evekhm/cms_iom_500 huggingface dataset:
Draft Article - Billing and Coding: Skin Substitutes for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers (DA57680)
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 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 clearly document that the criteria listed in the LCD has been met, as well as the appropriate diagnosis and response to treatment. Description of the wound(s) must be documented at baseline (prior to beginning conservative wound care measures) relative to size, location, stage, duration, and presence of infection, in addition to the type of conservative treatment given and the response. This information must be updated in the medical record throughout the episode of skin replacement surgery for wound care. The wound description must also be documented pre- and post- treatment with the skin substitute graft being used. The reason(s) for any repeat application should be specifically addressed in the medical record.Documentation must include an assessment outlining the plan for skin replacement surgery and the choice of skin substitute product for the 12-week period as well as any anticipated repeat applications within the 12-week period. An operative note must support the procedure (e.g., application of skin substitute graft to legs) for the relevant date of service (first application starts the 12-week episode of care) and include the reason for the procedure and a complete description of the procedure including product used (with identifying package label in the chart), and relevant findings.Any amount of wasted skin substitute must be clearly documented in the procedure note with ALL of the following information (at a minimum): Date, time and location of ulcer(s) treated; Name of skin substitute and package size; Approximate amount of product unit used; Approximate amount of product unit discarded; Reason for the wastage (including the reason for using a package size larger than was necessary for the size of the wound, if applicable); Manufacturers serial/lot/batch or other unit identification number of graft material. When the manufacturer does not supply unit identification, the record must document such.
Draft Article - Billing and Coding: Skin Substitutes for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers (DA57680)
The HCPCS code of the applicable skin substitute and the units billed must be consistent with the medical record regarding wound description and size.
Draft Article - Billing and Coding: Urine Drug Testing (DA56818)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 - A/B MAC (B) Contacts with Independent Clinical LaboratoriesArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD L36029 Urine Drug Testing.A qualitative/presumptive drug screen is used to detect the presence of a drug in the body. A blood, urine, or oral fluid sample may be used. However, urine is the best specimen for broad screening, as blood is relatively insensitive for many common drugs, including psychotropic agents, opioids, and stimulants.Common methods of drug analysis include chromatography, immunoassay, chemical ("spot") tests, and spectrometry.Coding GuidelinesOne presumptive drug testing code may be billed once per patient per day as indicated by the code description and should only be billed at one unit regardless of the provider.One definitive drug testing code may be billed once per patient per day as indicated by the code description and should only be billed at one unit regardless of the provider.The documentation should support the medical necessity of the drug testing ordered and should support the clinical indicators that led to ordering the test.Documentation RequirementsAll documentation must be maintained in the patients medical record and 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 record must include the identity of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record should support the use of the selected diagnosis code(s). The submitted CPT/HCPCS code should describe the service performed.Medical record documentation (e.g., history and physical, progress notes) maintained by the ordering physician/treating physician must indicate the medical necessity for performing a drug test. All tests must be ordered in writing by the treating provider and all drugs/drug classes to be tested must be indicated in the order.
Draft Article - Billing and Coding: Urine Drug Testing (DA56818)
If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of the lab results, along with copies of the ordering/referring physicians order for the drug test. The physician must include the clinical indication/medical necessity in the order for the drug test.This LCD does not apply to acute inpatient claims.Claims for drug screening services are payable under Medicare Part B in the following places of service: office (11), urgent care (20), independent clinic (49), federally qualified health center (freestanding) (50), rural health clinic (freestanding) (72), and independent laboratory (81).All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.All coverage criteria must be met before Medicare can reimburse this service.Billing for these services in a non-covered situation (e.g., does not meet indications of the LCD) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered.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: Sacroiliac Joint Injections and Procedures (A59233)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59233)
Refer to the draft Local Coverage Determination (LCD) Sacroiliac Joint Injections andProcedures for reasonable and necessary requirements and frequency limitations.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.Coding GuidanceProviders should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.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.This policy applies only to sacroiliac joint injections (SIJI) and procedures and does not apply to other joint procedures (such as facet, sacroiliitis, epidural or other spinal procedures).Diagnostic and Therapeutic procedures:Sacroiliac joint injections may be performed unilateral or bilateral in the same session.For professional services performed by the physician and billed on a CMS 1500 or electronic equivalent:Bilateral SIJIs procedures reported with CPT 27096 or 64451 should be reported with modifier 50. If a unilateral joint injection (CPT 27096) is performed and a unilateral sacral nerve block (CPT 64451) is performed on the contralateral side do not report modifier 50 with either code. Do not report a sacroiliac joint injection (CPT 27096) and a sacral nerve block (CPT 64451) for the same side, per the policy.For services performed in the Hospital Outpatient Department (TOB 13X) or an Ambulatory Surgical Center:ASC facility claims (specialty 49) report bilateral procedures on two separate lines, with one unit each. Modifiers -LT and -RT are appended to each line. ASC facilities should not report modifier 50. Professional services performed in the ASC should continue to report bilateral procedures with modifier 50.For services performed in the Hospital Outpatient Department (TOB 13X) or an Ambulatory Surgical Center:
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59233)
For services performed in the Hospital Outpatient Department (TOB 13X) or an Ambulatory Surgical Center:CPT 27096 is not a covered service for ASC facility (specialty 49) claims and is not recognized under OPPS. ASC facilities and OPPS hospital outpatient departments should report HCPCS code G0260 for sacroiliac joint injections. G0260 should be reported with an imaging code specific to the imaging modality employed. Report CPT 77002 for fluoroscopic guidance or CPT 77012 for CT guidance in the ASC and the hospital outpatient department. Injections of the nerves innervating the sacroiliac joint should be reported with CPT 64451. CPT 64451 includes imaging guidance. Imaging codes should not be reported with CPT 64451.Critical Access Hospitals (TOB 85X) should report sacroiliac joint injection with CPT 27096 and a sacral nerve block with CPT 64451. Bilateral injections should be reported using modifier 50. If a unilateral sacroiliac joint injection (CPT 27096) is performed and a unilateral sacral nerve block (CPT 64451) is performed on the contralateral side do not report modifier 50 with either code. Do not report a sacroiliac joint injection (CPT 27096) and a sacral nerve block (CPT 64451) for the same side, per the policy.Physician services in an ASC setting should report codes as noted above in the section on Professional services performed by the physician.KX modifier requirements:The KX modifier should be appended to the line for all diagnostic injections. The KX modifier will only be used for the initial diagnostic injections. Repeat diagnostic injections beyond the first one or two required to confirm the diagnosis, after beginning treatment are not reasonable and necessary.Utilization ParametersNo more than two (2) diagnostic joint sessions (CPT codes 27096 AND/OR 64451), unilateral or bilateral, will be considered reasonable and necessary, regardless of the code billed.No more than four (4) therapeutic SIJI sessions (CPT codes 27096 AND/OR 64451), unilateral or bilateral, will be reimbursed per rolling 12 months regardless of the code billed.
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59233)
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 procedural report should clearly document the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief achieved immediately post-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 agents into the sacroiliac joint. 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 180Medicare Benefit Policy Manual (cms.gov). Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59244)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59244)
Refer to the proposed Local Coverage Determination (LCD) L39462 Sacroiliac Joint Injections andProcedures for reasonable and necessary requirements and frequency limitations.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 theNCCI requirements.Coding GuidanceProviders should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.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.This policy applies only to sacroiliac joint injections (SIJI) and procedures and does not apply to other joint procedures (such as facet, sacroiliitis, epidural or other spinal procedures).Diagnostic and Therapeutic procedures:Sacroiliac joint injections may be performed unilateral or bilateral in the same session.For professional services performed by the physicianand billed on a CMS 1500 or electronic equivalent:Bilateral SIJIs procedures reported with 27096 or 64451 should be reported with modifier 50. If a unilateral joint injection (CPT 27096) is performed and a unilateral sacral nerve block (CPT 64451) is performed on the contralateral sidedo not reportmodifier 50 with either code. Do not report sacroiliac joint injection (CPT 27096) and a sacral nerve block (CPT 64451) for the same side, per the policy.For services performed in theHospital Outpatient Department (TOB 13X) or anAmbulatory Surgical Center:ASC facility claims (specialty 49) report bilateral procedures on two separate lines, with one unit each. Modifiers -LT and -RT are appended to each line. ASC facilities should not report modifier 50. Professional services performed in the ASC should continue to report bilateral procedures with modifier 50.
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59244)
CPT 27096 is not a covered service for ASC facility (specialty 49) claims and is not recognized under OPPS. ASC facilities and OPPS hospital outpatient departments should report HCPCS code G0260 for sacroiliac joint injections. The medical record must contain documentation that fluoroscopic guidance or CT guidance was used with HCPCS code G0260. Image guidance is packaged into G0260, and no separate payment is made to the ASC or OPPS hospital outpatient department for CPT codes 77002 and 77012.Injections of the nerves innervating the sacroiliac joint should be reported with CPT 64451. CPT 64451 includes imaging guidance. Imaging codes should not be reported with CPT 64451.Critical Access Hospitals (TOB 85X) should report sacroiliac joint injection with CPT 27096 and a sacral nerve block with CPT 64451. Bilateral injections should be reported using modifier 50. If a unilateral sacroiliac joint injection (CPT 27096) is performed and a unilateral sacral nerve block (CPT 64451) is performed on the contralateral side do not report modifier 50 with either code. Do not report a sacroiliac joint injection (CPT 27096) and a sacral nerve block (CPT 64451) for the same side, per the policy.Physician services in an ASC setting should report codes as noted above in the section on Professional services performed by the physician.KX modifier requirements:The KX modifier should be appended to the line for all diagnostic injections. The KX modifier will only be used for the initial diagnostic injections. Repeat diagnostic injections beyond the first one or two required to confirm the diagnosis, after beginning treatment are not reasonable and necessary.Utilization ParametersNo more than two (2) diagnostic joint sessions (CPT codes 27096 AND/OR 64451), unilateral or bilateral, will be considered reasonable and necessary, regardless of the code billed.No more than four (4) therapeutic SIJI sessions (CPT codes 27096 AND/OR 64451), unilateral or bilateral, will be reimbursed per rolling 12 months regardless of the code billed.
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59244)
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 procedural report should clearly document the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief achieved immediately post-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 agents into the sacroiliac joint. 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 180Medicare Benefit Policy Manual (cms.gov). Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59246)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59246)
Refer to the Local Coverage Determination (LCD) L39464 Sacroiliac Joint Injections andProcedures for reasonable and necessary requirements and frequency limitations.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 theNCCI requirements.Coding GuidanceProviders should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.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.This policy applies only to sacroiliac joint injections (SIJI) and procedures and does not apply to other joint procedures (such as facet, sacroiliitis, epidural or other spinal procedures).Diagnostic and Therapeutic procedures:Sacroiliac joint injections may be performed unilateral or bilateral in the same session.For professional services performed by the physicianand billed on a CMS 1500 or electronic equivalent:Bilateral SIJIs procedures reported with CPT 27096 or 64451 should be reported with modifier 50. If a unilateral joint injection (CPT 27096) is performed and a unilateral sacral nerve block (CPT 64451) is performed on the contralateral side do not report modifier 50 with either code. Do not report a sacroiliac joint injection (CPT 27096) and a sacral nerve block (CPT 64451) for the same side, per the policy.For services performed in theHospital Outpatient Department (TOB 13X) or anAmbulatory Surgical Center:ASC facility claims (specialty 49) report bilateral procedures on two separate lines, with one unit each. Modifiers -LT and -RT are appended to each line. ASC facilities should not report modifier 50. Professional services performed in the ASC should continue to report bilateral procedures with modifier 50.
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59246)
CPT 27096 is not a covered service for ASC facility (specialty 49) claims and is not recognized under OPPS. ASC facilities and OPPS hospital outpatient departments should report HCPCS code G0260 for sacroiliac joint injections. The medical record must contain documentation that fluoroscopic guidance or CT guidance was used with HCPCS code G0260. Image guidance is packaged into G0260, and no separate payment is made to the ASC or OPPS hospital outpatient department for CPT codes 77002 and 77012.Injections of the nerves innervating the sacroiliac joint should be reported with CPT 64451. CPT 64451 includes imaging guidance. Imaging codes should not be reported with CPT 64451.Critical Access Hospitals (TOB 85X) should report sacroiliac joint injection with CPT 27096 and a sacral nerve block with CPT 64451. Bilateral injections should be reported using modifier 50. If a unilateral sacroiliac joint injection (CPT 27096) is performed and a unilateral sacral nerve block (CPT 64451) is performed on the contralateral side do not report modifier 50 with either code. Do not report a sacroiliac joint injection (CPT 27096) and a sacral nerve block (CPT 64451) for the same side, per the policy.Physician services in an ASC setting should report codes as noted above in the section on Professional services performed by the physician.KX modifier requirements:The KX modifier should be appended to the line for all diagnostic injections. The KX modifier will only be used for the initial diagnostic injections. Repeat diagnostic injections beyond the first one or two required to confirm the diagnosis, after beginning treatment are not reasonable and necessary.Utilization ParametersNo more than two (2) diagnostic joint sessions (CPT codes 27096 AND/OR 64451), unilateral or bilateral, will be considered reasonable and necessary, regardless of the code billed.No more than four (4) therapeutic SIJI sessions (CPT codes 27096 AND/OR 64451), unilateral or bilateral, will be reimbursed per rolling 12 months regardless of the code billed.