evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: MolDx: ResponseDX Tissue of Origin® (A55204)
CMS National Coverage PolicyN/AArticle TextTissue of Origin, a microarray-based gene expression assay designed to determine the similarity of unknown or unresolved tumors to cancers from 1 of 15 known tumors of origin, has been assigned a unique identifier. To bill for Tissue of Origin services, please provide the following claim information:CPT code 81504  Oncology (tissue of origin)Enter 1 in the Days/Unit fieldLabs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.Enter DEX Z-Code Identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:SV101-7 for the 5010A1 837PSubmit Z-Code Identifier on an attachment to the claim form 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 diagnosis.Note: MolDX expects this test to ONLY be ordered by the treating physician.
Article - Billing and Coding: MolDX: RPS19 Gene Tests (A55205)
CMS National Coverage PolicyNAArticle TextEffective for dates of service on and after June 25, 2013.RPS19 gene sequencing, deletion/duplication and known familial mutation analysis may be performed during the diagnosis of Diamond-Blackfan Anemia (DBA). Since clinical symptoms and diagnosis usually occur prior to Medicare eligibility and carrier testing is not a covered benefit, the MolDX Team has determined RPS19 analysis is a statutorily excluded test. MolDX will also deny tests that include one or more of RPS19 analysis reported with CPT code 81479 as statutorily excluded services.To receive a RPS19 analysis service denial, please submit the following claim information:Select appropriate CPT code according to genetic material testedCode 81405 for gene sequencingCode 81479 for combinations of RPS19 analysisAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientLabs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.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 form
Article - Billing and Coding: MolDX: SEPT9 Gene Test (A55206)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Article TextThe MolDX team has determined that a Septin 9 methylation analysis test for colorectal cancer detection is not a Medicare covered service. Screening in the absence of signs and symptoms of an illness or injury is not defined as a Medicare benefit. Therefore, MolDX will deny Septin 9 methylation analysis tests as a statutorily excluded service.To receive a SEPT9 service denial, please submit the following claim information:81327- SEPT9 (Septin9) (e.g., colorectal cancer) promoter methylation analysisAn 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 modifierEnter DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter 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 form
Article - Billing and Coding: MolDX: SMPD1 Genetic Testing (A55208)
CMS National Coverage PolicyN/AArticle TextEffective for dates of service on and after February 7, 2013.Mutations found in sphingomyelin phosphodiesterase 1, (SMPD1) acid lysomal, are associated with Niemann-Pick Disease, characterized by acid sphingomyelinase (ASM) deficiency. For infants and children, SMPD1 genetic testing is used to confirm the clinical findings from blood tests to diagnose ASM. Genetic testing for adults is used to screen the population for potential carriers of the mutation. Therefore, the MolDX team has determined that SMPD1 genetic testing is not a Medicare benefit and is a statutorily excluded service. In addition to single disease testing, MolDX will also deny panels of tests that include a SMPD1 gene test as a statutorily excluded service.To receive a SMPD1 test denial, please submit the following claim information:CPT code 81330- SMPD1, common variantsCPT code 81412  Ashkenazi Jewish Associated DisordersFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifier. An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.
Article - Billing and Coding: MolDX: STAT3 Gene Testing (A55209)
CMS National Coverage PolicyN/AArticle TextEffective for dates of service on and after June 26, 2013.STAT3 gene testing may be performed during the diagnosis of Autosomal Dominant Hyper IgE Syndrome (AD-HIES). Since management is not determined by the presence or absence of a STAT3 mutation in patients with a probable clinical diagnosis, the MolDx Contractor has determined STAT3 analysis is a statutorily excluded test.To receive a STAT3 analysis service denial, please submit the following claim information:CPT code 81405  STAT3, targeted sequence analysisAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientFor CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.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 form
Article - Billing and Coding: MolDX: SULT4A1 Genetic Testing (A55210)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) statutory exclusion covers diagnostic testing "except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member".Article TextSulfotransferase 4A1 (SULT4A1) is an enzyme found in the brain that interacts with numerous neuroactive molecules, including some catecholamines and neural steroids. Findings suggest the SULT4A1-1 haplotype of SULT4A1 is associated with enhanced response to antipsychotic drug therapy. At present there is insufficient evidence to support SULT4A1 genotyping to determine medical management. Therefore, the MolDX Team has determined SULT4A1 genetic testing is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, MolDX will also deny panels of tests that include the SULT4A1 gene as a statutorily excluded service.To receive a SULT4A1 test denial, please submit the following claim information:CPT code 81479An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX HCPCS modifierTo indicate a statutorily excluded service, append with a GY HCPCS modifierFor CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.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 form
Article - Billing and Coding: MolDX: TERC Gene Tests (A55211)
CMS National Coverage PolicyN/AArticle TextEffective for dates of service on and after June 25, 2013.Since the associated conditions associated with telomerase RNA component (TERC) gene testing is limited to reproductive risk assessment, the MolDX team has determined TERC gene testing is a statutorily excluded service. MolDX will also deny tests that include one or more of TERC analysis reported with CPT code 81479 as a statutorily excluded service.To receive a TERC analysis service denial, please submit the following claim information:CPT 81479  Unlisted molecular pathology procedureAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientLabs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required informationEnter 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 form
Article - Billing and Coding: Incident To Clarification for OPPS and CAH Outpatient (A55214)
CMS National Coverage PolicyMedicare Benefit Policy Manual Chapter 6 Section 20.5.1Social Security Act (SSA) Section 1861(s)(2)(K)(i)42 CFR410.2742 CFR482.12(c)Article TextIn response to provider requests, Noridian Healthcare Solutions, LLC (Noridian) provides the following key points related to the incident to regulations in the outpatient hospital setting. Note: There is no "incident to" in the inpatient setting.Medicare may reimburse the costs of services provided either:1. delivered personally by eligible practitioners, e.g., MD, NP, PA; or2. delivered by hospital personnel working incident to the eligible practitioners care.When hospital personnel provide services, the following payment requirements must be met. Services delivered incident to the services of an eligible practitioner must:o Be an integral althoughincidental partof a physicians/non-physician practitioners (NPPs) professional service(s) and, hence, must always occur after an initial patient care service is provided by an eligible practitioner;o Be delivered in accordance with avalid and signed order, i.e., written by a practitioner who is authorized to write orders by hospital policy and in accordance with state law 42 CFR482.12(c);o Be delivered under thesupervision of a physicianwho is an employee or has another contractual relationship with the hospital and isimmediately availableto provide assistance to the personnel delivering the service;"Immediately available" in the outpatient hospital setting means that the physician must beavailable in the same time-frame as the personnel designated to manage cardiac arrests(codes) in the hospital.The supervisor need not be in the same department as the ordering physician/NPP or in the same department in which the services are rendered but must beon the physical premiseswhere and when the patient receives services.The physician/NPP that provides the oversight may not bill for the services of hospital employees. Only the hospital may bill for the services of hospital employees.All service providers must work in accordance with their skills, licensure, and/or other hospital and other Medicare requirements.
Article - Billing and Coding: Incident To Clarification for OPPS and CAH Outpatient (A55215)
CMS National Coverage PolicyMedicare Benefit Policy Manual Chapter 6 Section 20.5.1Social Security Act (SSA) Section 1861(s)(2)(K)(i)42 CFR410.2742 CFR482.12(c)Article TextIn response to provider requests, Noridian Healthcare Solutions, LLC (Noridian) provides the following key points related to the incident to regulations in the outpatient hospital setting. Note: There is no "incident to" in the inpatient setting.Medicare may reimburse the costs of services provided either:1. delivered personally by eligible practitioners, e.g., MD, NP, PA; or2. delivered by hospital personnel working incident to the eligible practitioners care.When hospital personnel provide services, the following payment requirements must be met. Services delivered incident to the services of an eligible practitioner must:o Be an integral althoughincidental partof a physicians/non-physician practitioners (NPPs) professional service(s) and, hence, must always occur after an initial patient care service is provided by an eligible practitioner;o Be delivered in accordance with avalid and signed order, i.e., written by a practitioner who is authorized to write orders by hospital policy and in accordance with state law 42 CFR482.12(c);o Be delivered under thesupervision of a physicianwho is an employee or has another contractual relationship with the hospital and isimmediately availableto provide assistance to the personnel delivering the service;"Immediately available" in the outpatient hospital setting means that the physician must beavailable in the same time-frame as the personnel designated to manage cardiac arrests(codes) in the hospital.The supervisor need not be in the same department as the ordering physician/NPP or in the same department in which the services are rendered but must beon the physical premiseswhere and when the patient receives services.The physician/NPP that provides the oversight may not bill for the services of hospital employees. Only the hospital may bill for the services of hospital employees.All service providers must work in accordance with their skills, licensure, and/or other hospital and other Medicare requirements.
Article - Billing and Coding: MolDX: TP53 Gene Test (A55221)
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 TextEffective for dates of service on and after June 24, 2013.TP53 gene testing may be performed during the diagnosis of Li-Fraumeni syndrome (LFS), a cancer predisposition syndrome associated with the development of specific tumors. Clinical symptoms and diagnosis usually occur prior to Medicare eligibility and carrier testing is not a covered benefit.To receive a TP53 gene sequencing service denial, please submit the following claim information:Select the appropriate CPT codeAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientEnter 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 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 form
Article - Billing and Coding: MolDX: Germline testing for use of PARP inhibitors (A55224)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Article TextThe United States (U.S.) Food and Drug Administration (FDA) has approved several poly ADP-ribose polymerase (PARP) inhibitor treatments indicated for patients with ovarian cancer, breast cancer, pancreatic cancer, and prostate cancer.Results of tests that assess for deleterious variants in homologous recombination repair (HRR) genes such as BRCA1 and 2 can be used as an aid in patients who are being considered for treatment with PARP inhibitors in accordance with published guidelines and approved therapeutic product labeling. These genes are often tested as part of routine management of these cancer patients as part of services that interrogate a panel of genes as described in LCD L39040. In rare circumstances limited testing for only a select group of genes may be tested to ensure compliance with FDA indicated drug usage, wherein additional genes outlined in guidelines such as the NCCN are not necessary because the patient does not meet testing criteria for larger panels.According to criteria defined by L39040, billing for these services can occur in the following situation:The patient meets clinical indication for immediate use of a PARP inhibitor for an FDA-approved use ANDThe patient has had no previous germline testing for hereditary cancer or somatic testing of the same cancer that included the genes necessary for testing ANDThe patient does not meet germline testing requirements per existing guidelines or standards of care outlined in policy L39040 requiring more comprehensive testing.To report a service, please submit the following claim information:Select appropriate CPT codeOne (1) unit of serviceAssigned DEX Z-Code Identifier in the 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 837PSubmit the assigned Z-Code Identifier on an attachment to the claim form 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 at least one ICD-10-CM diagnosis code.
Article - Billing and Coding: Incomplete Colonoscopy/Failed Colonoscopy (A55227)
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, 30.1B Digestive System - Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121)Article TextA covered colonoscopy that is attempted but cannot be completed because of extenuating circumstances is considered to be an incomplete colonoscopy (the inability to advance the colonoscope to the cecum or to the colon-small intestine anastomosis due to unforeseen circumstances). The failed procedure is billed and paid using CPTcode 45378, HCPCS code G0105 or G0121, or CPTcode 44388, if attempting to perform the colonoscopy through an existing stoma. Modifier -53 (discontinued procedure) must be appended to any procedure code submitted when billing for a failed colonoscopy attempt.When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to its payment methodology for this procedure, as long as all coverage conditions are met. This applies to both screening and diagnostic colonoscopies.
Article - Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities (A55229)
CMS National Coverage PolicyInternet Only Manual (IOM) Citations:CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 23, Section 20.9 National Correct Coding Initiative (CCI)Social 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.National Correct Coding Initiative:NCCI Policy Manual for Medicare ServicesChapter 1 General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services.Chapter 5 Surgery: Respiratory, Cardiovascular, Hemic and Lymphatic Systems (CPT Codes 30000-39999), Section D Cardiovascular System.Chapter 9 Radiology Services (CPT codes 70000-79999), Section D Interventional/Invasive Diagnostic Imaging, Section G Medically Unlikely Edits (MUEs), and Section H General Policy Statements.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L34924 Treatment of Chronic Venous Insufficiency of the Lower Extremities. 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.The sclerosant used in sclerotherapy procedures is included in the procedure code and is not separately reported.Liquid sclerotherapy is reported using CPT codes 36468, 36470, and 36471.Non-compounded foam (NCF) sclerotherapy, for treatment of incompetent extremity truncal veins, is reported using CPT codes 36465 and 36466.Non-compounded foam (NCF) sclerotherapy, for treatment of other incompetent extremity veins, is reported using CPT codes 36470 and 36471.
Article - Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities (A55229)
Non-compounded foam (NCF) sclerotherapy, for treatment of other incompetent extremity veins, is reported using CPT codes 36470 and 36471.Physician-compounded foam (PCF) sclerotherapy, for treatment of incompetent extremity truncal veins and other incompetent extremity veins, is reported using CPT codes 36470 and 36471.The Current Procedural Terminology (CPT) Professional edition code book states that when performed in the office setting, all required supplies and equipment are included in 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, and 36483 and may not be separately reported. In addition, application of compression dressing(s) (e.g., compression bandages/stockings) is included and may not be separately reported.According to the CPT Professional edition code book, CPT codes 37241-37244 are used to describe vascular embolization and occlusion procedures excluding the ablation/sclerotherapy procedures for venous insufficiency/telangiectasia of the extremities/skin, which are reported using 36468, 36470, and 36471. For sclerosis of veins or endovenous ablation of incompetent extremity veins, see 36468-36479. CPT code 37241 is not appropriate for reporting of vein ablation for the treatment of chronic venous insufficiency of the lower extremities and is incorrect coding.Per the NCCI Policy Manual for Medicare Services, Chapter 5, Section D., Subsection 43, Ligation procedures of the lower extremity (e.g., CPT codes 37700-37785) include application of a compression dressing, if performed. CPT code 29581 (application of multi-layer compression system) shall not be reported separately.Utilization Parameters