evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Deductible and coinsurance do not apply.   130.4 - Types of Bill (TOBs) and Revenue Codes  (Rev. 3461; Issued: 02- 05-16; Effective: 04 -13-15; Implementation: 03 -07-16 - non-shared A/B MAC edits; 07 -05-16 - CWF analysis and design; 10- 03-16 - CWF Coding, Testing and Implementation, MCS, and FISS Implementation; 01 -03-17 - Requirement 9403.04.9)   The applicable bill types for HIV screening, HCPCS codes G0432, G0433, G0435, and G0475 are: 12X, 13X, 14X, 22X, 23X, and 85X.  (Effective April 1, 2006, TOB 14X is for non- patient laboratory specimens.)  Use revenue code 030X (laboratory, clinical diagnos tic).  A/B MACs (A) shall apply contractor pricing for HCPCS code G0475, HIV screening, for claims with dates of service on and after April 13, 2015 through December 31, 2016.   130.5 - Diagnosis Code Reporting  (Rev. 3835, Issued: 08- 16-17, Effective: 04 -13-15, Implementation: 10- 02-17) A claim that is submitted for HIV screening shall be submitted with one or more of the following diagnosis codes in the header and pointed to the line item:   a. For claims where increased risk factors are reported : ICD -9/ICD -10 diagnosis code V73.89/Z11.4 as primary and ICD -9/ICD -10 diagnosis code V69.8/Z72.89, Z72.51, Z72.52, or Z72.53, as secondary.   b. For claims where increased risk factors are NOT reported : ICD -9/ICD -10 diagnosis code V73.89/Z11.4 as primary only.  c. For claims for pregnant Medicare beneficiaries , the following secondary diagnosis codes shall be submitted in addition to primary ICD -9/ICD -10 diagnosis code V73.89/Z11.4 to allow for more frequent screening than once per 12 -month period:
(Medicare Claims Processing Manual)
ICD-9: V22.0 Supervision of normal first pregnancy  ICD-10: Z34.00 Encounter for supervision of normal first pregnancy, unspecified trimester  Z34.01 Encounter for supervision of normal first pregnancy, first trimester  Z34.02 Encounter for supervision of normal first pregnancy, second trimester  Z34.03 Encounter for supervision of normal first pregnancy, third trimester   ICD-9:  V22.1 Supervision of other normal pregnancy  ICD-10: Z34.80 Encounter for supervision of other normal pregnancy, unspecified trimester  Z34.81 Encounter for supervision of other normal pregnancy, first trimester  Z34.82 Encounter for supervision of other normal pregnancy, second trimester  Z34.83 Encounter for supervision of other normal pregnancy, third trimester  Z34.90 Encounter for supervision of normal pregnancy, unspecified, unspecified trimester  Z34.91 Encounter for supervision of normal pregnancy, unspecified, first trimester  Z34.92 Encounter for supervision of normal pregnancy, unspecified, second trimester  Z34.93 Encounter for supervision of normal pregnancy, unspecified, third trimester   ICD-9: V23.9 Supervision of unspecified high- risk pregnancy ICD-10: O09.90 Supervision of high risk pregnancy, unspecified, unspecified trimester  O09.91 Supervision of high risk pregnancy, unspecified, first trimester  O09.92 Supervision of high risk pregnancy, unspecified, second trimester  O09.93 Supervision of high risk pregnancy, unspecified, third trimester   130.6 - Medicare Summary Notice (MSN) and Claim Adjustment Reason Codes (CARCs)  (Rev.  3835, Issued: 08- 16-17, Effective: 04 -13-15, Implementation: 10- 02-17)  Effective for dates of service on or after December 8, 2009, when denying claims for HIV screening, HCPCS codes G0432, G0433, or G0435, submitted without ICD -9/ICD -10 diagnosis codes V73.89/Z11.4, or V73.89/Z11.4 and V69.8/Z72.89, use the following message s:  Medicare Summary Notice (MSN) 16.10 -  Medicare does not pay for this item or service.   Medicare no paga por este articulo o servicio
(Medicare Claims Processing Manual)
Medicare Summary Notice (MSN) 16.10 -  Medicare does not pay for this item or service.   Medicare no paga por este articulo o servicio   Claim Adjustment Reason Code (CARC) 167-  This (these) diagnosis(es) is (are) not covered.   Group Code CO -  (Contractual Obligation)    Effective for dates of service on or after December 8, 2009, when denying claims for HIV screening, HCPCS codes G0432, G0433, or G0435, over the benefit maximum, use the following denial messages:   MSN 15.22  The information provided does not support the need for this many services or items in this period of time so Medicare will not pay for this item or service.   La informac n proporcionada no justifica la necesidad de esta cantidad de servicios o articulos en este periodo de tiempo por lo cual Medicare no pagar  por este articulo o servicio.   CARC 119  Benefit maximum for this time period or occurrence has been reached.   Group Code CO -  (Contractual obligation).    Effective for dates of service on or after April 13, 2015 , when denying claims for HIV screening, HCPCS code G0432, G0433, G0435, G0475 or  CPT -80081 for more than three in a pregnancy term, use the following denial messages:   CARC 119  Benefit maximum for this time period or occurrence has been reached.   Remittance Advice Remark Code (RARC) N386 - This decision was based on a National Coverage Determination (NCD).  An NCD provides a coverage determination as to whether a particular item or service is covered.  A copy of this policy is available at www.cms. gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
(Medicare Claims Processing Manual)
(Part A only) MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim.  You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Cal l 1-800-MEDICARE (1 -800-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto.  Un LCD se us para su reclamacin.  Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si pie nsa que puede cambiar nuestra decisin.  Para obtener una copia del LCD, llame al 1 -800 MEDICARE (1- 800-633-4227).  MSN 15.20: The following policies NCD210.7 were used when we made this decision.   Spanish Version  Las siguientes polticas NCD210.7 fueron utilizadas cuando se tom esta decisin.   NOTE:   Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.   MSN: 15.22: The information provided does not support the need for this many services or items in this period of time so Medicare will not pay for this item or service.   Spanish Version  La informacin proporcionada no justifica la necesidad de esta cantidad de servicios o artculos en este periodo de tiempo por lo cual Medicare no pagar por este artculo o servicio.   Group Code -  CO
(Medicare Claims Processing Manual)
Group Code -  CO   Effective for dates of service on or after April 13, 2015, when denying claims for HIV screening, HCPCS code G0475, if ICD -9/ICD -10 primary diagnosis code V73.89/Z11.4 and one of the following secondary ICD -9/ICD -10 diagnosis codes: V69.2/Z72.51, V69.8/Z72.89, V69.2/Z72.52, or V69.2/Z72.53 are not present and the beneficiary is less than 15 and greater than 65 years of age, use the following messages:   CARC 6: The procedure/revenue code is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N129: Not eligible due to the patients age.   (Part A only) MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim.  You can compare your case to the LCD, and send information from your doctor if you think it could change our decision.  Ca ll 1-800-MEDICARE (1 -800-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto.  Un LCD se us para su reclamacin.  Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si pie nsa que puede cambiar nuestra decisin.  Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).  MSN 15.20: The following policies NCD210.7 were used when we made this decision."   Spanish Version  Las siguientes polticas NCD210.7 fueron utilizadas cuando se tom esta decisin.
(Medicare Claims Processing Manual)
NOTE:   Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.   Group Code -  CO   Effective for dates of service on or after April 13, 2015, when denying claims for HIV screening, HCPCS code G0475, G0432, G0433, or G0435 is not submitted with the appropriate, primary ICD -9/ICD -10 diagnosis code V73.89/Z11.4, , use the following messages:   CARC 167  This (these) diagnosis(es) is (are) not covered.  Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   RARC N386  This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered.  A copy of this policy is available at www.cms.gov/mcd/search.asp.  If you do not have web access, you may contact the contractor to request a copy of the NCD.   (Part A Only) MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim.  You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Cal l 1-800-MEDICARE (1 -800-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto.  Un LCD se us para su reclamacin.  Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si pie nsa que puede cambiar nuestra decisin.  Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).  MSN 15.20: The following policies NCD210.7 were used when we made this decision.
(Medicare Claims Processing Manual)
MSN 15.20: The following policies NCD210.7 were used when we made this decision.   Spanish Version  Las siguientes polticas NCD210.7 fueron utilizadas cuando se tom esta decisin.   NOTE:   Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.   Group Code -  CO  Effective for dates of service on or after April 13, 2015, when denying claims for HIV screening, HCPCS code G0475, billed more than once per annum [at least 11 full months must elapse from the date of the last screening], use the following messages:   CARC 119: Benefit maximum for this time period or occurrence has been reached.   RARC N386: This decision was based on a National Coverage Determination (NCD).  An NCD provides a coverage determination as to whether a particular item or service is covered.  A copy of this policy is available at www.cms.gov/mcd/search.asp.  If you do not have web access, you may contact the contractor to request a copy of the NCD.   (Part A Only)MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered.  An LCD was used for your claim.  You can compare your case to the LCD, and send information from your doctor if you think it could change our decision.  Ca ll 1-800-MEDICARE (1 -800-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto.  Un LCD se us para su reclamacin.  Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si pie nsa que puede cambiar nuestra decisin.  Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).  MSN 15.20: The following policy NCD210.7 was used when we made this decision
(Medicare Claims Processing Manual)
MSN 15.20: The following policy NCD210.7 was used when we made this decision   Spanish Version  Las siguientes polticas NCD210.7 fueron utilizadas cuando se tom esta decisin.   NOTE:   Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.   Group Code -  CO   Effective for dates of service on or after April 13, 2015, when denying claims for HIV screening, HCPCS G0475 or  CPT -80081 if ICD -9/ICD -10 primary diagnosis code V73.89/Z11.4 and one of the following ICD -9/ICD -10 secondary diagnosis codes are not present for pregnant beneficiaries as listed in section 130.5 (c), use the following denial messages:   CARC 11: The diagnosis is inconsistent with the procedure.  Note:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service payment Information REF), if present.   RARC N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered.  A copy of this policy is available at www.cms.gov/mcd/search.asp.  If you do not have web access, you may contact the contractor to request a copy of the NCD.   Group Code CO   (Part A Only) MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim.  You can compare your case to the LCD, and send information from your doctor if you think it could change our decision.  Ca ll 1-800-MEDICARE (1 -800-633-4227) for a copy of the LCD.
(Medicare Claims Processing Manual)
Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto.  Un LCD se us para su reclamacin.  Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si pie nsa que puede cambiar nuestra decisin.  Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).  MSN 15.20: The following policies NCD210.7 were used when we made this decision.   Spanish Version  Las siguientes polticas NCD210.7 fueron utilizadas cuando se tom esta decision.   NOTE:   Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.   Effective for dates of service on or after April 13, 2015, when denying claims for CPT 80081 when submitted with one of the following secondary diagnosis codes denoting pregnancy, but the required HIV primary diagnosis codes listed below is not present:  For ICD -9: V22.0, V22.1, V23.9 For ICD -10: Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83,Z34,90, Z34.91, Z34.92, Z34.93, O09.90, O09.91, O09.92, O09.93 Use the following denial messages:   CARC 167  This (these) diagnosis(es) is (are) not covered.  Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF),  if present.
(Medicare Claims Processing Manual)
CARC 167  This (these) diagnosis(es) is (are) not covered.  Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF),  if present.   RARC N386  This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered.  A copy of this policy is available at www.cms.gov/mcd/search.asp.  If you do not have web access, you may contact the contractor to request a copy of the NCD.   (Part A Only) MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim.  You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Cal l 1-800-MEDICARE (1 -800-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto.  Un LCD se us para su reclamacin.  Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si pie nsa que puede cambiar nuestra decisin.  Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).   MSN 15.20: The following policies NCD210.7 were used when we made this decision.   Spanish Version  Las siguientes polticas NCD210.7 fueron utilizadas cuando se tom esta decisin.   NOTE:   Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.   Group Code  CO    Effective for dates of service on or after April 13, 2015, when denying claims for HCPCS 80081when the line item is submitted with one of the following required HIV primary diagnosis codes:   For ICD-9: V73.89   For ICD -10: Z11.4
(Medicare Claims Processing Manual)
For ICD-9: V73.89   For ICD -10: Z11.4   And none of the following secondary diagnosis codes denoting pregnancy are present.  For ICD -9: V22.0, V22.1, V23.9   For ICD -10: Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83,  Z34.90, Z34.91, Z34.92, Z34.93, O09.90, O09.91, O09.92, O09.93  Use the following denial messages,   CARC 11:  This diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.    RARC N386:  This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web ac cess, you may contact the contractor to request a copy of the NCD.   Group Code: CO (Contractual Obligation)   (Part A only) MSN 15.19:  Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1- 800-MEDICARE (1 -800-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto. Un LCD se us para su reclamacin. Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si piens a que puede cambiar nuestra decisin. Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).
(Medicare Claims Processing Manual)
MSN 15.20: The following policies NCD 210.7 were used when we made this decision.   Spanish Version  Las siguientes polticas NCD 210.7 fueron utilizadas cuando se tom esta decisin.   NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.     Effective for dates of service on or after April 13, 2015, when denying line level claims for G0475, G0432, G0433, G0435 or the CPT code 80081 is submitted with one of the pregnancy secondary diagnosis codes, but the Sex Code on the claim indicates Male,  use the following denial messages:   CARC 7: The procedure/revenue code is inconsistent with the patient's gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   Group Code: CO (Contractual Obligation)   (Part A only) MSN 15.19:  Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1- 800-MEDICARE (1 -800-+-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto. Un LCD se us para su reclamacin. Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si piens a que puede cambiar nuestra decisin. Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).   MSN 15.20: The following policies NCD 210.7 were used when we made this decision.
(Medicare Claims Processing Manual)
MSN 15.20: The following policies NCD 210.7 were used when we made this decision.   Spanish Version  Las siguientes polticas NCD 210.7 fueron utilizadas cuando se tom esta decisin.   NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.     Effective for dates of service on or after April 13, 2015, when denying line -items with POS other than 11 (Office) or 81 (Independent Lab) for the HIV screenings HCPCS G0475, G0432, G0433 and G0435, use the following denial messages:   CARC 171  Payment is denied when performed by this type of provider on this type of facility. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.  RARC N428 -  Not covered when performed in certain settings.  Group Code: CO (Contractual Obligation)   MSN 21.25 -  This service was denied because Medicare only covers this service in certain settings.     Spanish Version: El servicio fue denegado porque Medicare solamente lo cubre en ciertas situaciones."   MSN 15.19:  Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1- 800-MEDICARE (1 -800-633-4227) for a copy of the LCD.   Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto. Un LCD se us para su reclamacin. Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si piens a que puede cambiar nuestra decisin. Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1 -800-633-4227).
(Medicare Claims Processing Manual)
MSN 15.20: The following policies NCD 210.7 were used when we made this decision.   Spanish Version  Las siguientes polticas NCD 210.7 fueron utilizadas cuando se tom esta decisin.   140 - Annual Wellness Visit (AWV)  (Rev. 2159, Issued: 02- 15-11, Effective: 01 -01-11, Implementation: 04- 04-11)  Pursuant to section 4103 of the Affordable Care Act of 2010, the Centers for Medicare & Medicaid Services (CMS) amended section 411.15(a)(1) and 411.15(k)(15) of 42 CFR (list of examples of routine physical examinations excluded from coverage) effective fo r services furnished on or after January 1, 2011.  This expanded coverage is subject to certain eligibility and other limitations that allow payment for an annual wellness visit (AWV), including personalized prevention plan services (PPPS), for an individual who is no longer within 12 months after the effective date of his or her first Medicare Part B coverage period, and has not received either an initial preventive physical examination (IPPE) or an AWV within the past 12 months.  The AWV will include the establishment of, or update to, the individuals medical/family history, measurement of his/her height, weight, body- mass index (BMI) or waist circumference, and blood pressure (BP), with the goal of health promotion and disease detection and encouraging patients to obtain the screening and preventive services that may already be covered and paid for under Medicare Part B.  CMS amended 42 CFR 411.15(a)(1) and 411.15(k)(15) to allow payment on or after January 1, 2011, for an AWV (as established at 42 CFR 410.15) when performed by qualified health professionals.  Coverage is available for an AWV that meets the following requirements:   1. It is performed by a health professional;   2. It is furnished to an eligible beneficiary who is no longer within 12 months after the effective date of his/her first Medicare Part B coverage period, and he/she has not received either an IPPE or an AWV providing PPPS within the past 12 months.