evekhm/cms_iom_500 huggingface dataset:
Draft Article - Billing and Coding: Trigger Point Injections (TPI) (DA59498)
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.The procedural report should clearly document the indications and medical necessity for the injection(s), the name, and units of the injectant used, the location of the TPIs, along with the pre- and post- percent (%) pain relief achieved immediately post-injection.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 visit.Relevant medical history.Results of pertinent tests/procedures.Signed 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).When documenting the TPI procedure, there must be specific information to indicate the location of trigger points treated, the muscles injected, medication injected, amount of medications used, and the post-procedure plan.Use of BiologicalsThere are currently no FDA approved biologicals for use as trigger point injectable agents. 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 Medicare Benefit Policy Manual. Amniotic and placenta derived injectants, platelet rich plasma and vitamins fall in this category.Use of AnesthesiaNo anesthesia codes should be billed in conjunction with 20552 or 20553.
Article - Billing and Coding: Trigger Point Injections (TPI) (A59498)
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.CMSInternet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16,180 Services Related to and Required as a Result of Services Which Are Not Covered Under MedicareArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forTrigger Point Injections L39671.The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Please refer to theNCCI requirements.Coding GuidanceProviders should refer to the applicable American Medical Association (AMA) CPTManual 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 TPIs and does not apply to dry needling or acupuncture.Modifier 50- bilateral should NOT be reported with CPTcodes 20552 or 20553.Utilization ParametersNo more than 3 TPI sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed.CPT20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle.MedicationThe drug used for the injection must be on the same claim as the trigger point administration.The medication used with the injection is reported with a HCPCS Drug code J-code or a revenue code.Unclassified drugs billed with J3490, J3590, J9999 or C9399* must also include name of drug and dosage to Box 19 of the CMS-15000 paper form or electronic equivalent.*C3999 should only be used for Ambulatory Surgery Center (ASC) or outpatient facility claims.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.
Article - Billing and Coding: Trigger Point Injections (TPI) (A59498)
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.The procedural report should clearly document the indications and medical necessity for the injection(s), the name, and units of the injectant used, the location of the TPIs, along with the pre- and post- percent (%) pain relief achieved immediately post-injection.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 visit.Relevant medical history.Results of pertinent tests/procedures.Signed 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).When documenting the TPI procedure, there must be specific information to indicate the location of trigger points treated, the muscles injected, medication injected, amount of medications used, and the post-procedure plan.Use of BiologicalsThere are currently no FDA approved biologicals for use as trigger point injectable agents. 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 Medicare Benefit Policy Manual. Amniotic and placenta derived injectants, platelet rich plasma and vitamins fall in this category.Use of AnesthesiaNo anesthesia codes should be billed in conjunction with 20552 or 20553.
Draft Article - Billing and Coding: Trigger Point Injections (TPI) (DA57701)
CMS National Coverage PolicyN/AArticle TextRefer to the draft Local Coverage Determination (LCD) DL34211-Trigger Point Injections (TPI) 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 trigger point injections and does not apply to dry needling or acupuncture.Modifier 50- bilateral should not be reported with CPT codes 20552 or 20553.Utilization ParametersNo more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed.CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle.MedicationThe drug used for the injection must be on the same claim as the trigger point administration.The medication used with the injection is reported with a HCPCS Drug code J-code or a revenue code.Unclassified drugs billed with J3490, J3590, J9999 or C9399* must also include name of drug and dosage to Box 19 of the CMS-1500 paper form or electronic equivalent.*C3999 should only be used for ASC outpatient facility claims.Documentation Requirements
Draft Article - Billing and Coding: Trigger Point Injections (TPI) (DA57701)
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.The procedural report should clearly document the indications and medical necessity for the injections, the name, and units of the injectant used, the location of the TPIs, along with the pre and post percent (%) pain relief achieved immediately post injection.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 visit.Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Documentation to support the medical necessity of the procedure(s).When documenting the TPI procedure, there must be specific information to indicate the location of trigger points treated, the muscles injected, medication injected, amount of medications used, and the post-procedure plan.Use of BiologicalsThere are currently no FDA approved biologicals for use as trigger point injectable agents. 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.Use of AnesthesiaNo anesthesia codes should be billed in conjunction with 20552 or 20553.
Draft Article - Billing and Coding: Trigger Point Injections (TPI) (DA57702)
CMS National Coverage PolicyN/AArticle TextRefer to the draft Local Coverage Determination (LCD) DL36859-Trigger Point Injections (TPI) 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 trigger point injections and does not apply to dry needling or acupuncture.Modifier 50- bilateral should not be reported with CPT codes 20552 or 20553.Utilization ParametersNo more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed.CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle.MedicationThe drug used for the injection must be on the same claim as the trigger point administration.The medication used with the injection is reported with a HCPCS Drug code J-code or a revenue code.Unclassified drugs billed with J3490, J3590, J9999 or C9399* must also include name of drug and dosage to Box 19 of the CMS-1500 paper form or electronic equivalent.*C3999 should only be used for ASC outpatient facility claims.Documentation Requirements
Draft Article - Billing and Coding: Trigger Point Injections (TPI) (DA57702)
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.The procedural report should clearly document the indications and medical necessity for the injections, the name, and units of the injectant used, the location of the TPIs, along with the pre and post percent (%) pain relief achieved immediately post injection.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 visit.Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Documentation to support the medical necessity of the procedure(s).When documenting the TPI procedure, there must be specific information to indicate the location of trigger points treated, the muscles injected, medication injected, amount of medications used, and the post-procedure plan.Use of BiologicalsThere are currently no FDA approved biologicals for use as trigger point injectable agents. 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.Use of AnesthesiaNo anesthesia codes should be billed in conjunction with 20552 or 20553.
Draft Article - Billing and Coding: MolDX: Molecular Testing for Solid Organ Allograft Rejection (DA58019)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle Text
Draft Article - Billing and Coding: MolDX: Molecular Testing for Solid Organ Allograft Rejection (DA58019)
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Testing for Solid Organ Allograft Rejection DL38568.INTERPRETATIVE AND EDUCATIONAL INFORMATIONThe below section provides additional interpretative and educational content to help providers and other stakeholders better understand the intent of the existing coverage criteria language of the policy. Reasonable and necessary thresholds for coverage are defined in the policy Coverage Criteria section and are not altered by the article language.Intended use requirementsTests within scope of the policy must comply with the stated requirements of the coverage criteria of the policy. The policy lists intended uses, that when met, can allow for coverage of services within scope of the policy, provided all other listed requirements are also met. Of note, the analysis of the evidence in the policy reflects the underlying value proposition of the test as one that can preclude an unnecessary tissue biopsy. This is therefore reflected in the intended use section of the coverage criteria.The four intended uses that are established in the policy all require that the physician is concerned about at least one of the following: rejection (and would otherwise obtain a biopsy to evaluate the allograft), the adequacy of immunosuppression (and would otherwise obtain a biopsy to evaluate the allograft or is considering doing so), the probability of rejection with concerning clinical information (clinical pre-tests/information that inform whether a subsequent biopsy would likely be avoided), and/or the results of an inconclusive biopsy (wherein the test may subsequently preclude another biopsy).In all scenarios presented the patients must be in consideration for a tissue biopsy or additional biopsy (such that the test prevents this when the biopsy won't likely be of benefit) OR require allograft evaluation because ofa prioriconcern for rejection or rejection risk due to clinical or biological factors (pre-test). No other intended uses are allowed by the policy.This leads to the following conclusions:
Draft Article - Billing and Coding: MolDX: Molecular Testing for Solid Organ Allograft Rejection (DA58019)
This leads to the following conclusions:-If a biopsy is performed, the test and the biopsy cannot be performed simultaneously or within a short window of time such that the test cannot reasonably inform medical management regarding the biopsy. Performance of the test simultaneously with biopsy or within a very narrow window of time from biopsy such that the results would not be available prior to the biopsy being performed would infer that the biopsy is performed regardless of test result and therefore the test has no impact on patient management. This is not consistent with the policy language.-Per policy, one of the intended uses of the molecular test is For further evaluation of allograft status for the probability of allograft rejection after a physician-assessed pretest.A pre-test is defined here as other physiologic/laboratory/clinical evidence consistent with rejection or risk of rejection wherein additional evaluation is subsequently warranted. Therefore, the information that leads to the use of the test must pre-exist the performance of the test. The results of the pre-test must be available to the treating clinician to inform the need for a molecular test or biopsy. Performing the test before such conditions exist, or to establish such a condition cannot be interpreted to be in compliance with the policy.-Although most coverage criteria are relevant tofor causetests, if a patient population exists such that they are at particularly high risk for rejection, and the pre-test clinical information would otherwise indicate a biopsy to evaluate the allograft health based on the risk of that population, the use of these services may fit within the intent of the policy coverage criteria language and analysis rationale.An example of this may be in heart allografts within the first year of transplant that would otherwise get a tissue biopsy due to evaluated pre-test risk. As such, the use of a molecular test for surveillance (protocol) testing can only be reasonably seen as compliant with the policy if the patient would otherwise receive a surveillance (protocol) biopsy. Providers must demonstrate that such a practice (for protocol biopsies) would otherwise be performed to meet policy requirements. Other uses of surveillance testing are not compliant with the policy language and would require policy reconsideration for inclusion.Additional billing information
Draft Article - Billing and Coding: MolDX: Molecular Testing for Solid Organ Allograft Rejection (DA58019)
Additional billing information-For a given patient encounter, only one molecular test for assessing allograft rejection status (within scope of this policy) may be billed. Any additional molecular tests billed after the first will be denied. Of note, services that include multiple components are considered a single service by MolDX and should be registered as such, in alignment with established MolDX practice.-Different Z-Code identifiers must be used for protocol vs for-cause testing. This will allow this contractor to better understand the intended use of the test.To report a service, please submit the following claim information:
Draft Article - Billing and Coding: MolDX: Molecular Testing for Solid Organ Allograft Rejection (DA58019)
Select CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode 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 formSelect the appropriate ICD-10-CM codeCovered services can be identified on the DEX registry (dexzcodes.com).
Draft Article - Billing and Coding: MolDX: Molecular Biomarkers for Risk Stratification of Indeterminate Pulmonary Nodules Following Bronchoscopy (DA59505)
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 claimCMS Internet-Only Manuals, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Biomarkers for Risk Stratification of Indeterminate Pulmonary Nodules Following Bronchoscopy DL39678.Please submit the following claim information:Select CPTcode 81479Only 1 test may be billed per patientEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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 formSelect the appropriate ICD-10-CM code