evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Cardiac Catheterization and Coronary Angiography (A56500)
Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.
Article - Billing and Coding: Cardiac Catheterization and Coronary Angiography (A56500)
Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Other Comments:For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS to process their claims.Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes
Article - Billing and Coding: Cardiac Catheterization and Coronary Angiography (A56500)
Associated Information:1. Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed.2. The patients medical record should contain documentation that fully supports the medical necessity for cardiac catheterization and coronary angiography as it is covered by Medicare. This documentation includes, but is not limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or procedures.3. The medical record should contain a formal procedure report and interpretation for each procedure performed.4. The record must include documentation of the medical decision making when interventional procedures are not performed during the same session as the diagnostic procedures.5. The medical record must include documentation of the medical necessity for each procedure when multiple catheterization and angiographic procedures are performed during the same session.6. The medical record must include an interpretation and report of all angiograms. Imaging for each angiographic procedure (film, video or digital) must be retained in the medical record and be available for review by the Medicare contractor.7. The medical record must include documentation of request for extra-cardiac angiography from the referring/ordering provider treating the patient.8. Medical records must be made available to Medicare upon request.Not applicableDiagnostic coronary angiography may not be billed when performed during percutaneous coronary intervention, if it has been previously performed within the past six months resulting in the decision for the beneficiary to undergo the specific interventional procedure
Article - Billing and Coding: Hospice - Neurological Conditions (A56502)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1813 (a)(4)(A)(i) drugs and biologicals provided in a hospice programTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, 30.2 Payment Rates, 30.2.2 Service Intensity Add-on (SIA) Payments, and 30.3 Data Required on the Institutional Claim to A/B MAC (HHH)Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Hospice  Neurological Conditions L34547.
Article - Billing and Coding: Blepharoplasty, Eyelid Surgery, and Brow Lift (A56503)
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.CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 30, 20.2.1 Categorical DenialsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Blepharoplasty, Eyelid Surgery, and Brow Lift L34411.
Article - Billing and Coding: Transesophageal Echocardiography (TEE) (A56505)
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) L35016, Transesophageal Echocardiography (TEE). 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.CPT code 93355 is used to report TEE services during transcatheter intracardiac therapies. CPT code 93355 is reported once per intervention and only by an individual who is not performing the interventional procedure. CPT code 93355 includes the work of passing the endoscopic ultrasound transducer through the mouth into the esophagus, when performed by the individual performing the TEE, diagnostic transesophageal echocardiography and ongoing manipulation of the transducer to guide sizing and/or placement of implants, determination of adequacy of the intervention, and assessment for potential complications. Real-time image acquisition, measurements, and interpretation of image(s), documentation of completion of the intervention, and final written report are included in this code.CPT code 93312 (HCPCS code C8925 for Outpatient Prospective Payment System [OPPS]) should be billed when contrast is used or CPT code 93315 (HCPCS code C8926 for OPPS billing when contrast is used) for the complete procedure, including probe placement, image acquisition, interpretation and report. CPT code 93315 (HCPCS code C8926 for OPPS billing when contrast is used) should be used for congenital anomalies only.Hospitals should use guidelines and descriptors associated with the applicable Level 1 CPT code(s) to bill for echocardiograms without contrast.
Article - Billing and Coding: Transesophageal Echocardiography (TEE) (A56505)
Hospitals should use guidelines and descriptors associated with the applicable Level 1 CPT code(s) to bill for echocardiograms without contrast.All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.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: Mohs Micrographic Surgery (A56514)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Publications:CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 30, Physician ServicesCMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 16, Section 120, Cosmetic SurgeryCMS Publication 100-04,Medicare Claims Processing Manual, Chapter 12 Section 40-40.6, Surgeons and Global SurgeryCMS Publication 100-04,Medicare Claims Processing Manual, Chapter 12, Section 60, Payment for Pathology ServicesCMS Transmittal No. 434, Publication 100-04,Medicare Claims Processing Manual, Change Request #3458, January 14, 2005, Addition of CLIA Edits to Certain Health Care Procedure Coding System (HCPCS) Codes for Mohs Surgery.Article Text
Article - Billing and Coding: Mohs Micrographic Surgery (A56514)
The following coding and billing guidance is to be used with its associated Local Coverage Determination.As defined by the American Medical Association Current Procedural Terminology (American Medical Association, Chicago, IL), Mohs Micrographic Surgery (MMS) is a technique for the removal of complex or ill-defined skin cancer with histologic examination of 100% of the surgical margins. It is a combination of surgical excision and surgical pathology that requires a single physician to act in 2 integrated but separate and distinct capacities: surgeon and pathologist. The Mohs surgeon removes the tumor tissue and maps and divides the tumor specimen into pieces, and each piece is embedded into an individual tissue block for histopathologic (hematoxylin-eosin or toluidine blue) examination. Thus, a tissue block in MMS is defined as an individual tissue piece embedded in a mounting medium for sectioning.If a surgeon performs an excision using Mohs surgical techniques but does not personally provide the histologic evaluation of the specimen(s), the CPTcodes for MMS shall not be used. Instead standard excision codes should be chosen for such medically necessary services (e.g., 11600  11646).Medicare is aware that a biopsy of the skin lesion for which Mohs surgery is planned may be necessary for the physician to determine the exact nature of the lesion(s) to be removed. Occasionally, that biopsy may need to be done on the same day that the Mohs surgery is planned. To allow separate payment for a nonroutine histochemical stain on frozen tissue during Mohs surgery, report 88314 with modifier 59.If a prior biopsy of the site undergoing Mohs surgery has been previously performed within the last 60 days, the surgeon should make a reasonable effort to obtain those results rather than repeating the biopsy.
Article - Billing and Coding: Mohs Micrographic Surgery (A56514)
If a prior biopsy of the site undergoing Mohs surgery has been previously performed within the last 60 days, the surgeon should make a reasonable effort to obtain those results rather than repeating the biopsy.Reporting both Mohs Micrographic Surgery CPTcodes 17311-17315 and Surgical Pathology CPT88302-88309 or 88331-88332, on tissue used for margin evaluation during Mohs surgery is inappropriate and will indicate that true Mohs surgery was not done. Such claims for Mohs surgery (17311-17315) will be denied. There are occasional clinical situations in which tissue separate from the tissue examined during Mohs surgery is appropriately submitted for subsequent formalin fixed processing and histopathologic examination. The submitted tissue is not the same tissue that was processed during the Mohs surgery. It may constitute a tissue margin beyond that evaluated with Mohs surgery or it may involve a totally unrelated tissue specimen. In such situations both the Mohs surgery and the histopathology are subject to coverage. In such cases the clinical record must clearly show the reasoning for the histopathologic specimen and interpretation. To allow separate payment for a biopsy and pathology on a separate skin lesion, other than the lesion for which Mohs surgery is performed on the same day, the -59 modifier is appropriate.If reporting the -59 modifier with a skin biopsy/pathology code on the same day the Mohs surgery was performed, the physician's documentation should clearly indicate:
Article - Billing and Coding: Mohs Micrographic Surgery (A56514)
That the biopsy was performed on a lesion other than the one on which Mohs surgery was performed;If the biopsy is of the same lesion as the Mohs lesion, that a biopsy of that lesion had not been done within the previous 60 days; orIf there has been a recent (within 60 days) biopsy of the same lesion as the Mohs lesion, the results of that biopsy were unobtainable despite reasonable effort by the Mohs surgeon.Documentation requirementsThe majority of simple skin cancers can be managed by simple excision or destruction techniques. The medical records should clearly show that Mohs surgery was chosen because of the complexity, size and/or location of the lesion and why other approaches are not medically necessary and reasonable.The operative notes and pathology documentation in the patient's medical record must clearly show that Mohs micrographic surgery was performed using accepted Mohs technique, with the same physician performing both the surgical and pathology services. The notes should also contain the location, number and size of the lesion(s), the number of stages performed, and the number of specimens per stage.Documentation must be available to Medicare contractors upon request.The Mohs surgeon must describe the histology of the specimens taken in the first stage. That description should include depth of invasion, pathological pattern, cell morphology, and, if present, perineural invasion or presence of scar tissue. For subsequent stages, you may note that the pattern and morphology of the tumor (if still seen) is as described for the first stage; or, if differences are found, note the changes. There is no need to repeat the detailed description documented for the first stage, presuming that the description would fit the tumor found on subsequent stages.The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD in accordance with this LCD. This documentation should include, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures including biopsy reports along with the procedural note.Sources:American Medical Association. Mohs Micrographic Surgery. CPT Assistant 2006;16:1-7
Article - Billing and Coding: Mohs Micrographic Surgery (A56515)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Publications:CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 30, Physician ServicesCMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 16, Section 120, Cosmetic SurgeryCMS Publication 100-04,Medicare Claims Processing Manual, Chapter 12 Section 40-40.6, Surgeons and Global SurgeryCMS Publication 100-04,Medicare Claims Processing Manual, Chapter 12, Section 60, Payment for Pathology ServicesCMS Transmittal No. 434, Publication 100-04,Medicare Claims Processing Manual, Change Request #3458, January 14, 2005, Addition of CLIA Edits to Certain Health Care Procedure Coding System (HCPCS) Codes for Mohs Surgery.Article Text
Article - Billing and Coding: Mohs Micrographic Surgery (A56515)
The following coding and billing guidance is to be used with its associated Local Coverage Determination.As defined by the American Medical Association Current Procedural Terminology (American Medical Association, Chicago, IL), Mohs Micrographic Surgery (MMS) is a technique for the removal of complex or ill-defined skin cancer with histologic examination of 100% of the surgical margins. It is a combination of surgical excision and surgical pathology that requires a single physician to act in 2 integrated but separate and distinct capacities: surgeon and pathologist. The Mohs surgeon removes the tumor tissue and maps and divides the tumor specimen into pieces, and each piece is embedded into an individual tissue block for histopathologic (hematoxylin-eosin or toluidine blue) examination. Thus, a tissue block in MMS is defined as an individual tissue piece embedded in a mounting medium for sectioning.If a surgeon performs an excision using Mohs surgical techniques but does not personally provide the histologic evaluation of the specimen(s), the CPTcodes for MMS shall not be used. Instead standard excision codes should be chosen for such medically necessary services (e.g., 11600  11646).Medicare is aware that a biopsy of the skin lesion for which Mohs surgery is planned may be necessary for the physician to determine the exact nature of the lesion(s) to be removed. Occasionally, that biopsy may need to be done on the same day that the Mohs surgery is planned. To allow separate payment for a nonroutine histochemical stain on frozen tissue during Mohs surgery, report 88314 with modifier 59.If a prior biopsy of the site undergoing Mohs surgery has been previously performed within the last 60 days, the surgeon should make a reasonable effort to obtain those results rather than repeating the biopsy.
Article - Billing and Coding: Mohs Micrographic Surgery (A56515)
If a prior biopsy of the site undergoing Mohs surgery has been previously performed within the last 60 days, the surgeon should make a reasonable effort to obtain those results rather than repeating the biopsy.Reporting both Mohs Micrographic Surgery CPTcodes 17311-17315 and Surgical Pathology CPT88302-88309 or 88331-88332 on tissue used for margin evaluation during Mohs surgery is inappropriate and will indicate that true Mohs surgery was not done. Such claims for Mohs surgery (17311-17315) will be denied. There are occasional clinical situations in which tissue separate from the tissue examined during Mohs surgery is appropriately submitted for subsequent formalin fixed processing and histopathologic examination. The submitted tissue is not the same tissue that was processed during the Mohs surgery. It may constitute a tissue margin beyond that evaluated with Mohs surgery or it may involve a totally unrelated tissue specimen. In such situations both the Mohs surgery and the histopathology are subject to coverage. In such cases the clinical record must clearly show the reasoning for the histopathologic specimen and interpretation. To allow separate payment for a biopsy and pathology on a separate skin lesion, other than the lesion for which Mohs surgery is performed on the same day, the -59 modifier is appropriate.If reporting the -59 modifier with a skin biopsy/pathology code on the same day the Mohs surgery was performed, the physician's documentation should clearly indicate:
Article - Billing and Coding: Mohs Micrographic Surgery (A56515)
That the biopsy was performed on a lesion other than the one on which Mohs surgery was performed;If the biopsy is of the same lesion as the Mohs lesion, that a biopsy of that lesion had not been done within the previous 60 days; orIf there has been a recent (within 60 days) biopsy of the same lesion as the Mohs lesion, the results of that biopsy were unobtainable despite reasonable effort by the Mohs surgeon.Documentation requirementsThe majority of simple skin cancers can be managed by simple excision or destruction techniques. The medical records should clearly show that Mohs surgery was chosen because of the complexity, size and/or location of the lesion and why other approaches are not medically necessary and reasonable. The operative notes and pathology documentation in the patient's medical record must clearly show that Mohs micrographic surgery was performed using accepted Mohs technique, with the same physician performing both the surgical and pathology services. The notes should also contain the location, number and size of the lesion(s), the number of stages performed, and the number of specimens per stage.Documentation must be available to Medicare contractors upon request.The Mohs surgeon must describe the histology of the specimens taken in the first stage. That description should include depth of invasion, pathological pattern, cell morphology, and, if present, perineural invasion or presence of scar tissue. For subsequent stages, you may note that the pattern and morphology of the tumor (if still seen) is as described for the first stage; or, if differences are found, note the changes. There is no need to repeat the detailed description documented for the first stage, presuming that the description would fit the tumor found on subsequent stages.The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD in accordance with this LCD. This documentation should include, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures including biopsy reports along with the procedural note.Sources:American Medical Association. Mohs Micrographic Surgery. CPT Assistant 2006;16:1-7
Article - Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Testing in Cancer (A56518)
CMS National Coverage PolicyN/AArticle Text