evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Allergy Immunotherapy (A56424)
The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Include in the record the following information: Medical history, examination, and results of diagnostic testing (including allergy testing) upon which the need for the treatment is based.A plan of treatment and dosage regimen must be documented in the patients medical record. The record should be prepared so that the data regarding injection and responses can be appreciated in a logical and sequential sense.When an evaluation and management service is billed on the same day as allergen immunotherapy (by the same physician) a separately identifiable service must be documented in the medical record.Documentation must support the use of the code (e.g., number of venoms, number of vials).Documentation must be available to Medicare upon request.Other Comments:For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS to process their claims.Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.
Article - Billing and Coding: Allergy Immunotherapy (A56424)
Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.
Article - Billing and Coding: B-type Natriuretic Peptide (BNP) Testing (A56425)
CMS National Coverage PolicySection 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claimCMS Publication 100-04,Medicare Claims Processing Manual, Chapter 9: 100 General Billing RequirementsCMS Publication.100-04,Medicare Claims Processing Manual, Transmittal No. 820, Change Request #4210, dated 2/1/2006, changes the revenue codes both RHCs and FQHCs use when billing for RHC/FQHC services.Article TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L33943 B-type Natriuretic Peptide (BNP) Testing.As a diagnostic test, BNP testing is not expected to be performed more than four times in a given year. See the Indications and Limitations of Coverage section (above) for frequency parameters for BNP testing to monitor the effectiveness of nesiritide therapy.The use of BNP for monitoring CHF is not covered.General Guidelines for Claims submitted to Part A or Part B MAC: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. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. 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. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Article - Billing and Coding: B-type Natriuretic Peptide (BNP) Testing (A56425)
Advance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.
Article - Billing and Coding: B-type Natriuretic Peptide (BNP) Testing (A56425)
The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Other Comments:For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS to process their claims.Bill type codes only apply to providers who bill these services to the Part A MAC Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.
Article - Billing and Coding: Topical Oxygen Therapy (A56431)
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.42 CFR 410.27(f) Therapeutic outpatient hospital or CAH services and supplies incident to a physicians or nonphysician practitioners service: ConditionsCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, 30.1 Billing Requirements for HBO Therapy for the Treatment of Diabetic Wounds of the Lower ExtremitiesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Topical Oxygen Therapy L37873 Local Coverage Determination (LCD).
Article - Billing and Coding: Infliximab (A56432)
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.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Infliximab L35677.
Article - Billing and Coding: Hemophilia Factor Products (A56433)
CMS National Coverage PolicyInternet-Only Manuals (IOMs):CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 17, Section 80.4 Billing for Hemophilia Clotting Factors, Section 80.4.1 Clotting Factor Furnishing FeeSocial 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 periodArticle TextThis Billing and Coding Article provides billing and coding guidance for Hemophilia Factor Products.Coding GuidanceNotice: It is not appropriate to bill Medicare for services that are not covered as if they are covered. When billing for non-covered services, use the appropriate modifier.The Centers for Medicare & Medicaid Services (CMS) provided CR4229 to clarify billing practices for providers to ensure that units of service for blood clotting factor are reported accurately. Some Medicare providers have been billing units of drugs and biologicals incorrectly on outpatient bills as well as on inpatient claims for hemophilia clotting factors. The erroneous reporting of units of service has resulted in Medicare overpayments (reference Medicare Learning Network [MLN] Matters Number: 4229).General Billing InstructionsThe provider determines the dosage of hemophilia factor furnished to the beneficiary and using the definition of the appropriate HCPCS code, translates the dosage into units of service(s). See example below on translating the dosage administered into units of service.Note:Not all short version descriptions of HCPCS codes define units for the HCPCS code. Providers are reminded to refer to the long descriptors of the HCPCS codes in their HCPCS book.
Article - Billing and Coding: Hemophilia Factor Products (A56433)
Note:Not all short version descriptions of HCPCS codes define units for the HCPCS code. Providers are reminded to refer to the long descriptors of the HCPCS codes in their HCPCS book.When submitting claims for hemophilia clotting factors it is essential to submit the correct Quantity Billed (QB) to receive the correct reimbursement. Some of the codes are based on international unit (IU) and some may be per milligram (mg) or microgram (mcg) as specified in the code descriptor. Therefore, the units of service(s) reported should reflect the number of IU, mg, or mcg being administered.JW and JZ ModifiersWhen billing for Part B drugs and biologicals (except those provided under a competitive acquisition program [CAP]), the use of the JW modifier to identify unused drugs or biologicals from single-dose containers or single-use packages that are appropriately discarded is required. The discarded amount shall be billed on a separate claim line using the JW modifier. Providers are required to document the discarded drug or biological in the patients medical record.Any amount wasted must be clearly documented in the medical record and should include the date and time, amount of medication wasted, and the reason for the wastage.The use of the JZ modifier (attesting that there were no discarded amounts) is required on claims to report there are no discarded amounts of unused drugs or biologicals from single-dose containers or single-use packages.Claims for drugs separately payable under Medicare Part B from single-dose containers are required to report either the JW or JZ modifier, to identify any discarded amounts or to attest that there are no discarded amounts, respectively.The JW and JZ modifier policy does not apply for drugs that are not separately payable, such as packaged OPPS or ASC drugs, or drugs administered in the FQHC or RHC setting.The JW and JZ modifiers do not apply to drugs assigned status indicator N (Items and Services Packaged into APC Rates) under the OPPS. Similarly, the JW and JZ modifiers do not apply to drugs assigned payment indicator N1 (ASC).Example of Translating the Dosage Administered into Units of ServiceHCPCS CodeShort DescriptorBilling UnitDosage AdministeredUnits of Service
Article - Billing and Coding: Hemophilia Factor Products (A56433)
Example of Translating the Dosage Administered into Units of ServiceHCPCS CodeShort DescriptorBilling UnitDosage AdministeredUnits of ServiceJ7189Factor viiaPer mcg (1mcg)13,365 mcg13,365The provider would calculate the units of service with this equation: 13,365 mcg divided by 1 mcg equals 13,365. Note that the process for calculations based on one IU or one mg is the same as the process for calculations based on one mcg.After the dosage administered has been translated into the total number of units of service, then the provider determines if multiple claim lines should be billed. See Role of Medically Unlikely Edits (MUE) in Proper Billing.Role of Medically Unlikely Edits (MUE) in Proper BillingWhen billing for units of service on the same date of service for the same HCPCS code, MUEs play a role in proper billing and coding. The number of units of service reported on the same date of service for the same HCPCS code cannot have a claim line quantity that exceeds the MUE value for that HCPCS code or that exceeds 9,999 units per claim line.Refer to the CMS.gov website to verify theMUEfor each HCPCS code being billed. The units to bill per claim line can be determined by dividing the total number of units of service by the MUE value. However, if this amount is greater than 9,999 then an additional limitation will apply. See examples below.Billing Instructions when MUE isLess than9,999 Units Per LineIn the below example, the HCPCS code J7193 has a MUE Value of 4,000 units per line. This is the maximum number of units which can be billed per claim line (as per MUE Adjudication Indicator [MAI]). HCPCS code J7193 appears on the CMS.gov MUE spreadsheet as follows:HCPCSMUE ValueMUE Adjudication Indicator (MAI)MUE RationaleJ71934,0001 Line EditClinical: DataIf more than one line needs to be billed on the claim, the repeat service modifier (-76) must be appended to the second and subsequent lines.Example:
Article - Billing and Coding: Hemophilia Factor Products (A56433)
J71934,0001 Line EditClinical: DataIf more than one line needs to be billed on the claim, the repeat service modifier (-76) must be appended to the second and subsequent lines.Example:Using the HCPCS code J7193 from above, the MUE Value is 4,000 units per line. If 12,500 IUs were administered to a beneficiary on the same date of service, then the total number of units of service would be translated to 12,500 (based on the long descriptor, HCPCS code J7193 is per IU). The minimum number of claim lines to report this amount would be calculated as 4 lines (12,500  4,000 = 3.125, requiring 4 lines as shown below).LineDate of Service (From - To)Procedure Code/ModifierUnit of ServiceBilled Amount105 02 2022 - 05 02 2022J71934,000$4,520.00205 02 2022 - 05 02 2022J7193-764,000$4,520.00305 02 2022 - 05 02 2022J7193-764,000$4,520.00405 02 2022 - 05 02 2022J7193-76500$565.00Do not report a date range as the date of service. Indicate date span in the narrative of the claim. If the claim is for a monthly supply of clotting factor distributed to the beneficiary on the date of service, indicate monthly supply and the date span in the narrative of the claim or the EDI equivalent. For additional information on reporting DOS, see section below titled Date of Service (DOS).Billing Instructions when MUE isGreater than9,999 Units Per LineDue to system limitations, a maximum of 9,999 units of service may be billed on any one claim line. This limitation is applicable in addition to the established MUE limit for the HCPCS code. If the total number of units of service exceeds 9,999 divide the total number of units of service by the maximum number of units that can be billed on a claim line to determine the minimum number of claim lines to bill.Example:
Article - Billing and Coding: Hemophilia Factor Products (A56433)
Example:The MUE for HCPCS code J7192 is 22,000 units per line, which exceeds the system limit of 9,999 units per line. If 22,000 IUs were administered to a beneficiary on the same date of service, then the total number of units of service would be translated to 22,000 (based on the long descriptor, HCPCS code J7192 is per IU). The minimum number of claim lines to report this amount would be calculated as 3 lines (22,000  9,999 = 2.20, requiring 3 lines as shown below).LineDate of Service (From - To)Procedure Code/ModifierUnit of ServiceBilled Amount105 11 2022 - 05 11 2022J71929,999$13,489.65205 11 2022 - 05 11 2022J7192-769,999$13,489.65305 11 2022 - 05 11 2022J7192-762,002$2,702.70If reporting more than one line, bill all subsequent lines with modifier -76, repeat procedure. Do not report a date range as the date of service. Indicate date span in the narrative of the claim. If the claim is for a monthly supply of clotting factor distributed to the beneficiary on the date of service, indicate monthly supply and the date span in the narrative of the claim or the EDI equivalent.Billing for Not Otherwise Classified (NOC) CodesWhen billing NOC codes, enter the drug name, dosage and NDC in the claim narrative or the EDI equivalent. Report the number of units in the quantity billed field as 1.Dollar Amount Exceeds $99,999.99When providing a month supply and the total billed amount exceeds $99,999.99, two claims must be submitted.When billing two claims, ensure that the total dollar amounts are different on each claim.Example:The MUE for HCPCS code J7201 is 9,000 units per line. The beneficiary received 47,865 IUs of Factor IX (J7201) ($2.28 per unit). The billed amount is $109,132.20 for the same date of service. The claims should be billed as shown below.Claim one:
Article - Billing and Coding: Hemophilia Factor Products (A56433)
Claim one:Total Billed Amount is $99,998.52; total units would be 43,859.LineDate of Service (From - To)Procedure Code/ModifierUnit of ServiceBilled Amount106 01 2022 - 06 01 2022J72019,000$20,520.00206 01 2022 - 06 01 2022J7201-769,000$20,520.00306 01 2022 - 06 01 2022J7201-769,000$20,520.00406 01 2022 - 06 01 2022J7201-769,000$20,520.00506 01 2022 - 06 01 2022J7201-767,859$17,918.52Claim two:Total Billed Amount is $9,133.68; total units would be 4,006.LineDate of Service (From - To)Procedure Code/ModifierUnit of ServiceBilled Amount106 01 2022 - 06 01 2022J7201-764,006$9,133.68Note:Report a narrative description indicating "monthly billing" as well as the total number of units of service and total charge in item 19 of the 1500 claim form or the EDI equivalent.Date of Service (DOS)If the factor product is administered within a facility or "incident to" a physician service, the actual date the drug was administered should be reported as the DOS. If the factor product is being billed by a pharmacy to replenish the beneficiary's home supply, the date of delivery should be used as the DOS on the claim.Documentation Requirements
Article - Billing and Coding: Hemophilia Factor Products (A56433)
All 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.Medical record documentation maintained in the patients file must document the condition for which the blood clotting factor is being given.The name of the factor and the dosage required and/or given must be included in the records.This information is normally found in the office/progress notes, pharmacy forms, hospital records, and/or treatment notes.
Article - Billing and Coding: Blepharoplasty (A56439)
CMS National Coverage PolicyN/AArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L33944-Blepharoplasty.General Guidelines for Claims submitted to Part A or Part B MAC: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. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. 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. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.