evekhm/cms_iom_500 huggingface dataset:
Article - Local Coverage Determination (LCD) Reconsideration Process - Medical Policy Article (A52842)
Health Disparities Analysis (Recommended)Requestors are strongly encouraged to include an analysis of any relevant peer-reviewed medical literature that quantifies and/or describes any health disparities related to the specific LCD Reconsideration request, and how the requested change may impact health disparities.Submission MethodsMailNational Government Services, Inc. Medical Policy Unit Attention: LCD Reconsideration Request P.O. Box 7108 Indianapolis, IN 46207-7108E-MailNGS.lcd.reconsideration@anthem.comFax(317) 595-4334National Government Services ResponseWithin60 daysof the day the request is received, National Government Services will determine whether the request is valid or invalid and will notify the requestor of the determination.Valid Request Possible ActionsIf the request is valid, NGS will either open the LCD and follow the LCD process as outlined in CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.2, or include the LCD on the MACs waiting list.Invalid Request ActionIf the request is invalid, NGS will explain the reason(s) it was invalid.
Article - Home Health Skilled Nursing Care: Teaching and Training for Dementia Patients with Behavioral Disturbances - Medical Policy Article (A52845)
CMS National Coverage PolicyN/AArticle TextIndications and LimitationsThis medical policy article addresses a specific category of skilled nursing care currently available to Medicare home health beneficiaries who have dementia with behavioral disturbances. The category of skilled nursing care is called teaching and training activities. Teaching and training activities are defined in the CMS Manual System (see citation underCMS National Coverage Policylisted under the Other Comments section of this article) and in the case of the beneficiary population with dementia and behavioral disturbances, could be part of a unique beneficiary-centered care plan directed at teaching the family or caregiver how to manage the behavioral disturbances.Behavioral disturbances often complicate the medical management of beneficiaries with dementia, including Alzheimers disease. At baseline many individuals with dementia manifest activity limitations in such domains as communication and self-care. The occurrence of behavioral disturbances, if not addressed in a comprehensive and systematic manner, may further compromise the activity limitations present at baseline - resulting in sub-optimal clinical outcomes.Each behavioral disturbance should be fully characterized and answers to the following questions should be documented in the patients medical records:What is the specific behavioral disturbance being addressed?What is the frequency of the behavior?Are there specific situations or activities that trigger the behavior?When does it occur?Where does it occur?Who is involved?Are there other possible explanations for the behavior (e.g., pain, infection, change in medication, disruption in schedule, swallowing difficulties, catastrophic reaction induced by environment or personal interaction)?What are the consequences of the behavior?What interventions have been successful in addressing this behavior in the past?What other techniques or interventions can be used to address the behavior?Teaching and training interventions should be based on the answers to the above questions, the specific impairment(s) and activity limitation(s) identified for each beneficiary, and the ability of the family or caregiver to learn and implement the proposed interventions. Environmental factors impacting the identified behavior(s) and the resultant care plan must also be considered. Use of the World Health Organizations International Classification of Functioning Disability and Health (ICF) would facilitate the identification and documentation of specific impairments, activity limitations, and environmental factors.
Article - Home Health Skilled Nursing Care: Teaching and Training for Dementia Patients with Behavioral Disturbances - Medical Policy Article (A52845)
In the home health setting, skilled education services are no longer needed if it becomes apparent, after a reasonable period of time, that the patient, family, or caregiver could not or would not be trained. Further teaching and training would cease to be reasonable and necessary in this case, and would cease to be considered a skilled service. Notwithstanding that the teaching or training was unsuccessful, the services for teaching and training would be considered to be reasonable and necessary prior to the point that it became apparent that the teaching or training was unsuccessful, as long as such services were appropriate to the patient's illness, functional loss, or injury.Sample Case Scenarios:Scenario #1A beneficiary with moderate Alzheimers Disease is unable to bathe and groom herself. The family describes the beneficiary as uncooperative. The primary caregiver is a daughter who is trying her best to provide assistance and feels frustrated by the situation, but would like to learn how to work with her mother and keep her at home. The beneficiarys physician has determined that the uncooperativeness is the result of receptive language impairments, perceptual misinterpretations, and impairments in learned motor skills  all due to the Alzheimers Disease. The teaching services are reasonable and necessary for the beneficiarys treatment, and to maintain proper hygiene and skin care.Potential Behavioral and Environmental Interventions:1. Teach the patients daughter the primary symptoms of Alzheimers disease (amnesia, aphasia, apraxia, and agnosia), and how each of these symptoms can influence the patients level of cooperativeness with bathing and grooming activities. A learning objective for the daughter would be to define amnesia, aphasia, apraxia, and agnosia, and to give a clinical example of each symptom that she has encountered while caring for her mother.
Article - Home Health Skilled Nursing Care: Teaching and Training for Dementia Patients with Behavioral Disturbances - Medical Policy Article (A52845)
2. Teach the daughter how to simplify the patients environment to maximize the chance for successful activities of daily living (ADL) encounters. (Examples include, but would not be limited to: daughter having all bathing and grooming supplies ready and available for use before approaching patient, unnecessary items that clutter the bathroom/bedroom are moved out of the way, if a shower is used then add a hand-held shower nozzle so water can be directed and will not frighten the patient by spraying on her face, put liquid soap on washcloths ahead of time, so they can be handed to the patient to use, make sure the environment is the appropriate temperature, bath sponges are often easier for patients to hold and use than washcloths).3. Use a method of bathing that is familiar to the patient. For example, if the patient always took baths and did not take showers, use a bath now. Consider the time (e.g., morning or evening) that the individual habitually bathed. If she resists shampoos in the home, but historically had her hair done at a beauty shop, consider taking her to one for a shampoo. Consider separating bathing from hair washing, if doing them both together causes agitation.4. Keep communication simple. Break activities down into steps. Provide one direction at a time. Keep verbal instruction to a minimum and model (i.e., demonstrate on yourself) what you want the patient to do, such as pretend to wash your face then hand the patient the washcloth and nod telling her now you try. Alternatively you could try guiding the individuals hand in doing the activity, then removing your hand and letting them try.5. Be creative with your approach. If she wont get in the shower or tub on a particular day, wait and try again, or have her wash up at the sink, or wherever she is comfortable. Tell her that mother and daughter are having a spa day of beauty. Start with a manicure, which is often less threatening, then move to a facial, pedicure, etc.6. For dressing, lay clothes out in the order in which she should put them on and have other clothes out of the way.7. Teach the daughter that the patient will easily pick up on her daughters emotions, so the daughter should try to remain as calm as possible, appear relaxed, and smile.
Article - Home Health Skilled Nursing Care: Teaching and Training for Dementia Patients with Behavioral Disturbances - Medical Policy Article (A52845)
7. Teach the daughter that the patient will easily pick up on her daughters emotions, so the daughter should try to remain as calm as possible, appear relaxed, and smile.8. The nurse should first demonstrate these techniques to the daughter by doing them with the patient first, then on another visit, the daughter can provide a return demonstration for the nurse to observe.Scenario #2A physician has ordered skilled nursing care for teaching behavioral techniques to a care-giving niece of a patient with moderate Alzheimers disease to gain the patients cooperation during mealtime. Due to the patients wandering behaviors, she will not stay seated for a meal and the niece believes she is trying to be difficult. The patient has been gradually losing weight (10 pounds over 2 months) and she is less coordinated with her utensils due to her underlying dementia as well as a new onset tremor. The teaching services are reasonable and necessary for the patients treatment and adequate nutritional intake.Potential Interventions1. Teach the patients niece the primary symptoms of Alzheimers disease (amnesia, aphasia, apraxia, and agnosia), and how each of these symptoms can influence the patients functional ability and level of cooperativeness at mealtime.2. Explore strategies to decrease the patients wandering at mealtime (toilet before meals; take the patient for a walk before meals to expend excess energy; wait to seat patient when the meal is actually ready and on the plate; position the patient in a comfortable, supportive chair positioned directly in front of the table).3. If wandering persists or if the use of utensils is challenging for the patient due to apraxia, consider adding finger foods such as sandwiches, slices of fruit, chicken strips, etc.4. Limit the number of utensils and items on the table to decrease confusion and distractions.5. Give the patient one item of food at a time, so that the presentation of the food is not overwhelming and then the patient is less likely to become frustrated and walk away from the table.6. Limit verbal cueing to one step at a time. Physical cueing such as putting the cup in the patients hand, initially guiding the spoon to the patients mouth may also be helpful for initiation of the self-feeding activity.
Article - Home Health Skilled Nursing Care: Teaching and Training for Dementia Patients with Behavioral Disturbances - Medical Policy Article (A52845)
7. Eliminate unnecessary environmental stimulation that may distract or upset the patient (turn off television, avoid eating with large numbers of other people, etc.)8. Consider fortified supplements after a meal if intake is poor. Or consider multiple small meals or other finger foods throughout the day, to ensure adequate intake.9. Initially to stimulate appetite, give the patient her favorite foods to eat.10. Consider adaptive feeding equipment such as weighted utensils, no spill cups, bumper plates to increase the patients independence with eating.11. Cut or prepare food in a manner and consistency that maximizes the patients ability to eat it.12. Look for signs of poor dental hygiene, gingivitis and refer to dentist when appropriate. Pain when chewing may be affecting the patients oral intake. If the patient has oral heat and/or cold sensitivities, provide liquids and some food more at room temperature. If the patient routinely wore dentures, make sure the patient has them in her mouth and that they fit properly.13. Assess the patients medication regimen to see if any of the medications could be contributing to the patients tremor, or poor appetite and notify the physician.14. Check the patients bowel habits to make sure constipation is not causing loss of appetite.15. Monitor the patients weight at regular intervals.16. Try to have someone else eat at the same time the patient is so that behavior modeling can potentially occur.17. Assess for psychiatric symptoms (depression, paranoid delusions) that could result in a decreased food and fluid intake) and notify the physician.Coding Guidelines:General Guidelines for claims submitted to the Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.The diagnosis code(s) must best describe the patient's condition for which the service was performed.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.Home Health Advance Beneficiary Notice
Article - Home Health Skilled Nursing Care: Teaching and Training for Dementia Patients with Behavioral Disturbances - Medical Policy Article (A52845)
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.Home Health Advance Beneficiary NoticeAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 30, for complete instructions.
Article - Billing and Coding: Botulinum Toxins (A52848)
CMS National Coverage PolicyN/AArticle TextThis article contains coding or other guidelines that complement the local coverage determination (LCD) for Botulinum Toxins.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed.Specific coding guidelines for this policy:The appropriate injection/destruction codes should be submitted in conjunction with J0585, J0586, J0587, and J0588. Providers should report the CPT code that best describes the injection of Botulinum toxins. The corresponding medical conditions for which Botulinum toxins are used should be listed with the respective CPT code.Botulinum toxin type A (Botox) (onabotulinumtoxinA), is supplied in 100-unit vials, and is billed per unit. Claims for (onabotulinumtoxinA), should be submitted under HCPCS code J0585.Botulinum toxin type B (Myobloc) (rimabotulinumtoxinB) is manufactured in three dosing volumes  2500 units, 5000 units and 10,000 units and is billed per 100 units. Claims for rimabotulinumtoxinB should be submitted under HCPCS code J0587. Once (rimabotulinumtoxinB) is diluted, present recommendations call for its being used within four hours.Dysport (abobotulinumtoxinA) is manufactured in 300 unit vials and 500 unit vials. Reconstitution instructions are specific for each concentration and yield concentrations specific for use for each specific indication. Claims for abobotulinumtoxinA should be submitted under HCPCS code J0586.
Article - Billing and Coding: Botulinum Toxins (A52848)
Xeomin (incobotulinumtoxinA) is manufactured in 50 units, lyophilized powder in a single-use vial, and 100 units, lyophilized powder in a single-use vial. Reconstitution instructions are specific for each concentration and yield concentrations specific for use for each specific indication. HCPCS code J0588 should be used to report claims for incobotulinumA injections.The relevant anatomic modifier, or the modifier 59 (distinct procedural services) should be reported as applicable. Please indicate the left (LT) or right (RT) modifier.The Medicare Physician Fee Schedule Database (MPFSDB) bilateral modifier for CPT codes 64611 and 64615 is 2. Only one (1) unit of service should be reported for this injection. The bilateral modifier (50) should not be reported.The Medicare Physician Fee Schedule Database (MPFSDB) bilateral modifier for CPT codes 46505, 64612, 64616, 64617 and 67345 is 1. The bilateral modifier (50) should be used if these procedures are performed bilaterally.The Medicare Physician Fee Schedule Database (MPFSDB) bilateral modifier for CPT codes 43201, 43236, 52287, 64642-64647, 64650 and 64653 is 0. The bilateral modifier (50) should not be reported.For an Ambulatory Surgical Center (ASC), the appropriate site modifier (RT and/or LT) should be appended to indicate if the service was performed unilaterally or bilaterally. Bilateral services must be reported on separate lines using an RT and LT modifier (bilateral modifier (50) should not be used).
Article - Billing and Coding: Botulinum Toxins (A52848)
Appropriate CPT codes may be billed for electromyography used for injection needle guidance. Use 95873 and 95874 in conjunction with 64612, 64616, 64642, 64643, 64644, 64645, 64646, 64647 and other injection procedure codes when electromyography is medically necessary. Do not report CPT code 95874 in conjunction with code 95873. Electromyography used to guide injections for chemonervation for strabismus may be reported with CPT code 92265.The use of Botulinum toxin for cosmetic purposes is statutorily non-covered. If the beneficiary wishes injections of Botulinum toxin for cosmetic purposes, the beneficiary becomes liable for the service rendered. A claim for a cosmetic procedure does not have to be submitted to Medicare unless by patient request. The ICD-10-CM code that should be filed in this situation is Z41.1, "Encounter for cosmetic surgery."When HCPCS code J0585, J0586, J0587 or J0588 is denied, the related injection code(s) will also be subject to denial.For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.For coverage of Botulinum toxin treatment by Medicare, the medical record should include:documentation of the medical necessity for this treatment. For spastic conditions other than upper or lower limb spasticity, blepharospasm, hemifacial spasm, cervical dystonia or other focal dystonias, documentation should include a statement that the spastic condition has been unresponsive to conventional treatment;a covered diagnosis;dosage(s), site(s) and frequency(ies) of injection;documentation of the medical necessity for associated electromyography when used; anddescription of the effectiveness of this treatment.
Article - Billing and Coding: Botulinum Toxins (A52848)
Due to the short life span of the drug once it is reconstituted, Medicare will reimburse the unused portions of Botulinum toxins. When modifier JW is used to report that a portion of the drug is discarded, the medical record must clearly show the amount administered and the amount discarded.Effective July 1, 2023 (CR 13056) JZ Modifier is required on all claims that bill for drugs separately payable under Medicare Part B when there are no discarded amounts from single-dose containers or single-use packages.Documentation must be available upon request of the contractor. Peer-reviewed medical literature may be requested for case-by-case determinations.Utilization Guidelines:Dose and frequency should be in accordance with the FDA label. When services are performed in excess of established parameters, they may be subject to review for medical necessity.
Article - Billing and Coding: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography (A52849)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography (L33585).Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and UPIN or NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.An evaluation and management (E&M) service or consultation by the radiologist on the same day (or subsequent days) as a breast sonogram, MRI, or ductogram or their components should not be separately coded or billed.For breast sonography, breast MRI, and ductogram, the NPI of the treating/ordering physician or qualified non-physician practitioner is required on the claim. Report this number in item 17a of the CMS-1500 form or in the electronic equivalent.BREAST SONOGRAPHYIf performed bilaterally, a modifier 50 may be reported with CPT code 76641 or 76642.BREAST MRIOnly CPT codes77046, 77047, 77048, 77049may be reported for any given date of service.MAMMARY DUCTOGRAM OR GALACTOGRAMOnly CPT code 77053 or 77054 may be reported for any given date of service.Use CPT code 19030 for the injection of contrast.For claims submitted to the Part A MAC:CPT code 19030 is a packaged service and is not separately payable.BREAST SONOGRAPHYFor Part A billing of breast sonography, use the following:CPT codes 76641 and 76642BREAST MRI
Article - Billing and Coding: Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography (A52849)
CPT code 19030 is a packaged service and is not separately payable.BREAST SONOGRAPHYFor Part A billing of breast sonography, use the following:CPT codes 76641 and 76642BREAST MRIFor Part A billing of breast MRI, use the following:HCPCS code C8903,C8905, C8906, C8908CPT codes 77046 and 77047DUCTOGRAPHYFor Part A billing of ductography, use the following:CPT codes 77053 or 77054Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.A clear, clinical indication for the breast sonogram/breast MRI/ductogram must be documented in the medical record, as well as in the referral order.The medical record must include a formal written report describing all the views completed. The formal written report must include the reason for the test, a description of the test, the interpretation and results of the test, and the name of the physician to whom the report is being sent.Documentation must be available to Medicare upon request.