evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Claims for cryosurgery for the prostate gland are to be submitted on the ASC X12 837, or, in exceptional circumstances, on a hard copy Form CMS  1450.  This procedure can be rendered in an inpatient or outpatient hospital setting (types of bill (TOBs) 11x  13x, 83x, and 85x).  The A/B MAC (A) will look for the following when processing claims with cryosurgery services:   If ICD -9-CM is applicable, ICD-9 CM diagnosis code 185 or    If ICD -10-CM is applicable, ICD-10 CM diagnosis code C61 must be on all cryosurgical claims;   For outpatient claims HCPCS 55873 and revenue codes 0360, 0361, or 0369 Cryosurgery ablation of localized prostate cancer, stages T1 - T3 (includes ultrasonic guidance for interstitial cryosurgery probe placement, postoperative irrigations and aspiration of sloughing tissue included) must be on all outpatient claims; and    For inpatient claims correct procedure codes are:   o If ICD -9-CM is applicable, ICD-9-CM procedure code 60.62 (perineal prostatectomy- the definition includes cryoablation of prostate, cryostatectomy of prostate, and radical cryosurgical ablation of prostate)   o If ICD -10 is applicable,ICD-10-PCS procedure code 0V500ZZ (Destruction of Prostate, Open Approach), or 0V503ZZ (Destruction of Prostate, Percutaneous Approach), or 0V504ZZ (Destruction of Prostate, Percutaneous Endoscopic Approach).  180.3  Payment Requirements  (Rev. 1111, Issued: 11- 09-06, Effective: 04-01-07, Implementation: 04-02-07)  This service may be paid as a primary treatment for patients with clinically localized prostate cancer, Stages T1  T3.  The ultrasonic guidance associated with this procedure will not be paid for separately, but is bundled into the payment for the surgical procedure.  When one provider has furnished the cryosurgical ablation and another the ultrasonic guidance, the provider of the ultrasonic guidance must seek compensation from the provider of the cryosurgical ablation.
(Medicare Claims Processing Manual)
Effective July 1, 2001, cryosurgery performed as salvage therapy, will be paid only according to the coverage requirements described above.  Type of facility and setting determines the basis of payment:   For services performed on an inpatient or outpatient basis in a CAH, TOBs 11x and 85x: the FI will pay 101 percent of reasonable cost minus any applicable deductible and coinsurance.    For services performed on an inpatient basis in short term acute care hospitals, (including those in Guam, America Samoa, Virgin Islands, Saipan, and Indian Health Services Hospitals) TOB 11x:  the FI will pay the DRG payment minus any applicable deductibl e and coinsurance.    For services performed on an outpatient basis in hospitals subject to the Outpatient PPS, TOB 13x: the FI will pay the assigned APC minus any applicable deductible and coinsurance.    For outpatient services in hospitals that are exempt from OPPS (such as in American Samoa, Virgin Islands, Guam, and Saipan) TOBs 13x: the FI will pay reasonable cost, minus any applicable deductible and coinsurance.    For outpatient services in Indian Health Service hospitals TOBs 13x and 83x: the FI will pay the ASC payment amount for TOB 83x. minus any applicable deductible and coinsurance.    For inpatient or outpatient services in hospitals in Maryland, make payment according to the State Cost Containment system.   For services performed on an inpatient basis: the hospitals exempt from inpatient acute care PPS shall be paid on reasonable cost basis, minus any applicable deductible and coinsurance.   180.4 - Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Group Codes, and Medicare Summary Notice Messages (Rev 2544, Issued: 09 -13-2012, Effective: 10 -01-2012, Implementation: 10- 01-2012)   Contractors shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for alcohol misuse screening and alcohol misuse behavioral counseling sessions:
(Medicare Claims Processing Manual)
 For RHC and FQHC claims that contain screening for alcohol misuse HCPCS code G0442 and alcohol misuse counseling HCPCS code G0443 with another encounter/visit  with the same line item date of service, use group code CO and reason code:   o Claim Adjustment Reason Code (CARC) 97  The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.   Note:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Servic e Payment Information REF) if present     Denying claims containing HCPCS code G0442 and HCPCS code G0443 submitted on a TOB other than 13X, 71X, 77X, and 85X:   o Claim Adjustment Reason Code (CARC) 5 -  The procedure code/bill type is inconsistent with the place of service.  Note:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present   o Remittance Advice Remark Code (RARC) M77   Missing/incomplete/invalid place of service   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.    Denying  claims that contains more than one alcohol misuse behavioral counseling session G0443 on the same date of service:   o Medicare Summary Notice (MSN) 15.6  The information provided does not support the need for this many services or items within this period of time.   o Claim Adjustment Reason Code (CARC) 151  Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.   o Remittance Advice Remark Code (RARC) M86   Service denied because payment already made for same/similar procedure within set time frame.
(Medicare Claims Processing Manual)
o Remittance Advice Remark Code (RARC) M86   Service denied because payment already made for same/similar procedure within set time frame.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.    Denying claims that are not submitted from the appropriate provider specialties:   o Medicare Summary Notice (MSN) 21.18  This item or service is not covered when performed or ordered by this provider.   o Claim Adjustment Reason Code (CARC) 185 -  The rendering provider is not eligible to perform the service billed. NOTE:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   o Remittance Advice Remark Code (RARC) N95 -  This provider type/provider specialty may not bill this service.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.    Denying claims without the appropriate POS code:   o Medicare Summary Notice (MSN) 21.25  This service was denied because Medicare only covers this service in certain settings.   o Claim Adjustment Reason Code (CARC) 58  Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.  Note:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present.   o Remittance Advice Remark Code (RARC) N428  Not covered when performed in this place of service.
(Medicare Claims Processing Manual)
o Remittance Advice Remark Code (RARC) N428  Not covered when performed in this place of service.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.    Denying claims for alcohol misuse screening HCPCS code G0442 more than once in a 12- month period, and denying alcohol misuse counseling sessions HCPCS code G0443 more than four times in the same 12 -month period:   o Medicare Summary Notice (MSN) 20.5  These services cannot be paid because your benefits are exhausted at this time.   o Claim Adjustment Reason Code (CARC) 119  Benefit maximum for this time period or occurrence has been reached.   o Remittance Advice Remark Code (RARC) N362  The number of Days or Units of service exceeds our acceptable maximum.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.    Denying claims for alcohol misuse counseling session HCPCS code G0443 when there is no claim in history for the screening service HCPCS code G0442 in the prior 12 months:
(Medicare Claims Processing Manual)
 Denying claims for alcohol misuse counseling session HCPCS code G0443 when there is no claim in history for the screening service HCPCS code G0442 in the prior 12 months:    Medicare Summary Notice (MSN) 16.26  Medicare does not pay for services or items related to a procedure that has not been approved or billed.   Claim Adjustment Reason Code (CARC) B15  This service/procedure requires that a qualifying service/procedure be received and covered.  The qualifying other service/procedure has not been received/adjudicated.  Note: Refer to the 835 Healthcare Policy Iden tification Segment (loop 2110 Service Payment Information REF), if present.    Remittance Advice Remark Code (RARC) M16   Alert:  Please see our web site, mailings, or bulletins for more details concerning this policy/procedure/decision.     Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a modifier indicating a signed ABN is on file.    Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received without a modifier indicating no signed ABN is on file.  180.5  Additional CWF and Contractor Requirements  (Rev 2544, Issued: 09- 13-2012, Effective: 10 -01-2012, Implementation: 10- 01-2012)    When applying frequency, CWF shall count 11 full months following the month of the last alcohol misuse screening visit, G0442, before allowing subsequent payment of another G0442 screening.     CWF shall reject incoming claims when G0443 PROF is billed if four G0443 services have been billed and posted to the BEHV auxiliary file within the 12 month period.     CWF shall continue to reject incoming claims with consistency error code 32#3 when HCPCS code G0442 PROF and HCPCS code G0443 PROF are billed on same day for TOB 71X, 77X, 85X with 096X, 097X and 098X.   Contractors and CWF shall use the last date of G0442 PROF for counting the 12- month period for G0443 PROF services.
(Medicare Claims Processing Manual)
 Contractors and CWF shall apply all the same TOBs (13x,71x, 77x and  85x with Rev. Code 96, 97 and 98) POS (11, 22, 49 and 71), no deductible/co- insurance and institutional/professional processing for G0443 that was implemented for G0442 in CR 7633.    If a claim with G0442 is cancelled, CWF shall do a look back for claims with G0443 and create an IUR (Information Unsolicited Response) along with a Trailer 24 back to the contractor to reject the G0443 claim(s) paid within the 12 month period of the G0442 claims.     CWF shall display the number of counseling sessions remaining for G0443 PROF on all CWF provider query screens (HUQA, HIQA, HIQH, ELGA, ELGB, ELGH).    CWF shall display the remaining PROF services counting DOWN from four (4) for the HCPCS code G0443 on the MBD/NGD extract file.    CWF shall calculate a next eligible date for G0442 PROF and G0443 PROF for a given beneficiary.     The calculation shall include all applicable factors including beneficiary Part B entitlement status, beneficiary claims history and utilization rules.    When there is no next eligible date, the CWF provider query screens shall display an 8- position alpha code in the date field to indicate why there is not a next eligible date.    Any change to beneficiary master data or claims data that would result in a change to any next eligible date shall result in an update to the beneficiarys next eligible date.   NOTE:  If G0442 is not paid, the beneficiary is not eligible for G0443.    CWF shall create a utility to remove previously posted G0442 TECH for the AUX file.    CWF shall remove G0442/G0443 TECH from editing, MBD, NGD, Provider Inquiry screens and all other applicable areas (i.e., HICR) previously done under CR 7633.  Frequency Requirements
(Medicare Claims Processing Manual)
 CWF shall remove G0442/G0443 TECH from editing, MBD, NGD, Provider Inquiry screens and all other applicable areas (i.e., HICR) previously done under CR 7633.  Frequency Requirements   When applying frequency, CWF shall count 11 full months following the month of the last alcohol misuse screening visit, G0442, before allowing subsequent payment of another G0442 screening.  Additionally, CWF shall create an edit to allow alcohol misuse br ief behavioral counseling, HCPCS G0443, no more than 4 times in a 12- month period. CWF shall also count four alcohol misuse counseling sessions HCPCS G0443 in the same 12 -month period used for G0442 counting from the date the G0442 screening session was bi lled.  When applying frequency limitations to G0442 screening on the same date of service as G0443 counseling, CWF shall allow both a claim for the professional service and a claim for a facility fee.  CWF shall identify the following institutional claims as facility fee claims for screening services: TOB 13X, TOB 85X when the revenue code is not 096X, 097X, or 098X.  CWF shall identify all other claims as professional service claims for screening services (professional claims, and institutional claims with TOB 71 X, 77X, and 85X when the revenue code is 096X, 097X, or 098X).  NOTE: This does not apply to RHCs and FQHCs.   190  Billing Requirements for Extracorporeal Photopheresis  (Rev. 3050, Issued: 08- 22-14, Effective: 09 -23-14, ICD -10: Upon Implementation of ICD -10, Implementation: 09 -23-14, ICD -10: Upon Implementation of ICD- 10)
(Medicare Claims Processing Manual)
Effective for dates of services on and after December 19, 2006, Medicare has expanded coverage for extracorporeal photopheresis for patients with acute cardiac allograft rejection whose disease is refractory to standard immunosuppresive drug treatment and patients with chronic graft versus host disease whose disease is refractory to standard immunosuppresive drug treatment. (See the National Coverage Determinations (NCD) Manual, Pub. 100 -03, Chapter 1, part 2, section 110.4, for complete coverage guidelines .)   Effective for claims with dates of service on or after April 30, 2012, the Centers for Medicare & Medicaid Services has expanded coverage for extracorporeal photopheresis for the treatment of bronchiolitis obliterans syndrome ( BOS) following lung allograft transplantation only when extracorporeal photopheresis is provided under a clinical research study that meets specific requirements to assess the effect of extracorporeal photopheresis for the treatment of BOS following lung a llograft transplantation. Fur ther coverage criteria is outlined in Pub. 100- 03, Chapter 1, part 2, section 110.4 of the NCD Manual.  190.1  Applicable Intermediary Bill Types  (Rev. 1206; Issued:  03- 16-07; Effective:  December 19, 2006; Implementation:  04- 02-07)  11X, 13X, or 85X   190.2  Healthcare Common Procedural Coding System (HCPCS), Applicable Diagnosis Codes and Procedure Code  (Rev.10881; Issued: 08-06-2021; Effective: 09- 07-2021; Implementation: 09-07- 2021)   The following HCPCS procedure code is used for billing extracorporeal photopheresis:   36522 - Photopheresis, extracorporeal      Effective for claims with dates of service on or after Oct 1, 2015, the following are the applicable ICD-10-CM procedure codes for the new expanded coverage:   6A650ZZ Phototherapy, Circulatory, Single  6A651ZZ Phototherapy, Circulatory, Multiple   NOTE: Contractors shall edit for an appropriate oncological and autoimmune disorder diagnosis for payment of extracorporeal photopheresis according to the NCD.
(Medicare Claims Processing Manual)
NOTE: Contractors shall edit for an appropriate oncological and autoimmune disorder diagnosis for payment of extracorporeal photopheresis according to the NCD.  Effective for claims with dates of service on or after Oct 1, 2015, in addition to HCPCS 36522, the following ICD-10-CM codes are applicable for extracorporeal photopheresis for the treatment of BOS following lung allograft transplantation only when extracorporeal photopheresis is provided under a clinical research study as outlined in above sections 190 and 190.2 Healthcare Common Procedural Coding System (HCPCS) codes, and applicable diagnosis codes as below::   A reference listing of ICD -10-CM coding and descriptions is listed below:  CUTANEOUS T -CELL LYMPHOMA
(Medicare Claims Processing Manual)
C84.01  Mycosis fungoides, lymph nodes of head, face, and neck  C84.02  Mycosis fungoides, intrathoracic lymph nodes  C84.03  Mycosis fungoides, intra -abdominal lymph nodes  C84.04  Mycosis fungoides, lymph nodes of axilla and upper limb  C84.05  Mycosis fungoides, lymph nodes of inguinal region and lower limb  C84.06  Mycosis fungoides, intrapelvic lymph nodes  C84.07  Mycosis fungoides, spleen  C84.08  Mycosis fungoides, lymph nodes of multiple sites  C84.09  Mycosis fungoides, extranodal and solid organ sites  C84.11  Szary disease, lymph nodes of head, face, and neck  C84.12  Szary disease, intrathoracic lymph nodes  C84.13  Szary disease, intra -abdominal lymph nodes  C84.14  Szary disease, lymph nodes of axilla and upper limb  C84.15  Szary disease, lymph nodes of inguinal region and lower limb C84.16  Szary disease, intrapelvic lymph nodes  C84.17  Szary disease, spleen  C84.18  Szary disease, lymph nodes of multiple sites  C84.19  Sezary disease, extranodal/solid organ sites  C84.A0  Cutaneous T -cell lymphoma, unspecified, unspecified site  C84.A1  Cutaneous T -cell lymphoma, unspecified lymph nodes of head, face, and neck  C84.A2  Cutaneous T -cell lymphoma, unspecified, intrathoracic lymph nodes  C84.A3  Cutaneous T -cell lymphoma, unspecified, intra -abdominal lymph nodes  C84.A4  Cutaneous T -cell lymphoma, unspecified, lymph nodes of axilla and upper limb  C84.A5  Cutaneous T -cell lymphoma, unspecified, lymph nodes of inguinal region and lower limb
(Medicare Claims Processing Manual)
T -cell lymphoma, unspecified, lymph nodes of axilla and upper limb  C84.A5  Cutaneous T -cell lymphoma, unspecified, lymph nodes of inguinal region and lower limb  C84.A6  Cutaneous T -cell lymphoma, unspecified, intrapelvic lymph nodes  C84.A7  Cutaneous T -cell lymphoma, unspecified, spleen  C84.A8  Cutaneous T -cell lymphoma, unspecified, lymph nodes of multiple sites  C84.A9  Cutaneous T -cell lymphoma, unspecified, extranodal and solid organ sites
(Medicare Claims Processing Manual)
ACUTE CARDIAC ALLOGRAFT REJECTION/GRAFT -VERSUS -HOST -DISEASE   D89.811  Chronic graft -versus -host disease  D89.812  Acute on chronic graft -versus -host disease  D89.813  Graft -versus -host disease, unspecified  T86.01  Bone marrow transplant rejection  T86.02  Bone marrow transplant failure  T86.03  Bone marrow transplant infection  T86.21  Heart transplant rejection  T86.22  Heart transplant failure  T86.23  Heart transplant infection  T86.290  Cardiac allograft vasculopathy  T86.31  Heart -lung transplant rejection  T86.32  Heart -lung transplant failure  T86.33  Heart -lung transplant infection  T86.5  Complications of stem cell transplant  Z94.3  Heart and lungs transplant status  Z94.81  Bone marrow transplant status   BOS (CED/TRIAL ONLY)   J42 Unspecified chronic bronchitis  J44.0  Chronic obstructive pulmonary disease with (acute) lower respiratory infection  J44.1  Chronic obstructive pulmonary disease with (acute) exacerbation  J44.9  Chronic obstructive pulmonary disease, unspecified  T86.810  Lung transplant rejection  T86.811  Lung transplant failure  T86.812  Lung transplant infection  T86.818  Other complications of lung transplant  T86.819  Unspecified complication of lung transplant  Z94.2  Lung transplant status  Z00.6  Encounter for examination for normal comparison and control in clinical research program   190.3  Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RAs) and Claim Adjustment Reason Code  (Rev.10881; Issued: 08-06-2021; Effective: 09- 07-2021; Implementation: 09-07- 2021)   Contractors shall continue to use the appropriate existing messages that they have in place when denying claims submitted that do not meet the Medicare coverage criteria for extracorporeal photopheresis.  Medicare coverage for extracorporeal photopheresis is restricted to the inpatient or outpatient hospital settings specifically for BOS, and not for the other covered diagnosis (including chronic graft versus host disease) which remain covered in the hospital inpatient, hospital outpatient, and non- facility (physician -directed clinic or office settings) settings.
(Medicare Claims Processing Manual)
Contractors shall deny claims for extracorporeal photopheresis for BOS when the service is not rendered to an inpatient or outpatient of a hospital, including critical access hospitals using the following codes:    Claim Adjustment Reason Code (CARC) 96  Non -covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.) NOTE : Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if  present.    CARC 171  Payment is denied when performed/billed by this type of provider in this type of facility. NOTE : Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if  present.    Medicare Summary Notice 16.2 -  This service cannot be paid when provided in this location/facility." Spanish translation: "Este servicio no se puede pagar cuando es suministrado en esta sitio/facilidad. (Include either MSN 36.1 or 36.2 dependent on liability.)    Remittance Advice Remark Code (RARC) N428  Not covered when performed in this place of service. (A/MACs only)   B. Group Code CO (Contractual Obligations) or PR (Patient Responsibility)  dependent  on liability.   Contractors shall return to provider/ return as unprocessable claims for BOS containing HCPCS procedure code 36522 along with one of the  allowable ICD -10 codes if the claim is missing diagnosis code Z00.6 (as primary/secondary diagnosis, institutional only), condition code 30 (institutional claims only), clinical trial modifier Q0/Q1, and value code D4 with an 8- digit clinical trial identifier number (A/MACs only). Use the following messages:   When diagnosis code Z00.6 is missing, use:   CARC 16 Claim/service lacks information or has submission/billing error(s). and   RARC M76, Missing/incomplete/invalid diagnosis or condition.   When Condition Code 30 is missing, use CARC 16 and   RARC M44  Missing/incomplete/invalid condition code.