evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography (A57183)
Document the necessity for the test frequency, when applicable.Document (preferably on the test report) that any applicable physician supervision requirement is met.For tests performed by leased employees, maintain the leasing contract on file (e.g., in the office) and submit it to the contractor for review upon request.Utilization Guidelines:Stress testing is covered only at a frequency appropriate for the patients condition, and when the results will potentially affect the patients treatment.A routine follow-up test after an MI, CABG, or PTCA, in the absence of symptoms or clinical indications, outside of the reassessment period, is not reasonable and necessary. Annual testing in the absence of individualized clinical indications is not reasonable and necessary. For example, a patient who has had a MI, CABG, PTCA, or other coronary revascularization procedure may require an initial follow-up stress test several months later and a second test one year after the first follow-up test. Thereafter, a patient who initially presented with silent coronary disease (no reliable signs or symptoms) may require testing as often as annually. However, a patient who initially presented with reliable symptoms or signs of CAD (e.g., angina pectoris) typically will not need annual testing. When the clinical information is sufficient to reliably monitor the patient, an additional follow-up test once every five years may be sufficient.
Article - Billing and Coding: Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography (A57184)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made for items or 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.Title XVIII of the Social Security Act, 1862(a)(7) and 42 Code of Federal Regulations, Section 411.15, exclude routine physical examinations.Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 13, 50-50.4, and CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 12, 20.4.4, allows for a separate payment for the supply of a radiopharmaceutical diagnostic imaging agent and/or pharmacologic stressing agent with diagnostic nuclear medicine procedures.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 15, 50. This section specifies coverage for drugs and biologicals.CMS Manual System, Pub. 100-03,Medicare National Coverage Determinations Manual,Chapter 1, 20.10; Supplies, regarding pharmaceutic stressing agents. (Repealed 02/22/2010,see Pub. 100-04, Ch. 32, 140.)The Code of Federal Regulations (CFR), 42 CFR 410.32, specifies that all diagnostic tests must be ordered by the physician who is treating the beneficiary.Section 4317(b), of the Balanced Budget Act (BBA) of 1997, specifies that referring physicians are required to provide diagnostic information to the testing entity at the time the test is ordered.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 15, 80.6.1; Requirements for Ordering and Following Orders for Diagnostic Tests and Definitions.CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 12, 30.6.6.B, clarifies coverage for preoperative evaluations.
Article - Billing and Coding: Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography (A57184)
CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 12, 30.6.6.B, clarifies coverage for preoperative evaluations.CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 13, 20, 20.1, 20.2, 20.2.2, 20.2.3, 20.3.1 and 20.3.2; Payment conditions for Radiology Services.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 15, 80, Requirements for Diagnostic X-Ray, Diagnostic Laboratory and other Diagnostic Tests sets forth the various levels of physician supervision required for diagnostic tests.CMS Manual System, Pub.100.04,Medicare Claims Processing Manual,Chapter 32, 140.1, 140.1.1, 140.2, 140.2.2.1, 140.2.2.3, 140.2.2.4, 140.2.2.5, 140.2.2.6, 140.3, 140.3.1., Cardiac Rehabilitation.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Supportive documentation evidencing the condition and treatment is expected to be documented in the medical record and be available upon request.Documentation in the patients medical record must substantiate the medical necessity of the service, including the following: A clinical diagnosis, The specific reason for the study, Reason for performing a stress echocardiogram as opposed to only an electrical stress test, The reason for using any pharmacological stress, and The reason for a stress echocardiogram if a stress nuclear test is also performed for the same patient for the same clinical condition.Document the referral order (written or verbal) in the patients medical record. For example, if a referring physician calls a cardiologist to order a stress echocardiogram, the test report or office record must document the date of the call, name of the referring physician, and reason for referral.Document the interpretation and report of all segments of the service (e.g., the electrical and echo results).Document the necessity for the test frequency, when applicable.Document (preferably on the test report) that any applicable physician supervision requirement is met.
Article - Billing and Coding: Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography (A57184)
Document the necessity for the test frequency, when applicable.Document (preferably on the test report) that any applicable physician supervision requirement is met.For tests performed by leased employees, maintain the leasing contract on file (e.g., in the office) and submit it to the contractor for review upon request.Utilization Guidelines:Stress testing is covered only at a frequency appropriate for the patients condition, and when the results will potentially affect the patients treatment.A routine follow-up test after an MI, CABG, or PTCA, in the absence of symptoms or clinical indications, outside of the reassessment period, is not reasonable and necessary. Annual testing in the absence of individualized clinical indications is not reasonable and necessary. For example, a patient who has had a MI, CABG, PTCA, or other coronary revascularization procedure may require an initial follow-up stress test several months later and a second test one year after the first follow-up test. Thereafter, a patient who initially presented with silent coronary disease (no reliable signs or symptoms) may require testing as often as annually. However, a patient who initially presented with reliable symptoms or signs of CAD (e.g., angina pectoris) typically will not need annual testing. When the clinical information is sufficient to reliably monitor the patient, an additional follow-up test once every five years may be sufficient.
Article - Billing and Coding: Botulinum Toxin Types A and B Policy (A57185)
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 medically reasonable and necessary.Title XVIII of the Social Security Act, 1833(e). Prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.CMS Manual System, Publication 100-02,Medicare Benefit Policy Manual,Chapter 16, 120. General Exclusions from Coverage (Cosmetic Surgery).Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation must support the medical necessity of this service as outlined in the Indication and Limitations of Coverage and/or Medical Necessity section of the LCD Botulinum Toxin Types A and B.Additional Documentation Requirement:The patient's medical record should include the following elements to support the medical necessity of the botulinum toxin injection:Type of botulinum toxin used: Botox (onabotulinumtoxinA), Dysport (abotulinumtoxinA), Xeomin (incobotulinumtoxinA) or Myobloc (rimabotulinumtoxinB)Strength of toxin usedA covered diagnosis (However, when a form of botulinum toxin is used for an indication that is not a listed indication in the AHFS, a physician statement in the medical record stating the reason(s) why the unapproved form was used is also required).A statement that traditional methods of treatments have been tried and proven unsuccessful (except for focal dystonia, hemifacial spasm, orofacial dyskinesia, blepharospasm, severe writers cramp, laryngeal spasm, or dysphonia).Dosage used in the injections.Support for the medical necessity of electromyography procedures if performed.Support of the clinical effectiveness of the injections.A complete anatomic description of the site(s) injected.
Article - Billing and Coding: Botulinum Toxin Types A and B Policy (A57185)
When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary.Due to the short life of botulinum toxin, Medicare will reimburse the unused portion of these drugs. (R3538CP-1) Therefore, scheduling of more than one patient, where possible, is allowed to prevent wastage of botulinum toxin.In all cases, the documentation must show the exact dosage of the drug given to the patient, the reason for unavoidable wastage, and the amount of the discarded portion of the drug.If a single dose vial is split between multiple patients, Medicare will allow payment only for the portion used for the beneficiary plus a pro rata amount for wastage. Note that if non-Medicare patients are treated with a portion of the same vial, it would be expected that those non-Medicare patients be billed for their pro rata share of wastage.Bill Medicare patients for wastage using the -JW modifier on a separate line and the appropriate number of units, rounded to the nearest unit such that the total billed does not exceed the contents of the vial.For split vials, for example, if patient 1 received 30 units and patient 2 received 60 units from a 100 unit vial, wastage billed with -JW would be:patient 1: 3 units [(30 units used for the patient/90 total units used) * 10 units of wastage = 3.33 rounded to 3]patient 2: 7 units [(60 units used for the patient/90 total units used) * 10 units of wastage = 6.66 rounded to 7]If additional vials are needed to address the needs of a set of patients, pro rata wastage should be calculated over the total vial volume for that session. Furthermore it is expected that a provider will use the most economical combination of vials that will meet the needs of a set of patients should multiple sizes be available.If the HCPCS code for the administered drug represents other than 1 unit of drug (e.g., 100 units of the drug could be 1 HCPCS unit) rounding should be in relation to the nearest full HCPCS unit for the administered drug (rounded down)and any reported wastage (rounded up, but not to exceed the total contents of the vial)
Article - Billing and Coding: Botulinum Toxin Types A and B (A57186)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.CMS Manual System, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, 120. General Exclusions from Coverage (Cosmetic Surgery).Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation must support the medical necessity of this service as outlined in the Indication and Limitations Of Coverage and/or Medical Necessity section of the LCD Botulinum Toxin Types A and B (L35172).Additional Documentation Requirements:The patient's medical record should include the following elements to support the medical necessity of the botulinum toxin injection:Type of botulinum toxin used: Botox (onabotulinumtoxinA), Dysport (abotulinumtoxinA), Xeomin (incobotulinumtoxinA) or Myobloc (rimabotulinumtoxinB)Strength of toxin usedA covered diagnosis (However, when a form of botulinum toxin is used for an indication that is not a listed indication in the AHFS, a physician statement in the medical record stating the reason(s) why the unapproved form was used is also required).A statement that traditional methods of treatments have been tried and proven unsuccessful (except for focal dystonia, hemifacial spasm, orofacial dyskinesia, blepharospasm, severe writers cramp, laryngeal spasm, or dysphonia).Dosage used in the injections.Support for the medical necessity of electromyography procedures if performed.Support of the clinical effectiveness of the injections.A complete anatomic description of the site(s) injected.
Article - Billing and Coding: Botulinum Toxin Types A and B (A57186)
When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary.Due to the short life of botulinum toxin, Medicare will reimburse the unused portion of these drugs. (R3538CP-1) Therefore, scheduling of more than one patient, where possible, is allowed to prevent wastage of botulinum toxin.In all cases, the documentation must show the exact dosage of the drug given to the patient, the reason for unavoidable wastage, and the amount of the discarded portion of the drug.If a single dose vial is split between multiple patients, Medicare will allow payment only for the portion used for the beneficiary plus a pro rata amount for wastage. Note that if non-Medicare patients are treated with a portion of the same vial, it would be expected that those non-Medicare patients be billed for their pro rata share of wastage.Bill Medicare patients for wastage using the -JW modifier on a separate line and the appropriate number of units, rounded to the nearest unit such that the total billed does not exceed the contents of the vial.For split vials, for example, if patient 1 received 30 units and patient 2 received 60 units from a 100 unit vial, wastage billed with -JW would be:patient 1: 3 units [(30 units used for the patient/90 total units used) * 10 units of wastage = 3.33 rounded to 3]patient 2: 7 units [(60 units used for the patient/90 total units used) * 10 units of wastage = 6.66 rounded to 7]If additional vials are needed to address the needs of a set of patients, pro rata wastage should be calculated over the total vial volume for that session. Furthermore it is expected that a provider will use the most economical combination of vials that will meet the needs of a set of patients should multiple sizes be available.If the HCPCS code for the administered drug represents other than 1 unit of drug (e.g., 100 units of the drug could be 1 HCPCS unit) rounding should be in relation to the nearest full HCPCS unit for the administered drug (rounded down)and any reported wastage (rounded up, but not to exceed the total contents of the vial)
Article - Billing and Coding: Immune Globulin Intravenous (IVIg) (A57187)
CMS National Coverage PolicyTitle XVIII of the Social security Act; Section 1862(a)(1)(A) section allows coverage and payment for only those services that are considered to be reasonable and necessary.Title XVIII of the Social Security Act; Section 1833(e). This section prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.CMS Manual, Pub.100-2, Chapter 15, section 50.4 and section 50.4.2. This section addresses coverage of drugs and biologicals.CMS Manual, Pub.100-3, Chapter 1, Section 250.3. This section describes coverage for IVIg for treatment of Autoimmune Mucocutaneous Blistering Diseases."Intravenous immune globulin (IVIg) is a blood product prepared from the pooled plasma of donors. It has been used to treat a variety of autoimmune diseases, including mucocutaneous blistering diseases. It has fewer side effects than steroids or immunosuppressive agents.Effective October 1, 2002, IVIg is covered for the treatment of biopsy-proven: (1) Pemphigus Vulgaris, (2) Pemphigus Foliaceus, (3) Bullous Pemphigoid, (4) Mucous Membrane Pemphigoid (a.k.a., Cicatricial Pemphigoid), and (5) Epidermolysis Bullosa Acquisita for the following patient subpopulations: Patients who have failed conventional therapy. Contractors have the discretion to define what constitutes failure of conventional therapy; Patients in whom conventional therapy is otherwise contraindicated. Contractors have the discretion to define what constitutes contraindications to conventional therapy; or Patients with rapidly progressive disease in whom a clinical response could not be affected quickly enough using conventional agents. In such situations IVIg therapy would be given along with conventional treatment(s) and the IVIg would be used only until the conventional therapy could take effect.In addition, IVIg for the treatment of autoimmune mucocutaneous blistering diseases must be used only for short-term therapy and not as a maintenance therapy. Contractors have the discretion to decide what constitutes short-term therapy."See associated article for ICD-10 diagnosis codes.
Article - Billing and Coding: Immune Globulin Intravenous (IVIg) (A57187)
See associated article for ICD-10 diagnosis codes.CMS Manual, Pub. 100-2, Chapter 15, Section 50.6. This section describes coverage of IVIg for the treatment of Primary Autoimmune Deficiency Disease in the home."Beginning for dates of service on or after January 1, 2004, The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provides coverage of intravenous immune globulin (IVIg) for the treatment of primary immune deficiency diseases (ICD-10 diagnosis codes D80.0, D80.2, D80.3, D80.4, D80.5, D80.6, D80.7, D81.0, D81.1, D81.2, D81.5, D81.6, D81.7, D81.89, D81.9, D82.0, D82.1, D82.4, D83.0, D83.1, D83.2, D83.8, D83.9 and G11.3) in the home. The Act defines intravenous immune globulin as an approved pooled plasma derivative for the treatment of primary immune deficiency disease. It is covered under this benefit when the patient has a diagnosed primary immune deficiency disease, it is administered in the home of a patient with a diagnosed primary immune deficiency disease, and the physician determines that administration of the derivative in the patient's home is medically appropriate. The benefit does not include coverage for items or services related to the administration of the derivative. For coverage of IVIg under this benefit, it is not necessary for the derivative to be administered through a piece of durable medical equipment."See associated article for ICD-10 diagnosis codes.Article TextThe following billing coding and guidance is to be used with its associated Local Coverage Determination.Medical record documentation maintained by the treating physician must clearly document the medical necessity to initiate IVIg therapy and the continued need thereof. Required documentation of medical necessity could include: History and physical; Office/progress note(s); Test results with written interpretation; and An accurate weight in kilograms should be documented prior to the infusion since the dosage is based mg/kg/dosage.
Article - Billing and Coding: Routine Foot Care (A57188)
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 Text
Article - Billing and Coding: Routine Foot Care (A57188)
Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33941 Routine Foot Care. 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.In order for routine foot care to be a covered service, the patient must have one or more of the diagnoses listed under the ICD-10 Codes that Support Medical Necessity section. Otherwise, the service is noncovered and should be coded with a GY modifier (Item or service statutorily excluded or does not meet the definition of any Medicare benefit).An evaluation and management visit will be paid on the same day as routine foot care only if the visit was medically necessary and was for a significant, separately identifiable service, and the modifier 25 is used.For the treatment of mycotic nails, please refer to the LCD L33922 Nail Debridement for indications and limitations.On all claims submitted by a podiatrist with ICD-10-CM diagnosis codes containing an asterisk on the tables below, the name of the M.D., D.O., or non-physician practitioner (PA or NP) who diagnosed the complicating condition must be submitted with the claim. The approximate date the beneficiary was last seen by the physician/ non-physician practitioner must also be indicated.On all claims submitted by a podiatrist with ICD-10-CM diagnosis codes with non-asterisked conditions, the name of the M.D., D.O., or non-physician practitioner (PA or NP) or the podiatrist who diagnosed the complicating condition must be on the claim form.For all providers submitting claims for routine foot care with ICD-10-CM diagnosis codes in the Group 2 Codes table below, the claims should use the appropriate modifiers (Q7, Q8, or Q9) to indicate the findings the provider has made on the patients condition.Q7 = One Class A findingsQ8 = Two Class B findingsQ9 = One Class B and two Class C findingsClass A FindingsNontraumatic amputation of foot or integral skeletal portion thereof
Article - Billing and Coding: Routine Foot Care (A57188)
Q7 = One Class A findingsQ8 = Two Class B findingsQ9 = One Class B and two Class C findingsClass A FindingsNontraumatic amputation of foot or integral skeletal portion thereofClass B FindingsAbsent posterior tibial pulse, orAbsent dorsalis pedal pulse, orThree of the following advanced tropic changes are required to meet one class B finding:Hair growth (decrease or absence)Pigmentary changes (discoloration)Skin color (rubor and redness)Nail changes (thickening)Skin texture (thin, shiny)Class C FindingsClaudication (pain in calf when walking)Temperature changes in the feet (e.g., cold feet)EdemaParathesias (abnormal spontaneous sensations in the feet, e.g., tingling)BurningFor patients with peripheral neuropathy involving the feet but without vascular impairment, claims would be submitted without the Q7, Q8, or Q9 modifiers. Use the ICD-10-CM diagnosis codes in the Group 3 Codes table below.For patients requiring anticoagulation therapy, use the ICD-10-CM diagnosis codes in the Group 4 Codes table below.Documentation Requirements