response to injections.Support for the medical necessity of localization procedures if performed.Documentation supporting the management of a chronic migraine diagnosis along with a history that supports migraines occur greater than or equal to 15 days per month.
Article - Billing and Coding: Diagnostic Colonoscopy (A58428)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard ReferencesTitle 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) L38812 (Diagnostic Colonoscopy). 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.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 (office/progress notes) maintained by the ordering/referring physician must indicate the medical necessity of the colonoscopy procedure. The procedure results/report and any associated pathology report must be included in the patient's medical record.If the provider of the colonoscopy is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of procedure results/report and pathology report along with copies of the ordering/referring physician's order for the procedure.The patients medical record should contain documentation to support an incomplete procedure.
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers (A58434)
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 LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Minimal Residual Disease Testing for Cancer L38822.A Minimal Residual Disease (MRD) test, as defined in the related LCD, is aservicethat may include multiple components and/or multiple timepoints (i.e., serial assays).Testing schedules are set based on the validity established for the individual test comprising the service.Each component and timepoint of the service must be reasonable and necessary and adhere to the criteria set forth in the related LCD. The medical record must contain clear documentation of the medical necessity of this test, as per the conditions outlined in the LCD.The following tests have met the criteria for coverage under the policy:Indicated UseTestPATIENTS WITH CANCER-Initial Testwhere tumor profiling is utilized - from a prior analysisSignatera Bespoke Assay Design (by comprehensive genomic profile (CGP)) + Plasma SeriesBundlefor Molecular Residual Disease (Natera, Inc)where tumor profiling is utilizedSignatera Whole Exome + Plasma SeriesBundlefor Molecular Residual Disease (Natera, Inc)tumor nave testingGuardant Reveal MRDBundle(Guardant, Inc)Guardant 360 ResponseSubsequent TestMay only be performed if there is clinical evidence of apriorichange in genetic contentSignateraRecurrence MonitoringPlasma TestBundle(Natera, Inc)PATIENTS WITHOUT CANCER (as defined in the policy)Initial Testwhere tumor profiling is utilized - from a prior analysisSignateraRecurrence MonitoringBespoke Assay Design (CGP) + single Plasma Test (Natera, Inc)where tumor profiling is utilizedSignateraRecurrence MonitoringWhole Exome Design + single Plasma Test (Natera, Inc)Subsequent testSignateraRecurrence Monitoringsingle Plasma Test (Natera, Inc)RaDaRRecurrence Monitoringsingle Plasma Test (NeoGenomics Laboratories, Inc)Tumor Nave TestWhere baseline tumor profiling is not utilized
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers (A58434)
Subsequent testSignateraRecurrence Monitoringsingle Plasma Test (Natera, Inc)RaDaRRecurrence Monitoringsingle Plasma Test (NeoGenomics Laboratories, Inc)Tumor Nave TestWhere baseline tumor profiling is not utilizedNavDX (Naveris, Inc) single Plasma TestAdditional Test-specific Indications, Limitations and InstructionsIntended uses that have met clinical validity (CV) criteria under the policy include: (1) the diagnosis of disease progression, recurrence, or relapse for advanced colorectal (Natera and Guardant), bladder and breast cancers (Natera) (2) the diagnosis of disease recurrence or relapse for advanced breast (RaDaR) and HPV-driven oropharyngeal cancer (Naveris) (3) the monitoring of response to immune-checkpoint inhibitor therapy for colorectal cancer (Guardant) or any solid tumor (Natera). However, the tests listed in the table may have only been approved for one or more (but not necessarily all) of these indications.Note: 'Bundle' refers to multiple plasma assays.