evekhm/cms_iom_500 huggingface dataset:
Draft Article - Billing and Coding: Cataract Surgery in Adults (DA57196)
The patient's chief complaint which conveys the symptoms, such as blurred vision, reduced contrast sensitivity or complaints of glare which are associated with impaired functionality.A unique statement indicating the specific symptomatic (i.e., causing the patient to seek medical attention) impairment of visual function resulting in the patient's inability to function satisfactorily while performing Activities of Daily Life. Such activities would typically include, but are not limited to, reading, viewing television, driving, or meeting vocational or recreational expectations. The patients own words should be included in the statement where possible. If desired, completion of a VF-14 or VF-8R visual activities questionnaire (one for each eye) may be used.A best-corrected Snellen visual acuity at distance (and near if the primary visual impairment is at near) as determined by a careful refraction under standard testing conditions as appropriate must be recorded to establish the inability to correct the patient's visual function with a tolerable change to glasses or contact lenses. Neither uncorrected visual acuity nor corrected acuity with the patients current prescription will satisfy this requirement. The refraction may be performed by the surgeon or by suitably trained staff in the surgeons practice as permitted by law.A degree of lens opacity that correlates with the impairment of best-corrected visual acuity when cataract is the primary cause of visual compromise. A statement supported by documented symptoms and physical findings in the medical record indicating that the patient's impairment of visual function is not believed to be correctable with a tolerable change in glasses or contact lenses.When one or more concomitant ocular diseases are present that potentially affect visual function (e.g., macular degeneration or diabetic retinopathy), the statement should indicate that cataract is believed to be significantly contributing to the patients visual impairment or a statement indicating the medical condition or circumstance and the specific reason for surgical intervention (e.g., "Cataract surgery is being performed to establish clear media for the treatment [or monitoring] of diabetic retinopathy).
Draft Article - Billing and Coding: Cataract Surgery in Adults (DA57196)
A statement that the patient desires surgical correction, and that the risks, benefits, and alternatives have been explained. When the surgery is not being performed to improve vision, there should be a statement that the patient understands that the surgery is being performed to address the specified medical condition or circumstance. For example, cataract is impairing treatment and monitoring of diabetic retinopathy due to poor visualization of the retina. If vision is not expected to improve, the statement should include the patient's understanding of that fact.An appropriate preoperative ophthalmologic evaluation, which includes a comprehensive ophthalmologic exam (or its equivalent components occurring over a series of visits). Certain examination components may be appropriately excluded based on the specific condition and/or urgency of surgical intervention.Results and interpretation of specialized ophthalmic studies done for medically necessary reasons unique to the patient's situation.Results and interpretation of specialized ophthalmic studies that arenotroutinely expected to be routinely performed for routine cataract surgery with clear statements/explanation of the reasons they are needed to establish or exclude medical necessity.
Draft Article - Billing and Coding: Cataract Surgery in Adults (DA57196)
For Complex Cataract Surgery (CPT code 66982):The billing of CPT code 66982 isnotrelated to the surgeon's perception of the surgical difficulty. The use of this code is governed by the need to employ devices or techniques not generally required/utilized in routine cataract surgery. Every complex cataract surgery must have clear justification to meet the requirements of its CPT descriptor. Therefore, it is strongly recommended to include an initial supporting statement in the operative note. For example:Indication for Complex Cataract Surgery: The patient required suturing a posterior chamber intraocular lens because of insufficient capsular support.Indication for Complex Cataract Surgery: Iris hooks were required to address a severely miotic pupil.Indication for Complex Cataract Surgery: Trypan blue dye was needed to adequately visualize the lens capsule in the presence of a mature cataract.
Draft Article - Billing and Coding: Cataract Surgery in Adults (DA57196)
In general, all documentation supporting medical necessity must be legible, maintained in the patient's medical record, meet all Medicare signature requirements, and must be made available to the A/B MAC or other CMS review entity upon request.Utilization RequirementsMedicare benefits include a conventional intraocular lens (IOL) following cataract surgery, facility supplies and physician services to implant the conventional IOL and one pair of glasses or contact lenses as a prosthetic device post-operative.Ancillary tests that arenotroutinely indicated in the preoperative workup for cataract surgery (see Specialized Ophthalmic testing) will not be considered a covered benefit if performed unless medical necessity is clearly documented in the patient's record.If an optometrist or an ophthalmologist who is not the surgeon performs biometry for intraocular lens power calculation, he/she should do so in coordination with the operating surgeon so that only one procedure is necessary. If the operating surgeon repeats biometry due to inadequacy of the first study, the original eye care physician/provider should anticipate not being reimbursed for the study.When billing ICD-10 codes H26.231, H26.232, H26.233, H26.221, H26.222, H26.223, H26.211, H26.212, H26.213, E08.36, E09.36, E10.36, E11.36, E13.36, H28 note that coding guidelines require that the ICD-10 code for the underlying condition must appear and be coded first on the claim. For ICD-10 codes H26.31, H26.32, H26.33, H26.8, coding guidelines require that the causative agent be identified on the claim.
Draft Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) (DA57692)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act (SSA) 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physician examinations.Title XVIII of the Social Security Act (SSA) 1862(a)(1)(D), and (E). Investigational or Experimental.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD DL37086 Transcranial Magnetic Stimulation (TMS).Documentation RequirementsAll documentation must be maintained in the patients medical record and available to the contractor upon request. The medical record documentation must support the medical necessity of the services as directed in this policy as well as include sufficient detail to determine services rendered.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 attending physician must monitor and document the patient's clinical progress during treatment. The attending physician must use evidence-based validated depression monitoring scales such as the Geriatric Depression Scale (GDS), the Personal Health Questionnaire Depression Scale (PHQ-9), the Beck Depression Scale (BDI), Hamilton Rating Scale for Depression (HAM-D), the Montgomery Asberg Depression Rating Scale (MADRS), the Quick Inventory of Depressive Symptomatology (QIDS) or the Inventory for Depressive Symptomatology Systems Review (IDS-SR) to monitor treatment response and the achievement of remission of symptoms.Utilization GuidelinesThe treatment must be provided by use of a device approved by the FDA for the purpose of supplying Transcranial Magnetic Stimulation.It is expected that the services would be performed as indicated by current medical literature and standards of practice. Services performed in excess of established parameters may be subject to review for medical necessity.
Draft Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) (DA57692)
It is expected that the services would be performed as indicated by current medical literature and standards of practice. Services performed in excess of established parameters may be subject to review for medical necessity.TMS is reasonable and necessary for up to 20 treatment sessions over a 4-week period followed by five visits for tapering for those in remission. For those who show at least 25% improvement by means of the standard tests for depression, the therapy may be continued for an additional 2 weeks (an additional 10 visits) with an additional 6 visits for tapering.Retreatment may be considered for patients who met the guidelines for initial treatment and subsequently developed relapse of depressive symptoms if the patient responded to prior treatments as evidenced by a greater than 50% improvement in standard rating scale measurements for depressive symptoms or if there was a relapse after remission (e.g., (GDS), PHQ-9, BDI, HAM-D, MADRS, QIDS or IDS-SR score). A repeat treatment program is allowed as above.Maintenance therapy is considered experimental/investigational and therefore non-covered as not medically reasonable and necessary.
Draft Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) (DA57693)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act (SSA) 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physician examinations.Title XVIII of the Social Security Act (SSA) 1862(a)(1)(D), and (E). Investigational or Experimental.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD DL37088 Transcranial Magnetic Stimulation (TMS).Documentation RequirementsAll documentation must be maintained in the patients medical record and available to the contractor upon request. The medical record documentation must support the medical necessity of the services as directed in this policy as well as include sufficient detail to determine services rendered.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 attending physician must monitor and document the patient's clinical progress during treatment. The attending physician must use evidence-based validated depression monitoring scales such as the Geriatric Depression Scale (GDS), the Personal Health Questionnaire Depression Scale (PHQ-9), the Beck Depression Scale (BDI), Hamilton Rating Scale for Depression (HAM-D), the Montgomery Asberg Depression Rating Scale (MADRS), the Quick Inventory of Depressive Symptomatology (QIDS) or the Inventory for Depressive Symptomatology Systems Review (IDS-SR) to monitor treatment response and the achievement of remission of symptoms.Utilization GuidelinesThe treatment must be provided by use of a device approved by the FDA for the purpose of supplying Transcranial Magnetic Stimulation.It is expected that the services would be performed as indicated by current medical literature and standards of practice. Services performed in excess of established parameters may be subject to review for medical necessity.
Draft Article - Billing and Coding: Transcranial Magnetic Stimulation (TMS) (DA57693)
It is expected that the services would be performed as indicated by current medical literature and standards of practice. Services performed in excess of established parameters may be subject to review for medical necessity.TMS is reasonable and necessary for up to 20 treatment sessions over a 4-week period followed by five visits for tapering for those in remission. For those who show at least 25% improvement by means of the standard tests for depression, the therapy may be continued for an additional 2 weeks (an additional 10 visits) with an additional 6 visits for tapering.Retreatment may be considered for patients who met the guidelines for initial treatment and subsequently developed relapse of depressive symptoms if the patient responded to prior treatments as evidenced by a greater than 50% improvement in standard rating scale measurements for depressive symptoms or if there was a relapse after remission (e.g., (GDS), PHQ-9, BDI, HAM-D, MADRS, QIDS or IDS-SR score). A repeat treatment program is allowed as above.Maintenance therapy is considered experimental/investigational and therefore non-covered as not medically reasonable and necessary.
Article - Billing and Coding: Positron Emission Tomography (PET) Scan for Inflammation and Infection (A59318)
CMS National Coverage PolicyN/AArticle TextDocumentation RequirementsThe 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 patients medical record should include but is not limited to:Relevant medical historyPhysical examination findingsResults of pertinent tests/proceduresImaging testing performedRationale for decision for PET scan including rationale for PET scan over standard imaging modalities and why PET was necessaryResults of PET scanDocumentation in medical record of the role PET scan plays in clinical managementIn cases of fever of unknown fever curve with temperatures and documentation of  21 days since onset of fever and fevers in the 2 weeks prior to the study.Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient and indicate thereason(s) for which the service was performed. Claims submitted without ICD-10-CM codes willbe returned.The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, the reason for the tests, an interpretive report(s) and copies of images. The computerized image reconstruction data should also be maintained.Documentation must be available to Medicare upon request.
Draft Article - Billing and Coding: Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DA57512)
CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1862(a)(1)(D) refers to limitations on items or devices that are investigational or experimental.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.
Draft Article - Billing and Coding: Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (DA57513)
CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1862(a)(1)(D) refers to limitations on items or devices that are investigational or experimental.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.
Article - Billing and Coding: High Resolution Anoscopy (A59323)
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 claimArticle TextHigh-resolution anoscopy (HRA) is analogous to cervical colposcopy. During HRA, a lubricated anoscope is inserted into the anal canal. A cotton swab wrapped in gauze and soaked in 3-percent acetic acid is then inserted through the anoscope, and the anoscope is removed, leaving the gauze in place. The acetic acid gives dysplastic epithelium a white appearance. After 2 minutes, the gauze is removed and the anoscope reinserted. A high-resolution colposcope (magnification of 10x to 40x) is used to view the walls of the anus. A biopsy of suspicious tissue can be taken.Anal squamous dysplasia describes a spectrum of diseases that ranges from low-grade squamous intraepithelial lesions (LSIL) to higher grade squamous lesions, or to invasive anal squamous cell carcinoma (SCC). Recent reports have shown a significant increase in squamous lesions in immunocompromised individuals and men who have sex with men (MSM). These lesions are associated with chronic infection with the human papillomavirus (HPV).CPTcodes 46601 and 46607 should be used only in these circumstances: patients with abnormalities on anoscopy, abnormalities in digital rectal examination, history of HPV-related anal disease or abnormalities in anorectal cytology.Current evidence does not support coverage for routine screening in any population at this time. The clinical chart must have documentation of the abnormalities described above.
Draft Article - Billing and Coding: Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence (DA59332)
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 Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12,40.1 Definition of a Global Surgical Package,40.2 Billing Requirements for Global Surgeries, 40.3 Claims Review for Global Surgeries, 40.4 Adjudication of Claims for Global SurgeriesCMS Internet-Only Manual, Pub. 100-04, Medicare ClaimsProcessing Manual,Chapter 32,40 Sacral Nerve StimulationArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Sacral Nerve Stimulation for the Treatment of Urinary and Fecal IncontinenceDL39543.Note: Components of the Global Surgical Package includes miscellaneous services such as dressing changes; local incisional care; removal of cutaneous sutures and staples, lines, wires, tubes, drains.Note: Minor Surgeries and Endoscopies, separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure are not allowed.Services performed for any given diagnosis must meet all of the indications and limitations stated in the related LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS NCDs, and all Medicare payment rules.
Article - Billing and Coding: Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence (A59332)
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 Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12,40.1 Definition of a Global Surgical Package,40.2 Billing Requirements for Global Surgeries, 40.3 Claims Review for Global Surgeries, 40.4 Adjudication of Claims for Global SurgeriesCMS Internet-Only Manual, Pub. 100-04, Medicare ClaimsProcessing Manual,Chapter 32,40 Sacral Nerve StimulationArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Sacral Nerve Stimulation for the Treatment of Urinary and Fecal IncontinenceL39543.Note: Components of the Global Surgical Package includes miscellaneous services such as dressing changes; local incisional care; removal of cutaneous sutures and staples, lines, wires, tubes, drains.Note: Minor Surgeries and Endoscopies, separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure are not allowed.Services performed for any given diagnosis must meet all of the indications and limitations stated in the related LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS NCDs, and all Medicare payment rules.