evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: MolDX: Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C) Testing (A54976)
CMS National Coverage PolicyN/AArticle TextARVD/C, characterized by fatty replacement of heart cells predominantly in the right ventricle of the heart, is most often inherited as an autosomal dominant disease that may be associated with testing in at least seven genes (RYR2, TMEM43, DSP, PKP2, DSG2, DSC2 and JUP). Genetic testing may be performed in panels of 5-7 of these genes and disease-causing mutation is expected to be identified in 42-55% of cases. Testing would be performed to confirm an established diagnosis or on individuals already diagnosed with ARVD/C to identify family members at risk. Therefore, MolDX has determined that testing for ARVD/C is a statutorily excluded test.To receive an ARVD/C panel test denial, please submit the following claim information:An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientEnter the DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem19 for paper claimEnter the DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim form
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (A54982)
CMS National Coverage PolicyN/AArticle TextAbstract:The National Coverage Determination (NCD) 20.8.3, Single Chamber and Dual Chamber Permanent Cardiac Pacemakers, was revised with an effective date of August 13, 2013. The CMS A/B Medicare Administrative Contractors (MACs) have been instructed to implement the NCD at the local level. The following provides coding and billing instructions for the implementation of NCD 20.8.3. (CMS policy language is in quotation marks.) The NCD Item/Service Description and Indications and Limitations are repeated here."Item/Service DescriptionA. GeneralPermanent cardiac pacemakers refer to a group of self-contained, battery operated, implanted devices that send electrical stimulation to the heart through one or more implanted leads. They are often classified by the number of chambers of the heart that the devices stimulate (pulse or depolarize). Single chamber pacemakers typically target either the right atrium or right ventricle. Dual chamber pacemakers stimulate both the right atrium and the right ventricle.The implantation procedure is typically performed under local anesthesia and requires only a brief hospitalization. A catheter is inserted into the chest and the pacemakers leads are threaded through the catheter to the appropriate chamber(s) of the heart. The surgeon then makes a small pocket in the pad of the flesh under the skin on the upper portion of the chest wall to hold the power source. The pocket is then closed with stitches.The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to conclude that implanted permanent cardiac pacemakers, single chamber or dual chamber, are reasonable and necessary for the treatment of non-reversible symptomatic bradycardia due to sinus node dysfunction and second and/or third degree atrioventricular block. Symptoms of bradycardia are symptoms that can be directly attributable to a heart rate less than 60 beats per minute (for example: syncope, seizures, congestive heart failure, dizziness, or confusion).Indications and Limitations of CoverageB. Nationally Covered IndicationsThe following indications are covered for implanted permanent single chamber or dual chamber cardiac pacemakers:
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (A54982)
Indications and Limitations of CoverageB. Nationally Covered IndicationsThe following indications are covered for implanted permanent single chamber or dual chamber cardiac pacemakers:Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, andDocumented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block.C. Nationally Non-Covered IndicationsThe following indications are non-covered for implanted permanent single chamber or dual chamber cardiac pacemakers:Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and hypothermia,Asymptomatic first degree atrioventricular block,Asymptomatic sinus bradycardia,Asymptomatic sino-atrial block or asymptomatic sinus arrest,Ineffective atrial contractions (e.g., chronic atrial fibrillation or flutter, or giant left atrium) without symptomatic bradycardia,Asymptomatic second degree atrioventricular block of Mobitz Type I unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His Bundle (a component of the electrical conduction system of the heart),Syncope of undetermined cause,Bradycardia during sleep,Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) without syncope or other symptoms of intermittent atrioventricular block,Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-blocker drug therapy,Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the control of tachycardia, andA clinical condition in which pacing takes place only intermittently and briefly, and which is not associated with a reasonable likelihood that pacing needs will become prolonged.D. OtherMedicare Administrative Contractors will determine coverage under section 1862(a)(1)(A) of the Social Security Act for any other indications for the implantation and use of single chamber or dual chamber cardiac pacemakers that are not specifically addressed in this national coverage determination.(This NCD last reviewed August 2013.)"
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (A54982)
Please note:The Decision Memo for Cardiac Pacemakers: Single-Chamber and Dual-Chamber Permanent Cardiac Pacemaker (CAG-00063R3) states:"CMS initiated this current national coverage analysis to reconsider coverage indications for single chamber and dual chamber cardiac pacemakers. The scope of this reconsideration and this decision memorandum does not address biventricular pacemakers, pacemakers that stimulate more than two heart chambers, those devices used to treat tachyarrhythmias and cardiac dyssynchrony, cardiac resynchronization therapy, cardiac pacemaker evaluation services, or self-contained pacemaker monitors."The coding and billing guidelines only apply to those CPT codes for the initial insertion of cardiac pacemakers:33206 Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial33207 ventricular33208 atrial and ventricularThe NCD does not address replacement of pacemaker generators. CPT codes 33227, 33228, 33229 and 33233 are therefore not addressed in this coding article.CMS NCD Covered Conditions and Diagnosis Codes  Group IClinical Conditions:Documented non-reversible symptomatic bradycardia due to sinus node dysfunctionDocumented non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular blockDiagnosis Codes (ICD-10-CM) (Attest with Modifier - KX):Atrioventricular (AV) block (I44.2)Mobitz (type II) AV block (I44.1)Other second degree AV block (I44.1)Sinoatrial node dysfunction/Sick sinus syndrome (I49.5)Congenital heart block (Q24.6)Contractor (Additional) Diagnosis Codes (ICD-10-CM) Allowed by the NCD  Group II (Attest with Modifier - KX)
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (A54982)
Contractor (Additional) Diagnosis Codes (ICD-10-CM) Allowed by the NCD  Group II (Attest with Modifier - KX)Atrioventricular block, unspecified (Symptomatic) (I44.30)First-degree atrioventricular block (Symptomatic with PR interval more than 300 milliseconds) (I44.0)Left bundle branch block, other or unspecified (I44.7)Right bundle branch block, unspecified or other (I45.10 or I45.19)Bundle branch block, unspecified (I45.10 or I45.19)Right bundle branch block and left posterior fascicular block (I45.2)Right bundle branch block and left anterior fascicular block (I45.2)o Other bilateral bundle branch block (I45.2)o Bifascicular block (I45.2)o Trifascicular block (I45.3)Supraventricular tachycardias in which a pacemaker is specifically for control of the tachycardia (I47.1 or I47.9)Paroxysmal supraventricular tachycardia/supraventricular tachycardia (SVT that is reproducibly terminated by pacing when catheter ablation and/or drugs fail to control the arrhythmia or produce intolerable side effects) (I47.1 or I47.9)Atrial fibrillation/atrial fibrillation, persistent; unspecified atrial fibrillation (I48.11, I48.19or I48.91) with symptomatic bradycardia due to necessary medical therapyAtrial flutter/atrial flutter, typical/atypical/unspecified (I48.3, I48.4 or I48.92) with symptomatic bradycardia due to necessary medical therapyHypersensitive carotid sinus syndrome and neurocardiogenic syncope (Syncope without clear, provocative events and with a hypersensitive cardioinhibitory response of 3 seconds or longer or for significantly symptomatic neurocardiogenic syncope associated with bradycardia documented spontaneously or at the time of tilt-table testing) (G90.01)
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (A54982)
Other Conditions Not Addressed by the NCD or by the Contractor - Group III include but are not limited to the following (Attest with Modifier - SC):Cardiac resynchronization therapyObstructive hypertrophic cardiomyopathyPacing in children, adolescents, and patients with congenital heart diseasePacemaker or generator replacementsSustained pause-dependent ventricular tachycardia, with or without QT prolongationModifier Usage:Modifier - KX (Requirements specified in the medical policy have been met) must be used as an attestation by the practitioner and/or provider of the service that documentation is on file verifying the patient has a symptomatic arrhythmia or a high potential for progression of the rhythm disturbance requiring a permanent pacemaker forGroups I and II. Bradycardia that is the consequence of essential long-term drug therapy of a type and dose for which there is no acceptable alternativedoes not excludethe use of modifier - KX.In addition, use of modifier - KX may be used in patients without symptoms in Groups I and II in the following situations:
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (A54982)
In addition, use of modifier - KX may be used in patients without symptoms in Groups I and II in the following situations:Awake, symptomfree patients in sinus rhythm, with documented periods of asystole greater than or equal to 3.0 seconds or any escape rate less than 40 beats per minute (bpm), or with an escape rhythm that is below the AV nodeAwake, symptom-free patients with atrial fibrillation and bradycardia with one or more pauses of at least 5 seconds or longerCatheter ablation of the AV junctionPostoperative AV block that is not expected to resolve after cardiac surgeryPatients with neuromuscular diseases, e.g., myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb dystrophy, and peroneal muscular atrophy, with third-degree and advanced second-degree AV block at any anatomic levelAsymptomatic persistent third-degree AV block at any anatomic site with average awake ventricular rates of 40 bpm or faster if cardiomegaly or LV dysfunction is present or if the site of block is below the AV nodeSecond or third-degree AV block during exercise in the absence of myocardial ischemiaPersistent third-degree AV block with an escape rate greater than 40 bpm in asymptomatic adult patients without cardiomegalyAsymptomatic second-degree AV block at intra-or infra-His levels found at electrophysiological studyFirst- or second-degree AV block with symptoms similar to those of pacemaker syndrome or hemodynamic compromiseAsymptomatic type II second-degree AV block with a narrow QRS. Second-degree AV block with a wide QRS including isolated right bundle-branch blockFor medically necessary pacemaker insertion in conditions not addressed by the NCD or this article,Group III, use modifier - SC (Medically necessary service or supply).
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers (A54982)
For medically necessary pacemaker insertion in conditions not addressed by the NCD or this article,Group III, use modifier - SC (Medically necessary service or supply).Modifiers  GA and  GZ:Modifier  GA (Waiver of liability statement issued as required by payer policy, individual case) should be used when the provider wants to indicate that he/she anticipates that Medicare will deny a specific service as not reasonable and necessary, an Advanced Beneficiary Notice (ABN) Form CMS-R-131 has been signed by the beneficiary and is on file. Modifier  GA 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 are required.Modifier  GZ should be used when the provider wants to indicate that it is expected that Medicare will deny the specific services as not reasonable and necessary and the beneficiary was not asked to sign an ABN.Claims for pacemaker claims that do not meet the criteria for modifier  KX or  SC should have modifier  GA or  GZ appended depending on the ABN status and will be denied.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.Sources of InformationNational Government Services, Inc. Local Coverage Article A54909
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54992)
CMS National Coverage PolicyCMS National Coverage PolicyCode of Federal Regulations:42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who uses the results in the management of the beneficiarys specific medical problem.Federal Register:Federal Register Vol. 62, 59047, Supervision of Diagnostic Tests, describes the degree of physician supervision required for diagnostic tests.CMS Publications:CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2: 160.23 Sensory Nerve Conduction Threshold Tests (sNCTs)Program Memorandum Carriers Transmittal B-01-28 Change Request 850, describes tests that may be performed by PTs with ABPTS certification CMS Publication 100-2.Medicare Benefit Policy Manual, Chapter 15, Section 80: Requirements for Diagnostic Tests.Transmittal 2663 Change Request 8169 April Update to the CY 2013 Medicare Physician Fee Schedule Database (MPFSDB).Article Text
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54992)
Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Physical Therapists Performing EMGsProgram Memorandum Transmittal B-01-28/Change Request 850 sets forth revised levels of physician supervision required for diagnostic tests payable under the Medicare Physician Fee Schedule. Effective July 1, 2001, certain codes in the range of CPT 95860-95937 were assigned new supervision levels (21, 22, 6a, 66, 77 or 77a). This implementation date would make it possible for physical therapists to acquire the certification required to perform these services without supervision. A physical therapist who is presently certified by the American Board of Physical Therapy Specialties (ABPTS) can perform procedures assigned level of 21, 22, 66, 6a, 77, or 77a without supervision. These numeric levels assigned to the CPT codes are listed in the Medicare Physician Fee Schedule Database (MPFSDB).Physical therapists who do not possess the ABPTS certification by July 1, 2001, may continue to furnish those tests that require the certification if they have been furnishing such diagnostic tests prior to May 1, 2001.Payment will be based on the Medicare Physician Fee Schedule level of supervision designation.Nerve conduction code 95905 does not have one of the above designations and is therefore not allowed by Physical Therapists.The technical component (TC) of the neuromuscular junction testing code 95937 had its Physician Supervision of Diagnostic Procedures Indicator changed to 7A. This change is effective January 1, 2013.Needle EMG codes 95860-95872 and 95885-95887 have the designation of 6A for the technical portion of the test. Therefore, if authorized by state law, Physical Therapists are allowed the technical portion of the test according to the description of 6A.I. Coding GuidelinesA. Evaluation/Management (E/M)
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54992)
I. Coding GuidelinesA. Evaluation/Management (E/M)1. Usually an E&M service is included in the exam performed just prior to and during nerve conduction studies and/or electromyography. If the E&M service is a separate and identifiable service, the medical record must document medical necessity and the CPT code must be billed with a modifier 25.2. The clinical history from the referral source must indicate the need for testing. These medical records containing pertinent clinical information must be provided for review on request. Absolute inclusive or exclusive criteria for performance of a diagnostic test are difficult to enumerate.B. Nerve Conduction Studies
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54992)
B. Nerve Conduction Studies1. The table below provides a reasonable maximum number of studies per diagnostic category necessary for a physician to arrive at a diagnosis in 90% of patients with that final diagnosis.2. The appropriate number of studies to be performed is left to the judgment of the physician performing the evaluation; however, in the small number of cases which require testing in excess of the numbers listed in the table, the physician must be able to provide supplementary documentation to justify the additional testing.3. In some situations it may be necessary to test an asymptomatic contralateral limb to establish normative values for an individual patient. Documentation must support the medical necessity of the additional test.4. CPT code 95905 -Nerve conduction studies performed using automated devices (for example devices such as NC-stat System) cannot support testing of other locations and other nerves as needed depending on the concurrent results of testing.CPT code 95905 is payable only once per limb studied and cannot be used in conjunction with any other nerve conduction codes.When the beneficiary has a high pre-test or a priori probability for having the diagnosis of Carpal Tunnel Syndrome, the NC-stat System (alone) will be allowed, one service per arm, using CPT code 95905. The diagnosis codes G56.01, G56.02 or G56.03 should be used. All other diagnosis codes will be denied as not medically necessary.5. Codes 95907-95913 describe one or more nerve conduction studies. A single conduction test is defined as a sensory conduction test, a motor conduction test with or without an F wave test, or an H-reflex test. Each type of study (sensory, motor with or without F wave, H-reflex) for each anatomically distinct and separately named nerve is counted as a distinct study when determining the number of studies billed. Each type of study is counted only once when multiple sites on the same nerve are stimulated and recorded. The number of tests (sensory, motor with or without F wave, H-reflex) per nerve are added to determine the code to be billed.
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54992)
Nerve conduction codes 95907-95913 had their Physician Supervision of Diagnostic Procedures Indicators adjusted to 7A effective 01/01/2013 (CR 8169). Therefore if authorized by state law, Physical Therapists are allowed the technical portion and professional component of the test according to the description of 7A.7A = Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.77 = Procedure must be performed by a PT with ABPTS certification (TC & PC) or by a PT without certification under direct supervision of a physician (TC only; PC always physician).These changes for 7A are effective January 1, 2013.Codes designated for eliciting nerve conduction velocity, latency or amplitude, and those designed for short latency evoked potentials are not to be used for sNCT. The sNCT has a unique codeG0255: Effective October 1, 2002, CMS initially concluded that there was insufficient scientific or clinical evidence to consider the sNCT test and the device used in performing this test reasonable and necessary within the meaning of section 1862(a)(1)(A) of the law. Therefore, sNCT was noncovered. Based on a reconsideration [in March, 2004] of current Medicare policy for sNCT, CMS concludes that there continues to be insufficient scientific or clinical evidence to consider the sNCT test and the device used in performing this test as reasonable and necessary within the meaning of section 1862(a)(1)(A) of the law. CMS Publication 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 160.23Type of Study/ Maximum Number of StudiesIndicationLimbs Studied by Needle EMG (95860-95864, 95867-95870, 95885-95887)Nerve conduction Studies (Total nerves studied, 95907-95913)Neuromuscular Junction Testing (Repetitive Stimulation, 95937)Carpal Tunnel (Unilateral)17Carpal Tunnel (Bilateral)210Radiculopathy27Mononeuropathy18Polyneuropathy/Mononeuropathy Multiplex310Myopathy242
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54992)
Carpal Tunnel (Bilateral)210Radiculopathy27Mononeuropathy18Polyneuropathy/Mononeuropathy Multiplex310Myopathy242Motor Neuronopathy (e.g. ALS)462Plexopathy212Neuromuscular Junction243Tarsal Tunnel Syndrome (Unilateral)18Tarsal Tunnel Syndrome (Bilateral)211-Weakness, Fatigue, Cramps or Twitching (Focal)272Weakness, Fatigue, Cramps or Twitching (General)482Pain, Numbness or Tingling (Unilateral)19-Pain, Numbness or Tingling (Bilateral)212-Source: Current Procedural Terminology (CPT) 2016C. Electromyography1. Use EMG codes 95860-95864 and 95867-95870 when no nerve conduction studies (95907-95913) are performed on that day.2. Use 95885, 95886, and 95887 for EMG services when nerve conduction studies (95907-95913) are performed on the same day.3. To bill these codes, extremity muscles innervated by three nerves (for example, radial, ulnar, median, tibial, peroneal, femoral, not sub branches) or four spinal levels must be evaluated; a minimum of five muscles must have been studied.4.It is expected that providers will use CPT code 95870 for sampling muscles other than the paraspinals associated with the extremities, which have been tested. Medicare would not expect to see this code billed when the paraspinal muscles corresponding to an extremity are tested and when the extremity EMG code 95860, 95861, 95863 or 95864 is also billed.CPT Code 95869 - Needle electromyography; thoracic paraspinal muscles