evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Cosmetic and Reconstructive Surgery (A58774)
Claimsdo nothave to be submitted for cosmetic procedures. However, if a denial of Medicare coverage is necessary, a GY modifier (items or services statutorily excluded or does not meet the definition of any Medicare benefit) can be used on a cosmetic procedure to receive a non-covered denial. Use diagnosis code:Z41.1 Encounter for cosmetic surgery.All submitted non-covered or no payment claims using condition code 21 will be processed to completion, and all services on those claims, since they are submitted as non-covered, will be denied. The default liability for payment of these claims is assigned to the beneficiary, who may then submit the denial from Medicare, as the primary payer, to subsequent payer(s) for consideration. Since a denial is a Medicare determination of payment, all services submitted on no payment claims may be appealed later if unusual circumstances so warrant. That is, all payment determinations are subject to appeal, even denials of services submitted as non-covered.Documentation RequirementsFor all procedures:All documentation must be maintained in the patients 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 medical record documentation must support the medical necessity of the services as stated in this policy.Documentation Requirements for Specific ServicesReconstructive Surgery: Removal of Breast ImplantsThe medical record must describe the condition which supports the removal of a breast implant(s) as medically reasonable and necessary.Breast ReductionThe beneficiarys medical record must contain the following information:Height and weight.Body Surface Area (BSA)Clinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to breast reduction and the responses to these therapies.The operative report with documentation of the weight of tissue removed from each breast, obtained in the operating room.The pathology report with the weight of the tissue removed from each breast.Documentation of back or neck or shoulder pain from macromastia that was unrelieved by 6 months of conservative analgesia, supportive measures (garment, etc.), and physical therapy.Mastectomy for gynecomastia
Article - Billing and Coding: Cosmetic and Reconstructive Surgery (A58774)
Mastectomy for gynecomastiaGlandular breast tissue confirming true gynecomastia is documented on physical exam and/or mammographyDocumentation that the gynecomastia persists, despite correction of any underlying causesDocumentation supporting that the gynecomastia is classified as Grade III or IV per the American Society of Plastic Surgeons classificationDocumentation that hormonal causes, including hyperthyroidism, estrogen excess, hyperprolactinemia and hypogonadism have been excluded by appropriate laboratory testing (e.g. with levels of thyroid stimulating hormone [TSH], estradiol, prolactin, testosterone and or luteinizing hormone [LH])Documentation supporting that gynecomastia persists after 6 months of unsuccessful medical treatment, the use of potential gynecomastia-inducing drugs and substances has been ruled out and gynecomastia persist for at least one year. (ASPS)Tattooingor to correct color defects of the skin must indicate the prior condition i.e. post-mastectomy, trauma necessitating the reconstruction in the progress notes.Punch graft hair transplants:pre-operative photographs must be made available upon Contractor request.RhinoplastyThe medical record must include a description of the condition requiring the rhinoplasty.When performed for chronic obstruction the medical record must indicate what is causing the obstruction.Documentation of anterior rhinoscopy, endoscopy, Cottle maneuver/modified Cottle maneuver and/or CT report is recommended to help support medical necessity if requested.The medical record should include a description of any conservative treatment that has been utilized to treat obstruction and the length of time that the conservative treatment has been trialed.Surgical/pathology report if post operativeSeptoplasty
Article - Billing and Coding: Cosmetic and Reconstructive Surgery (A58774)
SeptoplastyThe medical record must contain the medical and antibiotic therapy that was utilized and the length of time treatment was trialed for recurrent sinusitis secondary to deviated septum.When the procedure is being done for asymptomatic septal deformity to gain access to other transnasal areas during another medically necessary procedure the medical record must indicate what surgical procedure is being performed.The medical record must contain the medical management utilized and the length of time that the treatment was trialed for obstructed nasal breathing due to septal deformity or deviation that is interfering with the effective use of Continuous Positive Airway Pressure (CPAP) for the treatment of an obstructive sleep disorder.Dermabrasion:The medical record must describe the injury, surgery, or disease process that resulted in the defect.Abdominal Lipectomy/PanniculectomyThe beneficiarys medical record must contain the following information:the evaluation and management supporting the medical necessity and/or complications with decision to perform surgery,surgical operative record,description of the pannus and the underlying skin,documentation that the panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing),description of conservative treatment undertaken and its results,evidence that the individual has maintained a stable weight for at least 6 months.Rhytidectomydocumentation should include the evaluation and management note in which the decision to perform surgery was made, surgical note and any notes documenting the functional impairment.
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58777)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 4, Section 280.14 Infusion PumpsCMS IOM Publication 100-04, Medicare Claims Processing Manual,Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)Social 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 Text
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58777)
This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39054 Epidural Procedures for Pain Management. Please refer to the LCD for reasonable and necessary requirements.The services addressed in this article only apply to epidural injections. Other joint procedures (e.g. sacral injections, facet join) are not addressed.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.The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to the NCCI requirements.An anatomic spinal region for epidurals is defined as cervical/thoracic (CPT codes 62321, 64479 and 64480) or lumbar/sacral (CPT codes 62323, 64483 and 64484).When the epidural injections (62322-62327) are used for cerebrospinal fluid flow imaging, cisternography (78630), the diagnosis code restrictions in this article do not apply. These services should be billed on the same claim.When epidural injections (62321, 62323 64479, 64480, 64483 or 64484) are used for postoperative pain management, the diagnosis code restrictions in this article do not apply.When epidural injection (62323) is used for an implantable infusion pump trial, the diagnosis code restrictions in this article do not apply.A transforaminal epidural steroid injection (TFESI) performed at the T12-L1 level should be reported with CPT code 64479.When reporting CPT codes 64479 through 64484 for a unilateral procedure, use one line with one unit of service. For bilateral procedures regarding these same codes, use one line and append the modifier-50.For services performed in the ASC, physicians must continue to use modifier 50. Only the ASC facility itself must report the applicable procedure code on 2 separate lines, with 1 unit each and append the RT and LT modifiers to each line.
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58777)
It is not medically reasonable and necessary to perform caudal ESIs or interlaminar ESIs bilaterally, therefore CPT 62321 and 62323 are not bilateral procedures.KX modifier requirements:A diagnostic selective nerve root block (DSNRB) is identically coded as an Epidural Injection. Therefore, when performing a DSNRB the -KX modifier should be appended to the appropriate line to distinguish the procedure from an epidural injection. Aberrant use of the -KX modifier may trigger focused medical review.Utilization ParametersOnly 1 spinal region may be treated per session (date of service).Consistent with the LCD, only 2 total levels per session are allowed for CPT codes 64479, 64480, 64483 and 64484. (2 unilateral or 2 bilateral levels). 64480 should be reported in conjunction with 64479 and 64484 should be reported in conjunction with 64483.Consistent with the LCD, CPT codes 62321 and 62323 may only be reported for 1 level per session.No more than 4 epidural injection sessions (CPT codes 62321, 62323, 64479, 64480, 64483, or 64484) may be reported per spinal region in a rolling 12-month period regardless of the number of levels involved.Documentation Requirements
Article - Billing and Coding: Epidural Steroid Injections for Pain Management (A58777)
All 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.Selective nerve root blocks (SNRBs) and TFESIs: The procedural report should clearly document the indications and medical necessity for the injections, along with the baseline pain score. SNRBs only: The procedural report should include the baseline pain score and percent (%) pain relief achieved immediately after the injection.Films that adequately document (minimum of 2 views) final needle position and contrast flow should be retained and made available upon request.The patients medical record should include, but is not limited to:The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visitRelevant 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.)Documentation to support the medical necessity of the procedure(s).Use of BiologicalsThere are currently no FDA approved biologicals for use as injectable agent into the epidural space or spine. The inclusion of biological and/or other non-FDA approved substances in the injectant may result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180. Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and not routinely reimbursable and therefore may be denied. In exceptional circumstances, if the medical necessity of sedation is unequivocal and clearly documented in the medical record, individual consideration may be considered on appeal.
Article - Billing and Coding: Platelet Rich Plasma Injections for Non-Wound Injections (A58788)
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 Injections for Non-Wound Injections L39058.NOTE:0232T is the HCPCS code representing platelet rich plasma injection, any site.It is Noridian's expectation that the HCPCS code P9020 (platelet rich plasma, each unit) be billed for one or more units of PRP transfused in the treatment of the conditions/coagulopathies for which it is indicated. This code MUST NOT be used to describe the injection of PRP into a specific site.The Center for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) 270.3 outlines the coverage of PRP for the treatment of certain chronic non-healing wounds. Please refer to NCD 270.3 for further information regarding coverage indications. Should PRP meet nationally covered indication as stated in NCD 270.3, HCPCS codes G0460/G0465 must be used accordingly.Do not use code 86965, Pooling of platelets or blood products for injection(s) of platelet rich plasma. Injections that utilize a kit to create the platelet rich plasma, must be billed with category III code 0232T, and according to the CPT codebook is not a transfusion medicine service.
Article - Billing and Coding: Platelet Rich Plasma Injections for Non-Wound Injections (A58790)
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 Injections for Non-Wound Injections L39060.NOTE:0232T is the HCPCS code representing platelet rich plasma injection, any site.It is Noridian's expectation that the HCPCS code P9020 (platelet rich plasma, each unit) be billed for one or more units of PRP transfused in the treatment of the conditions/coagulopathies for which it is indicated. This code MUST NOT be used to describe the injection of PRP into a specific site.The Center for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) 270.3 outlines the coverage of PRP for the treatment of certain chronic non-healing wounds. Please refer to NCD 270.3 for further information regarding coverage indications. Should PRP meet nationally covered indication as stated in NCD 270.3, HCPCS codes G0460/G0465 must be used accordingly.Do not use code 86965, Pooling of platelets or blood products for injection(s) of platelet rich plasma. Injections that utilize a kit to create the platelet rich plasma, must be billed with category III code 0232T, and according to the CPT codebook is not a transfusion medicine service.
Article - Billing and Coding: Genetic Testing for Cardiovascular Disease (A58795)
CMS National Coverage PolicyInternet Only Manual (IOM) Citations:CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 1, Section 60 Provider Billing of Non-covered Charges on Institutional ClaimsChapter 16, Laboratory ServicesChapter 23, Section 20.9 National Correct Coding Initiative (NCCI), Section 20.9.1.1 Instructions for Codes with Modifiers (A/B MACs (B) Only), and Section 40 Clinical Diagnostic Laboratory Fee ScheduleCMS IOM Publication 100-08,Medicare Program Integrity Manual,Chapter 3, Sections 3.4.1.3 Diagnosis Code Requirements and 3.6.2.3 Limitations of Liability DeterminationsNational Correct Coding Initiative (NCCI) Citation:NCCI Policy Manual for Medicare Services,Chapter 10, Pathology/Laboratory Services, (A) Introduction and (F) Molecular PathologySocial 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.Title XVIII of the Social Security Act, Section 1834A(d) This section addresses payment for new advanced diagnostic laboratory tests.Code of Federal Register (CFR) References:CFR, Title 42, Volume 2, Chapter IV, Part 410.32(d)(3) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.CFR, Title 42, Volume 3, Chapter IV, Part 414, Subpart G Payment for Clinical Diagnostic Laboratory Tests.CFR, Title 42, Volume 3, Chapter IV, Part 414.50 Physician or other supplier billing for diagnostic tests performed or interpreted by a physician who does not share a practice with the billing physician or other supplier.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39082 Genetic Testing for Cardiovascular Disease. Please refer to the LCD for reasonable and necessary requirements.Tier 2 CPT code 81406 is not appropriate to report for cardiovascular genetic testing because there are no genes associated with CPT code 81406 that meet the ClinGen evidence standards.Coding Guidance
Article - Billing and Coding: Genetic Testing for Cardiovascular Disease (A58795)
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.All limitations of the LCD apply.No genes currently meet criteria for coverage as outlined in the LCD.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.The medical record must demonstrate the treating clinician who is responsible for the cardiovascular disease management is the ordering clinician.The medical record must clearly document the communication and discussion of pre-test and post-test counseling and the risk associated with genetic testing.The medical record must demonstrate disease appropriate phenotyping to establish clinical diagnosis or suspected diagnosis for which the test results would directly impact the management of the patients condition.The clinical actionability of the gene-disease relationship for the patient must be documented in the medical record.
Article - Billing and Coding: Genetic Testing for Cardiovascular Disease (A58797)
CMS National Coverage PolicyInternet Only Manual (IOM) Citations:CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 1, Section 60 Provider Billing of Non-covered Charges on Institutional ClaimsChapter 16, Laboratory ServicesChapter 23, Section 20.9 National Correct Coding Initiative (NCCI), Section 20.9.1.1 Instructions for Codes with Modifiers (A/B MACs (B) Only), and Section 40 Clinical Diagnostic Laboratory Fee ScheduleCMS IOM Publication 100-08,Medicare Program Integrity Manual,Chapter 3, Sections 3.4.1.3 Diagnosis Code Requirements and 3.6.2.3 Limitations of Liability DeterminationsNational Correct Coding Initiative (NCCI) Citation:NCCI Policy Manual for Medicare Services,Chapter 10, Pathology/Laboratory Services, (A) Introduction and (F) Molecular PathologySocial 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.Title XVIII of the Social Security Act, Section 1834A(d) This section addresses payment for new advanced diagnostic laboratory tests.Code of Federal Register (CFR) References:CFR, Title 42, Volume 2, Chapter IV, Part 410.32(d)(3) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.CFR, Title 42, Volume 3, Chapter IV, Part 414, Subpart G Payment for Clinical Diagnostic Laboratory Tests.CFR, Title 42, Volume 3, Chapter IV, Part 414.50 Physician or other supplier billing for diagnostic tests performed or interpreted by a physician who does not share a practice with the billing physician or other supplier.Article Text
Article - Billing and Coding: Genetic Testing for Cardiovascular Disease (A58797)
Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39084 Genetic Testing for Cardiovascular Disease. Please refer to the LCD for reasonable and necessary requirements.Tier 2 CPT code 81406 is not appropriate to report for cardiovascular genetic testing because there are no genes associated with CPT code 81406 that meet the ClinGen evidence standards.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.All limitations of the LCD apply.No genes currently meet criteria for coverage as outlined in the LCD.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.The medical record must demonstrate the treating clinician who is responsible for the cardiovascular disease management is the ordering clinician.The medical record must clearly document the communication and discussion of pre-test and post-test counseling and the risk associated with genetic testing.The medical record must demonstrate disease appropriate phenotyping to establish clinical diagnosis or suspected diagnosis for which the test results would directly impact the management of the patients condition.The clinical actionability of the gene-disease relationship for the patient must be documented in the medical record.