evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing (A54961)
Atrioventricular block, unspecified (Symptomatic) (426.10 / I44.30)First-degree atrioventricular block (Symptomatic with PR interval more than 300 milliseconds) (426.11 / I44.0)Left bundle branch block, other or unspecified (426.3 / I44.7)Right bundle branch block, unspecified or other (426.4 / I45.10 / I45.19)Bundle branch block, unspecified (426.50 / I45.10 or I45.19)Right bundle branch block and left posterior fascicular block (426.51 / I45.2)Right bundle branch block and left anterior fascicular block (426.52 / I45.2)o Other bilateral bundle branch block (426.53 / I45.2)o Bifascicular block (I45.2)o Trifascicular block (426.54 / I45.3)Supraventricular tachycardias in which a pacemaker is specifically for control of the tachycardia (427.0 / I47.9)Paroxysmal supraventricular tachycardia/supraventricular tachycardia (SVT that is reproducibly terminated by pacing when catheter ablation and/or drugs fail to control the arrhythmia or produce intolerable side effects) (427.0 / 427.2 / I47.9)Atrial fibrillation/atrial fibrillation, persistent; unspecified atrial fibrillation (427.31 / I48.1 / I48.91) with symptomatic bradycardia due to necessary medical therapyAtrial flutter/atrial flutter, typical/atypical/unspecified (427.32 / I48.3 / I48.4 / I48.92 with symptomatic bradycardia due to necessary medical therapy
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing (A54961)
Atrial flutter/atrial flutter, typical/atypical/unspecified (427.32 / I48.3 / I48.4 / I48.92 with symptomatic bradycardia due to necessary medical therapyHypersensitive carotid sinus syndrome and neurocardiogenic syncope (Syncope without clear, provocative events and with a hypersensitive cardioinhibitory response of 3 seconds or longer or for significantly symptomatic neurocardiogenic syncope associated with bradycardia documented spontaneously or at the time of tilt-table testing (337.01 / G90.01)
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing (A54961)
Other Conditions Not Addressed by the NCD or by the Contractor - Group III include but are not limited to the following (Attest with Modifier - SC):Cardiac resynchronization therapyObstructive hypertrophic cardiomyopathyPacing in children, adolescents, and patients with congenital heart diseasePacemaker or generator replacementsSustained pause-dependent ventricular tachycardia, with or without QT prolongationModifier Usage:Modifier - KX (Requirements specified in the medical policy have been met) must be used as an attestation by the practitioner and/or provider of the service that documentation is on file verifying the patient has a symptomatic arrhythmia or a high potential for progression of the rhythm disturbance requiring a permanent pacemaker forGroups I and II. Bradycardia that is the consequence of essential long-term drug therapy of a type and dose for which there is no acceptable alternativedoes not excludethe use of modifier - KX.In addition, use of modifier - KX may be used in patients without symptoms in Groups I and II in the following situations:
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing (A54961)
In addition, use of modifier - KX may be used in patients without symptoms in Groups I and II in the following situations:Awake, symptomfree patients in sinus rhythm, with documented periods of asystole greater than or equal to 3.0 seconds or any escape rate less than 40 beats per minute (bpm), or with an escape rhythm that is below the AV nodeAwake, symptom-free patients with atrial fibrillation and bradycardia with one or more pauses of at least 5 seconds or longerCatheter ablation of the AV junctionPostoperative AV block that is not expected to resolve after cardiac surgeryPatients with neuromuscular diseases, e.g., myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb dystrophy, and peroneal muscular atrophy, with third-degree and advanced second-degree AV block at any anatomic levelAsymptomatic persistent third-degree AV block at any anatomic site with average awake ventricular rates of 40 bpm or faster if cardiomegaly or LV dysfunction is present or if the site of block is below the AV nodeSecond or third-degree AV block during exercise in the absence of myocardial ischemiaPersistent third-degree AV block with an escape rate greater than 40 bpm in asymptomatic adult patients without cardiomegalyAsymptomatic second-degree AV block at intra-or infra-His levels found at electrophysiological studyFirst- or second-degree AV block with symptoms similar to those of pacemaker syndrome or hemodynamic compromiseAsymptomatic type II second-degree AV block with a narrow QRS. Second-degree AV block with a wide QRS including isolated right bundle-branch blockFor medically necessary pacemaker insertion in conditions not addressed by the NCD or this article,Group III, use modifier - SC (Medically necessary service or supply).Modifiers  GA and  GZ:
Article - Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing (A54961)
For medically necessary pacemaker insertion in conditions not addressed by the NCD or this article,Group III, use modifier - SC (Medically necessary service or supply).Modifiers  GA and  GZ:Modifier  GA (Waiver of liability statement issued as required by payer policy, individual case) should be used when the provider wants to indicate that he/she anticipates that Medicare will deny a specific service as not reasonable and necessary, an Advanced Beneficiary Notice (ABN) Form CMS-R-131 has been signed by the beneficiary and is on file. Modifier  GA 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 are required.Modifier  GZ should be used when the provider wants to indicate that it is expected that Medicare will deny the specific services as not reasonable and necessary and the beneficiary was not asked to sign an ABN.Claims for pacemaker claims that do not meet the criteria for modifier  KX or  SC should have modifier  GA or  GZ appended depending on the ABN status and will be denied.
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54969)
CMS National Coverage PolicyCMS National Coverage PolicyCode of Federal Regulations:42 CFR Section 410.32 indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who uses the results in the management of the beneficiarys specific medical problem.Federal Register:Federal Register Vol. 62, 59047, Supervision of Diagnostic Tests, describes the degree of physician supervision required for diagnostic tests.CMS Publications:CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2: 160.23 Sensory Nerve Conduction Threshold Tests (sNCTs)Program Memorandum Carriers Transmittal B-01-28 Change Request 850, describes tests that may be performed by PTs with ABPTS certification CMS Publication 100-2.Medicare Benefit Policy Manual, Chapter 15, Section 80: Requirements for Diagnostic Tests.Transmittal 2663 Change Request 8169 April Update to the CY 2013 Medicare Physician Fee Schedule Database (MPFSDB).Article Text
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54969)
Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Physical Therapists Performing EMGsProgram Memorandum Transmittal B-01-28/Change Request 850 sets forth revised levels of physician supervision required for diagnostic tests payable under the Medicare Physician Fee Schedule. Effective July 1, 2001, certain codes in the range of CPT 95860-95937 were assigned new supervision levels (21, 22, 6a, 66, 77 or 77a). This implementation date would make it possible for physical therapists to acquire the certification required to perform these services without supervision. A physical therapist who is presently certified by the American Board of Physical Therapy Specialties (ABPTS) can perform procedures assigned level of 21, 22, 66, 6a, 77, or 77a without supervision. These numeric levels assigned to the CPT codes are listed in the Medicare Physician Fee Schedule Database (MPFSDB).Physical therapists who do not possess the ABPTS certification by July 1, 2001, may continue to furnish those tests that require the certification if they have been furnishing such diagnostic tests prior to May 1, 2001.Payment will be based on the Medicare Physician Fee Schedule level of supervision designation.Nerve conduction code 95905 does not have one of the above designations and is therefore not allowed by Physical Therapists.The technical component (TC) of the neuromuscular junction testing code 95937 had its Physician Supervision of Diagnostic Procedures Indicator changed to 7A. This change is effective January 1, 2013.Needle EMG codes 95860-95872 and 95885-95887 have the designation of 6A for the technical portion of the test. Therefore, if authorized by state law, Physical Therapists are allowed the technical portion of the test according to the description of 6A.I. Coding GuidelinesA. Evaluation/Management (E/M)
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54969)
I. Coding GuidelinesA. Evaluation/Management (E/M)1. Usually an E&M service is included in the exam performed just prior to and during nerve conduction studies and/or electromyography. If the E&M service is a separate and identifiable service, the medical record must document medical necessity and the CPT code must be billed with a modifier 25.2. The clinical history from the referral source must indicate the need for testing. These medical records containing pertinent clinical information must be provided for review on request. Absolute inclusive or exclusive criteria for performance of a diagnostic test are difficult to enumerate.B. Nerve Conduction Studies
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54969)
B. Nerve Conduction Studies1. The table below provides a reasonable maximum number of studies per diagnostic category necessary for a physician to arrive at a diagnosis in 90% of patients with that final diagnosis.2. The appropriate number of studies to be performed is left to the judgment of the physician performing the evaluation; however, in the small number of cases which require testing in excess of the numbers listed in the table, the physician must be able to provide supplementary documentation to justify the additional testing.3. In some situations it may be necessary to test an asymptomatic contralateral limb to establish normative values for an individual patient. Documentation must support the medical necessity of the additional test.4. CPT code 95905 -Nerve conduction studies performed using automated devices (for example devices such as NC-stat System) cannot support testing of other locations and other nerves as needed depending on the concurrent results of testing.CPT code 95905 is payable only once per limb studied and cannot be used in conjunction with any other nerve conduction codes.When the beneficiary has a high pre-test or a priori probability for having the diagnosis of Carpal Tunnel Syndrome, the NC-stat System (alone) will be allowed, one service per arm, using CPT code 95905. The diagnosis codes G56.01, G56.02 or G56.03 should be used. All other diagnosis codes will be denied as not medically necessary.5. Codes 95907-95913 describe one or more nerve conduction studies. A single conduction test is defined as a sensory conduction test, a motor conduction test with or without an F wave test, or an H-reflex test. Each type of study (sensory, motor with or without F wave, H-reflex) for each anatomically distinct and separately named nerve is counted as a distinct study when determining the number of studies billed. Each type of study is counted only once when multiple sites on the same nerve are stimulated and recorded. The number of tests (sensory, motor with or without F wave, H-reflex) per nerve are added to determine the code to be billed.
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54969)
Nerve conduction codes 95907-95913 had their Physician Supervision of Diagnostic Procedures Indicators adjusted to 7A effective 01/01/2013 (CR 8169). Therefore, if authorized by state law, Physical Therapists are allowed the technical portion and professional component of the test according to the description of 7A.7A = Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.77 = Procedure must be performed by a PT with ABPTS certification (TC & PC) or by a PT without certification under direct supervision of a physician (TC only; PC always physician).These changes for 7A are effective January 1, 2013.Codes designated for eliciting nerve conduction velocity, latency or amplitude, and those designed for short latency evoked potentials are not to be used for sNCT. The sNCT has a unique codeG0255: Effective October 1, 2002, CMS initially concluded that there was insufficient scientific or clinical evidence to consider the sNCT test and the device used in performing this test reasonable and necessary within the meaning of section 1862(a)(1)(A) of the law. Therefore, sNCT was noncovered. Based on a reconsideration [in March, 2004] of current Medicare policy for sNCT, CMS concludes that there continues to be insufficient scientific or clinical evidence to consider the sNCT test and the device used in performing this test as reasonable and necessary within the meaning of section 1862(a)(1)(A) of the law. CMS Publication 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 160.23Type of Study/ Maximum Number of StudiesIndicationLimbs Studied by Needle EMG (95860-95864, 95867-95870, 95885-95887)Nerve conduction Studies (Total nerves studied, 95907-95913)Neuromuscular Junction Testing (Repetitive Stimulation, 95937)Carpal Tunnel (Unilateral)17Carpal Tunnel (Bilateral)210Radiculopathy27Mononeuropathy18Polyneuropathy/Mononeuropathy Multiplex310Myopathy242
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54969)
Carpal Tunnel (Bilateral)210Radiculopathy27Mononeuropathy18Polyneuropathy/Mononeuropathy Multiplex310Myopathy242Motor Neuronopathy (e.g. ALS)462Plexopathy212Neuromuscular Junction243Tarsal Tunnel Syndrome (Unilateral)18Tarsal Tunnel Syndrome (Bilateral)211-Weakness, Fatigue, Cramps or Twitching (Focal)272Weakness, Fatigue, Cramps or Twitching (General)482Pain, Numbness or Tingling (Unilateral)19-Pain, Numbness or Tingling (Bilateral)212-Source: Current Procedural Terminology (CPT) 2016C. Electromyography1. Use EMG codes 95860-95864 and 95867-95870 when no nerve conduction studies (95907-95913) are performed on that day.2. Use 95885, 95886, and 95887 for EMG services when nerve conduction studies (95907-95913) are performed on the same day.3. To bill these codes, extremity muscles innervated by three nerves (for example, radial, ulnar, median, tibial, peroneal, femoral, not sub branches) or four spinal levels must be evaluated; a minimum of five muscles must have been studied.4.It is expected that providers will use CPT code 95870 for sampling muscles other than the paraspinals associated with the extremities, which have been tested. Medicare would not expect to see this code billed when the paraspinal muscles corresponding to an extremity are tested and when the extremity EMG code 95860, 95861, 95863 or 95864 is also billed.CPT Code 95869 - Needle electromyography; thoracic paraspinal muscles
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54969)
CPT Code 95869 - Needle electromyography; thoracic paraspinal muscles1. CPT code 95869 should be used to bill a limited EMG study of specific muscles. Examinations confined to distal muscles only, such as intrinsic foot or hand muscles, will be reimbursed as Code 95869 and not as 95860-95866.2. Use CPT Code 96869 to study thoracic paraspinal muscles between T3 and T11.3. One unit can be billed, despite the number of levels studied or whether unilateral or bilateral.CPT Code 95870 Needle electromyography, other than paraspinal1. CPT code 95870 is used for limited testing of specific muscles during an examination. This code should be used only when the muscles tested do not fit more appropriately under another CPT code.2. CPT code 95870 can be billed at one unit per extremity (one limb, arm or leg), when fewer than five muscles are examined.3. It can also be used for examining non-limb (axial) muscles (e.g., intercostal, abdominal wall, cervical and lumbar paraspinal muscles (unilateral or bilateral) regardless of the number of levels tested. However, it should not be billed when the paraspinal muscles corresponding to an extremity are tested, and when the extremity codes 95860, 95861, 95863, or 95864 are reported.CPT Code 95933 - Blink Reflexes1. Recordings should be made bilaterally with both ipsilateral and contralateral stimulation.2. The report of this study should include the presence or absence of the R1 and R2 components.CPT Code 95937 - Neuromuscular Junction Studies
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54969)
CPT Code 95937 - Neuromuscular Junction Studies1. Repetitive stimulation studies are used to identify and to differentiate disorders of the NMJ. This test consists of recording muscle responses to a series of nerve stimuli (at variable rates), both before, and at various intervals after, exercise or transmission of high-frequency stimuli.2. These codes may be used in association with motor and sensory NCS of the same nerves and are reimbursed separately.3. When this study is performed, the physician's report must document characteristics of the test, including the rate of repetition of stimulations, and any significant incremental or decremental response.II. Reasons for Denial in addition to those stated in LCD1. Narrative reports alluding to "normal" or abnormal" results without supporting numerical data.2. Descriptions of F-wave without reference to corresponding motor conduction data; pattern-setting unilateral H-reflex measurements; separate E/M charges without documentation requested from the referral source.3. Surface and/or macro EMGs will not be paid.4. Failure to submit, upon request or when requesting a review, a clinical history indicating the need for testing.5. Absence of a clinical history, preferably written by the referral source, indicating the need for the test.6. Absence of documentation to support repeated testing on the same beneficiary.7. Testing every beneficiary referred for pain.Needle electromyographic (EMG) codes 95860-95872, and 95885-95887 have the designation of 6A for the technical portion of the test. Therefore, if authorized by state law Physical Therapists are allowed the technical portion of the test according to the description of 6A. Definitions below:6A = Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.66 = May be personally performed by a physician or by a physical therapist with ABPTS certification and certification in this specific procedure.III. Comments
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54969)
66 = May be personally performed by a physician or by a physical therapist with ABPTS certification and certification in this specific procedure.III. Comments1. Certain less than optimal practices are discouraged, and may invite review. These include: exclusive testing of intrinsic foot muscles in the diagnosis of proximal lesions; definitive diagnostic conclusions based on paraspinal EMG in regions bearing scar of past surgeries (e.g., previous laminectomies); pattern-setting limited limb muscle examinations, without paraspinal muscle testing for diagnosis of radiculopathies, narrative reports without data, and premature EMG testing after trauma when EMG changes are unlikely to have taken place.2. There are situations in which EMG and nerve conduction studies can be valuable in a relatively acute situation with or without trauma, even though full-blown EMG changes may not yet have taken place. An example is, to assess the presence of pre-existing injury or disease after trauma or in the evaluation of some non-traumatic conditions, such as suspected Guillain-Barre syndrome. The clinical record must distinctly document such a need.3. Frequency of testing is a difficult issue to answer. Documented clinical justification, rather than an algorithm, should be the determinant in these instances. While this removes any recipe-style limits, it also calls for clear responsible and evidence-based documentation for any repeat study. Such a guideline applies to all studies including those for patients (i) under medical, surgical or rehabilitative treatment, (ii) for neuropathy and (iii) for patients with chronic renal failure and/or dialysis.
Article - Billing and Coding: MolDX: Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C) Testing (A54975)
CMS National Coverage PolicyN/AArticle TextARVD/C, characterized by fatty replacement of heart cells predominantly in the right ventricle of the heart, is most often inherited as an autosomal dominant disease that may be associated with testing in at least seven genes (RYR2, TMEM43, DSP, PKP2, DSG2, DSC2 and JUP). Genetic testing may be performed in panels of 5-7 of these genes and disease-causing mutation is expected to be identified in 42-55% of cases. Testing would be performed to confirm an established diagnosis or on individuals already diagnosed with ARVD/C to identify family members at risk. Therefore, MolDX has determined that testing for ARVD/C is a statutorily excluded test.To receive an ARVD/C panel test denial, please submit the following claim information:An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientEnter the DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem19 for paper claimEnter the DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim form