evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Treatment of Varicose Veins of the Lower Extremities (A57707)
CMS National Coverage PolicyLanguage quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review a NCD. See 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act, 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Manual System, Pub 100-08,Medicare Program Integrity Manual,Chapter 13, 13.5.1 indicates services will be considered medically reasonable and necessary only if ordered and furnished by appropriately trained personnel.This training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty or must reflect extensive continued medical education activities. If these skills have been acquired by way of continued medical education, the courses must be comprehensive, offered or sponsored or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States, and designated by the American Medical Association (AMA) as Category 1 Credit.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.1. Each claim must be submitted with an ICD-10-CM code(s) that reflects the condition of the patient and indicates the reason(s) for which the service was performed.2. The patient's medical record must contain a history and physical examination supporting the diagnosis of symptomatic varicose veins, and the failure of an adequate (at least 3 months) trial of conservative management.3. The medical record must document the performance of appropriate tests, if medically necessary, to confirm the pathology of the vascular anatomy.
Article - Billing and Coding: Treatment of Varicose Veins of the Lower Extremities (A57707)
3. The medical record must document the performance of appropriate tests, if medically necessary, to confirm the pathology of the vascular anatomy.4. This documentation must be made available to Medicare upon request.5. The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.6. When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.
Article - Billing and Coding: Botulinum Toxins (A57715)
CMS National Coverage PolicyInternet Only Manual (IOM) Citations:CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 17, Drugs and BiologicalsChapter 23, Section 20.9 National Correct Coding Initiative (CCI)Social Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33274 Botulinum Toxins. Please refer to the LCD for reasonable and necessary requirements.According to the FDA Label indications, botulinum toxin treatment for blepharospasm and chronic migraine headaches is limited to specific muscles. The muscles that are currently FDA approved are listed below. Please refer to the LCD for complete coverage guidelines.Currently the following muscles are FDA approved for Onabotulinumtoxin A (BOTOX) injections for chronic migraine headache treatment:CorrugatorProcerusFrontalisTemporalisOccipitalisCervical paraspinalsTrapeziusCurrently the following muscles are FDA approved for Onabotulinumtoxin A (BOTOX) injections for blepharospasm treatment:Medial and lateral pre-tarsal orbicularis oculi muscle of the upper lidLateral pre-tarsal orbicularis oculi muscle of the lower lidCurrently the following muscles are FDA approved for Incobotulinumtoxin A (Xeomin) injections for blepharospasm treatment:Lateral and medial superior pre-tarsal part of the orbicularis oculi muscleLateral canthus of the orbicularis oculi muscleInferolateral portion of the orbicularis oculi muscleCorrugator muscle
Article - Billing and Coding: Botulinum Toxins (A57715)
Lateral and medial superior pre-tarsal part of the orbicularis oculi muscleLateral canthus of the orbicularis oculi muscleInferolateral portion of the orbicularis oculi muscleCorrugator muscleCoding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.The administration/injection code should be reported on the same claim with the botulinum toxin medication. When the botulinum toxin medication is denied, the related injection code(s) will also be subject to denial.JW and JZ ModifiersWhen billing for Part B drugs and biologicals (except those provided under a competitive acquisition program [CAP]), the use of the JW modifier to identify unused drugs or biologicals from single-dose containers or single-use packages that are appropriately discarded is required. The discarded amount shall be billed on a separate claim line using the JW modifier. Providers are required to document the discarded drug or biological in the patients medical record.Any amount wasted must be clearly documented in the medical record and should include the date and time, amount of medication wasted, and the reason for the wastage.The use of the JZ modifier (attesting that there were no discarded amounts) is required on claims to report there are no discarded amounts of unused drugs or biologicals from single-dose containers or single-use packages.Claims for drugs separately payable under Medicare Part B from single-dose containers are required to report either the JW or JZ modifier to identify any discarded amounts or to attest that there are no discarded amounts respectively.The JW and JZ modifier policy does not apply for drugs that are not separately payable, such as packaged OPPS or ASC drugs, or drugs administered in the FQHC or RHC setting.The JW and JZ modifiers do not apply to drugs assigned status indicator N (Items and Services Packaged into APC Rates) under the OPPS. Similarly, the JW and JZ modifiers do not apply to drugs assigned payment indicator N1 (ASC).Documentation Requirements
Article - Billing and Coding: Botulinum Toxins (A57715)
Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.Medical record documentation maintained by the ordering/referring provider must support the medical necessity of the services as stated in the LCD and should include the following elements in the event of a post payment review:Documentation of unsuccessful, inadequate response, or not a candidate for conventional methods of treatment, and/or other appropriate methods used to control condition as applicable (a statement outlining relevant medical history is acceptable).Results of pertinent tests/procedures.Name of botulinum toxin, total dosage, each injection site with the dosage, and frequency of injections.Support of the clinical effectiveness of the injections.Documentation of the patient's response or lack of response to injections.Support for the medical necessity of localization procedures if performed.Documentation supporting the management of a chronic migraine diagnosis along with a history that supports migraines occur greater than or equal to 15 days per month.
Article - Billing and Coding: Vitamin D Assay Testing (A57718)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.42CFR410.32(a) requires a clinical diagnostic test be ordered by the physician who is treating the patient for a specific medical problem and uses the results in the management of the beneficiarys specific problem.MBPM Internet Only Manual(IOM 100-02), chap. 6, 20.4.3 applies 42CFR410.32 to hospitals.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation must clearly indicate the necessity for the test(s), any and all repeat testing and frequency of testing.The medical record must be made available to Medicare upon request.The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.
Article - Billing and Coding: Vitamin D Assay Testing (A57719)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.42CFR410.32(a) requires a clinical diagnostic test be ordered by the physician who is treating the patient for a specific medical problem and uses the results in the management of the beneficiarys specific problem.MBPM Internet Only Manual(IOM 100-02), chap. 6, 20.4.3 applies 42CFR410.32 to hospitals.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation must clearly indicate the necessity for the test(s), any and all repeat testing and frequency of testing.The medical record must be made available to Medicare upon request.The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.
Article - Billing and Coding: Psychiatric Inpatient Hospitalization (A57726)
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) L33975, Psychiatric Inpatient Hospitalization. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Documentation Requirements
Article - Billing and Coding: Psychiatric Inpatient Hospitalization (A57726)
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.The initial psychiatric evaluation with medical history and physical examination should be performed within 24 hours of admission in order to establish medical necessity for psychiatric inpatient hospitalization services. The documentation should include:Patients chief complaint or description of acute illness or exacerbation of chronic illness requiring admission;Current and past psychiatric history (if available), including evidence of failure at or inability to benefit from a less intensive, outpatient program; prior level of function; history of substance abuse; and any suicidal ideations.Current and past medical history (if available);Family, vocational and social history (if available);Mental status examination, including general appearance and behavior, orientation, affect, motor activity, thought content, long and short term memory, estimate of intelligence, capacity for self harm and harm to others, insight, judgment, capacity for activities of daily living (ADLs);Physical examination;Formulation of the patients status, including an assessment of the reasonable expectation that the patient will make timely and significant practical improvement in the presenting acute symptoms as a result of the psychiatric inpatient hospitalization services; andICD-10-CM/DSM-IV-TRTMdiagnoses, including all five axes of the multiaxial assessment as described in the DSM-IV-TRTM.A team approach may be used in developing the initial psychiatric evaluation and the plan of treatment, but the physician (MD/DO) or non-physician practitioner must personally document the mental status examination, physical examination, and diagnosis. It will not always be possible to obtain all the suggested information at the time of evaluation. In such cases, the limited information that is obtained and documented, must still be sufficient to support the need for an inpatient level of care.
Article - Billing and Coding: Psychiatric Inpatient Hospitalization (A57726)
The Plan of Treatment is the tool used by the physician and multi-disciplinary treatment team to implement the physician-ordered services and move the patient toward the expected outcomes and goals. Although the Plan of Treatment is a requirement, the format and specific items to be included are up to the provider. Documentation of the parameters below is suggested to support the medical necessity for the inpatient services throughout the patients stay.This individualized, comprehensive, outcome-oriented plan of treatment should be developed:within the first three (3) program days after admission;by the physician, the multidisciplinary treatment team, and the patient; and should bebased upon the problems identified in the physicians diagnostic evaluation, psychosocial and nursing assessments.The treatment plan should include:the specific treatments ordered, including the type, amount, frequency, and duration of the services to be furnished;the expected outcome for each problem addressed; andcontain outcomes that are measurable, functional, time-framed, and directly related to the cause of the patients admission.Treatment plan updates should show the treatment plan to be reflective of active treatment, as indicated by documentation of changes in the type, amount, frequency, and duration of the treatment services rendered as the patient moves toward expected outcomes. Treatment plan updates should be documented at least weekly, as the physician and treatment team assess the patients current clinical status and make necessary changes. Lack of progress and its relationship to active treatment and reasonable expectation of improvement should also be noted.The initial treatment plan and updated plans must be signed by the physician or non-physician practitioner and those mental health professionals contributing to the treatment plan.
Article - Billing and Coding: Psychiatric Inpatient Hospitalization (A57726)
A separate progress note should be written for each significant diagnostic and therapeutic service rendered and should be written by the team member rendering the service. Although each progress note may not contain every element, progress notes should include a description of the nature of the treatment service, the patients status (behavior, verbalizations, mental status) during the course of the service, the patients response to the therapeutic intervention and its relation to the long or short term goals in the treatment plan. Each progress note should be legible, dated and signed, including the credentials of the rendering provider. It should be clear from the progress notes how the particular service relates to the overall plan of care.Physician progress notes should be recorded at each patient encounter and contain pertinent patient history, changes in signs and symptoms, with special attention to changes to the patients mental status, and results of any diagnostic testing. The notes should also include an appraisal of the patients status and progress, and the immediate plans for continued treatment or discharge. The course of the patients inpatient diagnostic evaluation and treatment should be inferred from reading the physician progress notes.Individual and group psychotherapy and patient education and training progress notes should describe the service being rendered, (i.e., name of group, group type, brief description of the content of the individual session or group), the patients communications, and response or lack of response to the intervention. Each progress note should reflect the particular characteristics of the therapeutic/educational encounter to distinguish it from other similar interventions.
Article - Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains (A57733)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Special Histochemical Stains and Immunohistochemical Stains L36805.To report special histochemical stains and/or immunohistochemical stains services, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)
Article - Billing and Coding: Vitamin D Assay Testing (A57736)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.42CFR410.32(a) requires a clinical diagnostic test be ordered by the physician who is treating the patient for a specific medical problem and uses the results in the management of the beneficiarys specific problem.MBPM Internet Only Manual (IOM 100-02), Chapter 6, Section 20.4.3 applies 42CFR410.32 to hospitals.Article TextThis article contains coding or other guidelines that complement the local coverage determination (LCD) for Vitamin D Assay Testing.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.DocumentationDocumentation must justify the test(s) chosen for a particular disease entity. Various component sources of 25-OH Vitamin D, such as stored D or diet-derived D, should not be billed separately.If Vitamin D level is between 20 and 50 ng/ml and patient is clinically stable, documentation in the patient's medical record for repeat testing must clearly indicate the necessity of the test.
Article - Billing and Coding: Trigger Point Injections (A57751)
CMS National Coverage PolicyInternet-Only Manuals (IOM):CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 1, Section 30.3 AcupunctureChapter 1, Part 2, Section 150.7 Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing AgentsSocial 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) L35010, Trigger Point Injections. 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.Only one code from20552or20553should be reported on any particular day, no matter how many sites or regions are injected.