evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Peripheral Nerve Blocks (A57788)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33933 Peripheral Nerve Blocks. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Refer to the National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 2 and Chapter 8 for CPT codes 64400-64530 coding instructions.Refer to LCD L33930 Facet Joint Interventions for Pain Management for information regarding billing paravertebral facet joint blocks on the same date of service.Use of physical medicine and rehabilitation CPT/HCPCS codes (97032, 97139, G0282, G0283) for treatment of neuropathies or peripheral neuropathies caused by underlying systemic diseases is inappropriate.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.Assessment of the outcome of this procedure depends on the patients responses, therefore documentation should include:Whether the block was a diagnostic or therapeutic injectionPre- and post-procedure evaluation of the patientPatient education
Article - Billing and Coding: Peripheral Nerve Blocks (A57788)
When preemptive analgesia is performed by a provider other than the surgeon or the anesthesia professional who provides anesthesia/analgesia for the procedure, there must be a compelling patient care reason for the involvement of the additional provider. The rationale for this approach must be clearly documented in the medical record.
Article - Billing and Coding: Spinal Cord Stimulators for Chronic Pain (A57791)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e). Prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Article TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.Physicians with a low trial to permanent implant ratio (less than 50%) will be subject to post-payment review and may be asked to submit documentation as to the patient selection criteria, the radiologic imaging demonstrating proper lead placement, and the medical necessity of the trials. Failure to provide this documentation will be cause for post-payment denial and recoupment of reimbursement. It is understood that all patients may not have a favorable result of the trial implant; but careful selection should find the most appropriate patients.If a trial fails, a repeat trial is not appropriate unless there are extenuating circumstances that lead to trial failure. Appropriate medical documentation to support a repeat trial can be sent on appeal.Documentation RequirementsThe clinical record should include the elements leading to the diagnosis and the therapies tried before the decision to use spinal cord stimulators (SCS).The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary.Utilization Guidelines63650 - Two temporary spinal cord stimulator trials per anatomic spinal region (two per DOS) or (four units) per patient per lifetime (with exceptions allowed for technical limitations for the initial trials or for use of different modalities of stimulation, including new technology), in place of service office, ASC, out-patient hospital, or hospital. Since permanent neurostimulator arrays can also be placed percutaneously, code 63650 can be covered more often in place of service ASC, out-patient hospital, or hospital.63655 - One permanent spinal cord stimulator per patient per lifetime and must be performed in an ASC, out-patient hospital or hospital.63663 - Will not be reimbursed in the office setting since they are included in 63650.
Article - Billing and Coding: Spinal Cord Stimulators for Chronic Pain (A57792)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e). Prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Article TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.Physicians with a low trial to permanent implant ratio (less than 50%) will be subject to post-payment review and may be asked to submit documentation as to the patient selection criteria, the radiologic imaging demonstrating proper lead placement, and the medical necessity of the trials. Failure to provide this documentation will be cause for post-payment denial and recoupment of reimbursement. It is understood that all patients may not have a favorable result of the trial implant; but careful selection should find the most appropriate patients.If a trial fails, a repeat trial is not appropriate unless there are extenuating circumstances that lead to trial failure. Appropriate medical documentation to support a repeat trial can be sent on appeal.Documentation RequirementsThe clinical record should include the elements leading to the diagnosis and the therapies tried before the decision to use spinal cord stimulators (SCS).The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary.Utilization Guidelines63650 - Two temporary spinal cord stimulator trials per anatomic spinal region (two per DOS) or (four units) per patient per lifetime (with exceptions allowed for technical limitations for the initial trials or for use of different modalities of stimulation, including new technology), in place of service office, ASC, out-patient hospital, or hospital. Since permanent neurostimulator arrays can also be placed percutaneously, code 63650 can be covered more often in place of service ASC, out-patient hospital, or hospital.63655 - One permanent spinal cord stimulator per patient per lifetime and must be performed in an ASC, out-patient hospital or hospital.63663 - Will not be reimbursed in the office setting since they are included in 63650.
Article - Billing and Coding: MolDX: Immunohistochemistry (IHC) Indications for Breast Pathology (A57797)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Article TextBased on recommendations from the College of American Pathologists, the American Society of Clinical Oncologists (ASCO), and the National Comprehensive Cancer Network (NCCN), hormone receptor assays, estrogen receptor (ER), progesterone receptor (PR), and Her-2/neu are the only current biomarkers that demonstrate standardized value in breast cancer pathology evaluation. Although other biomarkers, such as Ki-67, PI3K, and gene expression assays, have been studied, no proven standardized value has been established. Therefore, MolDX will allow ER, PR, and Her2 testing by IHC for patients with primary invasive breast cancers and recurrent or metastatic cancers.To report an IHC service for an ER, PR, Her2, submit the following claim information:CPT CodeSpecimenUOS88342First single/multiplex stain188341Each additional2To report morphometric analysis,select oneof the following codes based on the type of morphometric analysis:CPT CodeService TypeUOS88360Manual388361Computer-assisted3Note: a unit of service applies to a single separately identifiable specimen.
Article - Billing and Coding: Hepatic (Liver) Function Panel (A57802)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33907 Hepatic (Liver) Function Panel. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.If the provider of the service is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of the test results and interpretation, along with copies of the ordering/referring physicians order for the studies. The physician must state the clinical indication/medical necessity for each test billed.
Article - Billing and Coding: High Sensitivity C-Reactive Protein (hsCRP) (A57803)
CMS National Coverage PolicyN/AArticle TextThis First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33908 High Sensitivity C-Reactive Protein (hsCRP) provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.Refer to the LCD for reasonable and necessary requirements and limitations.The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.Coding GuidelinesNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.Medical record documentation maintained by the ordering/referring physician/qualified nonphysician practitioner must indicate the medical necessity for performing the test and the test results. In addition, if the service exceeds the frequency parameter listed in the LCD, documentation of medical necessity must be submitted upon request.If the provider of the service is other than the ordering/referring physician/nonphysician practitioner, that provider must maintain a copy of test results, along with copies of the ordering/referring physician/nonphysician practitioners order for the test. The clinical indication/medical necessity for the test must be indicated in the order for the test.
Article - Billing and Coding: High Sensitivity C-Reactive Protein (hsCRP) (A57803)
Utilization GuidelinesIn accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.Compliance with the provisions in LCD L33908, High Sensitivity C-Reactive Protein (hsCRP) may be monitored and addressed through post payment data analysis and subsequent medical review audits.
Article - Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (A57804)
CMS National Coverage PolicyIOM CitationsCMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 23 Fee Schedule Administration and Coding Requirements, Section 10 Reporting ICD Diagnosis and Procedure codes and Section 20.9 National Correct Coding Initiative (NCCI)National Correct Coding Initiative (NCCI) Citation:NCCI Policy Manual for Medicare ServicesChapter XI Medicare Evaluation and Management Services CPT Codes 90000-99999, Section G, OphthalmologySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33751 Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI). Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Utilization ParametersOne month is defined as 28 days. No more than one (1) exam per month will be considered medically reasonable and necessary to manage the patient with retinal conditions undergoing active treatment.CPT code 92132 and 92133 may not be reported more than two (2) times per year. Please refer to the LCD for details on reasonable and necessary guidelines.CPT code 92134 may not be reported more than one (1) time every two (2) months. Please refer to the LCD for details on reasonable and necessary guidelines.Documentation Requirements
Article - Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (A57804)
CPT code 92134 may not be reported more than one (1) time every two (2) months. Please refer to the LCD for details on reasonable and necessary guidelines.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
Article - Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A57807)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60, Services and Supplies Furnished Incident to a Physician/NPP professional service, Section 80, Requirements for Diagnostic Xray, Diagnostic Laboratory, and Other Diagnostic TestsCMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 1, Section 10.1.1 Payment Jurisdictions Among A/B MACS (B) for Services Paid Under the Physician Fee Schedule and Anesthesia Services, Section 30.2 Assignment of Providers Right to PaymentChapter 35, Independent Diagnostic Testing Facility (IDTF)CMS IOM Publication 100-08,Medicare Program Integrity Manual,Chapter 3, Section 3.2.3.3 Third-Party Additional Documentation RequestChapter 10, Section 10.2.2.4 Independent Diagnostic Testing Facilities (IDTFs)Social Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior periodCode of Federal Regulations (CFR) References:CFR, Title 42, Chapter IV, Part 410 410.32(a) Ordering diagnostic testsCFR, Title 42, Chapter IV, Part 410 410.33 Independent diagnostic testing facilityArticle Text
Article - Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A57807)
Article TextThis Billing and Coding Article provides billing and coding guidance for Independent Diagnostic Testing Facilities (IDTFs). Diagnostic testing performed in an IDTF must follow the supervision and credentialing guidelines set forth in this Local Coverage Article. All enrolling IDTFs must meet the supervising physician qualification/proficiency requirements and technician qualification requirements at the time of their enrollment.Coding GuidanceIDTFs are required to report the exact CPT/HCPCS codes/procedures they intend to perform when enrolling with the CMS-855B form. If an IDTF which is already enrolled wants to perform additional CPT or HCPCS code tests that were not originally specified on its CMS-855B and that are for procedure types and supervision levels similar to its previously allowed codes, the contractor shall have the IDTF amend its CMS-855B to add the additional codes and equipment listing. A new site visit is not required. However, if the enrolled IDTF will be performing CPT or HCPCS codes for different types of procedures, or with different supervision levels, a new site visit is required. Claims submitted with procedure codes not reported on the CMS-855B form and reviewed by the contractor will be denied.Each IDTF will have a specific and unique list of CPT/HCPCS codes for which it can be paid by the contractor, and it is the responsibility of the IDTF to obtain specific contractor approval to bill each CPT/HCPCS code that it intends to bill. Based on equipment and personnel requirements, IDTFs are required to submit a list of all procedure codes performed by the facility to Medicare Provider Enrollment. The codes and equipment should be listed on Attachment 2, Section 1 of Enrollment Application Form CMS-855B.Desk and Site ReviewsAll new IDTF applications shall receive a thorough desk review, and a mandatory site review prior to the contractor's enrollment of the applicant and issuance of a billing number. The general purpose of both reviews is to determine whether the information listed on Attachment 2 of the CMS-855B is correct, verifiable, and in accordance with IDTF regulatory and manual requirements.Site Visits for Mobile Units and Electronic Monitoring ServicesMobile units are required to list their geographic service area. They can be site visited by the following methods:
Article - Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A57807)
The mobile unit may visit the office of the site reviewer,ORThe site reviewer can obtain an advance schedule of the locations the IDTF will be visiting and conduct the site visit at one of those locations.
Article - Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A57807)
Transtelephonic and electronic monitoring services (e.g., 24-hour ambulatory EKG monitoring; pacemaker monitoring and cardiac event detection) should be classified as IDTFs and must meet all IDTF requirements. These entities require a supervisory physician who performs general supervision. Final enrollment of a transtelephonic or electronic monitoring service, such as an IDTF, requires a site visit.Additional information may be found in CMS Internet-Only Manual (IOM) Publication 100-04,Medicare Claims Processing Manual, Chapter 35, Independent Diagnostic Testing Facility (IDTF).Supervising PhysiciansAn IDTF must have one or more supervising physicians who are responsible for the direct and ongoing oversight of the quality of the testing performed, the proper operation and calibration of the equipment used to perform tests, and the qualifications of non-physician personnel who use the equipment.Not every supervising physician has to be responsible for all these functions. These responsibilities may be divided among the supervising physicians. For example, one supervising physician may be responsible only for the operation and calibration of the equipment, while other supervising physicians are responsible for test supervision and/or the qualifications of the non-physician personnel.Additional information may be found in the CMS IOM Publication 100-02, Chapter 15, Section 80 and 42 CFR 410.32(b) and 410.33.Non-Physician PersonnelThe contractor does not establish a credentialing service, but the contractor is authorized to determine which organizations it recognizes. For example, the use of the word national in the organizations name does not, in itself, meet Medicare standards for national credentialing.The supervising physician and non-physician personnel credentialing requirements are listed below in the Credentialing Matrix.Additional information may be found in the CMS IOM Publication100-02, Chapter 15, Sections 80.2, 80.3, and 190 as well as 42 CFR 410.33.Interpreting PhysiciansAn IDTF is not restricted to billing only the technical component of diagnostic services. In certain situations, an IDTF can bill for both the technical component of the diagnostic test and interpretative services. This approach is referred to as billing "globally". The interpretative services must be performed by a licensed practitioner who is allowed to perform the service.
Article - Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A57807)
When enrolling or updating information, the IDTF shall list all physicians for whose diagnostic test interpretations it will bill. This includes physicians who are providing purchased interpretations to the IDTF (in accordance with CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual, Chapter 1, Section 30.2), as well as physicians who are reassigning their benefits to the IDTF. The contractor will ensure and document the following: