evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
12/30/2005  Redefined Type of Bill (TOB) 14X for Non -Patient Laboratory Specimens -CR 3835 Manualization  04/03/2006  4208  R766CP  12/02/2005  Stem Cell Transportation  01/03/2006  4173  R726CP  10/21/2005  Smoking and Tobacco -Use Cessation Counseling Services: Common Working File (CWF) Inquiry for Providers  01/24/2006  4104  R671CP  09/09/2005  Updated Manual Instructions for the Medicare Claims Processing Manual, Regarding Smoking and Tobacco-Use Cessation Counseling Services  10/03/2005  4045  R605CP  07/15/2005  Frequency Instructions for Smoking and Tobacco -Use Cessation Counseling Services  10/03/2005  3929  R601CP  07/01/2005  Cochlear Implantation  07/25/2005  3796  R597CP  06/24/2005  Coverage and Billing for Ultrasound Stimulation for Nonunion Fracture Healing  08/01/2005  3836  R589CP  06/24/2005  Cochlear Implantation  07/05/2005  3796  R562CP  05/20/2005  Smoking and Tobacco -Use Cessation Counseling Services  07/05/2005  3834  R526CP  04/15/2005  Updated Requirements for Autologous Stem Cell Transplantation (AuSCT)  05/16/2005  3797  R498CP  03/11/2005  Billing of the Diagnosis and Treatment of Peripheral Neuropathy with Loss of Protective Sensation in People with Diabetes  N/A 3580  R487CP  03/04/2005  Manualization of Claims Processing Instructions for Medicare Qualifying Clinical Trials  N/A 3625  Rev #  Issue Date  Subject  Impl Date  CR#  R486CP  03/04/2005  Manualization of Carrier Claims Processing Instructions for Stem Cell Transplantation  N/A 3684  R371CP  11/19/2004  Updated Billing Instructions for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)  04/04/2005  3487  R261CP  07/30/2004  Billing Requirements for Islet Cell Transplantation for Beneficiaries in a National Institutes of Health Sponsored Clinical Trial  10/04/2004  3385  R216CP  06/25/2004  Manualization of Instructions for of INR Monitoring  N/A 2323  R187CP  05/28/2004  Manualization of Instructions for
(Medicare Claims Processing Manual)
Institutes of Health Sponsored Clinical Trial  10/04/2004  3385  R216CP  06/25/2004  Manualization of Instructions for of INR Monitoring  N/A 2323  R187CP  05/28/2004  Manualization of Instructions for Billing for Hyberbaric Oxygen Therapy for the Treatment of Wounds of the Lower Extremities  06/28/2004  3172  R130aCP  03/26/2004  Manualization of Instructions for INR Monitoring  N/A 2323  R128CP  03/26/2004  Manualization of Instructions for Deep Brain Stimulation  N/A 2553  R125CP  03/26/2004  Manualization of Instructions for Sacral Nerve Stimulation  N/A 2532  R124CP  03/19/2004  Policy and Claims Processing Instructions for Electrical Stimulation And Electromagnetic Therapy  07/06/2004  3149  R109CP  02/27/2004  Updated Policy and Claims Processing Instructions for Ambulatory Blood Pressure Monitoring (AMPM)  04/05/2004  2726  Back to top of chapter
Article - Billing and Coding: Gender Reassignment Services for Gender Dysphoria (A53793)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claimArticle TextGender Dysphoria (GD) is defined by the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition, DSM-5 as a condition characterized by the "distress that may accompany the incongruence between ones experienced or expressed gender and ones assigned gender" also known as natal gender, which is the individuals sex determined at birth. Individuals with gender dysphoria experience confusion in their biological gender during their childhood, adolescence or adulthood. These individuals demonstrate clinically significant distress or impairment in social, occupational, or other important areas of functioning.GD is characterized by the desire to have the anatomy of the other sex, and the desire to be regarded by others as a member of the other sex. Individuals with GD may develop social isolation, emotional distress, poor self-image, depression and anxiety. The diagnosis of GD is not made if the individual has a congruent physical intersex condition such as congenital adrenal hyperplasia.Gender Reassignment TherapyGD cannot be treated by psychotherapy or through medical intervention alone. Integrated therapeutic approaches are used to treat GD, including psychological interventions and gender reassignment therapy. Gender reassignment therapy, either as male-to-female transsexuals (transwomen) or as female-to-male transsexuals (transmen), consists of medical and surgical treatment that changes primary or secondary sex characteristics.Initially, the individual may go through the real-life experience in the desired role, followed by cross-sex hormone therapy and gender reassignment surgery to change the genitalia and other sex characteristics. The difference between cross-sex hormone therapy and gender reassignment surgery is that the surgery is considered an irreversible physical intervention.Gender reassignment surgical procedures are not without risk for complications; therefore, individuals should undergo an extensive evaluation to explore psychological, family, and social issues prior to and post-surgery.Additionally, certain surgeries may improve gender- appropriate appearance but provide no significant improvement in physiological function. These surgeries are considered cosmetic and are non-covered.NON-SURGICAL TREATMENT
Article - Billing and Coding: Gender Reassignment Services for Gender Dysphoria (A53793)
Additionally, certain surgeries may improve gender- appropriate appearance but provide no significant improvement in physiological function. These surgeries are considered cosmetic and are non-covered.NON-SURGICAL TREATMENTInitiation of cross-sex hormone therapy may be provided after a psychosocial assessment has been conducted and informed consent has been obtained by a health professional.The criteria for cross sex hormone therapy are as follows:Persistent, well-documented gender dysphoria;Capacity to make a fully informed decision and to consent for treatment;Member must be at least 18 years of age;If significant medical or mental health concerns are present, they must be reasonably well controlled.The presence of co-existing mental health concerns does not necessarily preclude access to cross-sex hormones. These concerns should be managed prior to or concurrent with treatment of gender dysphoria.Cross-sex hormonal interventions are not without risk for complications, including irreversible physical changes. Medical records should indicate that an extensive evaluation was completed to explore psychological, family and social issues prior to and post treatment. Providers should also document that all information has been provided and understood regarding all aspects associated with the use of cross-sex hormone therapy, including both benefits and risks.READINESS FOR THE TREATMENT OF GENDER DYSPHORIAReadiness criteria for gender reassignment surgery includes the individual demonstrating progress in consolidating gender identity, and demonstrating progress in dealing with work, family, and interpersonal issues resulting in an improved state of mental health. In order to check the eligibility and readiness criteria for gender reassignment surgery, it is important for the individual to discuss the matter with a professional provider who is well-versed in the relevant medical and psychological aspects of GD. The mental health and medical professional providers responsible for the individual's treatment should work together in making a decision about the use of cross-sex hormones during the months before the gender reassignment surgery. Transsexual individuals should regularly participate in psychotherapy in order to have smooth transitions and adjustments to the new social and physical outcomes.TRANS-SPECIFIC CANCER SCREENINGS
Article - Billing and Coding: Gender Reassignment Services for Gender Dysphoria (A53793)
TRANS-SPECIFIC CANCER SCREENINGSProfessional organizations such as the American Cancer Society, American College of Obstetricians and Gynecologists and the US Preventive Services Task Force provide recommended cancer screening guidelines to facilitate clinical decision-making by professional providers. Some cancer screening protocols are sex/gender specific based on assumptions about the genitalia for a particular gender. There is little data on cancer risk specifically in transsexual individuals.There is difficulty in recommending sex/gender specific screenings (e.g., breast, cervix, ovaries, penis, prostate, testicles and uterus) for transsexual individuals because of their physiologic changes. For example, transmen who have not undergone a mastectomy have the same risks for breast cancer as natal women. In transwomen, the prostate typically is not removed as part of genital surgery, so individuals who do not take feminizing hormones may be at the same risk for prostate cancer as natal men. Therefore, cancer screenings (e.g., mammograms, prostate screenings) may be indicated based on the individual's original gender.Gender specific screenings may be medically necessary for transgender persons appropriate to their anatomy. Examples include:Breast cancer screening may be medically necessary for transmen who have not undergone a mastectomy.Prostate cancer screening may be medically necessary for transwomen who have retained their prostate.Claims for gender reassignment surgery will be reviewed on a case-by-case basis. Surgical treatment of gender reassignment surgery for gender dysphoria may be eligible when medical necessity and documentation requirements outlined within this article are met.Surgical treatment for gender dysphoria may be considered medically necessary whenALLof the following criteria are met:The individual is at least 18 years of age.A gender reassignment treatment plan is created specific to an individual beneficiaryThe individual has a documented Diagnostic and Statistical Manual of Mental Disorders -Fifth Edition, DSM-5  diagnosis of GD:A.A marked incongruence between ones experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:A marked incongruence between ones experienced/expressed gender and primary and/or secondary sex characteristics.
Article - Billing and Coding: Gender Reassignment Services for Gender Dysphoria (A53793)
A marked incongruence between ones experienced/expressed gender and primary and/or secondary sex characteristics.A strong desire to be rid of ones primary and/or secondary sex characteristics because of a marked incongruence with ones experienced/expressed gender.A strong desire for the primary and/or secondary sex characteristics of the other gender.A strong desire to be of the other gender (or some alternative gender different from ones assigned gender).A strong desire to be treated as the other gender (or some alternative gender different from ones assigned gender).A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from ones assigned gender).B.The condition is associated with clinically significant distress or impairment in social, occupational or other important areas of functioning.One letter from a mental health professional that the patient has had, at minimum, twelve months of psychotherapy therapy sessions attesting to all of the following clinical criteria:That any co-morbid psychiatric or other medical conditions are stable and that the individual is prepared to undergo surgery.That the patient has had persistent and chronic gender dysphoria.That the patient has completed twelve months of continuous, full-time, real-life experience (i.e., the act of fully adopting a new or evolving gender role or gender presentation in everyday life) in the desired gender.The individual, if required by the mental health professional provider, has regularly participated in psychotherapy throughout the real-life experience at a frequency determined jointly by the individual and the mental health professional provider.Unless medically contraindicated (or the individual is otherwise unable to take cross-sex hormones), there is documentation that the individual has participated in twelve consecutive months of cross-sex hormone therapy of the desired gender continuously and responsibly (e.g., screenings and follow-ups with the professional provider).The individual has knowledge of all practical aspects (e.g., required lengths of hospitalizations, likely complications, and post-surgical rehabilitation) of the gender reassignment surgery.SURGICAL TREATMENTS FOR GENDER REASSIGNMENTWhen all of the above criteria are met for gender reassignment surgery, the following genital surgeries may be considered for transwomen (male to female):
Article - Billing and Coding: Gender Reassignment Services for Gender Dysphoria (A53793)
SURGICAL TREATMENTS FOR GENDER REASSIGNMENTWhen all of the above criteria are met for gender reassignment surgery, the following genital surgeries may be considered for transwomen (male to female):Orchiectomy - removal of testiclesPenectomy - removal of penisVaginoplasty - creation of vaginaClitoroplasty - creation of clitorisLabiaplasty - creation of labiaMammaplasty - breast augmentationProstatectomy -removal of prostateUrethroplasty - creation of urethraWhen all of the above criteria are met for gender reassignment surgery, the following genital/breast surgeries may be considered for transmen (female to male):Breast reconstruction (e.g., mastectomy) - removal of breastHysterectomy - removal of uterusSalpingo-oophorectomy - removal of fallopian tubes and ovariesVaginectomy - removal of vaginaVulvectomy - removal of vulvaMetoidioplasty - creation of micro-penis, using clitorisPhalloplasty - creation of penis, with or without urethraUrethroplasty - creation of urethra within the penisScrotoplasty - creation of scrotumTesticular prostheses - implantation of artificial testesServices or procedures may not be covered when the criteria and documentation requirements outlined within this article are not met.The determination of whether to cover gender reassignment surgery and related care for a particular individual is based on whether the item or service is reasonable and necessary to treat the beneficiarys medical condition after considering the individuals specific circumstances. These decisions are made after the individual has obtained the medical service and a claim has been submitted by the Medicare provider.The individual's medical record must be submitted along with the claim and support the services billed. These medical records may include but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.When reporting procedure code 55970 (Intersex surgery; male to female), the following staged procedures to remove portions of the male genitalia and form female external genitals are included:
Article - Billing and Coding: Gender Reassignment Services for Gender Dysphoria (A53793)
When reporting procedure code 55970 (Intersex surgery; male to female), the following staged procedures to remove portions of the male genitalia and form female external genitals are included:The penis is dissected, and portions are removed with care to preserve vital nerves and vessels in order to fashion a clitoris-like structure.The urethral opening is moved to a position similar to that of a female.A vagina is made by dissecting and opening the perineum. This opening is lined using pedicle or split- thickness grafts.Labia are created out of skin from the scrotum and adjacent tissue.A stent or obturator is usually left in place in the newly created vagina for three weeks or longer.When reporting CPTcode 55980 (Intersex surgery; female to male), the following staged procedures to form a penis and scrotum using pedicle flap grafts and free skin grafts are included:Portions of the clitoris are used, as well as the adjacent skin.Prostheses are often placed in the penis to create a sexually functional organ.Prosthetic testicles are implanted in the scrotum.The vagina is closed or removed.
Article - NCD - Pharmacogenomic Testing for Warfarin Response (A53848)
CMS National Coverage PolicyN/AArticle TextBased on National Coverage Determination (NCD) 90.1 - Pharmacogenomic Testing for Warfarin Response, gene testing on CYP2C9 and/or VKORC1 will only be covered through coverage with evidence development (CED). Testing will be limited to once in a lifetime per beneficiary. Only genetic testing services for beneficiaries who meet the NCD criteria and are enrolled in a clinical trial will be reimbursed.Lab providers that perform services on eligible beneficiaries and described by Current Procedural Terminology (CPT) codes 81227 and 81355 must submit the following claim items:Healthcare Common Procedure Coding System (HCPCS) code:G9143(warfarin responsiveness testing by genetic technique using any method, any number of specimen(s))ICD-10-CM code:Z00.6(Examination of participant in clinical trial)HCPCS modifierQO(Investigational clinical service provided in a clinical research study that is in an approved clinical research study)Enter the appropriate identifier adjacent to HCPCS code G9143 in the comment/narrative field of the electronic or paper claim.Note:Report only HCPCS code G9143 and 1 unit of service. Do not report CPT codes 81227 and/or 81355 on the claim.References:Medicare National Coverage Determinations (NCD) 90.1 - Pharmacogenomic Testing for warfarin ResponseMedicare Claims Processing Manual (Pub 100-04), Chapter 32, Section 250 - Pharmacogenomic Testing for warfarin Response.
Article - Billing and Coding: Mohs Micrographic Surgery (MMS) (A53883)
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) L34961, Mohs Micrographic Surgery (MMS). 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.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.CPT codes 17311-17315 are reserved for the surgeon who removes a lesion, prepares, and interprets the slides. Select skin biopsy/excision services and pathology services are part of the Mohs surgery and bundled into 17311-17315. Refer to the NCCI Manual and CPT manual for additional information.Mohs surgery includes the pathologic examination of the specimen performed by the surgeon and should not be reported separately. There may be instances when a Mohs surgeon submits a specimen(s) derived from the procedure for pathologic examination to another physician (i.e., pathologist) for either frozen or permanent section. In those situations, the service is not considered a Mohs service and pathology service may be reported by the performing pathologist. The surgeon should report for excision and repair using appropriate codes.
Article - Billing and Coding: Mohs Micrographic Surgery (MMS) (A53883)
It isNOTappropriate to report modifier -59 when the biopsy and Mohs surgery are performed on the same lesion, in the same operative session and on the same date of service. However, if a suspected skin cancer is biopsied for pathologic diagnosis prior to proceeding to Mohs micrographic surgery, the biopsy and frozen section pathology may be reported separately using modifier -59 to distinguish the diagnostic biopsy from the definitive Mohs surgery (Reference American Hospital Association [AHA] Coding Clinc, 2013, Volume 13, Number 3 and theMedicare NCCI Policy ManualChapter 3).Modifier -59 shouldonlybe appended to the pathology codes, by the Mohs surgeon, if a biopsy is performed on a completely separate lesion that does not involve the Mohs surgery; however, Mohs surgery and pathology service may be reported when tissue separate from the tissue examined during the Mohs surgery is submitted for subsequent formalin-fixed processing and histopathologic examination (i.e., the submitted specimen originates from the same operative site or from a different operative site but is not the same tissue processed during the Mohs surgery). Reference AHA Coding Clinc, 2013, Volume 13, Number 3 andNCCI Policy ManualChapter 3 for additional information.There may be rare instances where a biopsy and pathology must occur on the same date as a Mohs procedure. In these instances, skin biopsy CPT codes and the pathology CPT codes may be reported with the -59 modifier appended if:The lesion for which Mohs is planned has not been biopsied within the previous 60 days, orIf the surgeon cannot obtain a pathology report from the referring physician with a reasonable effort, orThe biopsy is performed on a lesion that is not associated with the Mohs surgery.For example:If a biopsy is performed prior to the Mohs surgery for a diagnostic purpose, the biopsy can also be performed. Modifier -59 or -58 would be appended to distinguish the diagnostic biopsy from the definitive Mohs surgery (Reference AHA Coding Clinc, Volume 13, Number 3).When it is appropriate to report modifier -59, the modifier should be reported on the same line as the biopsy procedure codes. It shouldNOTbe reported on the same line as the Mohs procedure.
Article - Billing and Coding: Mohs Micrographic Surgery (MMS) (A53883)
When it is appropriate to report modifier -59, the modifier should be reported on the same line as the biopsy procedure codes. It shouldNOTbe reported on the same line as the Mohs procedure.The appropriate Mohs surgery code should be reported with the appropriate quantities for the specimens mapped in the days/units field.CPT code 17312 should be reported for additional stages with the first stage code 17311.CPT code 17314 should be reported for additional stages with the first stage code 17313.CPT code 17315 may be used to report each block after the first 5 blocks for any single stage.All surgical procedures performed in the same operative session should be reported on the same claim.Multiple instances of CPT codes 17312 and 17314 should not be reported on separate claim lines. The services should be totaled and entered as a single item with the appropriate number of units of service.Please note that these codes refer to the number of blocks, not number of slides.If a Mohs procedure is performed on acompletely separate lesionon the same date of service, each first stage (CPT code 17311 or 17313) code should be reported on a separate claim line with a -59 modifier signifying a separate and distinct lesion. If additional stages are required on the additional lesion, report the second stage codes (CPT code 17312 or 17314) on separate claim lines with a -59 modifier (Reference AHA Coding Clinc, Volume 13, Number 3).A Clinical Laboratory Improvement Act (CLIA) certification number is required on all claims submitted for Mohs surgery. The CLIA number should be submitted in item 23 on the CMS 1500 claim form or the electronic equivalent.The medical record must clearly document and support the situations where modifier -59 is appropriate.