evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms (A56867)
The diagnosis code(s) must best describe the patient's condition for which the service was performed.Specific Coding Information:Regarding Non-Small Cell Lung Cancer (NSCLC) and Metastatic Colorectal Cancer (mCRC), the following guidelines apply:Targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, 5-50 genes (CPT 81445 or 81449) is a useful representation of the aggregate of these gene tests, and may be used (along with other listed panel codes) as long as the panel contains, at a minimum, 5 or more gene tests for molecular biomarkers determined to meet Medicare coverage criteria as listed above. Evaluation of other genes or genomic sequences not addressed by NCCN or other professional guidelines are not precluded, but their inclusion in panels recognized by this code should not be interpreted as endorsement of such testing by genomic sequencing procedures and laboratories and users of such testing are advised to adhere to traditional regulatory and institutional oversight mechanisms to assure their clinical validity and utility.Documentation Requirements:Documentation must be adequate to verify that coverage guidelines listed above have been met. Thus, the medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed. 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, imaging results).Documentation requirements of the performing laboratory (when requested) include, but are not limited to, lab accreditation, test requisition, test record/procedures, reports (preliminary and final), and quality control record.Documentation requirements for LDT(s)/protocols (when requested) include diagnostic test/assay, lab/manufacturer, names of comparable assays/services (if relevant), description of assay, analytical validity evidence, clinical validity evidence, and clinical utility.
Article - Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms (A56867)
Providers are required to code to specificity however, if CPT 81479 (unlisted molecular pathology procedure) is used the documentation must clearly identify the unique molecular pathology procedure performed. When multiple procedure codes are submitted on a claim (unique and/or unlisted) the documentation supporting each code should be easily identifiable. If on review the contractor cannot link a billed code to the documentation, these services will be denied based on Title XVIII of the Social Security Act, 1833(e).For these tests, the ordering provider must provide to the laboratory copies of the signed informed consent documentation.Utilization Guidelines:
Article - Billing and Coding: Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms (A56867)
Screening services such as pre-symptomatic genetic tests and services used to detect an undiagnosed disease or disease predisposition are not a Medicare benefit and are not covered. Similarly, Medicare may not reimburse the costs of tests/examinations that assess the risk of a condition unless the risk assessment clearly and directly affects the management of the patient.A specific genetic test may only be performed once in a lifetime per beneficiary for inherited conditions; however, when medically reasonable and necessary, genetic testing may be done on acquired conditions such as malignancies (including separate malignancies developing at different times) as they are treated and are being followed, in order to assess response or other relevant clinical criteria. Likewise, there are situations where medical record and literature documentation are able to demonstrate that serial testing can be reasonably predicted to provide additional clinically useful information. When the record documents that this information, such as confirmed significant response to current therapy, is likely to assist in modifying treatment, serial testing can be considered reasonable and necessary and eligible for coverage.
Article - Billing and Coding: Outpatient Speech Language Pathology (A56868)
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. 100-02, Medicare Benefit Policy Manual, Chapter 12, 20.1 Required Services, 30 Rules for Provision of Services, and 30.1 Rules for Payment of CORF ServicesCMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 220 Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance, 220.1 Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services, 220.4 Functional ReportingCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 5, 10 Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services-General, 10.5 Notification for Beneficiaries Exceeding Financial Limitations, 10.6 Functional Reporting, 10.7 Multiple Procedure Payment Reductions for Outpatient Rehabilitation Services, 20 HCPCS Coding Requirement, 20.2 Reporting of Service Units With HCPCS, and 40.2 Applicable Types of Bill, 40.3 Applicable Revenue Codes, 40.4 Edit Requirements for Revenue Codes, and 40.5 Line Item Date of Service ReportingCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, 30.3 Audiology ServicesCMS 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) forOutpatient Speech Language Pathology L34429.Evaluation/Re-evaluationNote:Current Procedural Terminology (CPT) does not define a re-evaluation code for Speech Language Pathology: use the evaluation code.1.Treatment of speech, language, voice, communication, and/or auditory processing disorder (CPTcode 92507); individualRegarding speech-generating devices (SGDs), use CPTcode 92607 and 92608 for selection and prescription; use CPTcode 92609 for programming and modification.
Article - Billing and Coding: Outpatient Speech Language Pathology (A56868)
Regarding speech-generating devices (SGDs), use CPTcode 92607 and 92608 for selection and prescription; use CPTcode 92609 for programming and modification.2.Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals (CPTcode 92508)Note:Regardlessof the therapy being performed, if the patient is not receiving direct 1-on-1 contact but is being supervised by the therapist, the group therapy code should be used.
Article - Billing and Coding: Use of Laterality Modifiers (A56869)
CMS National Coverage PolicyN/AArticle TextIn order to facilitate claims processing and avoid denials for duplicate claims, claims which contain CPT/HCPCS codes describing services performed on anatomic structures that can be distinguished as left or right require laterality modifiers. This article is not a comprehensive listing of all such codes; however, all claims involving the CPTcodes included in this article will be rejected unless the appropriate laterality modifiers (-RT; -LT) for unilateral procedures are reported. Bilateral procedures should be indicated by the appropriate modifier for bilateral procedures. CPTcodes that are designated in their description asunilateral or bilateraldo not require additional laterality modifiers.Claim lines for CPT/HCPCS codes requiring use of the RT and LT modifiers, submitted without the RT and/or LT modifiers or with the RT/LT on a single claim line will be rejected as incorrect coding.
Article - Billing and Coding: MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) (A56870)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.2A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual Publication 100-04 Medicare Claims Processing Manual, Chapter 23 Section 10 "Reporting ICD Diagnosis and Procedure Codes"Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: Oncotype DXBreast Cancer for DCIS (Genomic Health) L36912.To report an Oncotype DXBreast Cancer for DCISservice, please submit the following claim information:Select PLA code 0045UEnter 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 the appropriate ICD-10-CM code
Article - Billing and Coding: In Vitro Chemosensitivity & Chemoresistance Assays (A56871)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS 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, Clinical Laboratory Services.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for In Vitro Chemosensitivity & Chemoresistance Assays L34554.To receive a CSRA denial, please submit the following claim information:CPTcodeAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifier
Article - Billing and Coding: GlycoMark® Testing for Glycemic Control (A56872)
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, 60.1.1 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure Codes.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for GlycoMark Testing for Glycemic Control L36761.To receive a GlycoMark test denial, please submit the following claim information:CPTcode 84378 or 84999An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifier
Article - Billing and Coding: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (A56874)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (A56874)
This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Stereotactic Radiation and Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT).Coding Information: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.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.SRS is typically performed in a single session. If more than one session is required, SBRT codes must be used.Documentation Requirements:All documentation must be available upon request of the Medicare contractor.The patient's record must support the necessity and frequency of treatment. The medical record must clearly indicate the critical nature of the anatomy or other circumstances necessitating the services, the patient's functional status and a description of current performance status (Karnofsky Performance Status).Documentation should include the date and the current treatment dose.Coverage may be considered at the Redetermination (Appeal) level on an individual basis for lesions when documentation clearly supports the necessity for high radiation dose per fraction and the necessity to avoid surrounding tissue exposure. When requesting an individual consideration through the written redetermination (formerly appeal) process, providers must include all relevant medical records and literature that supports the request. At a minimum two (2) Phase II studies (human feasibility studies suggesting efficacy, pilots) or one (1) Phase III study (primary evidence of safety and efficacy, pivotal) must be submitted for the Contractor Medical Directors review.Treatment devices, complex (CPT code 77334) is limited to one unit for each collimator in a linear accelerator system or one for each helmet in a cobalt-60 system. If the total number of units exceeds six (6) or the number of isocenters plus three (3) when multiple isocenters are necessary, a detailed explanation of medical necessity must be documented in the medical record. Documentation must specify factors, such as, multiple isocenters, irregularity of target volume(s), proximity of critical structures or other reasons which justify the units of service for dosimetry or treatment devices.
Article - Billing and Coding: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (A56874)
Utilization Guidelines:Codes 77373, G0339 and G0340 will payonly once per day of treatment regardless of the number of sessions or lesions. CPT code 77435 code will pay only once per course of therapy.
Article - Billing and Coding: MolDX: Breast Cancer Index® (BCI) Gene Expression Test (A56875)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.0 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests, 80.1.1 Certification ChangesCMS 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 2310 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: Breast Cancer Index (BCI) Gene Expression Test L37794.Effective 1/01/2019, MolDX will provide limited coverage for the BCI gene expression test.The BCI test is covered for postmenopausal women with invasive breast cancer when the following criteria are met:Pathology reveals invasive carcinoma of the breast that is ER+ and/or PR+ and HER2 -; andPatient has early-stage disease (T1-3, pN0-N1, M0); andPatient has no evidence of distant breast cancer metastasis (i.e., non-relapsed); andTest results will be used in determining treatment management of the patient for chemotherapy and/or endocrine therapy.MolDX expects this test will be performed once per patient lifetime on formalin-fixed, paraffin-embedded (FFPE) tissue from the primary tumor specimen obtained prior to adjuvant treatment.To report a BCI service, please submit the following claim information:Select CPTcode 81518Enter 1 unit of service (UOS)Enter the appropriate DEX Z-code identifier adjacent to the CPTcode in the comment/narrative field for the following claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claim
Article - Billing and Coding: MolDX: Breast Cancer Index® (BCI) Gene Expression Test (A56875)
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 the appropriate ICD-10-CM code
Article - Billing and Coding: Spinal Cord Stimulators for Chronic Pain (A56876)
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) forSpinal Cord Stimulators for Chronic Pain L37632.IndicationsThis A/B MAC will reimburse for placement of a maximum of 2 leads or 16 contacts, and for 2 spinal cord stimulator (SCS) trials per anatomic spinal region per patient per lifetime (with exceptions allowed for technical limitations for the initial trials or for use of different modalities of stimulation, including new technology).If a trial fails, a repeat trial is not appropriate, unless there are extenuating circumstances that lead to trial failure. Appropriate medical documentation to support a repeat trial can be sent on appeal. Generally, electronic analysis services (CPTcodes 95970, 95971 and 95972) are not considered medically necessary, when provided at a frequency more often than once every 30 days. More frequent analysis may be necessary in the first month after implantation.CPTcode 63650 - 2 temporary SCS trials per anatomic spinal region (2 per date of service (DOS)) or (4 units) per patient per lifetime (with exceptions allowed for technical limitations for the initial trials or for use of different modalities of stimulation, including new technology), in place of service office, ambulatory surgery center (ASC), outpatient hospital, or hospital. Since permanent neurostimulator arrays can also be placed percutaneously, code 63650 can be covered more often in place of service ASC, outpatient hospital, or hospital.CPTcode 63655 - 1 permanent SCS per patient per lifetime and must be performed in an ASC, outpatient hospital or hospital.CPTcodes63661 and 63663 - Will not be reimbursed in the office setting since they are included in 63650.TheCPT/HCPCScode(s) may be subject to Correct Coding Initiative (CCI) edits. This article does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.
Article - Billing and Coding: MolDX: HLA-DQB1*06:02 Testing for Narcolepsy (A56881)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manuals, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet Online Manual Pub. 100-04 (Medicare Claims Processing Manual), Chapter 23 (Section 10) "Reporting ICD Diagnosis and Procedure CodesCMS Internet-Only Manual, 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: HLA-DQB1*06:02 Testing for Narcolepsy L36485.
Article - Billing and Coding: MolDX: Breast Cancer Index™ (BCI) Gene Expression Test (A56884)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.0, 80.1.1, 80.2. Clinical Laboratory servicesCMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual Publication 100-04 Medicare Claims Processing Manual, Chapter 23 Section 10 "Reporting ICD Diagnosis and Procedure Codes"Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Breast Cancer Index (BCI) Gene Expression Test DL37832.Effective 1/01/2019, MolDX will provide limited coverage for the BCI gene expression test.The BCI test is covered for postmenopausal women with invasive breast cancer when the following criteria are metPathology reveals invasive carcinoma of the breast that is ER+ and/or PR+ and HER2 -; andPatient has early-stage disease (T1-3, pN0-N1, M0); andPatient is lymph node negativePatient has no evidence of distant breast cancer metastasis (i.e., non-relapsed); andTest results will be used in determining treatment management of the patient for chemotherapy and/or extension of endocrine therapy.MolDX expects this test will be performed once per patient lifetime on FFPE tissue from the primary tumor specimen obtained prior to adjuvant treatment.To bill a BCI service, please provide the following claim information:CPT code 81518Enter 1 in the Days/Unit fieldSelect the appropriate ICD-10-CM diagnosisEnter the assigned Z-code in the comment/narrative field for the following claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claim
Article - Billing and Coding: MolDX: Breast Cancer Index™ (BCI) Gene Expression Test (A56884)
Enter 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: HLA Testing for Transplant Histocompatibility (A56885)
CMS National Coverage PolicyCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Inpatient Hospital Billing, Chapter 3, Section 90 Billing Transplant ServicesTitle 42 CFR 412 Prospective Payment Systems for Inpatient Hospital ServicesArticle Text