evekhm/cms_iom_500 huggingface dataset:
Article - Wound care (L37166): Medicare Part A/B local coverage determination (LCD) comment summary (A55757)
Comment #17:A number of commenters requested removal of dermatologic conditions under Wound Care Surgical Debridements (eczema, bullous skin diseases, etc.) as these are not related to wounds.Contractor response:After consideration, some of the conditions which were referred to as dermatologic have been amended or removed.Comment #18:A number of comments were received requesting the addition of biofilm or bioburden to Covered Indications for debridement. The following statement is in the Limitations section of the draft policy: Removal of non-tissue integrated fibrin exudates, crusts, biofilms or other materials from a wound without removal of tissue does not meet the definition of any debridement code and may not be reported as such. Commenters state that a wound could look clean but have subclinical bioburden present that would need to be addressed through debridement.Contractor response:The contractor agrees that this statement is incorrect. There are active wound care management CPT codes that reference removal of biofilm and may be reported for such debridement. Please reference CPT and coding guidelines.Comment #19:A number of commenters requested removal of utilization guidelines for low-frequency, non-contact, non-thermal ultrasound (MIST Therapy) while several commenters supported the guidelines.Contractor response:The utilization guidelines have not been changed for MIST Therapy. Guidelines for the use of low-frequency, non-contact, non-thermal ultrasound (MIST Therapy) are supported by the manufacturer.Comment #20:Comments were submitted requesting removal of the debridement frequency limitation for debridement codes involving muscle / fascia or bone. Commenters expressed concern that five muscle debridement services per calendar year would not allow for appropriate wound care especially for bedridden decubitus patients that may have different wounds at different times in a given calendar year.
Article - Wound care (L37166): Medicare Part A/B local coverage determination (LCD) comment summary (A55757)
Contractor response:Debridement codes involving fascia or bone would be expected to lessen over a period of time as the wound heals. Data analysis illustrates that a minority of beneficiaries receiving wound care actually receive more than five debridements involving muscle/fascia or bone in a rolling 360 day period. Debridements of an unusually prolonged or excessive number should be accompanied by meticulous documentation illustrating that the service is both medical necessary and reasonable. It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. Utilization of more than five debridement codes involving fascia or bone in a rolling 360 day period may be subject to pre or post payment medical review (records requested).Comment #21:Several commenters expressed concerns with wording throughout the LCD and requested clarification or removal of specific statements.Contractor response:Comments related to wording or style, not relevant to coverage, were too numerous to be addressed on the comment response document. All comments were reviewed and noted.
Article - Billing and Coding: Lab: Coenzyme Q10 (CoQ10) (A55769)
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 On-Line Manual, Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, 80.0, 80.1.1, 80.2. Clinical Laboratory services.CMS Internet-Only Manuals, Publication 100-04,Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.12 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet Online Manual Pub. 100-04 (Medicare Claims Processing Manual), Chapter 23 (Section 10) "Reporting ICD Diagnosis and Procedure Codes."Article TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.To receive a Q10 service denial, please submit the following claim information:CPTcode 82542For a voluntary issued Advanced Beneficiary Notice (ABN), append with GX modifier
Article - Billing and Coding: Lab: Coenzyme Q10 (CoQ10) (A55770)
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 On-Line Manual, Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, 80.0, 80.1.1, 80.2. Clinical Laboratory services.CMS Internet-Only Manuals, Publication 100-04,Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.12 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet Online Manual Pub. 100-04 (Medicare Claims Processing Manual), Chapter 23 (Section 10) "Reporting ICD Diagnosis and Procedure Codes."Article TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.To receive a Q10 service denial, please submit the following claim information:CPTcode 82542For a voluntary issued Advanced Beneficiary Notice (ABN), append with GX modifier
Article - Billing and Coding: Reporting a Non-Covered Test Performed in Preparation for a Non-Covered Procedure (A55774)
CMS National Coverage PolicyN/AArticle TextWhen a diagnostic test is necessary for the performance of a non-covered service, that test typically may not be covered. For instance, when planning a cataract surgery using a non-covered, presbyopia and astigmatism correcting intraocular lens, it is often necessary to first perform a computerized corneal typography. Noridian wishes to remind providers to report this appropriately as a non-covered test by submitting the code 92025 with a -GY modifier.Effective ImmediatelyReference:Internet Only Manual (IOM)Medicare National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Part 1, Section 10.1;IOMMedicare Claims Processing Manual, Publication 100-04, Chapter 32, Section 120.
Article - Billing and Coding: Reporting a Non-Covered Test Performed in Preparation for a Non-Covered Procedure (A55775)
CMS National Coverage PolicyN/AArticle TextWhen a diagnostic test is necessary for the performance of a non-covered service, that test typically may not be covered. For instance, when planning a cataract surgery using a non-covered, presbyopia and astigmatism correcting intraocular lens, it is often necessary to first perform a computerized corneal typography. Noridian wishes to remind providers to report this appropriately as a non-covered test by submitting the code 92025 with a -GY modifier.Effective ImmediatelyReference:Internet Only Manual (IOM)Medicare National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Part 1, Section 10.1;IOMMedicare Claims Processing Manual, Publication 100-04, Chapter 32, Section 120.
Article - Billing and Coding: Wound Care (A55818)
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) L37166, Wound Care. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceClaims 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.Active Wound Care Management  CPT codes 97597, 97598, 97602, 97605, 97606, 97607, and 97608Currently, code 97602 is a status B (bundled) code for physicians services; therefore, separate payment is not allowed for this service.A therapist acting within their scope of practice and licensure performing active wound care management services must add the appropriate therapy modifier to the CPT code billed. In addition the therapy Revenue Code must be submitted for that service. If a non-therapist performs the service, no therapy modifiers are used and a non-therapy Revenue Code must be submitted for the service. Please see MM10176 for more information.For debridement codes 97597, 97598, or 97602:Debridement should be coded with either selective or non-selective CPT codes (97597, 97598, or 97602) unless the medical record supports a surgical debridement has been performed.Dressings applied to the wound are part of the services for CPT codes 97597, 97598 and 97602 and they may not be billed separately.It is not appropriate to report CPT code 97602 in addition to CPT code 97597 and/or 97598 for wound care performed on the same wound on the same date of service.
Article - Billing and Coding: Wound Care (A55818)
It is not appropriate to report CPT code 97602 in addition to CPT code 97597 and/or 97598 for wound care performed on the same wound on the same date of service.Code(s) 97597, 97598 and 97602 should not be reported in conjunction with code(s) 11042-11047. The wound depth debrided determines the appropriate code.For example, when only biofilm on the surface of a muscular ulceration is debrided, then codes 97597-97598 would be appropriate. If muscle substance was debrided, the 11043-11046 series would be appropriate, depending on the area.Codes 97602, 97605, 97606, 97607 and 97608 include the application of and the removal of any protective or bulk dressings. However, if only a dressing change is performed without any active wound procedure as described by these debridement codes, these debridement codes should not be reported.Generally, whirlpool is a component of CPT codes 97597/97598 and should not be reported separately during the same encounter. Only when there is a separately identifiable service being treated by the therapist, and the documentation supports this treatment, would the service be considered for payment utilizing modifier 59 or a more specific modifier as appropriate (e.g., LT, RT, XS, etc).Surgical Debridements  CPT codes 11000-11012 and 11042-11047Dressings applied to the wound are part of the service for CPT codes 11000-11012 and 11042-11047 and may not be billed separately.Medicare does not separately reimburse for dressing changes or patient/caregiver training in the care of the wound. It is only appropriate to provide an Advance Beneficiary Notice of Non-coverage (ABN) for services that are anticipated to be denied due to the absence of medical necessity. Based on this information, an ABN for a dressing change is not appropriate since the costs of the dressing change are packaged into other procedures billed.Debridement of Necrotizing Soft Tissue Infections (CPT codes 11004-11006, and 11008) are inpatient only procedure codes.
Article - Billing and Coding: Wound Care (A55818)
Debridement of Necrotizing Soft Tissue Infections (CPT codes 11004-11006, and 11008) are inpatient only procedure codes.The CPT guidelines give direction for reporting single wound debridements (CPT codes 11042-11047) that are at different layers in different parts of the wound, and debridement of wounds at the same and different levels. The depth reported for a single wound is the deepest depth of tissue removed. When debridement at the same depth is performed on two or more wounds, the surface areas of the wounds are combined. When the depth of debridement is not the same, the surface areas are not combined.For example, for the debridement codes 11042-11047, when the entire wound surface is debrided, then the measurement of the wound should be taken after the actual debridement procedure is performed. When only a portion of a wound surface is debrided, report the measurement of the area that was actually debrided. If the surface area, depth, and measurement listed in the code descriptor were not performed, then it would not be appropriate to report that code.CPT codes 11042, 11043, 11044, 11045, 11046, and 11047 are used to report surgical removal (debridement) of devitalized tissue from wounds.Use appropriate modifiers when more than one wound is debrided on the same day.The use of CPT codes 11042-11047 is not appropriate for the following services: washing bacterial or fungal debris from feet, paring or cutting of corns or calluses, incision and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Report these procedures, when they represent covered, reasonable and necessary services using the CPT/HCPCS code that most closely describes the service supplied.The CPT code selected should reflect the level of debrided tissue (e.g., skin, subcutaneous tissue, muscle and/or bone), not the extent, depth, or grade of the ulcer or wound.
Article - Billing and Coding: Wound Care (A55818)
The CPT code selected should reflect the level of debrided tissue (e.g., skin, subcutaneous tissue, muscle and/or bone), not the extent, depth, or grade of the ulcer or wound.For example, CPT code 11042 defined as debridement, subcutaneous tissue should be used if only necrotic subcutaneous tissue is debrided, even though the ulcer or wound might extend to the bone. In addition, if only fibrin is removed, this code would not be billed.Debridement of tissue in the surgical field of another musculoskeletal procedure is not separately reportable. However, debridement of tissue at the site of an open fracture or dislocation may be reported separately with CPT codes 11010-11012.For example, debridement of muscle and/or bone (CPT codes 11043-11044, 11046-11047) associated with excision of a tumor of bone is not separately reportable. Similarly, debridement of tissue (e.g., CPT codes 11042, 11045, 11720-11721, 97597, 97598) superficial to, but in the surgical field, of a musculoskeletal procedure is not separately reportable.The debridement code submitted should reflect the type and amount of tissue removed during the procedure as well as the depth, size, or other characteristics of the wound. Submitting documentation substantiating depth of debridement when billing the debridement procedure described by CPT code 11044 is encouraged.For example, if a wound involves exposed bone but the debridement procedure did not remove bone, CPT code 11044 cannot be billed.
Article - Billing and Coding: Wound Care (A55818)
Use of Evaluation and Management (E/M) Codes in Conjunction with Surgical DebridementsE/M codes are not usually billed in conjunction with a debridement procedure. When providing and billing surgical debridement, the surgical debridement service is to include: the pre-debridement wound assessment, the debridement, and the post-procedure instructions provided to the patient on the date of the service. When a "reasonable and necessary" E/M service is provided and documented on the same day as a debridement service, it is payable by Medicare when the documentation clearly establishes the service as a "separately identifiable service" that was reasonable and necessary, as well as distinct, from the debridement service(s) provided.Low frequency, non-contact, non-thermal ultrasound (MIST Therapy)  CPT code 97610One 97610 service per day is allowable for a qualifying wound. CPT Code 97610 is not separately reportable for treatment of the same wound on the same day as other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (e.g., CPT codes 11042-11047, 97597, 97598).Debridement and Unna bootAll supply items related to the Unna boot are inclusive in the reimbursement for CPT code 29580. When both a debridement is performed and an Unna boot is applied, only the debridement may be reimbursed. If only an Unna boot is applied and the wound is not debrided, then only the Unna boot application may be eligible for reimbursement. The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services Chapter 4, section G states that debridement codes (11042-11047, 97597) should not be reported with codes 29580, 29581 for the same anatomic area.Debridement including removal of foreign material at the site of an open fracture or open dislocation may be reported with CPT codes 11010-11012. Since these codes would be reported with a CPT code for treatment of the open fracture or dislocation, a casting/splinting/strapping code should not be reported separately.
Article - Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence (A55835)
CMS National Coverage PolicyN/AArticle TextBackgroundSacral Nerve Stimulation for urinary incontinence is covered for the treatment of urinary urge incontinence, urge-frequency syndrome, and urinary retention by the CMS National Coverage Determination (NCD) 230.18, http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf. Direct stimulation of the sacral nerve(s) via an electrode array implanted at the level of the sacrum is the only treatment modality covered by the NCD. In addition,CGS will cover sacral nerve stimulation by the same modality for the treatment of fecal incontinence, effectiveFebruary 1, 2018.Indications and LimitationsUrinary IncontinenceSacral nerve stimulation is covered for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. Sacral nerve stimulation involves both a temporary test stimulation to determine if an implantable stimulator would be effective and a permanent implantation in appropriate candidates. Both the test and the permanent implantation are covered.The NCD describes the following limitations for coverage to all three conditions: Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur. Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three indications are excluded. Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement through test stimulation. Improvement is measured through voiding diaries.Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.Fecal IncontinenceCGSwill cover sacral nerve modulation/stimulation for fecal incontinence effectiveFebruary 1, 2018, when all of the following criteria are met:
Article - Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence (A55835)
Fecal IncontinenceCGSwill cover sacral nerve modulation/stimulation for fecal incontinence effectiveFebruary 1, 2018, when all of the following criteria are met: Chronic fecal incontinence with greater than two incontinent episodes on average per week and duration of incontinence greater than six months or for more than twelve months after vaginal childbirth; AND Documented failure or intolerance to conventional therapy (e.g., dietary modification, the addition of bulking and pharmacologic treatment); AND A successful percutaneous test stimulation, defined as at least 50% sustained (more than one week) improvement in symptoms; AND Condition is not related to anorectal malformation (e.g., congenital anorectal malformation; defects of the external anal sphincter over 60 degrees; visible sequelae of pelvic radiation; active anal abscesses and fistulae) and/or chronic inflammatory bowel disease; AND Incontinence is not related to another neurologic condition such as peripheral neuropathy or complete spinal cord injury.Sacral nerve modulation/stimulation is consideredexperimental, investigational and unproven for the treatment of chronic constipation or chronic pelvic pain.Sources:
Article - Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence (A55835)
Sacral nerve modulation/stimulation is consideredexperimental, investigational and unproven for the treatment of chronic constipation or chronic pelvic pain.Sources:Internet Only Manual (IOM)Medicare National Coverage Determination Manual, Publication 100-03, Section 230.18Sacral Nerve Stimulation for Urinary Incontinence;Abrams P et al. Fourth International Consultation on Incontinence recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence;Neurourol Urodyn. 2010; 29(1):213-40;Annals of Surgery, March 2010, Vol 251, Number 3.Sacral Nerve Stimulation for Fecal Incontinence, Results of a 120-Patient Prospective Multicenter Study;Michelsen H, Thompson-Fawcett M, Lundy L, Krogh K, Laurberg S, Buntzen S;Six Year Experience with Sacral Nerve Stimulation for Fecal Incontinence;Dis Colon Rectum. 2010; 53(4)414-421; Mowatt G, Glazener CMA, Jarrett M. Sacral nerve stimulation for fecal incontinence and constipation in adults (Review);The Cochrane Library. 2009, Issue 1; National Institute for Health and Clinical Excellence. Fecal incontinence: the management of fecal incontinence in adults. NICE Clinical Guideline 49, June 2007;Trailblazer Health Enterprises, Local Coverage Determination forSacral Nerve Stimulation 4S-154AB-R9, Effective March 01, 2008
Article - Billing and Coding: Wound Care (A55909)
CMS National Coverage PolicyN/AArticle TextThis article addresses the CPT/HCPCS and ICD-10 codes associated with L37228 Wound Care policy. The article is to be used in conjunction with the indications and guidelines provided in L37228Wound Care.The listing of the procedure code does not imply coverage. All the procedure codes are subject to Medicare rules and regulations, applicable Local Coverage Determinations (LCDs), applicable National Coverage Determinations (NCDs), and medical necessity.The medical record must clearly show that the criteria under Coverage Indications, Limitations, and /or Medical Necessity provided in L37228 Wound Care have been met.For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Coverage Guidelines:Negative Pressure Wound Therapy(NWPT)Coverage of traditional Negative Pressure Wound Therapy (tNPWT) device/unit/type, or supplies is covered under the Durable Medical Equipment benefit (Social Security Act 1861(s)(6)), and providers should consult their DME LCD for specific coverage, parameters, and guidelines.Billing and Coding Guidelines for Wound CareWound Care (CPT Codes 97597, 97598 and 11042-11047)