evekhm/cms_iom_500 huggingface dataset:
Article - Mechanical In-exsufflation Devices - Policy Article (A52510)
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.Reimbursement may be made for replacement of A7020 (INTERFACE FOR COUGH STIMULATING DEVICE, INCLUDES ALL COMPONENTS, REPLACEMENT ONLY) only if the beneficiary owns or is purchasing the mechanical in-exsufflation device.The diagnosis code that justifies the need for these items must be included on the claim.CODING GUIDELINESMechanical in-exsufflation devices are designed to slowly inflate the lungs with positive pressure during inspiration and simulate cough with rapidly applied negative pressure during expiration.HCPCS code A7020 (INTERFACE FOR COUGH STIMULATING DEVICE, INCLUDES ALL COMPONENTS, REPLACEMENT ONLY) is for replacement only. It must not be billed at the time of initial issue.HCPCS code E0467 (HOME VENTILATOR, MULTI-FUNCTION RESPIRATORY DEVICE, ALSO PERFORMS ANY OR ALL OF THE ADDITIONAL FUNCTIONS OF OXYGEN CONCENTRATION, DRUG NEBULIZATION, ASPIRATION, AND COUGH STIMULATION, INCLUDES ALL ACCESSORIES, COMPONENTS AND SUPPLIES FOR ALL FUNCTIONS) describes a ventilator that integrates the function of multiple types of equipment into a single device. Code E0467 combines the function of a ventilator with all of the following:Oxygen equipmentNebulizer and compressorAspirator (suction device)Cough stimulator (multiple products)If the multifunction ventilator does not include all of the functions listed above, then the ventilator must not be coded as E0467. Multifunction ventilators that combine some but not all, of the listed functions, must be coded as E1399 (DURABLE MEDICAL EQUIPMENT, MISCELLANEOUS).Positive airway pressure (PAP) devices, respiratory assist devices (RAD), and custom fabricated oral appliances, are considered same or similar to the features of products coded E0467.The following mechanical in-exsufflation HCPCS codes for individual items are included in the functionality of code E0467:HCPCScodes E0482 and A7020
Article - Mechanical In-exsufflation Devices - Policy Article (A52510)
HCPCScodes E0482 and A7020For E0467 claims with dates of service before April 3, 2020:Claims for any of the HCPCS codes listed above that are submitted on the same claim or that overlap any date(s) of service for E0467 is considered to be unbundling.In addition, any claim for repair (HCPCS code K0739 for labor and any HCPCS code for replacement items) of beneficiary-owned equipment identified by HCPCS codes listed above is considered as unbundling if the date(s) of service for the repair overlaps any date(s) of service for code E0467.Claims for code E0467 with a date(s) of service that overlaps date(s) of service for any of the following scenarios are considered as a claim for same or similar equipment when the beneficiary:Is currently in a rental month for any of the items listed aboveOwns any of the equipment listed above that has not reached the end of its reasonable useful lifetime.
Article - Mechanical In-exsufflation Devices - Policy Article (A52510)
Is currently in a rental month for any of the items listed aboveOwns any of the equipment listed above that has not reached the end of its reasonable useful lifetime.For E0467 claims with dates of service on or after April 3, 2020:Any claim for repair (HCPCS code K0739 for labor and any HCPCS code for replacement items) of beneficiary-owned equipment identified by HCPCS codes listed above is considered as unbundling if the date(s) of service for the repair overlaps any date(s) of service for code E0467.Claims for code E0467 with a date(s) of service that overlaps date(s) of service in a rental month for any of the items listed above are considered as a claim for same or similar equipment.CODING VERIFICATION REVIEWThe only products which may be billed using the following list of HCPCS codes are those for which a written coding verification review (CVR) has been made by the PDAC contractor and subsequently published on the Product Classification List (PCL). Information concerning the documentation that must be submitted to the PDAC for a CVR can be found on the PDAC website or by contacting the PDAC. A PCL with products which have received a coding verification can be found on the PDAC website. The effective date of the CVR is included for each code.Effective for claims with dates of service on or after January 1, 2022:E0467If a product is billed to Medicare using a HCPCS code that requires written CVR, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Article - Negative Pressure Wound Therapy Pumps - Policy Article (A52511)
CMS National Coverage PolicyN/AArticle TextNON-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).Negative pressure wound therapy equipment 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 (LCD) must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.Disposable wound suction pumps and related supplies (A9272) will be denied as statutorily noncovered because they do not meet the DME benefit.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.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.
Article - Negative Pressure Wound Therapy Pumps - Policy Article (A52511)
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.Information describing the history, previous treatment regimens (if applicable), and current wound management for which a NPWT pump is being billed must be present in the beneficiarys medical record and be available for review upon request. This documentation must include such elements as length of sessions of use, dressing types and frequency of change, and changes in wound conditions, including precise measurements, quantity of exudates, presence of granulation and necrotic tissue and concurrent measures being addressed relevant to wound therapy (debridement, nutritional concerns, support surfaces in use, positioning, incontinence control, etc.).Information describing the wound evaluation and treatment, recorded in the beneficiarys medical record, must indicate regular evaluation and treatment of the beneficiarys wounds, as detailed in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD.Documentation of quantitative measurements of wound characteristics including wound length and width (surface area), and depth, and amount of wound exudate (drainage), indicating progress of healing must be entered at least monthly. The supplier of the NPWT equipment and supplies must obtain from the treating clinician, an assessment of wound healing progress, based upon the wound measurement as documented in the beneficiarys medical record, in order to determine whether the equipment and supplies continue to qualify for Medicare coverage. (The supplier need not view the medical records in order to bill for continued use of NPWT. Whether the supplier ascertains that wound healing is occurring from month to month via verbal or written communication is left to the discretion of the supplier. However, the beneficiarys medical records may be requested in order to corroborate that wound healing is/was occurring as represented on the suppliers claims for reimbursement.)
Article - Negative Pressure Wound Therapy Pumps - Policy Article (A52511)
When billing for NPWT, a diagnosis code (specific to the 5th digit or narrative diagnosis), describing the wound being treated by NPWT, must be included on each claim for the equipment and related supplies.The medical record must include a statement from the treatingpractitioner describing the initial condition of the wound (including measurements) and the efforts to address all aspects of wound care (listed in A1 through A4 in the related LCD). For each subsequent month, the medical record must include updated wound measurements and what changes are being applied to effect wound healing.Month-to-month comparisons of wound size must compare like measurements i.e. depth compared to depth or surface area compared to surface area.If the initiation of NPWT occurs during an inpatient stay, in order to accurately account for the duration of treatment, the initial inpatient date of service must be documented. This date must be available upon request.When NPWT therapy exceeds 4 months on the most recent wound and reimbursement ends, individual consideration for one additional month at a time may be sought using the appeals process. Information from the treating practitioners medical record, contemporaneous with each requested one-month treatment time period extension, must be submitted with each appeal explaining the special circumstances necessitating the extended month of therapy. Note, the LCD provides coverage for the use of NPWT limited to initiating healing of the problem wounds described in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD rather than continuation of therapy to complete healing since there is no published medical literature demonstrating evidence of a clinical benefit for the use of NPWT to complete wound healing. Therefore, general, vague or nonspecific statements in the medical record such as doing well, want to continue until healed provide insufficient information to justify the need for extension of treatment. The medical record must provide specific and detailed information to explain the continuing problems with the wound, what additional measures are being undertaken to address those problems and promote healing and why a switch to alternative treatments alone is not possible.When billing for quantities of canisters greater than those described in the related LCD as the usual maximum amounts, there must be clear and explicit information in the medical record that justifies the additional quantities.
Article - Negative Pressure Wound Therapy Pumps - Policy Article (A52511)
WRITTEN ORDER PRIOR TO DELIVERY (WOPD)Effective for claims with dates of service on or after 05/25/2017, a WOPD is no longer required.MODIFIERSKX, GA, and GZ Modifiers:Suppliers must add a KX modifier to a code only if all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD have been met.The KX modifier must not be used with a NPWT pump and supplies for wounds if:The pump has been used to treat a single wound and the claim is for the fifth or subsequent months rental, orThe pump has been used to treat more than one wound and the claim is for the fifth or subsequent months rental after therapy has begun on the most recently treated wound. In this situation, the KX modifier may be billed for more than four total months of rental.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 the NPWT pump and supplies. 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 KX, GA or GZ modifier will be rejected as missing information.CODING GUIDELINESNPWT is provided with an integrated system of components. This system contains a pump (E2402), dressing sets (A6550) and a separate collection canister (A7000). Wound suction systems that do not contain all of the required components are not classified as NPWT. See below for component specifications.
Article - Negative Pressure Wound Therapy Pumps - Policy Article (A52511)
EQUIPMENT:Code E2402 describes a stationary or portable Negative Pressure Wound Therapy (NPWT) electrical pump which provides controlled sub-atmospheric pressure that is designed for use with NPWT dressings (A6550) and canisters (A7000) to promote wound healing. The NPWT pump must be capable of being selectively switched between continuous and intermittent modes of operation and is controllable to adjust the degree of sub-atmospheric pressure conveyed to the wound in a range of 40-80 mm Hg sub-atmospheric pressure. The system must contain sensors and alarms to monitor pressure variations and exudate volume in the collection canister.Disposable wound suction system pumps and related supplies must be coded A9272 (WOUND SUCTION, DISPOSABLE, INCLUDES DRESSING, ALL ACCESSORIES AND COMPONENTS, ANY TYPE, EACH).
Article - Negative Pressure Wound Therapy Pumps - Policy Article (A52511)
SUPPLIES:Code A6550 describes an allowance for a dressing set which is used in conjunction with a stationary or portable NPWT pump (E2402). A single code A6550 is used for each single, complete dressing change, and contains all necessary components, including but not limited to any separate, non-adherent porous dressing(s), drainage tubing, and an occlusive dressing(s) which creates a seal around the wound site for maintaining sub-atmospheric pressure at the wound.HCPCS code A7000 describes a canister set which is used in conjunction with a stationary or portable NPWT pump and contains all necessary components, including but not limited to a container, to collect wound exudate. Canisters may be various sizes to accommodate stationary or portable NPWT pumps.Code A9272 (WOUND SUCTION, DISPOSABLE, INCLUDES DRESSING, ALL ACCESSORIES AND COMPONENTS, ANY TYPE, EACH) describes a disposable wound suction device. Suction is developed through the use of any type of mechanism. This device includes all components, accessories and dressings. Code A9272 is all-inclusive. Supplies used with disposable wound suction systems are not separately billable. Examples (not all-inclusive) include: SNaP (Spiracure), PICO (Smith and Nephew), VAC Via (KCI). Disposable wound suction items other than those coded as A9272 must be coded A9270 (noncovered item or service). For example, an elastomeric suction device would be correctly coded A9270.The only products which may be billed using codes E2402 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 should contact the PDAC for guidance on the correct coding of these items.
Article - Oral Appliances for Obstructive Sleep Apnea - Policy Article (A52512)
CMS National Coverage PolicyN/AArticle TextNON-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).Oral appliances used to treat obstructive sleep apnea (OSA) are covered under the Durable Medical Equipment benefit (SSA 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 must be met.No aspect of a home sleep test, including but not limited to delivery and/or pickup of the device, may be performed by a DME supplier. This prohibition does not extend to the results of studies conducted by hospitals certified to do such tests or to tests conducted in facility-based laboratories.Oral appliances generally are classified as dental devices and are not classified as durable medical equipment. The following items (not all-inclusive) are considered to be dental devices and will be denied as non-covered, not DME:Oral occlusal appliances used to treat temporomandibular joint (TMJ) disordersTongue retaining devices used to treat OSA and/or snoringAll oral appliances used only to treat snoring without a diagnosis of OSAOral appliances used to treat other dental conditionsOral appliances that require repeated fitting and/or adjustments, beyond the first 90-days, in order to maintain fit and/or effectiveness
Article - Oral Appliances for Obstructive Sleep Apnea - Policy Article (A52512)
All follow-up care, including fitting, adjustments, modifications, professional services (not all-inclusive) required during the first 90 days after provision of the oral appliance are considered to be included in the payment for device. Claims for these will be denied as not separately payable.After the initial 90-day period, adjustments, modifications and follow-up visits are not eligible for coverage under the DME benefit and are therefore not within the jurisdiction of the DME MAC.Repairs are covered for items that meet the coverage criteria. To repair means to fix or mend and to put the item back in good condition after damage or wear. Repairs are covered when necessary to make the item serviceable. If the expense for repairs exceeds the estimated expense of purchasing another item, no payment can be made for the excess.Oral appliances are eligible for replacement at the end of their 5-year reasonable useful lifetime (RUL). These items may be replaced prior to the end of the 5-year RUL in cases of loss, theft, or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood). Replacement due to wear-and-tear as the result of everyday use will be denied as statutorily non-covered prior to the expiration of the 5-year RUL.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.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.
Article - Oral Appliances for Obstructive Sleep Apnea - Policy Article (A52512)
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.Treating practitioners shall document the in-person clinical evaluation in a detailed narrative note in their charts in the format that they use for other entries. The report would commonly document pertinent information about the following elements, but may include other details. Each element would not have to be addressed in every evaluation.History
Article - Oral Appliances for Obstructive Sleep Apnea - Policy Article (A52512)
Signs and symptoms of sleep disordered breathing including snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headachesDuration of symptomsValidated sleep hygiene inventory such as the Epworth Sleepiness Scale (see Appendices of related LCD)Physical ExamFocused cardiopulmonary and upper airway system evaluationNeck circumferenceBody mass index (BMI)