evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Destruction of Malignant Skin Lesions (A57638)
CMS National Coverage PolicySocial 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 TextThis First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33813 Destruction of Malignant Skin Lesions provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.Please refer to the LCD for reasonable and necessary requirements and limitations.The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.Coding GuidelinesNotice: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.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/progress note should indicate the removal of a malignant lesion with a corresponding pathology report or a clinical description consistent with a skin malignancy. The size and location of the lesion must be included in the documentation.
Article - Billing and Coding: Lab: Cystatin C Measurement (A57643)
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 Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 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 CodesCMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests, 80.1.1 Certification Changes, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesArticle TextThe information in this article contains billing, coding, or, other guidelines that complement the Local Coverage Determination (LCD) for Lab: Cystatin C Measurement policy L37616.Documentation Requirements
Article - Billing and Coding: Lab: Cystatin C Measurement (A57643)
Article TextThe information in this article contains billing, coding, or, other guidelines that complement the Local Coverage Determination (LCD) for Lab: Cystatin C Measurement policy L37616.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 documentation must support the medical necessity of the services as directed in this policy.The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition (ICD-10-CM code) that warrants the test(s).Examples of documentation requirements of the ordering physician/non-physician practitioner (NPP) include, but are not limited to, history and physical or exam findings that support the decision making, problems/diagnoses, relevant data (e.g., lab testing).Medical record documentation must support cystatin C test was performed on an adult patient with creatinine based eGFR 4559 ml/min/1.73 m2 who does not have markers of kidney damage.Medical record documentation must clearly indicate the rationale which supports the medical necessity for performing eGFR by measurement of cystatin C (i.e. support GFR estimates based on serum creatinine are thought to be inaccurate and what decisions depend on more accurate knowledge of the GFR) and must reflect how the test result were used in the patients plan of care.To report a Cystatin C service, please submit the following claim information:Select CPT code 82610Enter 1 unit of service (UOS)Select the appropriate ICD-10-CM code
Article - Billing and Coding: Lab: Cystatin C Measurement (A57643)
To report a Cystatin C service, please submit the following claim information:Select CPT code 82610Enter 1 unit of service (UOS)Select the appropriate ICD-10-CM codeNote: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this article. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
Article - Billing and Coding: Lab: Cystatin C Measurement (A57644)
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 Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 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 CodesCMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests, 80.1.1 Certification Changes, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesArticle TextThe information in this article contains billing, coding, or, other guidelines that complement the Local Coverage Determination (LCD) for Lab: Cystatin C Measurement Policy L37618.Documentation Requirements
Article - Billing and Coding: Lab: Cystatin C Measurement (A57644)
Article TextThe information in this article contains billing, coding, or, other guidelines that complement the Local Coverage Determination (LCD) for Lab: Cystatin C Measurement Policy L37618.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 documentation must support the medical necessity of the services as directed in this policy.The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition (ICD-10-CM code) that warrants the test(s).Examples of documentation requirements of the ordering physician/non-physician practitioner (NPP) include, but are not limited to, history and physical or exam findings that support the decision making, problems/diagnoses, relevant data (e.g., lab testing).Medical record documentation must support cystatin C test was performed on an adult patient with creatinine based eGFR 4559 ml/min/1.73 m2 who does not have markers of kidney damage.Medical record documentation must clearly indicate the rationale which supports the medical necessity for performing eGFR by measurement of cystatin C (i.e. support GFR estimates based on serum creatinine are thought to be inaccurate and what decisions depend on more accurate knowledge of the GFR) and must reflect how the test result were used in the patients plan of care.To report a Cystatin C service, please submit the following claim information:Select CPT code 82610Enter 1 unit of service (UOS)Select the appropriate ICD-10-CM code
Article - Billing and Coding: Lab: Cystatin C Measurement (A57644)
To report a Cystatin C service, please submit the following claim information:Select CPT code 82610Enter 1 unit of service (UOS)Select the appropriate ICD-10-CM codeNote: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this article. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) in the Treatment of Adults with Major Depressive Disorder (A57647)
CMS National Coverage PolicyInternet-Only Manuals (IOMs):CMS IOM Publication 100-08,Medicare Program Integrity Manual,Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCDSocial 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 1862(a)(1)(D) prohibits the payment for any expenses incurred for items or services that are investigational or experimental.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L34522 Transcranial Magnetic Stimulation (TMS) in the Treatment of Adults with Major Depressive Disorder. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceThe ordering provider name and NPI must be included on the claim in the following locations:For Part A claims: Block 78/79 of the UB-04OR2420B for EMCFor Part B claims: Block 17 A and B for paper claims; 2310AOR2420F for EMCNotice: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.Utilization ParametersIt is expected that CPT code 90867 be reported only once per patient for the episode (for the initial planning) and NOT in conjunction with CPT codes 90868 or 90869.CPT code 90867 should not be reported more than once within a 6-week period of time.Do not report CPT code 90869 (motor threshold determination) in conjunction with 90867 or 90868.Documentation Requirements
Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) in the Treatment of Adults with Major Depressive Disorder (A57647)
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 documentation must support that the attending physician has met with the patient face to face for the initial assessment and for subsequent delivery and management when there is a change in the individuals mental status and/or other significant change in clinical status.The medical record documentation must include evidence of clinical judgment of the treating physician in evaluation of the absolute and relative contraindications in the pre-procedure record for the present episode of care.
Article - Billing and Coding: B-Type Natriuretic Peptide (BNP) (A57649)
CMS National Coverage PolicySocial 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 TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33267, B-Type Natriuretic Peptide (BNP). Please refer to the LCD for reasonable and necessary requirements.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.BNP is allowed when performed in an office (11), inpatient hospital (21), outpatient hospital (22), emergency room  hospital (23), independent laboratory (81), or in an urgent care facility (20) setting given that results are immediately available (e.g., < 2-4 hours).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.If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physicians order for the studies. The physician must state the clinical indication/medical necessity for the study in his order for the test.An order from the treating physician/nonphysician practitioner as required by CFR, Title 42, Volume 2, Chapter IV, Part 410.32(a) Ordering diagnostic tests.
Article - Billing and Coding: Autonomic Function Tests (A57651)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Autonomic Function Tests (A57651)
This First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33609 Autonomic Function Tests provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.Refer to the LCD for reasonable and necessary requirements and limitations.The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.Coding GuidelinesThe requirement forCPT code 95921Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including 2 or more of the following heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio is that at least two of the tests should be performed in order to bill this code. If only one test is performed, modifier 52 should be appended to indicate that a reduced service was provided.The requirement forCPT code 95922Testing of autonomic nervous system function; vasomotor adrenergic innervation (sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at least five minutes of passive tilt is that both a passive tilt and the Valsalva maneuver be performed. If only one of the components is performed, then modifier 52, reduced services, should be appended to code 95922.CPT code 95924should be reported only when both the parasympathetic function and vasomotor adrenergic function are tested together with at least 5 minutes of passive tilt.Definitions of the terms included in code descriptors:Valsalva maneuver: Any forced expiratory effort (strain) against a closed airway, whether at the nose and mouth or at the glottis. This causes high intrathoracic pressure that impedes venous return to the right atrium and, therefore, can be used to study cardiovascular effects of raised peripheral venous pressure and decreased cardiac filling and cardiac output, as well as, post strain responses.
Article - Billing and Coding: Autonomic Function Tests (A57651)
Valsalva ratio: The maximum heart rate divided by the lowest heart rate. The subject performs a standardized Valsalva maneuver, and the derived heart rate is analyzed.Quantitative sudomotor axon reflex test (QSART): An evaluation that uses a quantitative noninvasive method to determine the integrity of the distal postganglionic sympathetic nerve fibers in diabetic and other neuropathies affecting autonomic nerves and in the progressive autonomic disorders. It uses the stimulation of sympathetic nerve fibers to the sweat glands at standard sites. The test is done optimally on one forearm site and three lower extremity sites in order to determine the severity and distribution of the sympathetic deficit.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.Documentation Requirements
Article - Billing and Coding: Autonomic Function Tests (A57651)
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.General professional standards with FDA clearance apply for all equipment used in ANS testing. Providers may be asked to supply information on the equipment used to perform ANS studies to ensure all studies performed meet the requirements of the procedure.If the provider of the ANS studies is other than the ordering/referring physician/nonphysician practitioner, the provider of the service must maintain a copy of the test results and interpretation, along with copies of the ordering/referring physician/nonphysician practitioners order for the studies.An order from the treating physician/nonphysician practitioner as required by CFR, Title 42, Volume 2, Chapter IV, Part 410.32(a) Ordering diagnosis tests.Utilization GuidelinesIn accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.Compliance with the provisions in LCD L33609, Autonomic Function Tests may be monitored and addressed through post payment data analysis and subsequent medical review audits.
Article - Billing and Coding: Sedimentation Rate, Erythrocyte (A57657)
CMS National Coverage PolicySocial 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 TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L34021, Sedimentation Rate, Erythrocyte. Please refer to the LCD for reasonable and necessary requirements.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.Erythrocyte sedimentation rates performed on rheumatoid arthritis patients to assess for medication adjustments should be billed with the diagnosis code which reflects the medication the patient is receiving. These diagnosis codes are to be billed only for rheumatoid arthritis medication evaluation:T39.4X5A - T39.4X5S for patients receiving antirheumatics such as gold salts.T45.1X5A - T45.1X5S for patients receiving antineoplastic and immunosuppressive drugs such as methotrexateT45.8X5A - T45.8X5S for patients receiving other primarily systemic and hematological agents such as heavy metal antagonistsT50.6X5A - T50.6X5S for patients receiving antidotes and chelating agents, such as penicillamineDocumentation 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.