evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A58364)
Coding GuidanceProviders should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.This policy applies only to cervical/thoracic or lumbar facet procedures and does not apply to other joint procedures (such as sacral injections, sacroiliitis, epidural or other spinal procedures).Diagnostic and Therapeutic procedures:Each facet level in the spinal region is composed of bilateral facet joints (i.e., there are two facet joints per level, one on the right side and one on the left). Unilateral or bilateral facet interventions may be performed during the facet joint procedure (a diagnostic nerve block, a therapeutic facet joint (intraarticular) injection, a medial branch block injection, or the medial branch radiofrequency ablation (neurotomy) in one session. A bilateral intervention is still considered a single level intervention.Each unilateral or bilateral intervention at any level should be reported as one unit, with bilateral intervention signified by appending the modifier -50.
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A58364)
Regions:An anatomic spinal region for paravertebral facet joint block (diagnostic or therapeutic), is defined as cervical\thoracic (CPT codes 64490, 64491, 64492) or lumbar\sacral (CPT codes 64493, 64494, 64495) per the AMA CPT Manual.Levels:64490 (cervical or thoracic) or 64493 (lumbar or sacral) reports a single level injection performed with image guidance (fluoroscopy or CT). Procedures performed under ultrasound guidance are not covered.64491 or 64494 describes a second level which should be reported separately in addition to the code for the primary procedure. 64491 should be reported in conjunction with 64490 and 64494 should be reported in conjunction with 64493.64492 or 64495 describes a third and additional levels and should be listed separately in addition to the code for the primary procedure and the second level procedure and cannot be reported more than once per day. 64492 should be reported in conjunction with 64490/64491 and 64495 should be reported in conjunction with 64493/64494.Laterality:Bilateral paravertebral facet injection procedures 64490 through 64495 should be reported with modifier 50.One to two levels, either unilateral or bilateral, are allowed per session per spine region (i.e., two (2) unilateral or to two (2) bilateral levels per session).For services performed in the ASC, physicians must continue use modifier 50. Only the ASC Facility itself must report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each line.KX modifier requirements:The KX modifier should be appended to the line for all diagnostic injections. In most cases the KX modifier will only be used for the two initial diagnostic injections. If the initial diagnostic injections do not produce a positive response as defined by the policy and are not indicative of identification of the pain generator, and it is necessary to perform additional diagnostic injections, at a different level, append the KX modifier to the line. Aberrant use of the KX modifier may trigger focused medical review.Therapeutic injections:
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A58364)
Therapeutic injections:Documentation of why patient is not a candidate for RFA must be submitted for therapeutic treatment.Chemodenervation of nerve:Codes 64633, 64634, 64635, 64636are reported per joint, not per nerve. Although two nerves innervate each facet joint, only one unit per code may be reported for each joint denervated, regardless of the number of nerves treated (AMA CPT Manual 2020).Each unilateral or bilateral intervention at any level should be reported as one unit, with bilateral intervention signified by appending the modifier -50.
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A58364)
Region:An anatomic spinal region for thermal facet joint denervation is defined as cervical/thoracic (CPT codes 64633 and 64634) or lumbar/sacral (CPT codes 64635 and 64636) per the AMA CPT Manual.For neurolytic destruction of the nerves innervating the T12-L1 paravertebral facet joint, use 64633Levels:64633 or 64635 describes a single level destruction by neurolytic agent performed with image guidance (fluoroscopy or CT)64634 or 64636 describes each additional level which should be reported separately in addition to the code for the primary procedure. 64634 should be used in conjunction with 64633 and 64636 should be used in conjunction with 64635.Laterality:For bilateral procedures report modifier 50 on each line in which the intervention was of a bilateral nature.For services performed in the ASC, physicians must continue use modifier 50. Only the ASC Facility itself must report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each line.Non-thermal facet joint denervation (including chemical, low grade thermal energy (<80 degrees Celsius or any other form of pulsed radiofrequency) should not be reported with CPT codes 64633, 64634, 64635 or 64636. These services should be reported with CPT code 64999. Code 64999 is non-covered when used to report non-thermal facet joint denervation.If facet joints are injected with biologicals or other substances not designated for this use the entire claim will deny per Benefit Policy Manual Chapter 16: Section 180.Use of Moderate or Deep Sedation, General Anesthesia, and Monitored Anesthesia Care (MAC) is usually unnecessary or rarely indicated for these procedures and not routinely reimbursable and therefore may be denied. In exceptional circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record individual consideration may be considered on appeal.Documentation RequirementsThe patients medical record should include but is not limited to:
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A58364)
Documentation RequirementsThe 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.)
Article - Billing and Coding: Extracorporeal Shock Wave Therapy (ESWT) (A58367)
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 TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Extracorporeal Shock Wave Therapy (ESWT)L38775.
Article - Billing and Coding: MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (A58371)
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 CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease L38303.To report a Prostate Genomic Classifier service, please submit the following claim information:Select applicable CPTcodeEnter 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 837PBox 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 ICD-10-CM code C61
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers (A58376)
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 LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Minimal Residual Disease Testing for Cancer L38779.A Minimal Residual Disease (MRD) test, as defined in the related LCD, is aservicethat may include multiple components and/or multiple timepoints (i.e., serial assays).Testing schedules are set based on the validity established for the individual test comprising the service.Each component and timepoint of the service must be reasonable and necessary and adhere to the criteria set forth in the related LCD. The medical record must contain clear documentation of the medical necessity of this test, as per the conditions outlined in the LCD.The following tests have met the criteria for coverage under the policy:Indicated UseTestPATIENTS WITH CANCER-Initial Testwhere tumor profiling is utilized - from a prior analysisSignatera Bespoke Assay Design (by comprehensive genomic profile (CGP)) + Plasma SeriesBundlefor Molecular Residual Disease (Natera, Inc)where tumor profiling is utilizedSignatera Whole Exome + Plasma SeriesBundlefor Molecular Residual Disease (Natera, Inc)tumor nave testingGuardant Reveal MRDBundle(Guardant, Inc)Guardant360 ResponseSubsequent TestMay only be performed if there is clinical evidence of apriorichange in genetic contentSignateraRecurrence MonitoringPlasma TestBundle(Natera, Inc)PATIENTS WITHOUT CANCER (as defined in the policy)Initial Testwhere tumor profiling is utilized - from a prior analysisSignateraRecurrence MonitoringBespoke Assay Design (CGP) + single Plasma Test (Natera, Inc)where tumor profiling is utilizedSignateraRecurrence MonitoringWhole Exome Design + single Plasma Test (Natera, Inc)RaDaRRecurrence MonitoringWhole Exome Design + single Plasma Test (NeoGenomics Laboratories, Inc)Subsequent Test
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers (A58376)
where tumor profiling is utilizedSignateraRecurrence MonitoringWhole Exome Design + single Plasma Test (Natera, Inc)RaDaRRecurrence MonitoringWhole Exome Design + single Plasma Test (NeoGenomics Laboratories, Inc)Subsequent TestSignateraRecurrence Monitoringsingle Plasma Test (Natera, Inc)RaDaRRecurrence Monitoringsingle Plasma Test (NeoGenomics Laboratories, Inc)Tumor Nave TestWhere baseline tumor profiling is not utilizedNavDX (Naveris, Inc) single Plasma TestAdditional Test-specific Indications, Limitations and InstructionsIntended uses that have met clinical validity (CV) criteria under the policy include: (1) the diagnosis of disease progression, recurrence, or relapse for advanced colorectal (Natera and Guardant), bladder and breast cancers (Natera) (2) the diagnosis of disease recurrence or relapse for advanced breast (RaDaR) and HPV-driven oropharyngeal cancer (Naveris) (3) the monitoring of response to immune-checkpoint inhibitor therapy for colorectal cancer (Guardant) or any solid tumor (Natera). However, the tests listed in the table may have only been approved for one or more (but not necessarily all) of these indications.Note: 'Bundle' refers to multiple plasma assays.
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers (A58376)
These Tables will be updated to reflect revisions and additions of newly covered tests.Coverage of tests for other cancer indications and episodes of care, and modifications to the definition of an episode of care will be evaluated as needed.Additional process requirements for coverage and billing:MolDXmay make available specific forms to assist with test Technical Assessments (TAs). Please follow the instructions on the MolDXwebsite to assist with this process. If such forms are available that pertain to the test type in question, these forms are required for successful coverage determinations.For patients with cancer, the UOS for this type of test is 1. Billing should occur at the start of the episode of testing. Regarding the use of NGS-based MRD tests (i.e., Signatera) in patients with cancer Theservicemay be performed once per patient per cancer diagnosis, unless there is clinical evidence ofa priorichange in genetic content.For patients without cancer (as defined in the policy), a second kind of test may exist wherein asingle timepointmay constitute a single test (i.e., 1 UOS for a given date of service). Testing in these patients will be accompanied by the appropriate Personal history of cancer ICD-10 code. Testing may not be performed more than once in a month; the testing schedule is set based on the validity established of the individual test for the given indication.NOTE: Prophylactic therapeutic interventions in patients with a history of cancer are excluded from the definition of a patient "with cancer".Refer to additional instructions outlined in the relevant Group sections below.Regarding NGS panels:To submit a claim for MRD analysis by NGS that measures multiple analytes, use CPTcode 81479 and 1 UOS with the assigned DEXZ-Code.Billing instructions:Billing requires a Z-Code to be submitted with the claim. All tests must be registered with the DEXDiagnostic Exchange application.To report an episode of testing, please submit the following claim information:Select the appropriate CPTcode.If no specific CPT code existsfor the test submitted, bill with the NOC code 81479.Enter 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:
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Solid Tumor Cancers (A58376)
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 codeNOTE:When entering the DEX Z-Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.When submitting claims for the specific indicated use of monitoring response to ICI therapy, the ICI drug name must be included on the claim in the applicable detail line 2400 loop.
Article - Billing and Coding: Dexamethasone Intracanalicular Ophthalmic Insert (Dextenza®) (A58392)
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.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Dexamethasone Intracanalicular Ophthalmic Insert (Dextenza)L38792.
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A58395)
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.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Pharmacogenomics Testing L38435.Relevant National Coverage Determinations (NCDs):NCD 90:1: Testing for CYP2C9 and VKORC1 for Warfarin dosage must adhere to the requirements set forth in this NCD.Relevant Articles:Billing and Coding: MolDX: Testing of Multiple Genes A57880Billing and Coding: MolDX: Repeat Germline Testing A57100Additional documentation requirements for coverage and billing:Performing providers are required to acquire and retain records of the drugs under consideration for use or in use by the ordering physician that necessitate the use of ordered test.MolDX may make available specific forms to assist with test Technical Assessments (TAs). Please follow the instructions on the MolDX website to assist with this process. If such forms are available that pertain to the test type in question, these forms are required for successful coverage determinations.Billing instructions:To report a pharmacogenomics testing service, please submit the following claim information:Select the appropriate CPT or PLA codeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A58395)
Select the appropriate ICD-10-CM codeFor part B claims, the drug or drugs in consideration for use that require the use of the pharmacogenomics (PGx) test must be submitted in the applicable detail line 2400 loop. The character maximum for loop 2400 is 80. To prevent denials/rejects when indicating more than 80 characters, please indicate the required drug names first. If multiple drugs are being used/considered for the specified beneficiary on the claim, they should be added to the comment line separated by a "/" (example Drug 1/Drug 2). Do not list the same drug more than once. The use of generic name is strongly preferred. For Part B paper claims, the drug or drugs in consideration for use that require the use of the pharmacogenomics (PGx) test must be submitted in Item 19 field.Only one test may be performed per date of service; the test should be the most likely to identify the necessary alleles/variants for the drug/drugs in question. This applies to both single gene tests and multigene panels.The medical necessity for the additional testing and the clinical decision making for the additional testing must be documented in the medical record. The CPT code set relevant to this policy is listed in the table below. If no CPT code is available for the gene being tested, the NOC code 81479 may be used. The identification of the proper recommended billing code is established as part of the test application process.Gene/CPT coding /Drug InformationTable 1 represents relevant gene/drug associations related to metabolizing enzymes from CPIC and FDA sources.Table 1. This table represents metabolism gene/drug associations from CPIC and FDA sources.GeneCPT Code(s)Generic NameTrade Name(s)Intended use for Drug(s)GuidanceABCG281479rosuvastatinCrestorAntihyperlipidemicCPICBCHE81479mivacurium, succinylcholineMivacurium chloride, AnectineNeuromuscular blocking agentFDACYP2B681479efavirenzSustivaAntiretroviral; HIVCPIC/FDACYP2B681479sertralineZoloftAntidepressant-Selective Serotonin Reuptake Inhibitor (SSRI)CPIC/FDACYP2C19
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A58395)
CPIC/FDACYP2B681479sertralineZoloftAntidepressant-Selective Serotonin Reuptake Inhibitor (SSRI)CPIC/FDACYP2C1981225brivaracetam, clobazamBriviact, OnfiAnticonvulsantFDACYP2C1981225citalopram, escitalopram, sertralineCelexa, Lexapro, ZoloftAntidepressant - Selective Serotonin Reuptake Inhibitor (SSRI)CPIC/FDACYP2C1981225amitriptyline, clomipramine, doxepin, imipramine, trimipramineElavil, Anafranil, Silenor, Tofranil, SurmontilAntidepressant - TricyclicCPICCYP2C1981225voriconazoleVfendAntifungalCPIC/FDACYP2C1981225belzutifanWeliregAntineoplasticFDACYP2C1981225flibanserinAddyiMixed serotonin agonistFDACYP2C1981225clopidogrelPlavixPlatelet aggregation inhibitorCPIC/FDACYP2C1981225dexlansoprazole, lansoprazole, omeprazole, pantoprazoleDexilant, Prevacid, Prilosec, ProtonixProton Pump Inhibitor (PPI)CPIC/FDACYP2C1981225abrocitinibCibinqoSelective ImmunosuppressantFDACYP2C981227warfarinJantoven, CoumadinAnticoagulantCPIC/FDACYP2C981227fosphenytoin, phenytoinCerebyx, DilantinAnticonvulsantCPIC/FDACYP2C981227dronabinolMarinol, SyndrosAntiemeticFDACYP2C981227nateglinideStarlixAntihyperglycemicFDACYP2C981227fluvastatinLescolAntihyperglycemicCPICCYP2C981227erdafitinibBalversa
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A58395)
StarlixAntihyperglycemicFDACYP2C981227fluvastatinLescolAntihyperglycemicCPICCYP2C981227erdafitinibBalversaFGFR kinase inhibitor, bladder cancerFDACYP2C981227siponimodMayzentMultiple sclerosisFDACYP2C981227celecoxib, flurbiprofen, lornoxicam, meloxicam, piroxicam, tenoxicamCelebrex, Ansaid, Ocufen, Chlortenoxicam, Xefo, Mobic, Vivlodex, Anjeso, Qmiiz ODT, Feldene, MobiflexNon-steroidal anti-inflammatory (NSAID)CPIC/FDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UcarvedilolCoregAlpha - Beta blockerFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UpropafenoneRythmolAntiarrhythmicFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076Ufluvoxamine, paroxetine, venlafaxine, vortioxetineLuvox, Paxil, Effexor XR, Brintellix, TrintellixAntidepressant  Selective Serotonin Reuptake Inhibitor (SSRI)CPIC/FDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076Uamitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, trimipramine
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A58395)
amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, trimipramineElavil, Anafranil, Norpramin, Silenor, Tofranil, Aventyl, Pamelor, SurmontilAntidepressant - TricyclicCPICCYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076Umeclizine, ondansetron, tropisetronAntivert, Zofran ODT, TropisetronAntiemeticCPIC/FDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076Ugefitinib, tamoxifenIressa, Soltamox, NolvadexAntineoplasticCPIC/FDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076Uaripiprazole, aripiprazole lauroxil, brexpiprazole, clozapine, iloperidone, perphenazine, pimozide, thioridazineAbilify, Aristada, Rexulti, Clozaril, FazaClo, Versacloz, Fanapt, Trilafon, Orap, MellarilAntipsychoticFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076Uamphetamine, atomoxetineAdzenys ER, Dyanvel XR, Adderall, StratteraAttention Deficit - Hyperactivity (ADHD) TherapyCPIC/FDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UmetoclopramideReglanGastrointestinal prokinetic agentFDA
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A58395)
metoclopramideReglanGastrointestinal prokinetic agentFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UeliglustatCerdelgaGaucher's diseaseFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076Udeutetrabenazine, tetrabenazineAustedo, XenazineMovement disorder therapyFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UpitolisantWakixNarcolepsy therapy agentFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076Ucodeine, oliceridine, tramadolOlinvyk, UltramOpioidCPIC/FDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UlofexidineLucemyraOpioid withdrawalFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UcevimelineEvoxacSaliva stimulantFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UtolterodineDetrolUrinary antispasmodicFDACYP2D681226, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076UvalbenazineIngrezzaVMAT2 inhibitorFDACYP3A581231tacrolimusPrografAntirejectionCPIC/FDACYP4F2