evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities (A58250)
The timing of an intervention(s) must be outlined versus the timing of routine post-op (post procedure) follow-up (for example, procedure(s) on day 1 and reevaluation in 3 months versus procedure(s) on day 1 and 7 and reevaluation in 3 months). Therefore, any planned thermal ablation, and/or sclerotherapy, and/or cyanoacrylate/chemical adhesive ablation, and/or mechanochemical ablation, and/or surgical treatments must be addressed in the plan of care  and must be supported in a complete operative procedure note.Serial ablation procedures on the same leg within a 90 day episode of care must clearly be supported in the documentation based on patient specific clinical information that the ablation procedures cannot be performed on a single day.Incompetent perforator vein intervention must be clearly supported in the documentation based on patient specific clinical information as outlined in the LCD covered indications.The initial plan of care is expected to address all sites of clinically significant axial or non-axial reflux along with a description of the specific procedure(s) to be used in a 90 day episode of care consistent with the CEAP and VCSS classification and supporting clinical and diagnostic data.The plan of care must include the date(s) of the examination and diagnostic evaluation.For patients with C2 or C3 disease and VCSS <6, the plan of care shall include documentation of a period of conservative therapy (2-4 weeks) including graduated compression 20-30 mmHg or greater, ambulation, elevation, and avoiding prolonged sitting and standing.Duplex scan documentation must confirm the presence of reversed venous flow (reflux) with provocative maneuvers in the saphenous or perforator veins is 500 milliseconds or greater, and absence of deep venous obstruction.
Article - Billing and Coding: Transurethral Waterjet Ablation of the Prostate (A58264)
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) L38726 Transurethral Waterjet Ablation of the Prostate. 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.
Article - Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (A58275)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) L38737.Coding GuidelinesProcedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.Specific Coding GuidelinesNo separate payment for venography performed during the operative session may be allowed and it should not be separately billed.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Article - Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM) (A58277)
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 information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Implantable Continuous Glucose Monitors (I-CGM) L38743.Coding GuidanceImplantationof an implantable continuous glucose monitor (I-CGM) that meets the appropriate criteria as mentioned in LCD L38743 Implantable Continuous Glucose Monitors (I-CGM) is reported for either the 90 day or 180 day implantable sensor.For 90 day implantable glucose sensor report:CPTcode 0446T- Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient trainingRemovalof an I-CGM is reported with:CPTcode 0447T- Removal of implantable interstitial glucose sensor from subcutaneous pocket via incisionRemoval with immediate subsequent replacementof an I-CGM is reported with:CPTcode 0448T- Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activationNotice: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.
Article - Billing and Coding: Platelet Rich Plasma (A58282)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Platelet Rich Plasma L38745.
Article - Billing and Coding: Peroral Endoscopic Myotomy (POEM) (A58287)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claimArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Peroral Endoscopic Myotomy (POEM) L38747.
Article - Billing and Coding: Colon Capsule Endoscopy (CCE) (A58294)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states thatno 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) L38571, Colon Capsule Endoscopy (CCE). Please refer to the LCD for reasonable and necessary requirements.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10 code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Notice: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.For the purposes of this Article, ICD-10-CM code Z53.8 indicates that the instrument colonoscopy has been attempted and was incomplete and Z53.09 indicates the procedure is contraindicated when a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training determined from an evaluation of the patient that optical colonoscopy cannot be safely attempted.Documentation Requirements:
Article - Billing and Coding: Colon Capsule Endoscopy (CCE) (A58294)
The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See "Indications and Limitations of Coverage.")This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.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: MolDX: Blood Product Molecular Antigen Typing (A58308)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Blood Product Molecular Antigen Typing L38240.Blood product antigen typing is a germline test and the use of panels 0001U and 0084U will be limited to once in a beneficiary lifetime.The individual codes 0180U-0201U, 0221U and 0222U and codes 81105-81112 are also germline tests. These will benoncovered as multiple antigens must be utilized as part of a comprehensive antigen evaluation and will be considered only as part of a panel.To report aBlood Product Molecular Antigen Typingservice, please submit the following claim information:Select the appropriate CPTorPLA codeEnter unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A58318)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Pharmacogenomics Testing L38294.Relevant National Coverage Determinations (NCDs):NCD 90.1: Testing for CYP2C9 and VKORC1 for Warfarin dosage must adhere to the requirements set forth in this NCD.Relevant Articles:Billing and Coding: MolDX: Testing of Multiple Genes A57503Billing and Coding: MolDX: Repeat Germline Testing A58017Additional documentation requirements for coverage and billing:Performing providers are required to acquire and retain records of the drugs under consideration for use or in use by the ordering physician that necessitate the use of ordered test.MolDX may make available specific forms to assist with test Technical Assessments (TAs). Please follow the instructions on the MolDX website to assist with this process. If such forms are available that pertain to the test type in question, these forms are required for successful coverage determinations.Billing instructions:To report a pharmacogenomics testing service, please submit the following claim information:Select the appropriate CPTor PLA codeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Codeidentifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A58318)
Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM codeFor part B claims, the drug or drugs in consideration for use that require the use of the pharmacogenomics (PGx) test must be submitted in the applicable detail line 2400 loop. The character maximum for loop 2400 is 80. To prevent denials/rejects when indicating more than 80 characters, please indicate the required drug names first.If multiple drugs are being used/considered for the specified beneficiary on the claim, they should be added to the comment line separated by a "/" (example Drug 1/Drug 2). Do not list the same drug more than once. The use of the generic name is strongly preferred.For Part B paper claims, the drug or drugs in consideration for use that require the use of the pharmacogenomics (PGx) test must be submitted in Item 19 field.Only one test may be performed per date of service; the test should be the most likely to identify the necessary alleles/variants for the drug/drugs in question. This applies to both single gene tests and multigene panels.The medical necessity for the additional testing and the clinical decision making for the additional testing must be documented in the medical record. The CPT code set relevant to this policy is listed in the table below. If no CPT code is available for the gene being tested, the NOC code 81479 may be used. The identification of the proper recommended billing code is established as part of the test application process.Gene/CPT coding/Drug informationTable 1 represents relevant gene/drug associations related to metabolizing enzymes from CPIC and FDA sources.Table 1.This table represents metabolism gene/drug associations from CPIC and FDA sources.GeneCPT Code(s)Generic NameTrade Name(s)Intended use for Drug(s)GuidanceABCG281479rosuvastatinCrestorAntihyperlipidemicCPICBCHE81479mivacurium, succinylcholineMivacurium chloride, AnectineNeuromuscular blocking agentFDACYP2B681479efavirenzSustivaAntiretroviral; HIVCPIC/FDACYP2B681479sertralineZoloft
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A58318)
Neuromuscular blocking agentFDACYP2B681479efavirenzSustivaAntiretroviral; HIVCPIC/FDACYP2B681479sertralineZoloftAntidepressant-Selective Serotonin Reuptake Inhibitor (SSRI)CPIC/FDACYP2C1981225brivaracetam, clobazamBriviact, OnfiAnticonvulsantFDACYP2C1981225citalopram, escitalopram, sertralineCelexa, Lexapro, ZoloftAntidepressant - Selective Serotonin Reuptake Inhibitor (SSRI)CPIC/FDACYP2C1981225amitriptyline, clomipramine, doxepin, imipramine, trimipramineElavil, Anafranil, Silenor, Tofranil, SurmontilAntidepressant - TricyclicCPICCYP2C1981225voriconazoleVfendAntifungalCPIC/FDACYP2C1981225belzutifanWeliregAntineoplasticFDACYP2C1981225flibanserinAddyiMixed serotonin agonistFDACYP2C1981225clopidogrelPlavixPlatelet aggregation inhibitorCPIC/FDACYP2C1981225dexlansoprazole, lansoprazole, omeprazole, pantoprazoleDexilant, Prevacid, Prilosec, ProtonixProton Pump Inhibitor (PPI)CPIC/FDACYP2C1981225abrocitinibCibinqoSelective ImmunosuppressantFDACYP2C981227warfarinJantoven, CoumadinAnticoagulantCPIC/FDACYP2C981227fosphenytoin, phenytoinCerebyx, DilantinAnticonvulsantCPIC/FDACYP2C981227dronabinolMarinol, SyndrosAntiemeticFDACYP2C981227nateglinideStarlixAntihyperglycemicFDACYP2C981227
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A58318)
81227dronabinolMarinol, SyndrosAntiemeticFDACYP2C981227nateglinideStarlixAntihyperglycemicFDACYP2C981227fluvastatinLescolAntihyperlipidemicCPICCYP2C981227erdafitinibBalversaFGFR kinase inhibitor, bladder cancerFDACYP2C981227siponimodMayzentMultiple sclerosisFDACYP2C981227celecoxib, flurbiprofen, lornoxicam, meloxicam, piroxicam, tenoxicamCelebrex, Ansaid, Ocufen, Chlortenoxicam, Xefo, Mobic, Vivlodex, Anjeso, Qmiiz ODT, Feldene, MobiflexNon-steroidal anti-inflammatory (NSAID)CPIC/FDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UcarvedilolCoregAlpha - Beta blockerFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UpropafenoneRythmolAntiarrhythmicFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076Ufluvoxamine, paroxetine, venlafaxine, vortioxetineLuvox, Paxil, Effexor XR, Brintellix, TrintellixAntidepressant  Selective Serotonin Reuptake Inhibitor (SSRI)CPIC/FDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A58318)
CPIC/FDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076Uamitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, trimipramineElavil, Anafranil, Norpramin, Silenor, Tofranil, Aventyl, Pamelor, SurmontilAntidepressant - TricyclicCPICCYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076Umeclizine, ondansetron, tropisetronAntivert, Zofran ODT, TropisetronAntiemeticCPIC/FDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076Ugefitinib, tamoxifenIressa, Soltamox, NolvadexAntineoplasticCPIC/FDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076Uaripiprazole, aripiprazole lauroxil, brexpiprazole, clozapine, iloperidone, perphenazine, pimozide, thioridazineAbilify, Aristada, Rexulti, Clozaril, FazaClo, Versacloz, Fanapt, Trilafon, Orap, MellarilAntipsychoticFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076Uamphetamine, atomoxetineAdzenys ER, Dyanavel XR, Adderall, StratteraAttention Deficit - Hyperactivity (ADHD) TherapyCPIC/FDACYP2D6
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A58318)
amphetamine, atomoxetineAdzenys ER, Dyanavel XR, Adderall, StratteraAttention Deficit - Hyperactivity (ADHD) TherapyCPIC/FDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UmetoclopramideReglanGastrointestinal prokinetic agentFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UeliglustatCerdelgaGaucher's diseaseFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076Udeutetrabenazine, tetrabenazineAustedo, XenazineMovement disorder therapyFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UpitolisantWakixNarcolepsy therapy agentFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076Ucodeine, oliceridine, tramadolOlinvyk, UltramOpioidCPIC/FDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UlofexidineLucemyraOpioid withdrawalFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UcevimelineEvoxacSaliva stimulantFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UtolterodineDetrolUrinary antispasmodicFDA
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A58318)
tolterodineDetrolUrinary antispasmodicFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UvalbenazineIngrezzaVMAT2 inhibitorFDACYP3A581231tacrolimusPrografAntirejectionCPIC/FDACYP4F281479warfarinJantoven, CoumadinAnticoagulantCPIC/FDADPYD81232capecitabine, fluorouracilXeloda, Adrucil, Efudex, Fluoroplex, TolakAntineoplasticCPIC/FDAIFNL381283peginterferon alfa - 2a, peginterferon alfa - 2bPegasys, Pegasys ProClick, PegIntron, SylatronAntiviral, HCVCPICNAT281479procainamideProcan, PronestylAntiarrhythmicFDANAT281479sulfamethoxazole / trimethoprimBactrimAntibacterialFDANAT281479isoniazidNiazidAntitubercularFDANAT281479sulfasalazineAzulfidineDisease-Modifying Antirheumatic Drug (DMARD): Other - inflammatory bowel agentFDANAT281479amifampridine, amifampridine phosphateRuzurgi, FirdapseMultiple sclerosisFDANUDT1581306azathioprine, mercaptopurine, thioguanineAzasan, Purixan, TabloidAntineoplasticCPIC/FDASLCO1B181328simvastatin, atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatinFloLipid, Zocor, Lipitor, Lescol, Mevacor, Altoprev, Altocor, Livalo, Zypitamag, Pravachol, CrestorAntihyperlipidemicCPIC/FDATPMT81335, 0034U, 0286U
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A58318)
AntihyperlipidemicCPIC/FDATPMT81335, 0034U, 0286Uazathioprine, mercaptopurine, thioguanineAzasan, Purixan, TabloidAntineoplasticCPIC/FDAUGT1A181350belinostat, irinotecan, nilotinib, pazopanib, Sacituzumab Govitecan-HziyBeleodaq, Camptosar, Tasigna, Votrient, TrodelvyAntineoplasticFDAUGT1A181350atazanavirReyatazAntiretroviral, HIVCPICUGT2B1781479belzutifanWeliregAntineoplasticFDAVKORC181355warfarinJantoven, CoumadinAnticoagulantCPIC/FDATable 2 represents other relevant gene/drug associations that are not related to metabolism from CPIC and FDA sources.Table 2.This table represents other relevant therapeutic gene/drug associations from CPIC and FDA sources.GeneCPT Code(s)Generic NameTrade Name(s)Intended use for Drug(s)GuidanceAPOE81401lecanemabLeqembiAlzheimers DiseaseFDACACNA1S81479desflurane, enflurane, halothane, isoflurane, methoxyflurane, sevoflurane, succinylcholineSuprane, Ethrane, Fluothane, Forane, Penthrox, Ultane, Anectine, QuelicinVolatile anestheticCPICG6PD81247rasburicase, pegloticaseElitek, KrystexxaHyperuricemiaCPICG6PD81247dapsoneAccone, AvlosulfonAntibacterialCPICG6PD81247primaquine, tafenoquineJasoprim, ArakodaAntimalarialCPICHLA - A81381tebentafuspKimmtrakAntineoplasticFDAHLA - A81381, 81374carbamazepineTegretolAnticonvulsantCPIC/FDAHLA - B81381, 81374