evekhm/cms_iom_500 huggingface dataset:
Article - Tumor Treatment Field Therapy (TTFT) - Policy Article (A52711)
CMS National Coverage PolicyN/AArticle TextNON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary). Tumor treatment field therapy devices are covered under the Durable Medical Equipment benefit (Social Security Act 1861(s)(6)). In order for a beneficiarys equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.Code E0766 is in the frequent and substantial service payment category. Items included in this payment category are reimbursed a single monthly fee schedule amount for the device and all related supplies and accessories. Separate billing of supplies and/or accessories will be denied as unbundling.Code A4555 is not valid for billing to Medicare. If code A4555 is billed, it will berejected as an invalid code.
Article - Tumor Treatment Field Therapy (TTFT) - Policy Article (A52711)
Code A4555 is not valid for billing to Medicare. If code A4555 is billed, it will berejected as an invalid code.REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TOFINAL RULE1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated.The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD prior to delivery, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.INITIAL COVERAGE (FIRST THREE MONTHS):On claims for the first through third months, suppliers must add a KX modifier to code E0766 only if all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD ("Initial Coverage") have been met.
Article - Tumor Treatment Field Therapy (TTFT) - Policy Article (A52711)
CONTINUED COVERAGE BEYOND THE FIRST THREE MONTHS OF THERAPY:On the fourth months claim (and any month thereafter), the supplier must add a KX modifier to code E0766 only if both the "Initial Coverage" criteria and the "Continued Coverage" criteria in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD have been met.If the supplier does not obtain information from the practitioner that the beneficiary has demonstrated benefit from the use of, and is adhering to, TTFT treatment in time for submission of the fourth or succeeding months claims, the supplier may still submit the claims, but a KX modifier must not be added.If the supplier chooses to hold claims for the fourth and succeeding months pending receipt of information from the treating practitioner that the beneficiary received a clinical re-evaluation between the 60th and 91st day, had documented benefit from the use of, and is adhering to, TTFT treatment, those claims may then be submitted with the KX modifier.If the supplier chooses to hold claims for the fourth and succeeding month pending receipt of information from the treating practitioner but learns that the beneficiary did not receive a clinical re-evaluation between the 60th and 91st day but rather was re-evaluated at a later date and had documented benefit from the use of, and is adhering to, TTFT treatment, those claims may then be submitted with the KX modifier but only for dates of service following the date of the clinical re-evaluation.Documentation of adherence to TTFT shall be accomplished through direct download or visual inspection of usage data with documentation provided in a written report format to be reviewed by the treating practitioner and included in the beneficiarys medical record. This information does not have to be submitted with the claim but must be available upon request.If TTFT is interrupted for any reason, it is expected that the treating practitioner will document the reason for the interruption in therapy. This information does not have to be submitted with the claim but must be available upon request.
Article - Tumor Treatment Field Therapy (TTFT) - Policy Article (A52711)
EQUIPMENT RETAINED FROM A PRIOR PAYERWhen a beneficiary receiving a DMEPOS item from another payer (including a Medicare Advantage plan) becomes eligible for the Medicare Fee-For-Service (FFS) program, the first Medicare claim for that item or service is considered a new initial Medicare claim. Medicare does not automatically continue coverage for any item obtained from another payer when a beneficiary transitions to Medicare coverage.For Medicare to provide payment, the beneficiary must meet all Medicare coverage, coding, and documentation requirements for the DMEPOS items in effect on the DOS of the initial Medicare claim.A Proof of Delivery (POD) is required for all items, even those in the beneficiarys possession provided by another insurer prior to Medicare eligibility.PROOF OF DELIVERY REQUIREMENTS FOR RECENTLY ELIGIBLE MEDICARE FFS BENEFICIARIESThe supplier record must document:A statement, signed and dated by the beneficiary (or beneficiary's designee), that the supplier has examined the item, meets the POD requirements; and,A supplier attestation that the item meets Medicare requirements.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS.MODIFIERSGA, GZ, KF and KX MODIFIERS:In all of the situations above describing use of the KX modifier, if all of the coverage criteria have not been met, the GA or GZ modifier must be added to a claim line for code E0766. When there is an expectation of a reasonable and necessary denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.Claim lines billed without a GA, GZ or KX modifier will be rejected as missing information.Devices coded E0766 are classified by the Food & Drug Administration as Class III devices; therefore, all claims for code E0766 must include the KF modifier. Claim lines billed without a KF modifier will be rejected as missing information.MISCELLANEOUSThe supplier must enter the diagnosis code for code E0766 on each claim submitted.Refer to the Supplier Manual for additional information on documentation requirements.CODING GUIDELINES
Article - Tumor Treatment Field Therapy (TTFT) - Policy Article (A52711)
MISCELLANEOUSThe supplier must enter the diagnosis code for code E0766 on each claim submitted.Refer to the Supplier Manual for additional information on documentation requirements.CODING GUIDELINESCode E0766 describes devices that generate electromagnetic fields utilized in the treatment of cancer. The electromagnetic energy generated is transmitted to the body by means of surface electrodes or transducers.Code E0766 is inclusive of all associated supplies necessary for the effective use of code E0766 including, but not limited to, transducers/surface electrodes, lead wires, adhesive patches, connectors, conductive gel and skin preps.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Article - Vacuum Erection Devices (VED) - Policy Article (A52712)
CMS National Coverage PolicyN/AArticle Text
Article - Vacuum Erection Devices (VED) - Policy Article (A52712)
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Vacuum erection devices (L7900) and related supplies are considered Prosthetic Devices under the Prosthetic Devices benefit category (Social Security Act 1861(s)(8)). For dates of service on or after July 1, 2015, codes L7900 and L7902 are statutorily non-covered based on the Achieving a Better Life Experience (ABLE) Act of 2014 (see Social Security Act 1834(a)(1)(I)).REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated.The required Face-to-Face Encounter and Written Order Prior to Delivery List list is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD prior to delivery, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.
Article - Vacuum Erection Devices (VED) - Policy Article (A52712)
POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) contractor for guidance on the correct coding of these items.
Article - Transcutaneous Electrical Joint Stimulation Devices (TEJSD) - Policy Article (A52713)
CMS National Coverage PolicyN/AArticle Text
Article - Transcutaneous Electrical Joint Stimulation Devices (TEJSD) - Policy Article (A52713)
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).A Transcutaneous Electrical Joint Stimulation Device (TEJSD) is covered under the Durable Medical Equipment benefit (Social Security Act 1861(s)(6)). In order for a beneficiarys equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.The DME benefit limits the coverage of DME items to those used the beneficiarys home. Provision of TEJSD to beneficiaries in a Place of Service or facility considered to be other than home will be denied as statutorily non-covered. This includes a TEJSD incorporated into or used with any type brace (see below).Braces are covered under the Braces benefit (Social Security Act  1861(s)(9)). Coverage of items under the Braces benefit is not limited to the home.Use of a TEJSD with a brace does not change the benefit category for the TEJSD device or of the brace. A TEJSD/brace combination does not extend the DME Benefit limitation of use in the home.Refer to the applicable brace Local Coverage Determination and related Policy Article for information about coverage requirements for braces.REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.
Article - Transcutaneous Electrical Joint Stimulation Devices (TEJSD) - Policy Article (A52713)
Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.CODING GUIDELINESA transcutaneous electrical joint stimulation device (TEJSD) coded (E0762) is a noninvasive device that delivers electrical stimulation intended to reduce the level of pain and symptoms associated with arthritis in a joint. TEJSD may have variation in the parameters of the current, how the current is applied, etc.A TEJSD coded E0762 must be distinguished from other electrical stimulators (e.g., neuromuscular stimulators, functional electrical stimulators and transcutaneous electrical nerve stimulators, etc.) which also have unique HCPCS codes and are used to directly stimulate muscles and/or nerves. The appropriate applicable HCPCS code for these devices must be used.TEJSD is sometimes provided in combination with an orthosis (brace). When these items are provided in combination, the TEJSD and brace are always coded separately, using the codes assigned to each individual product. Braces designed to accommodate placement of electrodes and/or lead wires, that contain integrated electrodes and/or lead wires, storage for the TEJSD, etc. are considered braces, not supplies or accessories to the TEJSD and must be coded with the HCPCS code that appropriately describes the brace.
Article - Transcutaneous Electrical Joint Stimulation Devices (TEJSD) - Policy Article (A52713)
If the electronics are incorporated into a brace, the item is no longer considered a brace. Rather it is DME if it meets the benefit requirements for the DME Benefit or is statutorily non-covered (no benefit) if it does not.Code A4465 is used for replacement only of any wrap/strap used to position and hold electrodes used with TEJSD in place. Use of this code for replacement of wraps/straps used with a brace is incorrect coding.The supply allowance (A4595) includes electrodes (any type), conductive paste or gel (if needed, depending on the type of electrode), tape or other adhesive (if needed, depending on the type of electrode), adhesive remover, skin preparation materials, batteries (any type, single use or rechargeable), and a battery charger (if rechargeable batteries are used). One unit of service includes all necessary supplies for one months prescribed use of the device. Separate billing for individual supplies is considered unbundling.Codes A4556 (Electrodes, [e.g., apnea monitor], per pair) and A4558 (Conductive paste or gel), are not valid for claim submission to the DME MAC. Code A4595 should be used instead.For code A4557, one unit of service is for lead wires going to two electrodes.Other supplies, including but not limited to the following, will not be separately allowed: adapters (snap, banana, alligator, tab, button, clip), belt clips, adhesive remover, additional connecting cable for lead wires, carrying pouches, or covers.The only products which may be billed using code E0762 are those for which a written Coding Verification Review has been made by the Pricing, Data Analysis and Coding (PDAC) Contractor and subsequently published on the appropriate Product Classification List. Suppliers may not submit claims using E0762 for any other item.Claims for unlisted items using HCPCS code E0762 will be denied as incorrect coding.Suppliers should contact the PDAC for guidance on the correct coding of these items.
Article - Billing and Coding: Nerve Blockade for Treatment of Chronic Pain and Neuropathy (A52725)
CMS National Coverage PolicyN/AArticle TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.LCD L35457 states, "Nerve blockade and/or electrical stimulation are non-covered for the treatment of metabolic peripheral neuropathy. The peer-reviewed medical literature has not demonstrated the efficacy or clinical utility of nerve blockade or electrical stimulation, alone or used together, in the diagnosis and/or treatment of neuropathic pain."The use of peripheral nerve blocks for treating diabetic neuropathy is not considered reasonable and/or necessary and is not covered by Medicare Part A or B. Such use of peripheral nerve blocks is not supported by the current peer reviewed, published, evidence based scientific literature nor by specialty society guidelines. Claims are subject to review and recoupment.This notification does not affect those regional/local blocks done as part of an operative procedure (for example wound debridement in the operating room) when performed as an adjunct to or the sole means of regional/local anesthesia for the procedure.For somatic nerve blocks, it is inappropriate to bill for fluoroscopy (CPTcodes 77002 or 77003) with a 59 modifier when the procedure(s) billed on that date of service for the same patient by the same provider are included in the CPTdescription of the procedure(s) performed.Documentation RequirementsAll documentation must be maintained in the patients medical record and 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 record must include the physician or non-physician practitioner responsible for and providing the care of the patient.The submitted medical record should support the use of the selected diagnosis code(s). The submitted CPT/HCPCS code should describe the service performed.Sources:
Article - Billing and Coding: Nerve Blockade for Treatment of Chronic Pain and Neuropathy (A52725)
Sources:Neurology 2011;76;1758; V. Bril, J. England, G.M. Franklin, et al. Evidence-based guideline:Treatment of painful diabetic neuropathy: Report of the American Academy of Neurology, the American Association of Neuromuscular and Neurodiagnostic Medicine, and the American Academy of Physical Medicine and RehabilitationThis information is current as of February 7, 2013American Family Physician 2010;82(2):151-158 T. Lindsay, B. Rodgers, V. Savath, K. HettingerTreating Diabetic Peripheral Neuropathic Pain
Article - Billing and Coding: Hydration Services (A52732)
CMS National Coverage PolicyInternet Only Manual Pub 100-8; Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2 - Reasonable and Necessary CriteriaArticle TextNoridian Medical Review (MR) has observed errors in billing for intravenous (IV) hydration services. This article is to assist in better understanding the proper usage of the below codes for billing and coding purposes.CPT Definition:96360: Intravenous Infusion, hydration; initial, 31 minutes to 1 hour96361: Intravenous Infusion, hydration; each additional hour (list separately in addition to code for primary procedure)These codes are intended to report a hydration IV infusion consisting of pre-packaged fluid with or without electrolytes (e.g. normal saline, D5-1/2 normal saline+30mEq KCl/liter) and are not used to report infusion of drugs or other substances.Hydration Defined:The hydration codes 96360 and 96361 were developed to report specific therapeutic interventions undertaken when a patient presents with dehydration and volume loss requiring clinically necessary intravenous fluid.The necessity for hydration should be supported in the medical record.Documentation would include but is not limited to:A. Clinical assessment, typically on the same date of service, of the patients anticipated fluid needs. This can be demonstrated from the patients history, clinical examination, and pertinent laboratory testing to support the need for IV hydration therapy as reasonable and necessary for the patients treatment or diagnosis.Documentation of the assessment should describe symptoms warranting hydration, such as those associated with dehydration, the inability to ingest fluids or clear clinical contraindication to oral intake, abnormal fluid losses, abnormal vital signs, and/or abnormal laboratory studies, such as an elevated BUN, creatinine, glucose or lactic acid.Nausea itself does not necessarily indicate fluid volume depletion nor support necessity of fluid repletion.