evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Hemophilia Factor Products (A56482)
J7192-769,999$13,489.65305 11 2022 - 05 11 2022J7192-762,002$2,702.70If reporting more than one line, bill all subsequent lines with modifier -76, repeat procedure. Do not report a date range as the date of service. Indicate date span in the narrative of the claim. If the claim is for a monthly supply of clotting factor distributed to the beneficiary on the date of service, indicate monthly supply and the date span in the narrative of the claim or the EDI equivalent.Billing for Not Otherwise Classified (NOC) CodesWhen billing NOC codes, enter the drug name, dosage and NDC in the claim narrative or the EDI equivalent. Report the number of units in the quantity billed field as 1.Dollar Amount Exceeds $99,999.99When providing a month supply and the total billed amount exceeds $99,999.99, two claims must be submitted.When billing two claims, ensure that the total dollar amounts are different on each claim.Example:The MUE for HCPCS code J7201 is 9,000 units per line. The beneficiary received 47,865 IUs of Factor IX (J7201) ($2.28 per unit). The billed amount is $109,132.20 for the same date of service. The claims should be billed as shown below.Claim one:Total Billed Amount is $99,998.52; total units would be 43,859.LineDate of Service (From - To)Procedure Code/ModifierUnit of ServiceBilled Amount106 01 2022 - 06 01 2022J72019,000$20,520.00206 01 2022 - 06 01 2022J7201-769,000$20,520.00306 01 2022 - 06 01 2022J7201-769,000$20,520.00406 01 2022 - 06 01 2022J7201-769,000$20,520.00506 01 2022 - 06 01 2022J7201-767,859$17,918.52
Article - Billing and Coding: Hemophilia Factor Products (A56482)
J7201-769,000$20,520.00506 01 2022 - 06 01 2022J7201-767,859$17,918.52Claim two:Total Billed Amount is $9,133.68; total units would be 4,006.LineDate of Service (From - To)Procedure Code/ModifierUnit of ServiceBilled Amount106 01 2022 - 06 01 2022J7201-764,006$9,133.68Note:Report a narrative description indicating "monthly billing" as well as the total number of units of service and total charge in item 19 of the 1500 claim form or the EDI equivalent.Date of Service (DOS)If the factor product is administered within a facility or "incident to" a physician service, the actual date the drug was administered should be reported as the DOS. If the factor product is being billed by a pharmacy to replenish the beneficiary's home supply, the date of delivery should be used as the DOS on the claim.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.Medical record documentation maintained in the patients file must document the condition for which the blood clotting factor is being given.The name of the factor and the dosage required and/or given must be included in the records.This information is normally found in the office/progress notes, pharmacy forms, hospital records, and/or treatment notes.
Article - Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS) (A56491)
CMS National Coverage PolicyN/AArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy for L37578-Micro-Invasive Glaucoma Surgery (MIGS).The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.Coding GuidanceFor noncomplex cataract removal with insertion of aqueous drainage system, use CPT 66991.For complex cataract removal with intraocular lens implant and concomitant intraocular aqueous drainage device, use CPT code 66989.Please refer to the "Limitations" section in the related LCD for additional information.For Part A claims:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formFor Part B claims:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimFrequency LimitationsMedicare may cover only 1 unit per eye, per date of service of CPT code 66991 and 66989 for insertion of glaucoma drainage device(s) into the trabecular meshwork (e.g., iStent, or iStentinject), when performed in conjunction with cataract surgery and when the medically reasonable and necessary criteria as stated in the LCD are met. Although more than one drainage device into the trabecular meshwork of a single eye on a single day of service, using an insertion tool loaded with more than one device, (e.g., iStentinject), may be performed, once the insertion tool is deployed within the eye, there is negligible increase in work or expense. Therefore only one unit of 66991 and 66989 per eye, per day may be billed, regardless of the number of devices inserted into a single eye on the date of service.
Article - Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS) (A56491)
Medicare may cover only1 unit per eye, per date of service of CPT code 0449Tfor insertion of glaucoma drainage device(s) into the subconjunctival space (e.g., XEN45), when the medically reasonable and necessary criteria as stated in the LCD are met.Documentation RequirementsAll documentation must be maintained in the patient's medical record and must support the medical necessity of the services as directed in this article and be 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.
Article - Billing and Coding: Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy (A56493)
CMS National Coverage PolicyN/AArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy L33946.General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Article - Billing and Coding: Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy (A56493)
Advance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ?he/she accepts responsibility for payment.? The -GA modifier 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 is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.
Article - Billing and Coding: Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy (A56493)
The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. ?If the service is statutorily non-covered, or without a benefit category, submit the ?appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering 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.)Other Comments:For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS to process their claims.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.Associated Information:The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.The indications for a capsulotomy procedure performed less than three months after cataract surgery should be clearly documented in the medical record (e.g., significant visual debility as defined in the policy, preoperative uveitis, chronic glaucoma, diabetes mellitus, prolonged use of pilocarpine hydrochloride, etc.).
Article - Billing and Coding: Capsule Opacification Following Cataract Surgery: Discission and YAG Laser Capsulotomy (A56493)
Similarly, if a capsulotomy is performed more than once on the same eye during the same, or a separate, episode of care, the rationale and indications should be clearly documented in the medical record.Not applicableSurgical intervention for ACO/PCO is not often indicated less than three months after cataract surgery. If a claim is submitted for capsulotomy surgery within three months of cataract surgery, documentation justifying the need for the procedure would be required to support medical necessity. Payment will only be allowed for a physician or group once per eye per patient per global period (90 days), no matter how many YAG treatment sessions occur.
Article - Billing and Coding: Cardiovascular Nuclear Medicine (A56494)
CMS National Coverage PolicyN/AArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy Cardiovascular Nuclear Medicine L33960.General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Article - Billing and Coding: Cardiovascular Nuclear Medicine (A56494)
Advance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier 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 is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.
Article - Billing and Coding: Cardiovascular Nuclear Medicine (A56494)
The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering 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.)
Article - Billing and Coding: Vestibular Function Testing (A56497)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim that lacks the necessary information to process that claim.CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code RequirementsArticle Text
Article - Billing and Coding: Vestibular Function Testing (A56497)
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Vestibular Function Testing L34537.Appropriate ICD-10-CM codes must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.It is not enough to link the procedure code to a payable ICD-10-CM code. The diagnosis or clinical suspicion must be present for the procedure to be paid, and the patient's medical record must document that the coverage criteria in this policy have been met. Covered services must meet general community standards of appropriate medical care. For example, extremely mild symptoms of very short duration may not justify procedures or testing, even though a listed ICD-10-CM symptom might superficially be met. Inclusion of certain "not otherwise specified" codes does not mean that any other associated disorder is covered.Repeat testing on a regular basis, in the absence of the resumption of symptoms, is not warranted. A few conditions may require testing on multiple days due to variably acute symptoms, such as benign positional vertigo, which varies with inner ear canal stones. However, in this case, isolated testing with CPT92542 is usually sufficient, and within several episodes, a diagnosis should be established.CPTcodes 92541 and 92542 are more likely to be medically necessary for follow up of disorders, likely secondary to canal block pathology. For this purpose, there may be testing at several visits, at intervals, for evaluation of interval change and symptoms.Scope of PracticeDiagnostic procedures 92541-92542 and 92544-92548 may be performed only by licensed audiologists with a physicians order; by a licensed physician, preferably with certification by the American Board of Medical Specialties in Otolaryngology, Neurology or Otology/Neurology; or other providers licensed to practice medicine under the personal supervision of an appropriate physician as described in the Code of Federal Register (CFR).Basic Audiometry
Article - Billing and Coding: Vestibular Function Testing (A56497)
Basic AudiometryCPTcode 92552 or 92553 will be covered if ordered and performed in conjunction withVFT. CPTcode 92557 will also be covered if ordered and performed in conjunction with Vestibular Function Testing (VFT), instead of CPTcode 92553, when the speech recognition component of the CPTcode 92557 is reasonable and necessary in the diagnosis or treatment of an individual Medicare beneficiary (e.g., Vestibular Schwannoma). No other hearing tests will be covered, when performed in conjunction with VFT for the diagnosis of balance problems.CPTcode 92557 - This is a comprehensive audiometry evaluation, which includes a battery of tests comprised both of the elements of threshold evaluation (hearing threshold levels at various frequencies presented by both air and bone conduction) and speech audiometry, including both speech reception and speech recognition testing. CPTcode 92557 includes the elements of CPTcodes 92553 and 92556; therefore, these codes cannot be billed on the same date of service in addition to CPTcode 92557.SummaryCPTcodes 92542, 92544, 92545, 92546, and 92548 are billable once per day, and repeated analysis or confirmation of findings within the session is considered part of 1 test. Note, for example, that CPTcode 92542 specifically requires 4 or more positions tested in order to bill for 1 unit (per CPTdefinition).
Article - Billing and Coding: Vestibular Function Testing (A56497)
CPTcode 92537 is intended to report a complete caloric vestibular testing procedure that includes bilateral performance of bithermal irrigation (i.e.,one warm andone cool irrigation for each ear). Fewer irrigation procedures require a different method of reporting according to what was done. For 3 irrigations (e.g., irrigation of both ears using monothermal irrigation of 1 ear and bithermal irrigation of the contralateral ear), code 92537 and report with modifier 52. Monothermal irrigation (i.e., irrigation of both ears with either cool or warm irrigation) is reported once with CPTcode 92538. If a single ear is irrigated with a single method of irrigation (cool or warm) code 92538 is reported once with modifier 52,as described in the CPTInsiders View January 2016.CPTcode 92547 may be billed multiple times as required by other medically necessary tests. Since the same electrodes are typically used for several serial tests, billing more than 6 per day would be atypical.CPTcodes 92531, 92532, 92533, and 92534 for vestibular function tests, without electrical recording are considered bundled physical examination codes by Centers for Medicare and Medicaid Services (CMS), have Relative Value Units (RVUs) of zero, and are not payable.
Article - Billing and Coding: Cardiac Catheterization and Coronary Angiography (A56500)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Cardiac Catheterization and Coronary Angiography (A56500)
This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L33959 Cardiac Catheterization and Coronary Angiography.General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Advance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.