evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Allergen Immunotherapy (A57678)
Please refer to the CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 12, Section 200 Allergy Testing and Immunotherapy for instructions on billing for allergy services.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 should support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code should describe the service performed.Documentation of any therapeutic expectations, level of antigens, time frame for administration, and any adjustments to the expectation based on local reactions, systemic reactions, missed dosing will need to be very clear in the medical records.Documentation for all references to the therapeutic effective dose in the medical record should be referenced to the maintenance concentrate and should be noted as a volume-to-volume dilution (e.g., 1:100 vol/vol dilution of maintenance concentrate).In the event that allergen immunotherapy is administered to a patient in a home setting, medical record documentation must clearly demonstrate that the benefits of immunotherapy outweigh the risks, include a copy of the patients informed consent, and include validation regarding the training and ability of the individual administering the injection to recognize and manage immunotherapy reactions, particularly anaphylaxis.
Article - Billing and Coding: Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities (A57680)
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) L36377 Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Per the Current Procedural Terminology (CPT) definition, skin substitute grafts include non-autologous skin (dermal or epidermal, cellular and acellular) grafts (e.g., homograft, allograft), non-human skin substitute grafts (i.e., xenograft), and biological products that form a sheet scaffolding for skin growth. Skin substitute graft codes are not to be reported for application of non-graft wound dressings (e.g., gel, powder, ointment, foam, liquid) or injected skin substitutes.Non-graft wound dressings or injected skin substitute codes are not used with skin replacement surgery application codes and are considered incorrect coding. Such products are bundled into other standard management procedures if medically necessary and not separately payable.Application procedure and associated supply must be coded correctly. The units of service must be reported correctly. The units of service billed for the supply must be accounted for in the medical record (i.e., amount used, amount discarded and reason for the discarded amount).Removal of current graft and/or simple cleansing of wound is included in the skin replacement surgery application codes. Active wound care management (CPT code 97602) procedures should never be reported.Documentation Requirements
Article - Billing and Coding: Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities (A57680)
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.The medical record must clearly show that the criteria listed in the LCD has been met, as well as, the appropriate diagnosis and response to treatment. Description of the wound(s) must be documented at baseline (prior to beginning conservative wound care measures) relative to size, location, stage, duration, and presence of infection, in addition to the type of treatment given and response. This information must be updated in the medical record throughout the episode of skin replacement surgery wound care. Wound description must also be documented pre- and post- treatment with the skin substitute graft being used. The reason(s) for any continued application should be specifically addressed in the medical record.Documentation should include an assessment (generally in an E/M service) outlining the plan for skin replacement surgery and the choice of skin substitute product for the 12 week period as well as any anticipated repeat applications in the 12 week period. An operative note must support the procedure (e.g., application of skin substitute graft to legs) for the relevant date of service (first application starts the 12 week episode of care). At a minimum, the operative note(s) should include pre and post op diagnosis, name of surgeon, anesthesia, reason for the procedure, complete description of the procedure including product used (with identifying package label in the chart), and relevant findings.Any amount of wasted skin substitute must be clearly documented in the procedure note with the following minimum information: Date, time and location of ulcer(s) treated; Name of skin substitute and how product supplied; Approximate amount of product unit used; Approximate amount of product unit discarded; Reason for the wastage; Manufacturers serial/lot/batch or other unit identification number of graft material. When manufacturer does not supply unit identification, record must document such.
Article - Billing and Coding: Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities (A57680)
Documentation requirements include addressing how product supplied, any wastage, etc. The HCPCS code of the applicable skin substitute and the units billed must be consistent with medical record in regard to wound description and size.
Article - Billing and Coding: Cystatin C Measurement (A57682)
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) L37561 Cystatin C Measurement. 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.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 laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition that warrants the test(s).
Article - Billing and Coding: Total Hip Arthroplasty (A57683)
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 following billing and coding guidance is to be used with its associated Local Coverage Determination.Documentation RequirementsIn order to qualify for coverage of both Medicare Part A inpatient services and Part B provider services the medical record must contain documentation that fully supports the medical necessity and justification of the procedure performed and must be made available to Noridian upon request. When the documentation does not meet the criteria for the service(s) rendered or the documentation does not establish the medical necessity for the service(s), such service(s) will be denied as not reasonable and necessary.A history and physical, discharge summary, physician progress notes and an operative report are typically in the hospital record for the procedures in this LCD.Other relevant information addressing coverage criteria related to the patients episode of care prior to the hospitalization, should be included in the hospital record (see below). Failure to include this information in the hospital record may result in denial of coverage for Part A services and trigger a review of the Part B provider claim to determine whether the Part B service rendered was reasonable and necessary.When the procedure is indicated for advanced joint disease, the following should be documented in the medical record: Arthritis of the hip supported by X-ray, MRI or CT. The X-ray, MRI or CT, as medically necessary, should demonstrate and the provider must document one or more of the following:a) subchondral cysts,b) subchondral sclerosis,c) periarticular osteophytes,d) joint subluxation,e) the degree of joint space narrowing,f) avascular necrosis org) bone on bone articulations Pain or functional disability at the hip. Pain and/or functional disability should be described in context. For example, documented pain that interferes with ADLs (functional disability), or pain that is increased with initiation of activities or pain that increases with weight bearing.
Article - Billing and Coding: Total Hip Arthroplasty (A57683)
 Unsuccessful conservative therapy (non-surgical medical management) if appropriate. The documentation should demonstrate a history of a reasonable attempt at conservative therapy as appropriate for the patient in his/her current episode of care. For example, documented trial of NSAIDs or contraindication to such therapy and/or documented supervised physical therapy. Documentation should support that ADLs are diminished due to pain and/or disability despite non-surgical medical management. For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as THA should be appropriately addressed in the medical record.Medical record documentation for other THR/THA indications outlined in the LCD should include the following, when indicated: Supporting evidence (e.g., pathology reports and referral from an Oncologist for a malignancy of the joint or X-ray of a fracture). Pain at the hip when indicated as a reason for the procedure (e.g., for revision/replacement TKR/THA). For example, documented pain that interferes with ADLs (functional disability), pain that is increased with initiation of activities or pain that increases with weight bearing. For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as THR/THA should be appropriately addressed in the medical record. When infection is the reason for revision THR/THA surgery, laboratory and/or pathology reports must be in the medical record and all documentation regarding treatment of the infection and a physician note indicating that it is appropriate to proceed with surgery should be in the medical record as well.In the instance that the patient is undergoing a bilateral hip replacement, all criteria listed above would apply to the bilateral surgery when indicated. The medical record should also support the medical necessity for performing a bilateral THR/THA.
Article - Billing and Coding: Total Hip Arthroplasty (A57683)
In the instance that the patient is undergoing a bilateral hip replacement, all criteria listed above would apply to the bilateral surgery when indicated. The medical record should also support the medical necessity for performing a bilateral THR/THA.The treating physician must discuss the significant benefit and risks with the patient. In order to meet Medicares reasonable and necessary (R&N) threshold for coverage of a procedure, the physicians documentation for the case should clearly support both the diagnostic criteria for the indication (standard test results and/or clinical findings as applicable) and the medical need (the procedure does not exceed the medical need and is at least as beneficial as existing alternatives & the procedure is furnished with accepted standards of medical practice in a setting appropriate for the patients medical needs and condition).Lacking compelling arguments for an exception in the supporting documentation, the hospital and physician services can be denied.If in certain circumstances the patient does not meet all of the required criteria outlined in the local coverage determination (LCD) for a procedure, but the treating physician feels that the procedure is a covered procedure given the current standards of care, then the documentation must clearly outline the patients episode of care that supports the major procedure and must clearly address the reason(s) for coverage. For example, if clinical findings (or lack of) for an indication are not consistent with the LCD criteria, it should be directly addressed in the pre-procedure documentation. For example,if certain conservative measures are not necessary or appropriate for a given patient, it should be directly noted in the pre-procedure documentation. The clinical judgment of the treating physician is always a consideration if clearly addressed in the pre-procedure record and if consistent with the episode of care for the patient as documented in patient records and claim history.Review of the medical record must indicate that inpatient hospital care was medically necessary, reasonable, and appropriate for the diagnosis and condition of the beneficiary at any time during the stay. The beneficiary must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basis.
Article - Billing and Coding: Total Hip Arthroplasty (A57684)
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 following billing and coding guidance is to be used with its associated Local Coverage Determination.Documentation RequirementsIn order to qualify for coverage of both Medicare Part A inpatient services and Part B provider services the medical record must contain documentation that fully supports the medical necessity and justification of the procedure performed and must be made available to Noridian upon request. When the documentation does not meet the criteria for the service(s) rendered or the documentation does not establish the medical necessity for the service(s), such service(s) will be denied as not reasonable and necessary.A history and physical, discharge summary, physician progress notes and an operative report are typically in the hospital record for the procedures in this LCD.Other relevant information addressing coverage criteria related to the patients episode of care prior to the hospitalization, should be included in the hospital record (see below).Failure to include this information in the hospital record may result in denial of coverage for Part A services and trigger a review of the Part B provider claim to determine whether the Part B service rendered was reasonable and necessary.When the procedure is indicated for advanced joint disease, the following should be documented in the medical record: Arthritis of the hip supported by X-ray, MRI or CT. The X-ray, MRI or CT, as medically necessary, should demonstrate and the provider must document one or more of the following:a) subchondral cysts,b) subchondral sclerosis,c) periarticular osteophytes,d) joint subluxation,e) the degree of joint space narrowing,f) avascular necrosis org) bone on bone articulations Pain or functional disability at the hip. Pain and/or functional disability should be described in context. For example, documented pain that interferes with ADLs (functional disability), or pain that is increased with initiation of activities or pain that increases with weight bearing.
Article - Billing and Coding: Total Hip Arthroplasty (A57684)
 Unsuccessful conservative therapy (non-surgical medical management) if appropriate. The documentation should demonstrate a history of a reasonable attempt at conservative therapy as appropriate for the patient in his/her current episode of care. For example, documented trial of NSAIDs or contraindication to such therapy and/or documented supervised physical therapy. Documentation should support that ADLs are diminished due to pain and/or disability despite non-surgical medical management. For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as THA should be appropriately addressed in the medical record.Medical record documentation for other THR/THA indications outlined in the LCD should include the following, when indicated: Supporting evidence (e.g., pathology reports and referral from an Oncologist for a malignancy of the joint or X-ray of a fracture). Pain at the hip when indicated as a reason for the procedure (e.g., for revision/replacement THR/THA). For example, documented pain that interferes with ADLs (functional disability), pain that is increased with initiation of activities or pain that increases with weight bearing. For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as THR/THA should be appropriately addressed in the medical record. When infection is the reason for revision THR/THA surgery, laboratory and/or pathology reports must be in the medical record and all documentation regarding treatment of the infection and a physician note indicating that it is appropriate to proceed with surgery should be in the medical record as well.In the instance that the patient is undergoing a bilateral hip replacement, all criteria listed above would apply to the bilateral surgery when indicated. The medical record should also support the medical necessity for performing a bilateral THR/THA.
Article - Billing and Coding: Total Hip Arthroplasty (A57684)
In the instance that the patient is undergoing a bilateral hip replacement, all criteria listed above would apply to the bilateral surgery when indicated. The medical record should also support the medical necessity for performing a bilateral THR/THA.The treating physician must discuss the significant benefit and risks with the patient. In order to meet Medicares reasonable and necessary (R&N) threshold for coverage of a procedure, the physicians documentation for the case should clearly support both the diagnostic criteria for the indication (standard test results and/or clinical findings as applicable) and the medical need (the procedure does not exceed the medical need and is at least as beneficial as existing alternatives & the procedure is furnished with accepted standards of medical practice in a setting appropriate for the patients medical needs and condition).Lacking compelling arguments for an exception in the supporting documentation, the hospital and physician services can be denied.If in certain circumstances the patient does not meet all of the required criteria outlined in the local coverage determination (LCD) for a procedure, but the treating physician feels that the procedure is a covered procedure given the current standards of care, then the documentation must clearly outline the patients episode of care that supports the major procedure and must clearly address the reason(s) for coverage. For example, if clinical findings (or lack of) for an indication are not consistent with the LCD criteria, it should be directly addressed in the pre procedure documentation. For example,if certain conservative measures are not necessary or appropriate for a given patient, it should be directly noted in the pre procedure documentation. The clinical judgment of the treating physician is always a consideration if clearly addressed in the pre procedure record and if consistent with the episode of care for the patient as documented in patient records and claim history.Review of the medical record must indicate that inpatient hospital care was medically necessary, reasonable, and appropriate for the diagnosis and condition of the beneficiary at any time during the stay. The beneficiary must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basis.Utilization GuidelinesIt is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters they may be subject to review for medical necessity.
Article - Billing and Coding: Total Hip Arthroplasty (A57684)
Utilization GuidelinesIt is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters they may be subject to review for medical necessity.The devices/implants utilized for total hip replacement surgeries are regulated by the FDA as medical devices. The devices used should be class II or class III devices that meet the requirements outlined in CFR 21, Chapter 1, subchapter H, Part 888.