evekhm/cms_iom_500 huggingface dataset:
Draft Article - Billing and Coding: MolDX: Molecular Assays for the Diagnosis of Cutaneous Melanoma (DA59261)
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 Manuals, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS 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: Molecular Assays for the Diagnosis of Cutaneous Melanoma.Please submit the following claim information:Regarding the myPathMelanoma assay:Select CPT code 81479 for dates of service prior to 7/1/2019Select proprietary CPT code 0090U for dates of service on or after 7/1/2019Regarding other molecular assays for the diagnosis of cutaneous melanoma:Select CPT code 81479 if there is not an applicable CPT or PLA code listed belowOnly 1 test may be billed per patient per melanocytic lesion.Enter 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: Molecular Assays for the Diagnosis of Cutaneous Melanoma (A59261)
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 Manuals, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS 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 MolDX: Molecular Assays for the Diagnosis of Cutaneous Melanoma.Please submit the following claim information:Regarding the myPathMelanoma assay:Select CPTcode 81479 for dates of service prior to 7/1/2019Select proprietary CPTcode 0090U for dates of service on or after 7/1/2019Regarding other molecular assays for the diagnosis of cutaneous melanoma:Select CPTcode 81479 if there is not an applicable CPT or PLA code listed belowOnly 1 test may be billed per patient per melanocytic lesion.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: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 code
Article - Billing and Coding: Ambulatory Electrocardiograph (AECG) Monitoring (A59268)
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.Medicare National Correct Coding Initiative (NCCI) Policy Manual:Chapter 1, Section E Modifiers and Modifier Indicators and Section V Medically Unlikely Edits (MUEs).Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39490, Ambulatory Electrocardiograph (AECG) Monitoring. Please refer to the LCD for reasonable and necessary requirements.Table of Various AECG MonitorsType of MonitorDescriptionCPT CodesExternal ECG (Holter)Monitors for up to 48 hours by continuous rhythm recording and storage93224-93227Extended or long-term external ECGMonitors greater than 48 hours up to 7 days by continuous rhythm recording and storage93241-93244Extended or long-term external ECGMonitors greater than 7 days up to 15 days by continuous rhythm recording and storage93245-93248External patient-activated/auto-activated ECG rhythm derived event recording (Event monitors)Monitors with symptom-related memory loop with Remote download capability or 24-hour attended monitoring. May be worn for up to 30 days.93268-93272External mobile cardiovascular telemetry monitorsConcurrent computerized real-time data analysis and greater than 24 hours of accessible ECG data storage with ECG-triggered and patient-selected events transmitted to a remote attended surveillance center. May be worn for up to 30 days93228- 93229Subcutaneous Cardiac Rhythm Monitor (SCRM)Implanted, continuous recording that is patient or rhythm activated. The recording is transmitted for delayed interpretation and/or is interpreted by a 24- hour attendant surveillance office in real time.93298Refer to the National Coverage Determination NCD 20.15 - Electrocardiographic Services for monitoring after post-infarct guidelines.
Article - Billing and Coding: Ambulatory Electrocardiograph (AECG) Monitoring (A59268)
Refer to the National Coverage Determination NCD 20.15 - Electrocardiographic Services for monitoring after post-infarct guidelines.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.Consistent with Current Procedural Terminology (CPT) instruction, report CPT codes 93228 and 93229 only once per 30 days.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 medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. It is not enough to link the procedure code to a correct, payable ICD-10-CM diagnosis code. Consistent with the LCD, the diagnosis or clinical suspicion of a cardiac event, leading to cardiac monitoring, must be present in the medical record.Medical record documentation should support the medical necessity for greater than 24-hour monitoring and should support the medical necessity for the type of monitoring utilized.Medical record documentation must support the presence of specific symptoms such as syncope, dizziness, shortness of breath, chest discomfort, palpitations, other abnormal test results which would indicate the need for extended monitoring, or an underlying history of cardiac disease that may correlate with a cardiac diagnosis.The AECG rhythm strip transmission for 24-hour attended monitoring stations should include the following information:the name of the patient,the presenting diagnosis,the time and date of the transmission,the channel of the AECG transmission,the PR interval (when abnormal),the QRS interval (when abnormal),the rate,the rhythm,cardiovascular symptomatology reported by the patient, or lack of symptoms, at the time of the transmission; andany necessary actions (e.g., notification of physician, emergency instructions given to patient, etc.) taken by the staff should be included in the report.
Article - Billing and Coding: Ambulatory Electrocardiograph (AECG) Monitoring (A59268)
The medical record should include the interpretation of the monitoring along with the name of the interpreting physician.
Article - Billing and Coding: Ambulatory Electrocardiograph (AECG) Monitoring (A59270)
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.Medicare National Correct Coding Initiative (NCCI) Policy Manual:Chapter 1, Section E Modifiers and Modifier Indicators and Section V Medically Unlikely Edits (MUEs).Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39492, Ambulatory Electrocardiograph (AECG) Monitoring. Please refer to the LCD for reasonable and necessary requirements.Table of Various AECG MonitorsType of MonitorDescriptionCPT CodesExternal ECG (Holter)Monitors for up to 48 hours by continuous rhythm recording and storage93224-93227Extended or long-term external ECGMonitors greater than 48 hours up to 7 days by continuous rhythm recording and storage93241-93244Extended or long-term external ECGMonitors greater than 7 days up to 15 days by continuous rhythm recording and storage93245-93248External patient-activated/auto-activated ECG rhythm derived event recording (Event monitors)Monitors with symptom-related memory loop with Remote download capability or 24-hour attended monitoring. May be worn for up to 30 days.93268-93272External mobile cardiovascular telemetry monitorsConcurrent computerized real-time data analysis and greater than 24 hours of accessible ECG data storage with ECG-triggered and patient-selected events transmitted to a remote attended surveillance center. May be worn for up to 30 days93228- 93229Subcutaneous Cardiac Rhythm Monitor (SCRM)Implanted, continuous recording that is patient or rhythm activated. The recording is transmitted for delayed interpretation and/or is interpreted by a 24- hour attendant surveillance office in real time.93298Refer to the National Coverage Determination NCD 20.15 - Electrocardiographic Services for monitoring after post-infarct guidelines.
Article - Billing and Coding: Ambulatory Electrocardiograph (AECG) Monitoring (A59270)
Refer to the National Coverage Determination NCD 20.15 - Electrocardiographic Services for monitoring after post-infarct guidelines.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.Consistent with Current Procedural Terminology (CPT) instruction, report CPT codes 93228 and 93229 only once per 30 days.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 medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. It is not enough to link the procedure code to a correct, payable ICD-10-CM diagnosis code. Consistent with the LCD, the diagnosis or clinical suspicion of a cardiac event, leading to cardiac monitoring, must be present in the medical record.Medical record documentation should support the medical necessity for greater than 24-hour monitoring and should support the medical necessity for the type of monitoring utilized.Medical record documentation must support the presence of specific symptoms such as syncope, dizziness, shortness of breath, chest discomfort, palpitations, other abnormal test results which would indicate the need for extended monitoring, or an underlying history of cardiac disease that may correlate with a cardiac diagnosis.The AECG rhythm strip transmission for 24-hour attended monitoring stations should include the following information:the name of the patient,the presenting diagnosis,the time and date of the transmission,the channel of the AECG transmission,the PR interval (when abnormal),the QRS interval (when abnormal),the rate,the rhythm,cardiovascular symptomatology reported by the patient, or lack of symptoms, at the time of the transmission; andany necessary actions (e.g., notification of physician, emergency instructions given to patient, etc.) taken by the staff should be included in the report.
Article - Billing and Coding: Ambulatory Electrocardiograph (AECG) Monitoring (A59270)
The medical record should include the interpretation of the monitoring along with the name of the interpreting physician.
Article - Complex Drug Administration Coding (A59272)
CMS National Coverage PolicyN/AArticle Text
Article - Complex Drug Administration Coding (A59272)
The Medicare Administrative Contractor has determined in review of submitted claims that there is inappropriate use of CPT codes 96401-96549 for chemotherapy and other highly complex drug or highly complex biologic agent administration.The Current Procedural Terminology (CPT) codebook contains the following information and direction for the Chemotherapy and Other Highly Complex Drug or Highly Complex Biological Agent Administration CPT codes: Chemotherapy Administration codes 96401-96549 apply to parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of non-cancer diagnoses (e.g. cyclophosphamide for auto-immune conditions) or to substances such as certain monoclonal antibody agents, and other biologic response modifiers. The highly complex infusion of chemotherapy or other drug or biologic agents requires physician or other qualified health care professional work and/or clinical staff monitoring well beyond that of therapeutic drug agents (96360-96379) because the incidence of severe adverse patient reactions are typically greater. These services can be provided by any physician or other qualified health care professional. Chemotherapy services are typically highly complex and require direct supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intraservice supervision of staff. Typically, such chemotherapy services require advanced practice training and competency for staff who provide these services; special considerations for preparation, dosage, or disposal; and commonly, these services entail significant patient risk and frequent monitoring. Examples are frequent changes in the infusion rate, prolonged presence of the nurse administering the solution for patient monitoring and infusion adjustments, and frequent conferring with the physician or other qualified health care professional about these issues. When performed to facilitate the infusion of injection, preparation of chemotherapy agent(s), highly complex agent(s), or other highly complex drugs is included and is not reported separately. To report infusions that do not require this level of complexity, see 96360-96379. Codes 96401-96402, 96409-96425, 96521-96523 are not intended to be reported by the individual physician or other qualified health care professional in the facility setting.
Article - Complex Drug Administration Coding (A59272)
The term chemotherapy in 96401-96549 includes other highly complex drugs or highly complex biologic agents. (End quotation from CPT)Medicare has determined under Section 1861(t) that these drugs may be paid when they are administered incident to a physicians service and determined to be medically reasonable and necessary. Such determination of reasonable and necessary is currently left to the discretion of the Medicare Administrative Contractors (MACs). The documentation in the patients medical record must support the drugs as being medically reasonable and necessary.As stated in the CMS Internet Only Manual Publication 100-04,Medicare Claims Processing Manual, Chapter 12-Physicians/Nonphysician Practitioners, Section 30.5 Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions, Part D-Chemotherapy Administration,A/B MACs (B) may provide additional guidance as to which drugs may be considered to be chemotherapy drugs under Medicare.Not Otherwise Classified (NOC) Drug Billing:Office/Clinic:Providers submit NOC codes in the 2400/SV101-2 data element in the 5010 professional claim transaction (837P). When billing an NOC code, providers are required to provide a description in the 2400/SV101-7 data element. The 5010 TR3 Implementation Guide instructs: "Use SV101-7 to describe non-specific procedure codes." (Do not use the 2400 NTE segment to describe non-specific procedure codes with 5010.) The SV101-7 data element allows for 80 bytes (i.e., characters, including spaces) of information.In order for the A/B MAC to correctly reimburse NOC drugs and biologicals, providers must indicate the following in the 2400/SV101-7 data element, or Item 19 of the CMS 1500 form:
Article - Complex Drug Administration Coding (A59272)
The name of the drugThe total dosage (plus strength of dosage, if appropriate), andThe method of administration.Important: List one unit of service in the 2400/SV1-04 data element or in item 24G of the CMS 1500 form. Do not quantity-bill NOC drugs and biologicals even if multiple units are provided. Medicare determines the proper payment of NOC drugs and biologicals by the narrative information, not the number of units billed.Medicare will reject as unprocessable claims for NOC drugs and biologicals if any of the information above is missing, or if the NOC code is billed with more than one unit of service. (Note: The remittance notice will include remark code M123, "Missing/incomplete/invalid name, strength, or dosage of the drug furnished," even if the rejection is due to the number of units billed.)See Billing and Describing Not Otherwise Classified (NOC) Codes on our website for further information:https://cgsmedicare.com/partb/pubs/news/2014/0414/cope25420.html.
Article - Complex Drug Administration Coding (A59272)
ASC and Hospital Outpatient Departments:HCPCS code C9399, Unclassified drug or biological, should be used for new drugs and biologicals that are approved by FDA on or after January 1, 2004, for which a specific HCPCS code has not been assigned.JW ModifierJW Modifier effective January 1, 2017. Claims for discarded drugs or biologicals amount not administered to any patient shall be submitted using the JW modifier.Unused drugs or biologicals from single use vials or single use packages that are opened, and the entire dose/quantity is not administered, and the remainder is discarded. (Except those provided under the Competitive Acquisition Program (CAP) for Part B drugs and biologicals).Providers must document the discarded drugs or biologicals in the patient's medical record.This modifier, billed on a separate line, will provide payment for the amount of discarded drugs or biologicals.A situation in which the JW modifier is not permitted is when the actual dose of the drug or biological administered is less than the billing unit. For example, one billing unit for a drug is equal to 10mg of the drug in a single use vial. A 7mg dose is administered to a patient while 3mg of the remaining drug is discarded. The 7mg dose is billed using one billing unit that represents 10mg on a single line item. The single line item of 1 unit would be processed for payment of the total 10mg of drug administered and discarded. Billing another unit on a separate line item with the JW modifier for the discarded 3mg of drug is not permitted because it would result in overpayment. Therefore, when the billing unit is equal to or greater than the total actual dose and the amount discarded, the use of the JW modifier is not permitted.(See MLN Matters Number: MM9603 athttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9603.pdfRoute of Administration Modifier:
Article - Complex Drug Administration Coding (A59272)
Route of Administration Modifier:The use of the JA and JB modifiers is required for drugs which have one HCPCS Level II (J or Q) code but multiple routes of administration. Drugs that fall under this category must be billed with JA Modifier for the intravenous infusion of the drug or billed with JB Modifier for subcutaneous injection of the drug.The lists below are not an all-inclusive list and may be subject to further revision.Subcutaneous and Intramuscular Injection Non-ChemotherapyThe administration of the following drugs should not be billed using a chemotherapy administration code. Instead, the administration of the following drugs in their subcutaneous or intramuscular forms should be billed using CPT code 96372, (therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular).To avoid unnecessary rejections, claims for these types of drugs and their non-chemotherapy administration should be billed as a pair on a separate claim from any chemotherapy.Generic/Trade Names:
Article - Complex Drug Administration Coding (A59272)
Generic NameTrade NameHCPCS CodebenralizumabFasenraJ0517canakinumabIlarisJ0638certolizumab pegol*Cimzia*J0717*denosumabProlia/XygevaJ0897filgrastim (g-csf) excludes biosimilars ***Neupogen **J1442**tbo-filgrastimGranixJ1447filgrastim-sndz biosimilar **Zarxio**Q5101**filgrastim-aafi **Nivestym**Q5110**luspatercept-aamtReblozyl J0896mepolizumabNucalaJ2182octreotide acetate depotSandotstatin LAR depotJ2353omalizumabXolairJ2357pegfilgrastim, excludes biosimilar**Neulasta**J2506*pegfilgfrastim-jmdb, biosimilarFulphilaQ5108pegfilgrastim-cbqvUdenycaQ5111pegfigrastim-bmezZiextenzoQ5120pegfilgrastim-apgf, biosimilarNyvepriQ5122rilonaceptArcalystJ2793tezepelumab-ekkoTezspireJ2356tildrakizumab-asmnIlumyaJ3245*Note: Effective 01/01/2018 providers are instructed to use 96377 for the on body application injector for Neulasta Onpro Kit.**When billing filgrastim (HCPCS code J1442, Q5101 or Q5110), append the JA modifier for the IV formulation or the JB modifier for the subcutaneous formulationInfusions Non-Chemotherapy