evekhm/cms_iom_500 huggingface dataset:
Draft Article - Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM) (DA58136)
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) L38664 Implantable Continuous Glucose Monitors (I-CGM). 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.For 90-day implantable glucose sensor report:CPT code 0446T - Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient trainingRemovalof an I-CGM is reported with:CPT code 0447T - Removal of implantable interstitial glucose sensor from subcutaneous pocket via incisionRemoval with immediate subsequent replacementof an I-CGM is reported with:CPT code 0448T - Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activationDocumentation 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.
Draft Article - Billing and Coding: Cervical Fusion (DA59668)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)National Correct Coding Initiative (NCCI):Medicare NCCI Policy Manual,Chapter 1, General Correct Coding Policies for Medicare National Correct Coding Initiative Policy ManualSocial 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 Proposed Local Coverage Determination (LCD) DL39793 Cervical Fusion. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceThis article applies only to cervical fusion and related procedures and does not apply to other joint procedures (such as facet, sacroiliitis, epidural or other spinal procedures).Providers should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.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.Notice: 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.Documentation Requirements
Draft Article - Billing and Coding: Cervical Fusion (DA59668)
Notice: 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.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 patients medical record should include, but is not limited to:The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit.Relevant medical history.Results of pertinent tests/procedures.Signed and dated office visit record/operative report. (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)The operative note should include the procedure performed and any associated/additional procedures performed at the same time.Documentation to support the medical necessity of the procedure(s).Use of BiologicalsThere are currently no FDA approved biologicals to be injected into the joint at the time of surgery. The inclusion of biological and/or other non-FDA approved substances in the injectant will result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180. Amniotic and placenta derived injectants, amino acids, vitamins, and platelet rich plasma fall in this category.
Draft Article - Billing and Coding: Infliximab and biosimilars (DA52423)
CMS National Coverage PolicyN/AArticle TextThis article contains billing and coding guidelines that complement the Local Coverage Determination (LCD) Drugs and Biologicals, Coverage of, for Label and Off-Label Uses.Abstract:Infliximab is a chimeric monoclonal antibody that binds to tumor necrosis factor alpha (TNFa), which is believed to be critical to the human bodys reaction to inflammation. TNFa is a cytokine that is a key biologic response mediator found to be increased in such chronic and inflammatory disorders as Crohns disease and rheumatoid arthritis, among others.Infliximab-dyyb is the second biosimilar of reference biologic Remicade (infliximab)Infliximab-abda and infliximab axxq are other biosimilars of reference biologic Remicade (infliximab)Documentation Requirements:Medical records should include:1) The basis for each diagnosis and that the diagnosis was made in accordance with recognized standards such as guidelines published by the American College of Rheumatology (ACR).2) Weight when needed to determine appropriate dosing.3) Evaluation for latent tuberculosis infection through medical evaluation and TB test. Treatment of latent tuberculosis infection should be initiated prior to therapy with infliximab.4) Documentation of the disease specific relevant symptoms and signs which are both being treated and being followed to assess for response to treatment.5) Documentation of Inadequate Response (includes lack of efficacy, adverse effects prohibiting further use of the drug or medical contraindications) to a 3 month trial of appropriately dosed and disease specific conventional (non-biologic) therapy).Crohns disease: Relevant information includes the presence and severity of abdominal pain, diarrhea, extra-intestinal manifestations, enterocutaneous and/or rectovaginal fistulae. Retreatment of patients with Crohns disease will be covered when the medical record substantiates that the patient had a reduction in the clinical signs and symptoms of the disease after the initial treatment.
Draft Article - Billing and Coding: Infliximab and biosimilars (DA52423)
Plaque Psoriasis: For the treatment of plaque psoriasis, documentation to support that the conditions is chronic, severe, extensive or disabling could include percent body surface area (BSA) affected; Psoriasis Area Severity Index (PASI) score; Psoriasis Disability Index (PDI) score; and/or results from other psoriasis assessment tool(s). Infliximab given to treat plaque psoriasis should only be administered to patients who will be closely monitored and have regular follow-up visits with a physician. Psoriasis patients should be monitored for nonmelanoma skin cancers, particularly those patients who have had prior prolonged phototherapy treatment.Rheumatoid Arthritis: To support the continued use of infliximab beyond 30 weeks for the treatment of rheumatoid arthritis, the medical record must include evidence of at least 20% improvement in tender joint count and at least 20% improvement in swollen joint count. The patients medical record mustdocument that the patient is also receiving methotrexate orclearly indicates the reason that the patient cannot take methotrexate.Utilization:Dose and frequency for infliximaband biosimilars,should be in accordance with the FDA label or recognized compendia (for off-label uses). When services are performed in excess of established parameters, they may be subject to review for medical necessity.Services performed for excessive frequency are subject to denial as not medically necessary. Frequency is considered excessive when services are performed more frequently than recommended in the FDA-approved package insert.Coding Information:Claims submitted for treatment of pyoderma gangrenosum with coexisting inflammatory bowel disease must be submitted with a primary and a secondary ICD-10-CM code. If both the primary and secondary ICD-10-CM codes are not indicated on the claim, the service will be denied.For claims submitted to the Part B MAC:Infliximaband biosimilars are available in 100-mg vials. The dosage associated with the HCPCS code is 10 mg. The number of units (rounded up to a whole unit) used, should be entered in Item 24G of the CMS 1500 claim form or the electronic equivalent.
Draft Article - Billing and Coding: Infliximab and biosimilars (DA52423)
The following is an example of the correct reporting methodology for infliximaband biosimilars:If the dosage administered is 375 mg, 4 vials (or a total of 400 mg) will be used. Report this with a "40" in the units field. Since this will result in product wastage, the JW modifier should be applied to the amount of the drug or biological that is discarded and should be billed as a separate line item. Effective July 1, 2023, the JZ modifier should be reported on all claims that bill for infliximab and biosimilars when there are no discarded amounts from single-dose containers or single-use packages.FDA and Compendia Review:
Draft Article - Billing and Coding: Infliximab and biosimilars (DA52423)
FDA and Compendia Review:American Society of Health-System Pharmacists, Inc.AHFS Drug Information.Bethesda, MD: 2007.Clinical Pharmacology Web site. http://www.clinicalpharmacology.com/. Accessed 09/05/2022.FDA label for infliximab-dyyb (Inflectra). FDA Web site: http://www.accessdata.fda.gov/scripts/cder/drugsatfda/. Accessed on 06/08/2016FDA label for infliximab-abda (Renflexis). FDA Web site: https://www.accessdata.fda.gov/scripts/cder/daf/index. Accessed on 08/21/2017.FDA label for inflizimab-axxq (Avsola). FDA Web site: https://www.accessdata.fda.gov/scripts/cder/daf/. Accessed on 07/14/2020.Lexi-Drugs Web site. http://online.lexi.com. Accessed 09/05/2022.Micromedex DrugDex. Thomson Web site. http://www.thomsonhc.com/home/dispatch. Accessed 09/05/2022.National Comprehensive Cancer Network Web site. http://www.nccn.org/index.asp. Accessed 09/05/2022.U.S. Food and Drug Administration label approved 08/24/1998 accessed on line athttp://www.accessdata.fda.gov/scripts/cder/drugsatfda/ on 02/01/2008.United States Pharmacopoeia (USP), Volume I; Drug Information for the Health Care Professional, 2007.
Draft Article - Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) (DA59672)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ) DL39797.Coding InformationProcedure codes may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and National Provider Identifier (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 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.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD (SeeCoverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Medical record documentation must be available to Medicare upon request.
Draft Article - Billing and Coding: Cervical Fusion (DA59674)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)National Correct Coding Initiative (NCCI):Medicare NCCI Policy Manual,Chapter 1, General Correct Coding Policies for Medicare National Correct Coding Initiative Policy ManualSocial 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 Proposed Local Coverage Determination (LCD) DL39799 Cervical Fusion. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceThis article applies only to cervical fusion and related procedures and does not apply to other joint procedures (such as facet, sacroiliitis, epidural or other spinal procedures).Providers should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.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.Notice: 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.Documentation Requirements
Draft Article - Billing and Coding: Cervical Fusion (DA59674)
Notice: 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.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 patients medical record should include, but is not limited to:The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit.Relevant medical history.Results of pertinent tests/procedures.Signed and dated office visit record/operative report. (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)The operative note should include the procedure performed and any associated/additional procedures performed at the same time.Documentation to support the medical necessity of the procedure(s).Use of BiologicalsThere are currently no FDA approved biologicals to be injected into the joint at the time of surgery. The inclusion of biological and/or other non-FDA approved substances in the injectant will result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180. Amniotic and placenta derived injectants, amino acids, vitamins, and platelet rich plasma fall in this category.
Article - MolDX: Defining panel services in MolDX (A59678)
CMS National Coverage PolicyN/AArticle Text
Article - MolDX: Defining panel services in MolDX (A59678)
Medical testing services have become more comprehensive and complex over time. In the past, it was generally considered that any given condition could be diagnosed or defined with a single analyte test. Additionally, limits in technology meant that if any additional testing was necessary, an independent and subsequent service would need to be performed. Neither condition above is true today. First, many diseases require multiple genetic or other relevant analytes to be assessed simultaneously for either diagnosis or to inform the clinician on subsequent medical interventions; second, tests today are more comprehensive and parallelized, such that many analytes can be obtained at once, reducing waste and turnaround time while also increasing accuracy. As such, the old model of one gene/analyte for one disease must be wholly discarded for a majority of disorders known today.The National Correct Coding Initiative (NCCI), reflecting CMS policy, provides instruction with this line of thinking, as outlined in Chapter 10, particularly section F pertaining to Molecular Pathology. Effectively, if a multianalyte test is performed, it should be billed as a single service. If no specific code exists for that panel, it is not appropriate to bill for the components of that service (this constitutes unbundling) and should be billed with the NOC codes such as 81479, 81599, or 87999, depending on analytes measured.Additionally, the role of the payor is to pay for services that have demonstrated medical value (reasonable and necessary in the case of Medicare), and the role of coding with the payor is to ensure clarity on the service performed. Ensuring panels are appropriately billed as a single service greatly reduces the complexity and confusion in billing.Here, we define a distinction between the performance of a medical service as a panel or a discrete single analyte service. Of note this was similarly defined for germline panels in article A57503 in the Medicare Coverage Database.Defining criteria:A service is a panel if:1. If aclinician orders a group of molecular analytes (more than 1) marketed as a single service;2. The service contains multiple analytes (more than 1) that would result in a single result or single report or several independent services are performed that would result in a single result; OR
Article - MolDX: Defining panel services in MolDX (A59678)
2. The service contains multiple analytes (more than 1) that would result in a single result or single report or several independent services are performed that would result in a single result; OR3. The medical value of the service/s performed is only obtained if more than one analyte is measured and the analytes are generally performed together. As an example, if 2 analytes (A and B) are tested, and BOTH must be performed together to have medical value, then it is a panel because analyte A or B alone is insufficient to provide medical value even if each analyte independently provides partial medical information; OR4.If multiple analytes (more than 1) are measured in parallel, regardless of how they are performed or reportedOf note, it is not particularly relevant if the analytes are measured with different instruments or reagents. We consider these internal lab processes that are not relevant to the test ordered, the relevance of the analytes measured, and the resultant report.
Article - MolDX: Defining panel services in MolDX (A59678)
A service is NOT a panel if a single analyte is measured defined by a single CPT code, and that single analyte alone provides the necessary information for proper patient management without other analytes being measured for the same disease indication.Examples of a panel:A service of 2, 5, 10, or 500 genes for evaluating a patient with colorectal cancer, with or without RNA analysisA screening test looking for 5 commonly mutated genes in the prenatal settingA test that measures multiple alterations within a gene with one or more assays that have more than one associated CPT code, such as DMD sequence AND copy number analysisA respiratory pathogen test that includes 2 or more pathogens that must generally be tested together for relevance, for example Influenza A/B, RSV, and COVID-19
Article - External Upper Limb Tremor Stimulator Therapy - Policy Article (A59680)
CMS National Coverage PolicyN/AArticle Text