evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Transthoracic Echocardiography (TTE) (A57306)
The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.CAMZYOS REMS programEchocardiograms done as part of the CAMZYOS REMS program must be billed with a KX modifier and meet all requirements of the REMS program. This program is limited to patients with NYHA Class II-III Obstructive Hypertrophic Cardiomyopathy (I42.1).Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A57307)
CMS National Coverage PolicyCMS Publications:CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2:160.23 Sensory Nerve Conduction Threshold Tests (sNCTs)Program Memorandum Carriers Transmittal B-01-28 Change Request 850, describes tests that may be performed by PTs with ABPTS certificationCMS IOM 100-2. Medicare Benefit Policy Manual Chapter 15 Section 80 Requirements for Diagnostic Tests p. 88-91. 2009.Transmittal 2663 Change Request 8169 April Update to the CY 2013 Medicare Physician Fee Schedule Database (MPFSDB)Article TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policyNerve Conduction Studies and Electromyography L35897.When the beneficiary has a high pre-test or a prior probability for having the diagnosis of Carpal Tunnel Syndrome, the NC-stat System (alone) will be allowed, one service per arm, using CPT code 95905. The diagnosis codes G56.01, G56.02, or G56.03 should be used. All other diagnosis codes will be denied as not medically necessary.General Guidelines for Claims submitted to 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. 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.
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A57307)
Advance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn 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.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A57307)
The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)The patient's medical records must clearly document the medical necessity for the test. It is not necessary to include documentation with each claim submission. Data gathered during NCS, however, should be available which reflect the actual numbers (latency, amplitude, etc.), preferably in a tabular (not narrative) format. The reason for referral and a clear diagnostic impression are required for each study. In cases where a review becomes necessary, either a hard copy of waveforms or a complete written report with an interpretation of the test must be submitted upon request.Normal findings and abnormalities uncovered during the study should be documented with the muscles tested, the presence and type of spontaneous activity, as well as the characteristics of the voluntary unit potentials and interpretation.
Article - Billing and Coding: Physical Therapy - Home Health (A57311)
CMS National Coverage PolicySocial Security Act, Title XVIII, section 1834 (K)(5) incorporates the provisions in the Balanced Budget Act (BBA) of 1997; Section 4541 (a)(2) to require payment under a prospective payment system of outpatient rehabilitation servicesSocial Security Act, Title XVIII, section 1835 (a)(C) establishes conditions for payment of claims to institutional providers of outpatient therapy services, including certification and plan of treatment requirementsSocial Security Act, Title XVIII, sections 1861(g)(p)(s)(u), and (cc)(ll) establish definitions for services, institutions, and other Medicare termsSocial Security Act, Title XVIII, section 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and medically necessarySocial Security Act, Title XVIII, section 1862(a)(7) excludes routing physical examinations42 Code of Federal Regulations (42CFR) Parts:409 includes the definition of 'reasonable and necessary' therapy services that applies to both Part A and Part B services411 describes those specific services excluded from Medicare or that are subject to limitations on payment420 describe specific Medicare program integrity requirements to prevent fraud and abuse. It also sets forth appeal rights of providers.421 identifies the activities required of the MACs that process Medicare claims424 describes the conditions for Medicare payment, including those governing Part B outpatient physical therapy services. In particular, it sets forth certification and plan of treatment requirements484 includes the personnel qualifications that Medicare requires for identification as a physical therapist or a physical therapy assistantMedicare General Information, Eligibility, and Entitlement Manual (Pub 100-01), Chapter 4, Section 30Medicare Benefit PolicyManual (Pub 100-02), Chapter 7, Sections 30.4, 40, and 40.2Medicare Claims Processing Manual (Pub 100-04), Chapter 10Medicare National Coverage Determinations (NCDs) Manual (Pub 100-03).CMS Manual System, Publication 100-08, Medicare Program Integrity, Transmittal 248, Change Request 5971, dated March 28, 2008.CMS Manual System, Publication 100-08, Medicare Program Integrity, Transmittal 63, Change Request 3010, dated January 23, 2004Article Text
Article - Billing and Coding: Physical Therapy - Home Health (A57311)
Article TextFor documentation requirements see the following reference: Medicare Benefit Policy Manual (Pub 100-02), Chapter 7, Section 40.2. Additional documentation requirements may be found under the appropriate CPT/HCPCS code, at:www.cms.hhs.gov. A recent update to the documentation requirements was published in the Federal Register on November 17, 2010 but has not yet been manualized. To view this update, please go to the home page forHome Health Prospective Payment System, select Home Health Prospective Payment System Regulations and Notices and review Regulation Number CMSA 1510-F.General InformationTo qualify for the Medicare home health PPS benefit, under Sections 1814(a)(2)(C) and 1835(a)(2)(A), a Medicare beneficiary must meet the following requirements, which should be documented:Be confined to the homeUnder the care of a physicianReceiving services under a plan of care established and periodically reviewed by a physicianBe in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology, or have a continued need for occupational therapyPhysical Therapy ServicesSkilled physical therapy services are reimbursable under Medicare if the services are documented as being:Ordered by a physicianProvided by a skilled physical therapist, or under the general supervision of a skilled physical therapistReasonable and necessary to the treatment of the illness or injury, or to the restoration or maintenance of function affected by the illness or injuryProvided as a result of a valid, written, physician's signed and dated plan of treatment. The plan of treatment is established prior to the provision of physical therapy services and outlines the type, amount, frequency, and duration of the physical therapy services to be provided, identifies the functional diagnosis deficits, and anticipates the short and long term goals to be accomplishedIn accordance with the above guidelines as set forth in this LCDSignature RequirementsMedicare requires a legible identity for services provided/ordered. The method used may be hand-written or electronic subject to state laws. The individual whose name is on the alternate signature method bears the responsibility for authenticity.Treatment NotesTreatment notes should be completed per visit. They should be legible and clearly relate back to the established goals. Symbols, acronyms, and notation used in treatment notes should be:
Article - Billing and Coding: Physical Therapy - Home Health (A57311)
Treatment NotesTreatment notes should be completed per visit. They should be legible and clearly relate back to the established goals. Symbols, acronyms, and notation used in treatment notes should be:Consistent with standard documentationDiscernable, either on their face (e.g. PT = Physical Therapy), or by supplied legendsObjective (e.g., 3/10 for pain)Treatment notes should readily reflect all services billed.Failure of treatment notes to meet the above may result in non-coverage.This LCD should be interpreted to incorporate future changes in the ICD-10-CM or CPT/HCPCS coding systems such that its original intent and scope will not be substantively changed.Utilization GuidelinesThroughout the LCD are stated utilization guidelines (i.e., number of visits), andDO NOTimply coverage or non-coverage of a service. Services must be reasonable and necessary for each individual and be supported by the plan of care and other documentation.ProgramsMedicare does not cover "packaged" or "constellation of predetermined" services (i.e., "programs"). Services must be individualized and reasonable and necessary for each beneficiary.Qualified PersonnelMedicare does not pay for the services provided by aides/technicians regardless of the level of supervision. Medicare pays only for services delivered by qualified physical therapists and physical therapy assistants.
Article - Billing and Coding: Electrocardiograms (A57326)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made for items or services that "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, 1862(a)(7) and 42 Code of Federal Regulations, 411.15, exclude routine physical examinations.Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Medicare's Carrier's Manual (MCM), 15047(D), explains coverage for preoperative diagnostic tests performed to determine a patient's perioperative risks and optimize perioperative care. (The reference will be crosswalked to the CMS Manual System, Publication 100-04,Medicare Claims Processing Manual,Chapter 12, 30.6.6.1 as soon as it becomes available.)Medicare Carriers Manual, 15047(G), explains how to report preoperative tests. (The reference will be crosswalked to the CMS Manual System, Publication 100-04,Medicare Claims Processing Manual,Chapter 12, 30.6.6.1 as soon as it becomes available.)CMS Manual System, Publication 100-04,Medicare Claims Processing Manual,Chapter 12, 20.3(E), describes bundling of payment for ECG services supplied concomitantly with other physician services.CMS Manual System, Publication 100-04,Medicare Claims Processing Manual,Chapter 13, 100.1, states that in general only one payment is made for one interpretation of an EKG.CMS Manual System, Publication 100-04,Medicare Claims Processing Manual,Chapter 23, 20.9.1. Correct Coding Initiative (CCI) describes correct usage of the 59 modifier for repeat procedural services performed on the same day.
Article - Billing and Coding: Electrocardiograms (A57326)
CMS Manual System, Publication 100-04,Medicare Claims Processing Manual,Chapter 23, 20.9.1. Correct Coding Initiative (CCI) describes correct usage of the 59 modifier for repeat procedural services performed on the same day.CMS Manual System, Publication 100-03,Medicare National Coverage Determinations Manual,Chapter 1, 20.15, Electrocardiogram Service, "No payment is made for EKG interpretations by individuals other than physicians' and "A separate charge by an attending or consulting physician for EKG interpretation is allowed only when it is the normal practice to make such charge".CMS Manual System, Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, 190 and 200, allow for services supplied by physician assistants and nurse practitioners.CMS Manual System, Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, 250, states that payment may be made under Part B for the medical and other health services enumerated in paragraph C, but only where no payment can be made for such services under Part A.Article Text
Article - Billing and Coding: Electrocardiograms (A57326)
The following billing and coding guidance is to be used with its associated Local Coverage Determination (LCD).Coding Guidelines:The results of the ECG must be relevant to the management of the patient.When an ECG is performed on the same day as a cardiac stress test, but is not part of that stress test, it is separately payable. The ECG must add additional information to the stress test. For example, an ECG may be reasonable and necessary to rule out an acute MI prior to a same day stress ECG performed to evaluate possible accelerating angina. Typically, when the ECG stress test is scheduled in advance, a separate ECG on the same day is not reasonable and necessary.An ECG is not a covered benefit when used for screening purposes or as part of a routine physical examination. Routine physical examinations (screening) are evaluation and management services supplied in the absence of associated signs, symptoms or complaints. These services are denied as not a benefit of the Medicare program. Patients may choose to pay privately for these services.A second ECG performed to replace a technically inadequate ECG may not be reported as an additional service.Rhythm ECGs are used to evaluate signs and symptoms that may reflect a cardiac rhythm disorder.A rhythm ECG interpretation and report only (93042) is included in a 12-lead ECG interpretation and report (93000 or 93010).A rhythm ECG tracing (93040 or 93041) is included in a 12-lead ECG tracing (93000 or 93005).When several ECG rhythm (or monitor) strips from a single date of service are reviewed at a single setting, report only one unit of service, regardless of the number of strips reviewed.If one physician bills a rhythm strip interpretation, and another physician bills an ECG interpretation for the same patient on the same date of service, then both services must be reasonable and necessary. Typically, the patient will receive and requireprolongedrhythm monitoring in addition to a 12-lead ECG.An ECG furnished on anemergencybasis by a laboratory or a portable X-ray supplier requires that a physician be in attendance at the time the service was performed or immediately thereafter.Payments for a home-based ECG above the ECG base amount (i.e., for transportation costs) requires a medical need for performing the service in the patient's home, in addition to the need for the ECG itself. Typically, qualifying patients will be
Article - Billing and Coding: Electrocardiograms (A57326)
ECG above the ECG base amount (i.e., for transportation costs) requires a medical need for performing the service in the patient's home, in addition to the need for the ECG itself. Typically, qualifying patients will be homebound or bed-confined.Payment for the technical component of an ECG will be denied when the facility is paid for the technical component through the fiscal intermediary (i.e., during a Part A covered nursing home stay). In these cases, the ECG supplier is paid by the facility under a contract arrangement.Payment for more than one Professional Component (PC) of a single ECG:Medicare will not pay twice for a service that is required only once to diagnose or treat an illness or injury. Typically, this A/B MAC will pay for only one PC of an ECG. This A/B MAC may pay for a second PC when the additional physician expertise is necessary and reasonable to diagnose or treat the patient, such as to clarify a questionable finding. The physician performing the initial PC must have a valid reason to require another physicians expertise, such as, to interpret a confusing ECG. The second physician's knowledge and expertise must be significantly greater than that of the first reader, and it must contribute substantially to the interpretation.Multiple Interpretations of a Diagnostic Test in Institutional Settings:Medicare generally pays for only one reading of a diagnostic test. Medicares rules are clearly explained in the Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, Section 100.1 which made clear with public notice and comment that CMS policy would not pay for routine second readings). While Chapter 13 is titled, Radiology Services, Section 100.1 is titled X-rays and EKGs furnished to Emergency Room Patients. The principles apply to double-readings of diagnostic tests in general. The following paragraphs quote extensively from Section 100.1. [Emphasis added by this A/B MAC]Generally, A/B MACs (B) must pay for only one interpretation of an EKGor x-ray procedure furnished to an emergency room patient. They pay for a second interpretation (which may be identified through the use of modifier -77)only under unusual circumstances(for which documentation is provided) such as a questionable finding for which the physician performing the initial interpretation believes another physicians expertise is needed or a
Article - Billing and Coding: Electrocardiograms (A57326)
(which may be identified through the use of modifier -77)only under unusual circumstances(for which documentation is provided) such as a questionable finding for which the physician performing the initial interpretation believes another physicians expertise is needed or a changed diagnosis resulting from a second interpretation of the results of the procedure. When A/B MACs (B) receive only one claim for an interpretation, they must presume that the one service billed was a service to the individual beneficiary rather than a quality control measure and pay the claim if it otherwise meets any applicable reasonable and necessary test.When A/B MACs (B) receive multiple claims for the same interpretation, they must generally pay for the first bill received. A/B MACs (B) must pay for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient. Consideration is not given to physician specialty as the primary factor in deciding which interpretation and report to pay regardless of when the service is performed. Consideration is not given to designation as the hospitals official interpretation as a factor in determining which claim to pay. A/B MACs (B) pay for the interpretation billed by the cardiologist or radiologist if the interpretation of the procedure is performed at the same time as the diagnosis and treatment of the beneficiary. (This interpretation may be an oral report to the treating physician that will be written at a later time.) [End quotations]Section 100.1 provides one example of a medically appropriate double payment for a second interpretation, an example where an ER physician diagnoses pneumonia but a radiologist provides a requested second reading for possible tumor. For double reading of an EKG, a similar circumstance must apply, an unusual reason why a second interpretation (for example, a reading by a cardiologist) was specifically medically necessary. Otherwise, the second interpretation must be denied per the manual as a quality control service.Alternatively, if the first physician defers diagnosis with a telegraphic note and passes the test to the second physician for his/her diagnostic interpretation, only the second physician should bill. Chapter 13, Section 100.1 states that a telegraphic note in an E/M record is considered part of the E/M service and not a separate report. For example, a treating physician may see an x-ray with a radiologists report of a fractured tibia, and he may