evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Endovenous Stenting (A56644)
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) L38231 Endovenous Stenting. Please refer to the LCD for reasonable and necessary requirements.Medicare reimbursement for endovenous stenting is limited to the treatment of severely symptomatic venous obstructions as outlined in the related LCD.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.Claims must be submitted with an ICD-10-CM code that represents the reason the procedure was done. The ICD-10-CM code must be billed to the highest level of specificity for that code set. The ICD-10-CM code must be linked to the appropriate procedure code.Documentation Requirements
Article - Billing and Coding: Endovenous Stenting (A56644)
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.Medical record documentation should list type and length of conservative treatment as applicable per the LCD.Pre- and post-deployment intervention images should be obtained and made available upon request. Intermediate stages pertinent to the endovascular procedure may also be documented with images. Details should include the position of the device, and when appropriate, the nature of the obstruction (if a determination can be made regarding the etiology), and effect of the device on target or nontarget vessels.Medical record documentation should list guide catheter used, as well as stent type, diameter and length.
Article - Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing (A56645)
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) L35006, Controlled Substance Monitoring and Drugs of Abuse Testing. Please refer to the LCD for reasonable and necessary requirements and limitations.Coding Guidance: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.Utilization ParametersConsistent with the related LCD:It is not appropriate to report more than twelve (12) presumptive UDT testing (CPT code 80305, 80306, or 80307) testing services per calendar year.As stated in the related LCD, an exception will be made for patients with documented diagnoses consistent with a substance abuse disorder (SUD). It is not appropriate to report more than three (3) presumptive UDT tests (80305, 80306, or 80307) in seven (7) days when billed with any of the ICD-10 codes noted in ICD-10 Group 1 Paragraph.It is not appropriate to report more than twelve (12) definitive UDT testing services (CPT/HCPCS code G0480, G0481, G0482, G0483, or G0659) per calendar year for chronic opioid therapy (COT), as noted in ICD-10 Group 2 Paragraph. Refer to the related LCD for more information.It is not appropriate to report more than one (1) presumptive test result per patient per date of service regardless of the number of billing providers.Documentation RequirementsNote: Refer to the LCD for documentation requirements, in the patients medical record, of medical necessity for testing ordered on an individual patient basis by the clinician.
Article - Billing and Coding: Controlled Substance Monitoring and Drugs of Abuse Testing (A56645)
Documentation RequirementsNote: Refer to the LCD for documentation requirements, in the patients medical record, of medical necessity for testing ordered on an individual patient basis by the clinician.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.
Article - Billing and Coding: Chemodenervation (A56646)
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.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Chemodenervation L33458.
Article - Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS) (A56647)
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) L38233, Micro-Invasive Glaucoma Surgery (MIGS). 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.Utilization ParametersMedicare may cover only1 unit per eye, per date of service of CPT code 66989 or 66991for insertion of glaucoma drainage device(s) into the trabecular meshwork (e.g., iStent, or iStentinject), performed in conjunction with cataract surgery and when the medically reasonable and necessary criteria as stated in the LCD are met. Although more than one drainage device into the trabecular meshwork of a single eye on a single day of service, may be performed using an insertion tool loaded with more than one device, (e.g., iStentinject) once the insertion tool is deployed within the eye, the work and clinical skill required to place additional device(s) is equivalent to placement of other U.S. Food and Drug Administration (FDA) cleared devices, described by the same codes. Therefore, only one unit of 66989 or 66991 per eye per day may be billed, regardless of the number of devices inserted into a single eye on the same date of service.Medicare may cover only1 unit per eye, per date of service of CPT code 0449Tfor insertion of glaucoma drainage device(s) into the subconjunctival space (e.g., XEN45), when the medically reasonable and necessary criteria as stated in the LCD are met.Note:CPT Code 0450T for additional device insertion is not covered.
Article - Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS) (A56647)
Note:CPT Code 0450T for additional device insertion is not covered.Note: CPT code 0671T does not need to be reported with any of the following codes: 66982, 66983, 66984, 66987, and 66988.Documentation RequirementsAll documentation must be maintained in the patient's medical record and must support the medical necessity of the services as directed in this article and be 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: Home Health-Surface Electrical Stimulation in the Treatment of Dysphagia (A56648)
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 10, 10.1.10.4 Claim Submission and Processing, 30.11 Exhibit: Chart Summarizing the Effects of NOA/Claim Actions on the HH PPS Episode File, 40.1 Notice of Admission (NOA), 40.2 HH PPS Claims, 70.1 General, 90 Medical and Other Health Services Submitted Using Type of Bill 034x, and 90.1 Osteoporosis Injections as HHA BenefitCMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, 6.2.4 Coding and 6.2.7 Medical Review of Home Health Demand BillsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forHome Health-Surface Electrical Stimulation in the Treatment of Dysphagia L34565.
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A56651)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-02,Medicare Benefit Policy Manual,Chapter 16, Section 180 Services Related to and Required as a Result of Services Which Are Not Covered Under MedicareCMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 4, Section 280.14 Infusion PumpsCMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)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) L33906, Epidural Steroid Injections for Pain Management. Please refer to the LCD for reasonable and necessary requirements.The services addressed in this article only apply to epidural injections. Other joint procedures (e.g., sacral injections, facet joint) are not addressed.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) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to the NCCI requirements.An anatomic spinal region for epidurals is defined as cervical/thoracic (CPT codes 62321, 64479 and 64480) or lumbar/sacral (CPT codes 62323, 64483 and 64484).
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A56651)
When CPT codes 62321, 62323, 64479, 64480, 64483 or 64484 are used to report postoperative pain management, the diagnosis code restrictions in this article do not apply when reporting these codes with ICD-10 codes G89.12 (acute post-thoracotomy pain) or G89.18 (other acute postprocedural pain).If epidural injection (CPT code 62323) is used for an implantable infusion pump trial for severe spasticity, the restrictions in this article do not apply as coverage is determined by NCD 280.14 Infusion Pumps.When the epidural injection (CPT code 62323) is used for cerebrospinal fluid flow imaging, cisternography (CPT code 78630), the diagnosis code restrictions in this article do not apply. These services should be billed on the same claim.Consistent with the LCD, it is not medically reasonable and necessary to perform caudal ESIs or interlaminar ESIs bilaterally, therefore CPT codes 62321 and 62323 are not bilateral procedures.CPT codes 64479 and 64483 are used to report a single level injection. CPT codes 64480 and 64484 represent each additional level, respectively and should be reported separately in addition to the primary procedure when applicable.A transforaminal epidural steroid injection (TFESI) performed at the T12-L1 level should be reported with CPT code 64479.When reporting CPT codes 64479 through 64484 for a unilateral procedure, use one line with one unit of service. For bilateral procedures regarding these same codes, use one line and append the modifier-50.For services performed in the ASC, modifier -50 should not be utilized. Report the applicable procedure code on two separate lines, with one unit of service each and append the -RT and -LT modifiers to each line.KX Modifier Requirements
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A56651)
KX Modifier RequirementsA diagnostic selective nerve root block (DSNRB) is identically coded as an epidural injection. Therefore, when performing a DSNRB, the -KX modifier should be appended to the appropriate line to distinguish the procedure from an epidural injection. This applies to TFESI CPT codes 64479, 64480, 64483, and 64484. Aberrant use of the -KX modifier may trigger focused medical review.Use of BiologicalsThere are currently no U.S. Food and Drug Administration (FDA) approved biologicals for use as an injectable agent into the epidural space or spine. The inclusion of a biological and/or other non-FDA approved substance in the injectant may result in denial of the entire claim based on the CMS IOM Publication 100-02,Medicare Benefit Policy Manual, Chapter 16, Section 180. Amniotic and placenta derived injectants, platelet rich plasma, and vitamins fall into this category.Utilization ParametersOnly one spinal region may be treated per session (date of service).Consistent with the LCD, only two total levels per session are allowed for CPT codes 64479, 64480, 64483 and 64484 (two unilateral or two bilateral levels). CPT code 64480 should be reported in conjunction with CPT code 64479 and CPT code 64484 should be reported in conjunction with CPT code 64483.Consistent with the LCD, CPT codes 62321 and 62323 may only be reported for one level per session.No more than 4 epidural injection sessions (CPT codes 62321, 62323, 64479, 64480, 64483, or 64484) may be reported per anatomic region in a rolling 12-month period regardless of the number of levels involved.Documentation Requirements
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A56651)
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.SNRBs and TESIs:The procedural report should clearly document the indications and medical necessity for the injections, along with the baseline pain score.SNRBs only:The procedural report should include the baseline pain score and percent (%) pain relief achieved immediately after the injection.Films that adequately document (minimum of two views) final needle position and contrast flow should be retained and made available upon request.The patients medical record should include, but is not limited to:The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit.Relevant medical history.Results of pertinent tests/procedures.Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed).Documentation to support the medical necessity of the procedure(s).
Article - Billing and Coding: 4Kscore Test Algorithm (A56653)
CMS National Coverage PolicyN/AArticle TextThis article provides coding guidance forthe Local Coverage Determination (LCD) L37792 4Kscore Test Algorithm which will become effective on December 30, 2019. Refer to L37792 for reasonable and necessary guidelines.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. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.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 should support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code should describe the service performed.Documentation of shared decision making (SDM) concerning the 4Kscore testing, between the ordering provider and patient, must be present in the medical record and a copy of same shall be provided to the performing laboratorypriorto the test being performed.A simple notation that SDM occurred is insufficient for documentation. The actual process must be documented in the patients record.The document(s) shall be dated and include the ordering provider and patients names and signatures legibly noted to attest that the SDM occurred.
Article - Billing and Coding: Cosmetic and Reconstructive Surgery (A56658)
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 16, 120 Cosmetic Surgery, 140 Dental Services Exclusion and 180 Services Related to and Required as a Result of Services Which Are Not Covered Under MedicareCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, 260 Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (FLS), 260.1 Policy, 260.2 Billing Instructions, 260.2.1 Hospital Billing Instructions, 260.2.2 Practitioner Billing InstructionsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) Cosmetic and Reconstructive Surgery L33428.
Article - Billing and Coding: Trastuzumab – Trastuzumab Biologics (A56660)
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) L34026 (Trastuzumab  Trastuzumab Biologics). 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.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 L34026 Trastuzumab  Trastuzumab Biologics may be monitored and addressed through post payment data analysis and subsequent medical review audits.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: Trastuzumab – Trastuzumab Biologics (A56660)
Medical record documentation maintained by the ordering/referring physician must substantiate the medical need for the use of these chemotherapy drugs by clearly indicating the condition for which these drugs are being used. This might include the type of cancer, staging, if applicable, prior therapy and the patients response to that therapy. This documentation is usually found in the history and physical or in the office/progress notes.If the provider of the service is other than the ordering/referring physician, that provider must maintain copies of the ordering/referring physicians order for the chemotherapy drug. The physician must state the clinical indication/medical need for using the chemotherapy drug in the order.Dosage and AdministrationFor specific dosage and administration, please refer to the FDA approved drug label for recommended dosages for specific FDA indications. This can be accessed athttps://labels.fda.gov/.