evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Frequency of Hemodialysis (A56666)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L37564, Frequency of Hemodialysis. Please refer to the LCD for reasonable and necessary requirements.This article outlines how to line item bill dialysis sessions of End Stage Renal Disease (ESRD) patients. This does not address line item billing for sessions associated with training or other modalities such as peritoneal dialysis. This article does not change any other billing requirements for dialysis claims.Note: This article uses the terms dialysis session and treatment interchangeably.Coding GuidanceNotice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.CMS IOM Publication 100-04,Medicare Claims Processing Manual, Chapter 8 requires line item billing for all ESRD claims with dates of service (DOS) on or after April 1, 2007. Each dialysis session performed should be reported on a separate line.CMS IOM Publication 100-02,Medicare Benefit Policy Manual, Chapter 11 discusses that ESRD facilities furnishing dialysis treatments in facility or in the beneficiarys home are paid for up to three treatments per week. Payment for additional treatments, defined as any treatments in excess of three treatments per week, may be considered in addition to the ESRD PPS per treatment payment amount paid for up to three treatments per week.For monthly claims submitted with Bill Type 72X and Revenue Codes 0821 and 0881, three approaches of billing per line are available. Based on the Patients Plan of Care (POC) or other available medical documents, the following scheme should be followed when billing sessions.Note: Dialysis sessions in the patients POC that are not furnished should not be billed.
Article - Billing and Coding: Frequency of Hemodialysis (A56666)
For dialysis sessions that have been furnished three times (3X) per week, each line should be 90999 without any modifiers appended. That is, when the hemodialysis-prescription is three times (3X) per week and each session is furnished, all of these sessions should be billed as 90999 (no modifier appended) and they will be paid as routine conventional dialysis up to 13/14 per month.For each dialysis session furnished in addition to the three sessions per week that do not include medical documentation supporting a medically reasonable and necessary determination for payment, each line for these sessions should be billed as 90999 CG. Examples of when this could occur include short, more frequent treatments furnished for the convenience of the patient or staff, etc. Additional sessions should be billed as 90999 CG when medical documentation has not been submitted to support the extra sessions as medically reasonable and necessary. The CG modifier indicates that the facility attests the additional treatment is not medically reasonable and necessary and should not receive additional payment. Each line billed as 90999 CG will be denied. However, the use of the modifier is used for data analysis. Please refer to CR 9989, Implementation of Modifier CG for Type of Bill 72X, dated May 12, 2017.
Article - Billing and Coding: Frequency of Hemodialysis (A56666)
For each dialysis session furnished in addition to three sessions per week that includes medical documentation supporting a medically reasonable and necessary determination for payment, each line for these services should be billed as 90999 KX. These include medical conditions for acute and occasionally chronic conditions that have supporting documentation that the extra sessions are medically reasonable and necessary (e.g., through documents from recent hospital care, office visits, dialysis progress notes or MCP visits). These sessions must be medically reasonable and necessary for additional payment based on clinical conditions. On these claims, the 90999 lines without a modifier will be paid as 3X per week and those lines with 90999 KX will be considered for additional payments. Omission of the KX modifier will result in no additional payment for the line item. For diagnoses not listed in this article but felt to be medically reasonable and necessary, the KX modifier should be appended as well. A denial will occur on these lines, but the redetermination process (an appeal) will be available to submit supportive documentation for review.
Article - Billing and Coding: Frequency of Hemodialysis (A56666)
The expectation is that these three scenarios will be seen on monthly claims, i.e., claims with 90999 lines only, or those with lines of 90999 mixed with 90999 CG or KX modifier appended. Ongoing data analysis may trigger provider specific requests for documentation should unusual patterns occur, i.e., claims with only lines of 90999 KX submitted.Please note that the POC and other supporting medical documentation to justify any of these events will be most important and may be requested.Please see LCD L37564 for instructions when clinical conditions outside those listed in the available diagnosis should occur.Please see LCD L37564 for Documentation Requirements and Utilization Guidelines.
Article - Billing and Coding: Hospice - Liver Disease (A56669)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1813 (a)(4)(A)(i) drugs and biologicals provided in a hospice programCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, 30.2, 30.2.2, and 30.3Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Hospice - Liver Disease L34544.
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A56670)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 12, Section 40.7 Claims for Bilateral SurgeriesChapter 13, Section 10.1 Billing Part B Radiology Services and Other Diagnostic Procedures, Section 20 Payment Conditions for Radiology Services, and Section 30 Computerized Axial Tomography (CT) ProceduresSocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L34892, Facet Joint Interventions for Pain Management. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Diagnostic and Therapeutic Procedures:Each paravertebral facet level refers to either the facet joint, also called the zygapophyseal jointORthe two medial branch nerves that innervate each zygapophyseal joint.Each facet level has a pair of facet joints (one on the right side and one on the left side of the spine). Unilateral or bilateral facet interventions may be performed during the facet joint procedure (a diagnostic nerve block, a therapeutic facet joint [intraarticular] injection, or a medial branch block) injection, in one session. A bilateral facet nerve intervention is still considered a single level intervention.For paravertebral spinal nerves and branch injections, image guidance (fluoroscopy or computed tomography [CT]) is required for the performance of CPT codes 64490, 64491, 64493, and 64494 with any injection contrast, which is an included component of the code.
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A56670)
As defined by the Current Procedural Terminology (CPT) Professional edition code book, there are two distinct anatomic spinal regions for paravertebral facet injections: cervical /thoracic (codes 64490, 64491) and lumbar/sacral (codes 64493, 64494).For each initial, single level injection, diagnostic or therapeutic, performed with image guidance (fluoroscopy or CT), use code 64490 (cervical or thoracic) or code 64493 (lumbar or sacral).For any additional diagnostic or therapeutic procedures on the same day, use add-on codes 64491 (cervical/thoracic) or 64494 (lumbar/sacral) to report second level injections performed with image guidance (fluoroscopy or CT) in addition to the primary procedure codes 64490 or 64493.Note:Each unilateral or bilateral intervention at any level should be reported as one unit of service (UOS).If an initial (64490 or 64493) or second level add-on (64491 or 64494) paravertebral facet injection procedure is performed bilaterally, report the procedure with modifier -50 as a single line item using one UOS. Do not use modifier RT or LT when performing these procedures bilaterally (modifier -50).For unilateral paravertebral facet injection of the T12-L1 and L1-L2 levels or nerves innervating that joint, use 64490 and 64494 once.For bilateral paravertebral facet injection of the T12-L1 and L1  L2 levels or nerves innervating that joint, use 64490 with modifier 50 and 64494 with modifier 50.For services performed in the Ambulatory Surgical Center (ASC), do not use modifier 50. Report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each line.For CPT codes 64492 and 64495, the need for a three-level procedure may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal.KX modifier requirements:
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A56670)
For CPT codes 64492 and 64495, the need for a three-level procedure may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal.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 LCD 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.Neurolytic Destruction Procedures (Radiofrequency Ablation):For destruction of paravertebral facet joint medial branch nerves, image guidance and localization (fluoroscopy or CT) are required and inclusive in codes 64633, 64634, 64635, and 64636.Per the current CPT Professional edition code book, codes 64633, 64634, 64635, and 64636 are 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. There are two distinct anatomic spinal regions for paravertebral facet destruction: cervical/thoracic (codes 64633, 64634) and lumbar/sacral (codes 64635, 64636). For each initial, single level thermal radiofrequency destruction performed with image guidance (fluoroscopy or CT), use code 64633 (cervical or thoracic) or code 64635 (lumbar or sacral).For any additional thermal radiofrequency destruction performed on the same day, use add-on codes 64634 (cervical/thoracic) or 64636 (lumbar/sacral) in addition to the primary procedure codes 64633 or 64635.Note:Each unilateral or bilateral intervention at any level should be reported as one UOS.
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A56670)
Note:Each unilateral or bilateral intervention at any level should be reported as one UOS.If initial (64633 or 64635) or each additional add-on (64634 or 64636) paravertebral neurolytic destruction procedure is performed bilaterally, report the procedure with modifier -50 as a single line item using one UOS. Do not use modifier RT or LT when performing these services bilaterally (modifier -50).For services performed in the Ambulatory Surgical Center (ASC), do not use modifier 50. 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. CPT code 64999 is non-covered when used to report non-thermal facet joint denervation.Note:CPT code 64999 is non covered when used to report non thermal facet joint denervation including chemical, low grade thermal energy (less than 80 degrees Celsius) or any form of pulsed radiofrequency.Note:When reporting CPT code 64999 ensure that the description of the service is included on the claim.If facet joints are injected with biologicals or other substances not designated for this use the entire claim may deny per CMS IOMMedicare Benefit Policy Manual, Chapter 16, Section 180-Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare.Utilization ParametersNote:A session is defined as all procedures (i.e., MBB, IA, facet cyst ruptures, and destruction by a neurolytic agent (e.g., RFA) performed on the same date of service.CPT codes 64490 through 64494 will be limited to no more than four (4) sessions, per region, per rolling 12 months.
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A56670)
CPT codes 64490 through 64494 will be limited to no more than four (4) sessions, per region, per rolling 12 months.CPT code 64490 through 64494 with the KX modifier will be limited to no more than four (4) sessions, per region, per rolling 12 months.CPT codes 64633 through 64636 will be limited to no more than two (2) sessions, per region, per rolling 12 months.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.The medical record must include the assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit, relevant medical history, and the results of any pertinent tests/procedures.Documentation of why the patient is not a candidate for radiofrequency ablation (RFA) must be submitted for therapeutic injection procedures.The scales used to assess the measurement of pain and/or disability must be documented in the medical record. Acceptable scales include but are not limited to: verbal rating scales, Numerical Rating Scale (NRS), Visual Analog Scale (VAS) for pain assessment, Pain Disability Assessment Scale (PDAS), Oswestry Disability Index (ODI), Oswestry Low Back Pain Disability Questionnaire (OLBPDQ), Quebec Back Pain Disability Score (QBPDS), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS), and the Patient-Reported Outcomes Measurement Information System (PROMIS) profile domains to assess function.
Article - Billing and Coding: Nonobstetric Pelvic Ultrasound (A56671)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) states that no payment shall be made to any provider 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 Nonobstetric Pelvic Ultrasound L37636.Indications76856is a complete evaluation and must minimally include:Female: description and measurements of the uterus and adnexal structures, measurement of the endometrium and bladder, and a description of any pelvic pathology.Male: evaluation and measurement of the bladder, evaluation of the prostate and seminal vesicles and any pelvic pathology.76857is a limited study and typically focuses on one or more elements listed under 76856 and/or the reevaluation of one or more pelvic abnormalities.LimitationsPost voiding residual bladder volume is not reimbursable by CPTcodes 76856 and 76857. Measurement of post voiding residual should be billed using CPTcode 51798.
Article - Billing and Coding: Electroretinography (ERG) (A56672)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L37371, Electroretinography (ERG). Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.When reporting ICD-10 code Z79.899, the medical record must reflect the medication administered as well as the underlying condition for which it was given.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.
Article - Billing and Coding: Outpatient Observation Bed/Room Services (A56673)
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 claimArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Outpatient Observation Bed/Room Services L34552.
Article - Billing and Coding: Home Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus (A56674)
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.Title XVIII of the Social Security Act, 1835(a)(2)(A) Procedure for payment of claims of providers of servicesCMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, 6.2.4Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forHome Health Plans of Care: Monitoring Glucose Control in the Medicare Home Health Population with Type II Diabetes Mellitus L35132.
Article - Billing and Coding: Homocysteine Level, Serum (A56675)
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. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code RequirementsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forHomocysteine Level, Serum L34419.Limitations:Serum homocysteine levels will not be covered other than for suspected B12/folate deficiency, or for risk stratification for the conditions noted in theICD-10-CM Codes that Support Medical Necessitysection of this article. It is covered only once in a lifetime for the initial determination for risk stratification. Subsequent determinations will be covered only if appropriate treatment does not correct the anemia or symptoms.
Article - Billing and Coding: Hospice – HIV Disease (A56677)
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.Title XVIII of the Social Security Act, 1813(a)(4)(A)(i) addresses drugs and biologicals provided in a hospice program.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, 30.2 Payment Rates, 30.2.2 Service Intensity Add-on (SIA) Payments, and 30.3 Data Required on the Institutional Claim to A/B MAC (HHH)CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9, 80.2 PaymentArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forHospice  HIV Disease L34566.
Article - Billing and Coding: Hospice The Adult Failure To Thrive Syndrome (A56679)
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 11, 30.2 Payment Rates, 30.2.2 Service Intensity Add-on (SIA) Payments, 30.3 Data Required on the Institutional Claim to A/B MAC (HHH), and 30.4 Claims From Medicare Advantage OrganizationsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forHospice The Adult Failure To Thrive Syndrome L34558.Hospices may not report diagnosis codes that cannot be used as the principal diagnosis according to ICD-10-CM Coding Guidelines or require further compliance with various ICD-10-CM coding conventions, such as those that have principal diagnosis code sequencing guidelines. Hospices may not report debility, failure to thrive, or dementia codes classified as unspecified as principal hospice diagnoses on the hospice claim.