evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Pulmonary Rehabilitation Services (A56152)
Expertise in the management of individuals with respiratory pathophysiology.Cardiopulmonary training in basic life support or advanced cardiac life support.Be licensed to practice medicine in the State in which the PR program is offered.Education or training that is closely and clearly related to the individuals care and treatment which is tailored to the individuals needs and assists in achievement of goals toward independence in activities of daily living, adaptation to limitations and improved quality of life. Education must include information on respiratory problem management and, if appropriate, brief smoking cessation counseling.The education requirement is not met by:Handing out a booklet, "How to Stop Smoking with no additional follow-up."Having the patient take an assessment at the beginning and end of the program.Documenting sporadic and/or vague instruction provided e.g., "discussed self-management techniques."Psychosocial assessment and reassessment must be thorough and occur at periodic intervals. This includes evaluation of an individuals mental and emotional functioning as it relates to the individuals rehabilitation or respiratory condition, an assessment of those aspects of an individuals family and home situation that affects the individuals rehabilitation treatment,and psychosocial evaluation of the individuals response to and rate of progress under the treatment plan.Significant outcomes assessment with clinical measures (initial/ending) must be evident in the medical record. This includes evaluations based on patient-centered outcomes, objective clinical measures of exercise performance and self-reported measures of shortness of breath and behavior.
Article - Billing and Coding: Pulmonary Rehabilitation Services (A56152)
The patient may require an additional 36 sessions for COVID-19 if he/she has already received pulmonary rehabilitation services for COPD initially or vice versa. When billing for these additional sessions for the second approved condition, providersmustappend the KX modifier to the second 36 sessions.Hospitals and practitioners may report a maximum of 2 1-hour sessions per day. In order to report one session ofPRin a day, the duration of treatment must be at least 31 minutes. Two sessions ofPRmay only be reported in the same day if the duration of treatment is at least 91 minutes.Therapy modifiers (GN/GO/GP) and revenue codes (42x/43x) should not be coded.CMS deleted the Pulmonary Rehabilitation Program HCPCS code G0424 effective 12/31/2021. The following CPTcodes replaced G0424 for the Pulmonary Rehabilitation Program effective January 1, 2022, and may only be billed when all the above program requirements are met.94625 - Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; without continuous oximetry monitoring (per session), or94626 - Physician or other qualified health care professional services for outpatient pulmonary rehabilitation; with continuous oximetry monitoring (per session.Public Health Emergency Telehealth ServicesOn March 6, 2020, the Centers for Medicare & Medicaid Services (CMS) broadened access to Medicare telehealth services during the COVID-19 public health emergency (PHE) so beneficiaries can get a wider range of services from their doctors and other clinicians without traveling to a health care facility. These guidelines are effective for dates of service (DOS) on and after March 1, 2020, until the end of the designated PHE.Telehealth services- Visits conducted between a provider and a patient using two-way telecommunication systems with audio and video capabilities.
Article - Billing and Coding: Pulmonary Rehabilitation Services (A56152)
Use of two-way, real-time interactive audio/video telecommunication capability is needed.Bill professional claims for all telehealth services with DOS on and after March 1, 2020, and for the duration of the PHE to Medicare with place of service (POS) equal to what it would have been had the service been furnished in-person (example: POS 11 for office or POS 19 for provider-based outpatient hospital).Bill appropriate covered telehealth service code(s).Modifier 95 should be applied to claim lines for services furnished via telehealth.Only 94625 and 94626 have been added to the list of Covered Telehealth Services foundhere.Due to the Public Health Emergency (PHE) ending on May 11, 2023, this exception is no longer in effect as of May 11, 2023.Sources:Social Security Act (SSA) 1862(a)(1)(A);42 Code of Federal Regulations (CFR), Part 410, Subpart B, Sections 410.17, 410.26, 410.27, 410.47;National Coverage Determination 240.8;IOMMedicare Benefit Policy Manual,Publication 100-02, Chapter 12, Section 40.5 and Chapter 15, Sections 220-230, 230.5, 231;IOMMedicare Claims Processing Manual,Chapter 5, Section 20(C) and Chapter 32, Section 140.4;CMS MLN Matters MM6823-RevisedTransmittal 11426CP, CR 12613 dated May 20, 2022
Article - Billing and Coding: Intraarticular Knee Injections of Hyaluronan (A56157)
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 claimCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, 30.6.7(D) Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201-99215) - Drug Administration Services and E/M Visits Billed on Same Day of ServiceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, 40 Discarded Drugs and Biologicals and 90.2 Drugs, Biologicals, and RadiopharmaceuticalsCMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 50.3 Incident-to Requirements and 50.4.1 Approved Use of DrugArticle TextPurified natural hyaluronates have been approved by the FDA for the treatment of symptomatic osteoarthritis of the knee in patients who have failed to respond to simple analgesics or conservative nonpharmacologic therapy. Osteoarthritis leads to changes in hyaluronan, a natural substance that helps provide the fluid within the joint with elasticity and viscosity. The therapeutic goal of administration of intraarticular hyaluronate is to provide and maintain intraarticular lubrication, which increases the viscoelastic properties of synovial fluid; this form of therapy is therefore termed viscosupplementation. Osteoarthritis (OA) is a common condition affecting the knee/s. Comprehensive management of OA should always include a combination of treatment options directed toward the common goal of alleviating pain and improving function. These include symptomatic pharmacological treatment with analgesics, non-steroidal anti-inflammatory drugs (NSAID) and intraarticular corticosteroid injections. Muscle strengthening exercises, weight loss, and assistive devices such as canes have been helpful in managing osteoarthritis.Various polymers of hyaluronic acid have been approved and marketed as implanted prosthetic devices.
Article - Billing and Coding: Intraarticular Knee Injections of Hyaluronan (A56157)
The FDA has approved Viscosupplementation as a device. Medicare is allowing this nonpharmacologic therapy. The contractor expects the use of those drugs and biologicals not listed here to be medically necessary and used according to their FDA indications.This treatment will only be covered for the treatment of pain in osteoarthritis of the knee. All other uses will be denied as investigational.All procedures are furnished by and administered by a physician and/or appropriately trained providers in the appropriate setting.Documentation in the patient's medical record must support the patient failed to respond adequately over a three-month period to a past history of treatment with analgesics and conservative nonpharmacological therapy (exercise or physical therapy, weight loss if appropriate, use of assistive devices).A radiological exam to support the clinical diagnosis of osteoarthritis of the knee will be available in the patients medical record.If subsequent courses of treatment are given, the medical records must support the effectiveness of the prior treatment and must clearly establish reduction of patient symptomatology and medication usage. This documentation must be submitted upon request. Claims submitted without requested supporting evidence in the medical record will be denied as being not medically necessary.Repeat treatments are considered medically necessary for patients being treated for osteoarthritis of the knee, who meet both of the following criteria:Significant improvement in knee pain and known improvement in functional capacity resulted from the previous series of injections which has been documented in the record; andAt least six (6) months have elapsed since the last injection in the series.The Medicare program covers drugs that are furnished incident to a physicians service provided, that the drugs are not usually self-administered by the patients. Please refer to the WPS GHA Guides and Resources: Incident to Services.The following guidelines identify three categories in which medications would not be reasonable and necessary according to accepted standards of medical practice:
Article - Billing and Coding: Intraarticular Knee Injections of Hyaluronan (A56157)
Medications given for a purpose other than the treatment of a particular condition, illness, or injury are not covered.Medications administered for treatment of a disease and which exceed the frequency or duration of injections indicated by accepted standards of medical practice are not covered.If a medication is determined not to be medically reasonable and necessary for diagnosis or treatment of an illness or injury according to these guidelines, the entire charge (i.e., for both the drug and its administration) is not considered medically necessary.Billing of ViscosupplementsWhen reporting C, J or Q HCPCS codes for hyaluronan acid therapy, it should be noted that some codes are per dose and some are per mg as specified in the code descriptor. When reporting a per mg drug code, report the appropriate number of units that reflect the dosage given. Units of service are to be billed in multiples of the dosage specified in the full HCPCS descriptor. This descriptor does not always match the dose given. The units billed must correspond with the smallest dose (vial) available for purchase from the manufacturer(s) that could provide the appropriate dose for the patient. Dosing frequency of injections per series and/or dosing frequency per series as listed/supported with the FDA approved dosing/package insert must be documented in the medical record. Providers are responsible for determining the code that most accurately describes the intraarticular agent furnished.HYALURONAN Drug Dosing Tables1.The following HCPCS codes are per dose codes:HCPCSCodeBillingUnitDrugName(s)Dosing frequency per series(per knee)*Dose (perknee)*Units per dose(per knee)J7321per doseHyalgan3 to 5 weekly injections20 mg once weekly1 unitJ7321per doseSupartz3 to 5 weekly injections25 mg once weekly1 unitJ7321per doseVisco-33 weekly injections25 mg once weekly1 unitJ7323per doseEuflexxa3 weekly injections20 mg once weekly1 unitJ7324per doseOrthovisc3 to 4 weekly injections30 mg once weekly1 unitJ7326per doseGel-OneSingle injection**30 mg x 1 dose1 unit
Article - Billing and Coding: Intraarticular Knee Injections of Hyaluronan (A56157)
J7324per doseOrthovisc3 to 4 weekly injections30 mg once weekly1 unitJ7326per doseGel-OneSingle injection**30 mg x 1 dose1 unitJ7327per doseMonoviscSingle injection**88 mg x 1 dose1 unit*Note:Dose frequency and dose listed is from package insert or is FDA approved dosing.**Note:Gel-One and Monovisc are administered through a single intra-articular injection.2.The following HCPCS codes are per mg codes (not per dose):HCPCSCodeBillingUnitDrugName(s)Dosing frequency per series(per knee)*Dose (perknee)*Units per dose(per knee)J7328per 0.1 mgGelsyn-33 weekly injections16.8 mg once weekly168 unitsJ7329per 1 mgTriVisc3 weekly injections25 mg once weekly25 unitsJ7318per 1 mgDurolaneSingle Injection**60 mg x 1 dose60 unitsJ7320per 1 mgGenvisc 8503 to 5 weekly injections25 mg once weekly25 unitsJ7325per 1 mgSynvisc3 weekly injections16 mg once weekly16 unitsJ7325per 1 mgSynvisc-OneSingle injection**48 mg x 1 dose48 unitsJ7322per 1 mgHymovis2 weekly injections24 mg once weekly24 unitsJ7331per 1 mgSynojoynt3 weekly injections20 mg once weekly20 unitsJ7332per 1 mgTriluron3 weekly injections20 mg once weekly20 units
Article - Billing and Coding: Intraarticular Knee Injections of Hyaluronan (A56157)
J7331per 1 mgSynojoynt3 weekly injections20 mg once weekly20 unitsJ7332per 1 mgTriluron3 weekly injections20 mg once weekly20 units*Note:Dose frequency and dose listed is from package insert or is FDA approved dosing.**Note:Synvisc-One and Durolane are administered through a single intra-articular injection.Billing subsequent injections in a series (EJ modifier)A series is defined as a set of injections for each joint and each treatment. The EJ modifier must be used with the HCPCS code for the drug administered to indicate subsequent injections of a series. The modifier is not to be used with the first injection of each series.JW Modifier RequirementEffective 01/01/2017, per CR 9603, when billing for Part B drugs and biologicals (except those provided under CAP), the use of the JW modifier to identify unused drugs or biologicals from single use vials 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. Please refer to the WPS GHA Guides and Resources: Modifier JW Fact Sheet.Billing the injection procedure
Article - Billing and Coding: Intraarticular Knee Injections of Hyaluronan (A56157)
The procedure code (CPT code) 20610 or 20611 may be billed for the intraarticular injection. The charge, if any, for the drug or biological must be included in the physicians bill and the cost of the drug or biological must represent an expense to the physician.If an aspiration and an injection procedure are performed at the same session, bill only one unit for CPT code 20610 or 20611.When additional substances are concomitantly administered (e.g. cortisone, anesthetics) with viscosupplementation, only one injection service is allowed per knee.The appropriate site modifier (RT or LT) must be appended to CPT code 20610 or CPT code 20611 to indicate if the service was performed unilaterally and modifier (-50) must be appended to indicate if the service was performed bilaterally.If the drug is denied as not reasonable and necessary, the associated injection code will also be denied.Please refer to the WPS GHA Guides and Resources  Modifier 50, LT, RT Fact Sheets.Evaluation and management serviceAn E&M service may be appropriate if the decision to start the series of injections is made after an evaluation during the same visit. Indicate this by using an E&M code with modifier -25.An E&M service should not be reported for subsequent injections unless there was a separately identifiable problem for which the E&M service was required and rendered.Please refer to the WPS GHA Guides and Resources  Modifier 25 Fact Sheet.Sources of Information:FDA package inserts for hyaluronic acids including Safety and Effectiveness Data;The Medical Letter (August 27, 2018). Two New Intra-articular Injections for Knee Osteoarthritis. Vol. 60 (1554);Hunter, D. (2015) Viscosupplementation for Osteoarthritis of the Knee. NEJM, 372:1040-7.Other MACs LCD/Articles.WPS GHA Guides and Resources  Modifier JW, LT, RT, 50, and 25 Fact Sheets.
Article - Billing and Coding: Frequency of Hemodialysis (A56159)
CMS National Coverage PolicyN/AArticle TextRefer to the CGS Administrators Local Coverage Determination (LCD) L37575, Frequency of Hemodialysis, for reasonable and necessary requirements and frequency limitations.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.This article outlines how to line item bill dialysis sessions for End Stage Renal Disease (ESRD) patients. This does not address line item billing for sessions associated with training or other modalities such as peritoneal dialysis. This article does not change any other billing requirements for dialysis claims. Note: This article uses the terms dialysis "session" and "treatment" interchangeably.CMS IOM Publication 100-04, Medicare Claims Processing Manual,Chapter 8 requires line item billing for all ESRD claims with dates of service (DOS)on or after April 1, 2007. Each dialysis session performed should be reported on a separate line.CMS IOM Publication 100-02,Medicare Benefit Policy Manual, Chapter 11 discusses that ESRD facilities furnishing dialysis treatments in-facility or in the beneficiarys home are paid for up to 3 treatments per week. Payment for additional treatments, defined as any treatments in excess 3 treatments per week, may be considered in addition to the ESRD PPS per treatment payment amount paid for up to 3 treatments per week.For monthly claims submitted with Bill Type 72X and Revenue Codes 0821 and 0881, three approaches of billingper lineare available. Based on the Patients Plan of Care (POC) or other available medical documentation, the following scheme should be followed when billing sessions. Note: Dialysis sessions in a patient's POC that are not furnished should not be billed.:
Article - Billing and Coding: Frequency of Hemodialysis (A56159)
For dialysis session that have been furnished 3 times (3X) per week,each line should be 90999 without any modifiers appended. That is, when the hemodialysis prescription is 3 times (3X) per week and each session is furnished, all of these sessions should be billed as 90999 (no modifier appended) and they will be paid as routine conventional dialysis up to 13/14 per month. POC outline3 X week in the prescription, all of these sessions should be billed as 90999 (no modifier appended) and will be paid as routine conventional dialysis up to 13/14 per month.
Article - Billing and Coding: Frequency of Hemodialysis (A56159)
For each dialysis session furnished in addition to 3 sessions per week that do not include medical documentation supporting a reasonable and necessary determination for payment, each line for these sessions should be billed as 90999 CG.Examples of when this could occur include short, more frequent treatments furnished for the convenience of the patient or staff, etc. Additional sessions need to be billed as 90999 CG when medical documentation has not been submitted to support the extra sessions as reasonable and necessary.The CG modifier indicates that the facility attests the additional treatment is not reasonable and necessary and should not receive additional payment. Each line billed as 90999 CG will be denied however use of the modifier is used for data analysis.Please refer to CR 9989, Implementation of Modifier CG for Type of Bill 72X, dated May 12, 2017.For each dialysis session furnished in addition to 3 sessions per week that include medical documentation supporting a reasonable and necessary determination for payment, each line for these sessions should be billed as 90999KX.These includemedical conditions that have supporting documentation that extra sessions are reasonable and necessary (e.g., through documents from recent hospital care, office visits, dialysis progress notes or MCP visits). These sessions must be reasonable and necessary for additional payment based on clinical conditions. On these claims, the 90999 lines without out a modifier will be paid as 3X week and those lines with 90999 KX will be considered for additional payments. Omission of the KX modifier will result in no additional payment for the line item.For diagnoses not listed in in this article but felt to be reasonable and necessary, the KX modifier should be appended as well. A denial will occur on these lines, but the redetermination process (an appeal) will be available to submit supportive documentation for review.
Article - Billing and Coding: Frequency of Hemodialysis (A56159)
The expectation is that these three scenarios will be seen on monthly claims, i.e., claims with 90999 lines only, or those with lines of 90999 mixed with 90999 CG or KX modifier appended. Ongoing data analysis may trigger provider specific requests for documentation should unusual patterns occur, i.e., claims with only lines of 90999 KX submitted.Please note that the POC and other supportingmedical documentation to justify any of the line item sessionswill be most important and may be requested.Please see L37575 for instructions when clinical conditions outside those listed in the available diagnosis should occur.Please see L37575 for Documentation Requirements and Utilization Guidelines.
Article - Low frequency, non-contact, non-thermal ultrasound (CPT code 97610) (A56175)
CMS National Coverage PolicyN/AArticle TextLow frequency, non-contact, non-thermal ultrasound (CPT code 97610) describes a system employed in wound care that uses continuous low frequency ultrasonic energy to atomize a liquid and deliver continuous low frequency ultrasound to the wound bed. MIST therapy or other similar products are included in the payment for the treatment of the same wound with other active wound care management CPT codes (97597, 97598, 97602, 97607, 97608) or wound debridement CPT codes (e.g., CPT codes 11042-11047, 97597, 97598). Effective November 1, 2018, MIST Therapy or other similar treatments would be separately billable if other active wound management and/or wound debridement is NOT performed.
Article - Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF) (A56178)
CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (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 Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an 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 (SSA):Section 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.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Publications:CMS Publication 100-04;Medicare Claims Processing Manual, Chapter 13:80 Supervision and Interpretation (S & I) Codes and Interventional RadiologyCMS Transmittal No. 423, Publication 100-04,Medicare Claims Processing Manual, Change Request #3632, January 6, 2005. Update of the Hospital Outpatient Prospective Payment, includes Kyphoplasty.Article Text