evekhm/cms_iom_500 huggingface dataset:
Article - Polysomnography and Sleep Studies – Medical Policy Article (A53019)
HST scoring must be performed by an individual certified by the Board of Registered Polysomnographic Technologists as a Registered Polysomnographic Technologist (RPSGT), or equivalent, or by a polysomnographic technician under the supervision of a RPSGT, or by a Registered Respiratory Therapist-Sleep Disorder Specialist (RRT-SDS) or a Certified Respiratory Therapist-Sleep Disorder Specialist (CRT-SDS), or equivalent. RPSGTs, RRT-SDS, CRT-SDS and polysomnographic technicians must meet the standards for such individuals promulgated by the American Academy of Sleep Medicine Standards for Accreditation of Laboratories for Sleep Related Breathing Disorders, or by the Accreditation Commission for Health Care, Inc. Standards for Accreditation for Sleep Programs or by the National Board for Respiratory Care (NBRC) Inc. and be licensed or certified by the state in which they practice, if such licensure or certification exists. The laboratory physician must review the entire raw data recording for every patient studied.The above credentialing information must be documented and available upon request.Documentation Requirements:Sleep studies and polysomnography refer to the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep with 6 or more hours of recording with physician review, interpretation and report.The following minimal information must be included in the sleep disorders evaluation report:Parameters monitored;Start time and duration of day/night of study;Total sleep time, sleep efficiency, number/duration of awakenings;For tests involving sleep staging: time and percent time spent in each stage;For tests monitoring sleep latency or maintenance of wakefulness testing: latency to both NREM and REM sleep;Individual sub-test sleep latencies, mean sleep latency, and the number of REM occurrences on MSLT.Respiratory patterns including type (central/obstructive/periodic), number and duration, effect on oxygenation, sleep stage/body position relationship, and response to any diagnostic/therapeutic maneuvers;Cardiac rate/rhythm and any effect of sleep disordered breathing on EKG,Detailed behavioral observations; andEEG or EMG abnormalities.
Article - Polysomnography and Sleep Studies – Medical Policy Article (A53019)
The patient must be referred to the clinic by the attending/treating physician. The referring physician's order for the testing must be kept in the medical record. Sleep testing must be conducted by an entity that qualifies as a Medicare provider of sleep testing and is in compliance with all applicable state regulatory requirements. The patient who undergoes HST must receive, prior to the test, adequate instruction on how to properly apply a portable sleep monitoring device. This instruction must be provided by the provider conducting the HST.Sources of Information:CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 6:50 Sleep Disorder ClinicsCMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15:70 Sleep Disorder ClinicsAccreditation Commission for Healthcare, Inc. Accreditation standards for sleep testing. 05/18/2011:1-39.American Academy of Sleep Medicine. Assessment and management of sleep disorders in a primary care practice. http://www.asda.org/MEDSleep/Products/(RosenG)primarycare.pdf. Accessed April 2, 2002.American Academy of Sleep Medicine. Standards of Practice Parameters; Polysomnography. Report practice parameters for the indications for polysomnography and related procedures: An update for 2005. American Academy of Sleep Medicine Web site: http://www.aasmnet.org/PracticeParameters.aspx?cid=104. Accessed March 11, 2009.American Sleep Disorder Association. Practice parameters for the indications for polysomnography and related procedures. SLEEP Web site. http://www.journalsleep.org/Search.aspx. 1997. Accessed March 11, 2009.American Sleep Disorder Association. Practice parameters for the use of actigraphy in the clinical assessment of sleep disorders. SLEEP Web site. http://www.journalsleep.org/Search.aspx. 1995. Accessed March 11, 2009.American Sleep Disorder Association. Practice parameters for the use of polysomnography in the evaluation of insomnia. SLEEP Web site. http://www.journalsleep.org/Search.aspx. 1995. Accessed March 11, 2009.American Sleep Disorder Association. Practice parameters for the use of portable recording in the assessment of obstructive sleep apnea. SLEEP Web site. http://www.journalsleep.org/Search.aspx. 1994. Accessed March 11, 2009.
Article - Polysomnography and Sleep Studies – Medical Policy Article (A53019)
American Thoracic Society. Indications and standards for cardiopulmonary sleep studies. ATS Web site. http://www.thoracic.org/sections/publications/statements/pages/archive/iscss-1989.html. 1989. Accessed March 10, 2009.American Thoracic Society/American Sleep Disorder Association. Statement on health outcomes research in sleep apnea. ATS Web site. http://www.thoracic.org/sections/publications/statements/resources/sleepap1-7.pdf. 1998. Accessed March 10, 2009.Collop NA, Anderson WM, Boehlecke B, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine.J Clin Sleep Med.2007;3(7):737-747.National Board for Respiratory Care Web site. https://www.nbrc.org/Pages/default.aspx. Accessed 06/08/2016.
Article - Self-Administered Drug Exclusion List: Medical Policy Article (A53021)
CMS National Coverage PolicyN/AArticle TextCoverage for self-administered drugs for both Part A and Part B is determined by the MAC Contractor in each jurisdiction. HCPCS codes used under Outpatient Prospective Payment System (OPPS) are included, in addition to the codes used for Part B claims, when appropriate.The table below lists drugs that are not covered by Medicare, the effective date of non-coverage, and the rationale. (Please see Process for Determining Self-Administered Drug Exclusions  Medical Policy Article). The column, Brand Names, provides one or more examples but may not include all brand names.Information about drugs not separately reimbursed or not covered for reasons other than usually self-administered, is detailed in Part A and Part B MAC publications and postings available elsewhere.Route of Administration ModifierThe use of the JA and JB modifiers is required for drugs which have one HCPCS Level II (J or Q) code but multiple routes of administration. Drugs that fall under this category will be marked with an asterisk (*) and must be billed with the JA modifier for the intravenous infusion of the drug or billed with the JB modifier for the subcutaneous injection form of administration. Subcutaneously administered drugs listed on the Usually Self-Administered list will be denied as a benefit exclusion. Claims for drugs marked with an asterisk (*) billed without either a JA or JB modifier will also be denied.
Article - Self-Administered Drug Exclusion List: Medical Policy Article (A53022)
CMS National Coverage PolicyN/AArticle TextCoverage for self-administered drugs for both Part A and Part B is determined by the MAC Contractor in each jurisdiction. HCPCS codes used under Outpatient Prospective Payment System (OPPS) are included, in addition to the codes used for Part B claims, when appropriate.The table below lists drugs that are not covered by Medicare, the effective date of non-coverage, and the rationale. (Please see Process for Determining Self-Administered Drug Exclusions  Medical Policy Article). The column, Brand Names, provides one or more examples but may not include all brand names.Information about drugs not separately reimbursed or not covered for reasons other than usually self-administered, is detailed in Part A and Part B MAC publications and postings available elsewhere.Route of Administration ModifierThe use of the JA and JB modifiers is required for drugs which have one HCPCS Level II (J or Q) code but multiple routes of administration. Drugs that fall under this category will be marked with an asterisk (*) and must be billed with the JA modifier for the intravenous infusion of the drug or billed with the JB modifier for the subcutaneous injection form of administration. Subcutaneously administered drugs listed on the Usually Self-Administered list will be denied as a benefit exclusion. Claims for drugs marked with an asterisk (*) billed without either a JA or JB modifier will also be denied.
Article - Billing and Coding: JW and JZ Modifier Billing Guidelines (A53024)
CMS National Coverage PolicyN/AArticle TextThis article addresses the required use of the JW and JZ modifier to indicate drug wastage. CMS and Noridian encourage physicians, hospitals and other providers and suppliers to administer drugs and biologicals to patients in such a way that these are used most efficiently, in a clinically appropriate manner (IOM100-4 Chapter 17, Sections 40-40.1).When a physician, hospital or other provider or supplier must discard the remainder of a single-use vial or other single-use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the discarded drug or biological amount as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label.The following serves to clarify billing guidelines and provide examples of proper billing with a single-dose vial and discarded drug billing:Providers and hospitals are reminded to ensure amounts of drugs administered to patients are accurately reported in terms of the dosage specified in the long descriptor for the applicable HCPCS codes. This is because the short descriptors are limited to 28 characters so they do not always capture the complete description of the drug.When submitting Medicare claims, units of service (UOS) should be reported in multiples of the dosage included in the long HCPCS code descriptor. If the dosage given is not a multiple of the number provided in the HCPCS code description, the provider shall round up to the nearest whole number in order to express the number as a multiple.If the provider must discard the remainder of a single-use vial or other package after administering the prescribed dosage of any given drug, Medicare may cover the amount of the drug discarded along with the amount administered. The following elements must be followed in order for the discarded amount to be covered.The vial must be a single-use vial. Multi-use vials are not subject to payment for any discarded amounts of the drug.Any amount of drug billed as wastage from a single-dose vial, must actually be discarded and may not be used for another patient regardless of whether or not that other patient has Medicare.
Article - Billing and Coding: JW and JZ Modifier Billing Guidelines (A53024)
Please clearly document in the patient's medical record the actual dose administered in addition to the exact amount wasted and the total amount of the vial is labeled to contain. This kind of detailed documentation helps benefit your practice by justifying your billing in the event a medical review should occur.Medicare requires discarded drugs be reported with the JW modifier on a separate line, the total number of discarded units reported should not include amounts of the drug also included on the administered line due to the rounding up of units.Please remember to verify the milligrams administered to the patient and then convert to the proper units for billing.Due to single-use vial type, the provider may bill for the amount administered as well as the amount appropriately discarded. The discarded amount is reported with the JW modifier. The JW modifier is only applied to the amount of the drug or biological that is discarded. A situation in which the JW modifier is not permitted is when the actual dose of the drug or biological administered is less than the billing unit. (See "Medicare Claims Processing Manual," Chapter 17, Section 40). As an example, if one billing unit for a drug is equal to 10mg of the drug in a single-use vial, and a 7mg dose is administered to a patient resulting in 3mg remaining drug being discarded, then the 7mg dose is billed using one UOS that represents 10mg on a single line item. The single line item would be processed for payment of the total 10mg of the drug administered and discarded. Billing another unit on a separate line item with the JW modifier for the discarded 3mg of the drug is not permitted because it would result in an overpayment. Therefore, when the billing unit is equal or greater than the total actual dose and the amount discarded, the use of the JW modifier is not permitted.Effective July 1, 2023, Medicare requires the JZ modifier on all claims for single-dose containers where there are no discarded amounts.To submit claims for a waste-required claim, submit two complete claim lines.Claim line #1:HCPCS code for drug givenNo modifierNumber of units given to the patientCalculated submitted price for ONLY the amount of drug givenClaim line #2:HCPCS code for drug wastedJW modifier to indicate wasteNumber of units wastedCalculated submitted price for ONLY the amount of drug wasted
Article - Billing and Coding: JW and JZ Modifier Billing Guidelines (A53024)
Claim line #2:HCPCS code for drug wastedJW modifier to indicate wasteNumber of units wastedCalculated submitted price for ONLY the amount of drug wastedTo submit claims for a non-discarded claim, submit one complete claim line.HCPCS code for drug givenJZ modifier to indicate no wasteNumber of units given to the patientCalculate submitted price for the amount givenSources:CR 9603-JW Modifier: Drug amount discarded/not administered to any patientInternet Only Manual (IOM) 100-4-Claims Processing Manual; Chapter 17-Drugs and Biologicals; Sections 40-40.1Discarded Drugs and Biologicals - JW Modifier and JZ Modifier Policy Frequently Asked Questions (cms.gov)
Article - Billing and Coding: Bariatric Surgery Coverage (A53026)
CMS National Coverage PolicyN/AArticle TextBackgroundCoverage of bariatric surgery is described in the Internet Only Manual (IOM)Medicare National Coverage Determinations Manual, Publication 100-03, Section 100.1Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid ObesityandMedicare Claims Processing Manual, Publication 100-04, Chapter 32, Section 150.The following coding guidance is published based on the requirements in effect as of the effective date of this article and no longer addresses past coverage. Prior coverage may be different depending upon the date of service and can be obtained from the National Coverage Determination 100.1.As of the effective date of this article revision Medicare (CMS) has established by NCD 100.1 that the following bariatric surgery procedures are reasonable and necessary under specified conditions for the treatment of complications of morbid obesity.1. Roux-en-Y Gastric Bypass (RYGBP)2. Biliopancreatic Diversion with Duodenal Switch (BPD/DS) or Gastric Reduction Duodenal Switch (BPD/GRDS)3. Laparoscopic Adjustable Gastric Banding (AGB)4. Laparoscopic Sleeve GastrectomyTo be eligible for bariatric surgery the patient must have a body-mass index (BMI)  35, and at least one co-morbidity related to obesity. Further, the documentation must clearly demonstrate the failure of reasonable non-invasive/non-surgical treatments for obesity with which the beneficiary has been compliant.Noridian considers the following, based on national guidelines for bariatric care, to be the minimum specifications to be documented in the patient record in order to demonstrate the beneficiary has been previously unsuccessful with medical treatment for obesity as required by the NCD:
Article - Billing and Coding: Bariatric Surgery Coverage (A53026)
1. The beneficiary has been previously unsuccessful with medical treatments for obesity. The latter includes but is not limited to: active participation within the last 12 months prior to bariatric surgery in a weight-management program that is supervised by a physician or other health care professionals for a minimum of four consecutive months. The weight-management program must include monthly documentation of patients weight and BMI, current dietary regimen and physical activity (e.g. exercise program).2. Physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement.3. A thorough multidisciplinary evaluation is required within the previous six months which includesALLof the following:a. an evaluation by a bariatric surgeon recommending surgical treatment, including a description of the proposed procedure(s)b. a separate medical evaluation from a physician other than a surgeon and preferably the beneficiarys primary care physician that includes both a recommendation for bariatric surgery as well as a medical clearance for the proposed bariatric surgeryc. mental health and psychosocial clearance for bariatric surgery by a mental health provider including a statement regarding motivation and ability to follow post-surgical requirementsd. a nutritional evaluation by a physician or registered dietician.Noridian Covered Inpatient Facility ICD-10-CM Procedure Codes for Laparoscopic Sleeve Gastrectomy: 0DV64CZNationally Covered Inpatient Facility ICD-10-CM Procedure CodesFor services on or after October 1, 2014, the following ICD-10 procedure codes are covered for bariatric surgery:Laparoscopic gastroenterostomy (laparoscopic Roux-en-Y), or ONE of the following ICD-10-PCS codes:0DB64Z30DV64CZ0D164790D1647A0D1647B0D1647L0D164J90D164JA0D164JB0D164JL0D164K90D164KA0D164KB0D164KL0D164Z90D164ZA0D164ZB0D164ZL
Article - Billing and Coding: Bariatric Surgery Coverage (A53026)
Other gastroenterostomy (open Roux-en-Y), or ONE of the following ICD-10-PCS codes:0D160790D1607A0D1607B0D1607L0D160J90D160JA0D160JB0D160JL0D160K90D160KA0D160KB0D160KL0D160Z90D160ZA0D160ZB0D160ZL0D168790D1687A0D1687B0D1687L0D168J90D168JA0D168JB0D168JL0D168K90D168KA0D168KB0D168KL0D168Z90D168ZA0D168ZB0D168ZLTo describe either laparoscopic or open BPD with DS or GRDS,onecode fromeachof the following threegroupsmust be on the claim:Group 1:0DB60Z30DB60ZZ0DB63Z30DB63ZZ0DB67Z30DB67ZZ0DB68Z3Group 2:One code from Groups A-C below is required.Group A:0DB80ZZ0DB90ZZ0DBB0ZZGroup B:0D160ZBGroup C:0F190Z3
Article - Billing and Coding: Bariatric Surgery Coverage (A53026)
Group A:0DB80ZZ0DB90ZZ0DBB0ZZGroup B:0D160ZBGroup C:0F190Z3Group 3:0D190790D1907A0D1907B0D190J90D190JA0D190JB0D190K90D190KA0D190KB0D190Z90D190ZA0D190ZB0D194790D1947A0D1947B0D194J90D194JA0D194JB0D194K90D194KA0D194KB0D194Z90D194ZA0D194ZB0D198790D1987A0D1987B0D198J90D198JA0D198JB0D198K90D198KA0D198KB0D198Z90D198ZA0D198ZB0D1A07A0D1A07B0D1A0JA0D1A0JB0D1A0KA0D1A0KB0D1A0ZA0D1A0ZB0D1A47A0D1A47B0D1A4JA0D1A4JB0D1A4KA0D1A4KB0D1A4ZA0D1A4ZB0D1A87A0D1A87B0D1A8JA0D1A8JB0D1A8KA0D1A8KB0D1A8ZA0D1A8ZB0D1A8ZH0D1B07B0D1B0JB0D1B0KB0D1B0ZB0D1B47B0D1B4JB0D1B4KB0D1B4ZB0D1B87B0D1B8JB0D1B8KB0D1B8ZB0D1B8ZH
Article - Billing and Coding: Bariatric Surgery Coverage (A53026)
NOTE:There is no distinction between open and laparoscopic BPD with DS or GRDS for the inpatient setting. For either approach, one code from each of the above three groups must appear on the claim to be covered.Nationally Non-Covered ProceduresFor services on or after February 21, 2006, Medicare (CMS) has determined that the following bariatric surgery procedures are not reasonable and necessary for the treatment of morbid obesity (primary ICD-10-CM diagnosis code E66.01): Open adjustable gastric banding (Billed with a Not Otherwise Classified (NOC) code) Open sleeve gastrectomy; Laparoscopic sleeve gastrectomy (prior to June 27, 2012); Open and laparoscopic vertical banded gastroplasty; Intestinal bypass surgery; and, Gastric balloon for treatment of obesity.
Article - Billing and Coding: Bariatric Surgery Coverage (A53028)
CMS National Coverage PolicyN/AArticle TextBackgroundCoverage of bariatric surgery is described in the Internet Only Manual (IOM)Medicare National Coverage Determinations Manual, Publication 100-03, Section 100.1Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid ObesityandMedicare Claims Processing Manual, Publication 100-04, Chapter 32, Section 150.The following coding guidance is published based on the requirements in effect as of the effective date of this article and no longer addresses past coverage. Prior coverage may be different depending upon the date of service and can be obtained from the National Coverage Determination 100.1.As of the effective date of this article revision Medicare (CMS) has established by NCD 100.1 that the following bariatric surgery procedures are reasonable and necessary under specified conditions for the treatment of complications of morbid obesity.1. Roux-en-Y Gastric Bypass (RYGBP)2. Biliopancreatic Diversion with Duodenal Switch (BPD/DS) or Gastric Reduction Duodenal Switch (BPD/GRDS)3. Laparoscopic Adjustable Gastric Banding (AGB)4. Laparoscopic Sleeve GastrectomyTo be eligible for bariatric surgery the patient must have a body-mass index (BMI)  35, and at least one co-morbidity related to obesity. Further, the documentation must clearly demonstrate the failure of reasonable non-invasive/non-surgical treatments for obesity with which the beneficiary has been compliant.Noridian considers the following, based on national guidelines for bariatric care, to be the minimum specifications to be documented in the patient record in order to demonstrate the beneficiary has been previously unsuccessful with medical treatment for obesity as required by the NCD:
Article - Billing and Coding: Bariatric Surgery Coverage (A53028)
1. The beneficiary has been previously unsuccessful with medical treatments for obesity. The latter includes but is not limited to: active participation within the last 12 months prior to bariatric surgery in a weight-management program that is supervised by a physician or other health care professionals for a minimum of four consecutive months. The weight-management program must include monthly documentation of patients weight and BMI, current dietary regimen and physical activity (e.g. exercise program).2. Physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement.3. A thorough multidisciplinary evaluation is required within the previous six months which includesALLof the following:a. an evaluation by a bariatric surgeon recommending surgical treatment, including a description of the proposed procedure(s)b. a separate medical evaluation from a physician other than a surgeon and preferably the beneficiarys primary care physician that includes both a recommendation for bariatric surgery as well as a medical clearance for the proposed bariatric surgeryc. mental health and psychosocial clearance for bariatric surgery by a mental health provider including a statement regarding motivation and ability to follow post-surgical requirementsd. a nutritional evaluation by a physician or registered dietician.Noridian Covered Inpatient Facility ICD-10-CM Procedure Codes for Laparoscopic Sleeve Gastrectomy: 0DV64CZNationally Covered Inpatient Facility ICD-10-CM Procedure CodesFor services on or after October 1, 2014, the following ICD-10 procedure codes are covered for bariatric surgery:Laparoscopic gastroenterostomy (laparoscopic Roux-en-Y), or ONE of the following ICD-10-PCS codes:0DB64Z30DV64CZ0D164790D1647A0D1647B0D1647L0D164J90D164JA0D164JB0D164JL0D164K90D164KA0D164KB0D164KL0D164Z90D164ZA0D164ZB0D164ZL
Article - Billing and Coding: Bariatric Surgery Coverage (A53028)
Other gastroenterostomy (open Roux-en-Y), or ONE of the following ICD-10-PCS codes:0D160790D1607A0D1607B0D1607L0D160J90D160JA0D160JB0D160JL0D160K90D160KA0D160KB0D160KL0D160Z90D160ZA0D160ZB0D160ZL0D168790D1687A0D1687B0D1687L0D168J90D168JA0D168JB0D168JL0D168K90D168KA0D168KB0D168KL0D168Z90D168ZA0D168ZB0D168ZLTo describe either laparoscopic or open BPD with DS or GRDS,onecode fromeachof the following threegroupsmust be on the claim:Group 1:0DB60Z30DB60ZZ0DB63Z30DB63ZZ0DB67Z30DB67ZZ0DB68Z3Group 2:One code from Groups A-C below is required.Group A:0DB80ZZ0DB90ZZ0DBB0ZZGroup B:0D160ZBGroup C:0F190Z3