evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Claim Adjustment Reason Code (CARC) 50  These are non -covered services because this is not deemed a medical necessity by the payer. This change to be effective April 1, 2010: These are non -covered services because this is not deemed a medical necessity by the payer.   NOTE: Refer to the 835 Healthcare Policy Identification Segment, if present.  Remittance Advice Remark Code (RARC) N362   The number of Days or Units of Service exceeds our acceptable maximum.   Group Code CO  Contractual Obligation   Medicare Summary Notice (MSN) 16.76   This service/item was not covered because you have exceeded the lifetime limit for getting this service/item. (Este servicio/artculo no fue cubierto porque usted ya se ha pasado del lmite permitido de por vida, para recibirlo.).  The Medicare shared system and the A/B MACs (B) will also ensure that pharmacogenomic testing for warfarin response is billed in accordance with clinical trial reporting requirements. In other words, the shared system and the A/B MACs (B) will return to provider/return as unprocessable lines for pharmacogenomic testing for warfarin response when said line is not billed with HCPCS modifier Q0 and ICD-10- CM diagnosis code if applicable, ICD -10-CM Z00.6 is not present as a secondary diagnosis. When the system or the A/B MAC (B) initiates the line - item return to provider or returns the claim as unprocessable, the Medicare contractor will respond with the following messages:  For a missing Q0 modifier: CARC 4 - The procedure code is inconsistent with the modifier used or a required modifier is missing.   For a missing Z00.6 diagnosis code when a HCPCS Q0 modifier is reported with  HCPCS G9143:  CARC 16  - Claim/service lacks information which is needed for adjudication. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.)  Remark Code M64 - Missing/incomplete/invalid other diagnosis.   For either a missing Q0 modifier and/or a missing ICD-10-CM Z00.6 diagnosis code:
(Medicare Claims Processing Manual)
Remark Code M64 - Missing/incomplete/invalid other diagnosis.   For either a missing Q0 modifier and/or a missing ICD-10-CM Z00.6 diagnosis code:  Group Code CO- Contractual Obligation   MSN 16.77  This service/item was not covered because it was not provided as part of a qualifying trial/study. (Este servicio/artculo no fue cubierto porque no estaba incluido como parte de un ensayo clnico/estudio calificado.)  260 - Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (LDS) (Rev. 2105, Issued: 11- 24-10, Effective: 03-23-10, Implementation: 07-06-10)  260.1  Policy (Rev. 2105, Issued: 11- 24-10, Effective: 03-23-10, Implementation: 07-06-10)  The Centers for Medicare & Medicaid Services (CMS) received a request for national coverage of treatments for facial lipodystrophy syndrome (LDS) for human immunodeficiency virus (HIV)- infected Medicare beneficiaries.  Facial LDS is often characterized by a loss of fat that results in a facial abnormality such as severely sunken cheeks.  This fat loss can arise as a complication of HIV and/or highly active antiretroviral therapy.  Due to their appearance and stigma of the condition, patients with facial LDS may become depressed, socially isolated, and in some cases may stop their HIV treatments in an attempt to halt or reverse this complication.   Effective for claims with dates of service on and after March 23, 2010, dermal injections for facial LDS are only reasonable and necessary using dermal fillers approved by the Food and Drug Administration for this purpose, and then only in HIV- infected beneficiaries who manifest depression secondary to the physical stigmata of HIV treatment.  See Pub. 100-03, National Coverage Decision manual, section 250.5, for detailed policy information concerning treatment of LDS.  260.1.1  Hospital Billing Instructions  (Rev. 11021; Issued: 10-01- 21; Effective: 10 -29-21; Implementation: 10-29-21)  A - Hospital Outpatient Claims
(Medicare Claims Processing Manual)
A - Hospital Outpatient Claims   For hospital outpatient claims, hospitals must bill covered dermal injections for treatment of facial LDS by having all of the required elements on the claim:   1. A line with HCPCS codes Q2026 or Q2027 with a Line Item Date of service (LIDOS) on or after March 23, 2010,               NOTE: Q2027 is replaced with Q2028 effective 1/1/14 as per the 2014 HCPCS update.   2. A line with HCPCS code G0429 with a LIDOS on or after March 23, 2010,   3. If ICD -10-CM is applicable, ICD-10-CM diagnosis codes B20 Human Immunodeficiency Virus (HIV) disease and E88.1 Lipodystrophy, not elsewhere classified       The applicable NCD is 250.5 Facial Lipodystrophy.  B - Outpatient Prospective Payment System (OPPS) Hospitals or Ambulatory Surgical Centers (ASCs):   For line item dates of service on or after March 23, 2010, and until HCPCS codes Q2026 and Q2027 are billable, facial LDS claims shall contain a temporary HCPCS code C9800, instead of HCPCS G0429 and HCPCS Q2026/Q2027, as shown above.      NOTE: Q2027 is replaced with Q2028 effective 1/1/14 as per the 2014, HCPCS update.   C - Hospital Inpatient Claims   Hospitals must bill covered dermal injections for treatment of facial LDS by having all of the required elements on the claim:   C. Discharge date on or after March 23,  2010,  D. If ICD -10-PCS is  applicable,    ICD-10-PCS procedure code 3E00XGC Introduction of Other Therapeutic Substance into Skin and Mucous Membrances, External Approach, or  E. If ICD -10-CM is  applicable on or after 10/01/2015,     ICD-10-CM diagnosis codes B20 Human Immunodeficiency Virus [HIV] disease and E88.1 Lipodystrophy not elsewhere classified.   A diagnosis code for a comorbidity of depression may also be required for coverage on an outpatient and/or inpatient basis as determined by the individual Medicare contractors policy.
(Medicare Claims Processing Manual)
A diagnosis code for a comorbidity of depression may also be required for coverage on an outpatient and/or inpatient basis as determined by the individual Medicare contractors policy.   260.2 Billing Instructions  (Rev. 2105, Issued: 11- 24-10, Effective: 03-23-10, Implementation: 07-06-10)  260.2.1  Hospital Billing Instructions  (Rev.  2998, Issued: 07- 25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD -10)  A - Hospital Outpatient Claims   For hospital outpatient claims, hospitals must bill covered d ermal injections for treatment of facial LDS by having all of the required elements on the claim:   A line with HCPCS codes Q2026 or Q2027 with a Line Item Date of service (LIDOS) on or after March 23, 2010,   A line with HCPCS code G0429 with a LIDOS on or after March 23, 2010,    If ICD -9-CM is applicable,  ICD-9-CM diagnosis codes 042 (HIV) and 272.6 (Lipodystrophy) or,   If ICD-10-CM is applicable, ICD -10-CM diagnosis codes B20 Human Immunodeficiency Virus (HIV) disease and E88.1 Lipodystrophy, not elsewhere classified   The applicable NCD is 250.5 Facial Lipodystrophy.  B - Outpatient Prospective Payment System (OPPS) Hospitals or Ambulatory Surgical Centers (ASCs):   For line item dates of service on or after March 23, 2010, and until HCPCS codes Q2026 and Q2027 are billable, facial LDS claims shall contain a temporary HCPCS code C9800, instead of HCPCS G0429 and HCPCS Q2026/Q2027, as shown above.  C - Hospital Inpatient Claims   Hospitals must bill covered dermal injections for treatment of facial LDS by having all of the required elements on the claim:    Discharge date on or after March 23, 2010,   If ICD -9-CM is applicable,
(Medicare Claims Processing Manual)
Hospitals must bill covered dermal injections for treatment of facial LDS by having all of the required elements on the claim:    Discharge date on or after March 23, 2010,   If ICD -9-CM is applicable,    o ICD-9-CM procedure code 86.99 (other operations on skin and subcutaneous tissue, i.e., injection of filler material), or  o ICD-9-CM diagnosis codes 042 (HIV) and 272.6 (Lipodystrophy)   If ICD -10-PCS is applicable,    o ICD-10-PCS procedure code 3E00XGC Introduction of Other Therapeutic Substance into Skin and Mucous Membrances, External Approach, or   o ICD-10-CM diagnosis codes B20 Human Immundodeficiency Virus [HIV] disease and E88.1 Lipodystrophy not elsewhere classified.  A diagnosis code for a comorbidity of depression may also be required for coverage on an outpatient and/or inpatient basis as determined by the individual Medicare contractors policy.  260.2.2  Practitioner Billing Instructions  (Rev. 11021; Issued: 10-01- 21; Effective: 10 -29-21; Implementation: 10-29-21)  Practitioners must bill covered claims for dermal injections for treatment of facial LDS by having all of the required elements on the claim:  Performed in a non- facility setting :   A line with HCPCS codes Q2026 or Q2027 with a LIDOS on or after March 23, 2010,    NOTE : Q2027 is replaced with Q2028 effective 1/1/14 per the 2014 HCPCS update.   A line with HCPCS code G0429 with a LIDOS on or after March 23, 2010,   51 If ICD -10-CM applies, diagnosis codes B20 Human Immunodeficiency Virus (HIV) disease and E88.1 (Lipodystrophy not elsewhere  classified). Both diagnoses are required on the claim.   NOTE: A diagnosis code for a comorbidity of depression may also be required for coverage based on the individual Medicare contractors policy.     52 A line with HCPCS code G0429 with a LIDOS on or after March 23, 2010,
(Medicare Claims Processing Manual)
52 A line with HCPCS code G0429 with a LIDOS on or after March 23, 2010,   53 If ICD -10 CM - applies, ICD -10-CM diagnosis codes B20 Human immunodeficiency Virus (HIV) disease and E88.1 (Lipodystrophy not elsewhere  classified). Both diagnoses are required on the claim.   NOTE: A diagnosis code for a comorbidity of depression may also be required for coverage based on the individual Medicare contractors policy.   260.3  Claims Processing System Editing  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Billing for Services Prior to Medicare Coverage   Hospitals and practitioners billing for dermal injections for treatment of facial LDS prior to the coverage date of March 23, 2010, will receive the following messages upon their Medicare denial:    Claim Adjustment Reason Code (CARC) 26: Expenses incurred prior to coverage.    NOTE: Outpatient hospitals and beneficiaries that received services in a hospital outpatient setting may receive different message as established by their particular Medicare contractor processing the claim.)    Medicare beneficiaries whose provider bills Medicare for dermal injections for treatment of facial LDS prior to the coverage date of March 23, 2010, will receive the following Medicare Summary Notice (MSN) message upon the Medicare denial:    - This service was not covered by Medicare at the time you received it. (Spanish Version: Este servicio no estaba cubierto por Medicare cuando usted lo recibi .)  Billing for Services Not Meeting Comorbidity Coverage Requirements   Hospitals and practitioners billing for dermal injections for treatment of facial LDS on patients that do not have a comorbidity of HIV and lipodystrophy (or even depression if deemed required by the Medicare contractor) will receive the following messages  upon their Medicare denial:    CARC 50: These are non -covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if  present.
(Medicare Claims Processing Manual)
 CARC 50: These are non -covered services because this is not deemed a 'medical necessity' by the payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if  present.    RARC N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the  NCD.    RARC M64: Missing/incomplete/invalid other  diagnosis.   Group Code: CO   Medicare beneficiaries who do not meet Medicare comorbidity requirements of HIV and lipodystrophy (or even depression if deemed required by the Medicare contractor) and whose provider bills Medicare for dermal injections for treatment of facial LDS will receive the following MSN message upon the Medicare denial:   15.4 -  The information provided does not support the need for this service or item. (Spanish Version: La informacin proporcionada no confirma la necesidad para este servicio oculo.)   270  Claims Processing for Implantable Automatic Defibrillators  (Rev. 2005, Issued: 7- 23-10, Effective: 8 -31-10, Implementation: 8- 31-10)  Coverage Requirements - The implantable automatic defibrillator is an electronic device designed to detect and treat life threatening tachyarrhythmias.  The device consists of a pulse generator and electrodes for sensing and defibrillating.   See 20.4 - Medicare National Coverage Determinations (NCD) Manual for the complete list of covered indications.   270.1  Coding Requirements for Implantable Automatic Defibrillators  (Rev.  2998, Issued: 07- 25-14, Effective: Upon implementation of ICD -10; 01- 01-12 - ASC X12, Implementation: 08- 25-2014 -  ASC X12; Upon Implementation of ICD -10)
(Medicare Claims Processing Manual)
The following are the applicable HCPCS procedure codes for implantable automatic defibrillators:  33240-  (Insertion of single or dual chamber pacing cardioverter -defibrillator pulse generator)  33241(Subcutaneous removal of single or dual chamber pacing cardioverter -defibrillator pulse generator)  33243 (Removal of single or dual chamber pacing cardioverter -defibrillator electrode(s); by thoracotomy)  33244 (Removal of single or dual chamber pacing cardioverter -defibrillator electrodes by transvenous extraction)  33249-  (Insertion or repositioning of electrode leads(s) for single or dual chamber pacing cardioverter -defibrillator and insertion of pulse generator)   For inpatient hospitals claims, if ICD -9 CM is applicable use procedure code 37.94.  If ICD -10-PCS is applicable the following applies.
(Medicare Claims Processing Manual)
More than one ICD -10-PCS code (a cluster) is required. There are two possible clusters:  FIRST CLUSTER:  Use 1 code from the first list and one code from the second list.  Cluster 1 first list:  0JH608Z Insertion of Defibrillator Generator into Chest Subcutaneous Tissue and Fascia, Open Approach  0JH638Z Insertion of Defibrillator Generator into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach  0JH808Z Insertion of Defibrillator Generator into Abdomen Subcutaneous Tissue and Fascia, Open Approach  0JH838Z Insertion of Defibrillator Generator into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach  Cluster 1 second list:  02H60KZ Insertion of Defibrillator Lead into Right Atrium, Open Approach 02H63KZ Insertion of Defibrillator Lead into Right Atrium, Percutaneous Approach  02H64KZ Insertion of Defibrillator Lead into Right Atrium, Percutaneous Endoscopic Approach  02H70KZ Insertion of Defibrillator Lead into Left Atrium, Open Approach 02H73KZ Insertion of Defibrillator Lead into Left Atrium, Percutaneous Approach  02H74KZ Insertion of Defibrillator Lead into Left Atrium, Percutaneous Endoscopic Approach  02HK0KZ Insertion of Defibrillator Lead into Right Ventricle, Open Approach  02HK3KZ Insertion of Defibrillator Lead into Right Ventricle, Percutaneous Approach  02HK4KZ Insertion of Defibrillator Lead into Right Ventricle, Percutaneous Endoscopic Approach  02HL0KZ Insertion of Defibrillator Lead into Left Ventricle, Open Approach 02HL3KZ Insertion of Defibrillator Lead into Left Ventricle, Percutaneous Approach  02HL4KZ Insertion of Defibrillator Lead into Left Ventricle, Percutaneous Endoscopic Approach  SECOND CLUSTER:  Use 1 code from 1st list & 1 code from the 4th list; also add one code from each of the 2nd & 3rd lists if doing a replacement instead of initial insertion.  Cluster 2 first list:  0JH608Z Insertion of Defibrillator Generator into Chest Subcutaneous Tissue and Fascia, Open Approach  0JH638Z Insertion of Defibrillator Generator into Chest
(Medicare Claims Processing Manual)
instead of initial insertion.  Cluster 2 first list:  0JH608Z Insertion of Defibrillator Generator into Chest Subcutaneous Tissue and Fascia, Open Approach  0JH638Z Insertion of Defibrillator Generator into Chest Subcutaneous Tissue and Fascia, Percutaneous Approach  0JH808Z Insertion of Defibrillator Generator into Abdomen Subcutaneous Tissue and Fascia, Open Approach  0JH838Z Insertion of Defibrillator Generator into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Approach  Cluster 2 second list:  0JPT0PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Open Approach  0JPT3PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Percutaneous Approach  Cluster 2 third list:  02PA0MZ Removal of Cardiac Lead from Heart, Open Approach  02PA3MZ Removal of Cardiac Lead from Heart, Percutaneous Approach  02PA4MZ Removal of Cardiac Lead from Heart, Percutaneous Endoscopic Approach  02PAXMZ Removal of Cardiac Lead from Heart, External Approach  Cluster 2 fourth list:  02H60KZ Insertion of Defibrillator Lead into Right Atrium, Open Approach 02H63KZ Insertion of Defibrillator Lead into Right Atrium, Percutaneous Approach  02H64KZ Insertion of Defibrillator Lead into Right Atrium, Percutaneous Endoscopic Approach  02H70KZ Insertion of Defibrillator Lead into Left Atrium, Open Approach  02H73KZ Insertion of Defibrillator Lead into Left Atrium, Percutaneous Approach  02H74KZ Insertion of Defibrillator Lead into Left Atrium, Percutaneous Endoscopic Approach  02HK0KZ Insertion of Defibrillator Lead into Right Ventricle, Open Approach  02HK3KZ Insertion of Defibrillator Lead into Right Ventricle, Percutaneous Approach  02HK4KZ Insertion of Defibrillator Lead into Right Ventricle, Percutaneous Endoscopic Approach  02HL0KZ Insertion of Defibrillator Lead into Left Ventricle, Open Approach 02HL3KZ Insertion of Defibrillator Lead into Left Ventricle, Percutaneous Approach  02HL4KZ Insertion of Defibrillator Lead into Left Ventricle, Percutaneous
(Medicare Claims Processing Manual)
Left Ventricle, Open Approach 02HL3KZ Insertion of Defibrillator Lead into Left Ventricle, Percutaneous Approach  02HL4KZ Insertion of Defibrillator Lead into Left Ventricle, Percutaneous Endoscopic Approach
(Medicare Claims Processing Manual)
270.2  Billing Requirements for Patients Enrolled in a Data Collection System  (Rev.11759, Issued:12- 21-2022, Effective:01 -23-2023, Implementation:01- 23-2023)   Effective for dates of service on or after April 1, 2005, Medicare required that patients receiving a defibrillator for the primary prevention of sudden cardiac arrest be enrolled in a qualifying data collection system.  Providers shall use modifier Q0 to identify patients whose data is being submitted to a data collection system.   The following diagnosis codes identify non -primary prevention (secondary prevention) patient or replacement implantations (e.g. due to recalled devices):   If ICD -9-CM is applicable, select from the following diagnosis codes:   427.1 Ventricular tachycardia   427.41 Ventricular fibrillation  427.42 Ventricular flutter   427.5 Cardiac arrest   427.9 Cardiac dysrhythmia, unspecified   V12.53 Personal history of sudden cardiac arrest   996.04 Mechanical complication of cardiac device, implant, and graft, due to automatic implantable cardiac defibrillator   V53.32 Fitting and adjustment of other device, automatic implantable cardiac defibrillator
(Medicare Claims Processing Manual)
V53.32 Fitting and adjustment of other device, automatic implantable cardiac defibrillator   If ICD -10-CM is applicable, select from the following list:  I47.0 Re -entry Ventricular Arrhythmia  I47.2 Ventricular Tachycardiaselect -  end date September 30, 2022  I47.20 Ventricular Tachycardia, unspecified - effective October 1, 2022  I47.21 Torsades De Pointes -  effective October 1, 2022 I47.29 Other Ventricular Tachycardia - effective October 1, 2022   I49.3 Ventricular Premature depolarization  I49.01 Ventricular Fibrillation I49.02 Ventricular Flutter  I46.2 Cardiac arrest due to underlying cardiac condition  I46.8 Cardiac arrest due to other underlying condition I46.9 Cardiac arrest, cause unspecified  I49.9 Cardiac arrhythmia, unspecified  T82.110A Breakdown (mechanical) of cardiac electrode, initial encounter  T82.111A Breakdown (mechanical) of cardiac pulse generator (battery), initial encounter  T82.118A Breakdown (mechanical) of other cardiac electronic device, initial encounter  T82.119A Breakdown (mechanical) of unspecified cardiac electronic device, initial encounter  T82.120A Displacement of cardiac electrode, initial encounter  T82.121A Displacement of cardiac pulse generator (battery), initial encounter  T82.128A Displacement of other cardiac electronic device, initial encounter  T82.129A Displacement of unspecified cardiac electronic device, initial encounter  T82.190A Other mechanical complication of cardiac electrode, initial encounter  T82.191A Other mechanical complication of cardiac pulse generator (battery), initial encounter  T82.198A Other mechanical complication of other cardiac electronic device, initial encounter  T82.199A Other mechanical complication of unspecified cardiac device, initial encounter  Z86.74 Personal history of sudden cardiac arrest  Z45.02 Encounter for adjustment and management of automatic implantable cardiac defibrillator  When any of the above codes appear on a claim, the Q0 modifier is not required.  The Q0 modifier may be appended to claims for secondary prevention indications when data is being entered into a qualifying data collection system.
(Medicare Claims Processing Manual)
280 - Autologous Cellular Immunotherapy Treatment of Prostate Cancer  (Rev. 2380, Issued: 01- 06-12, Effective: 06 -30-11, Implementation: 08- 08-11)  280.1 - Policy  (Rev. 2380, Issued: 01- 06-12, Effective: 06 -30-11, Implementation: 08- 08-11)  Effective for services furnished on or after June 30, 2011, a National Coverage Determination (NCD) provides coverage of sipuleucel -T (PROVENGE) for patients with asymptomatic or minimally symptomatic metastatic, castrate -resistant (hormone refractory) pr ostate cancer.  Conditions of Medicare Part A and Medicare Part B coverage for sipuleucel -T are located in the Medicare NCD Manual, Publication 100- 03, section 110.22.  280.2 - Healthcare Common Procedure Coding System (HCPCS) Codes and Diagnosis Coding (Rev. 2380, Issued: 01- 06-12, Effective: 06 -30-11, Implementation: 08- 08-11)  HCPCS Codes   Effective for claims with dates of service on June 30, 2011, Medicare providers shall report one of the following HCPCS codes for PROVENGE:    C9273 -  Sipuleucel -T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion, or   J3490  Unclassified Drugs, or    J3590  Unclassified Biologics.   NOTE : Contractors shall continue to process claims for HCPCS code C9273, J3490, and J3590, with dates of service June 30, 2011, as they do currently.   Effective for claims with dates of service on and after July 1, 2011, Medicare providers shall report the following HCPCS code:    Q2043  Sipuleucel -T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion; short descriptor, Sipuleucel -T auto CD54+.   ICD- 9 Diagnosis Coding
(Medicare Claims Processing Manual)
ICD- 9 Diagnosis Coding  For claims with dates of service on and after July 1, 2011, for PROVENGE, the on- label indication of asymptomatic or minimally symptomatic metastatic, castrate -resistant (hormone refractory) prostate cancer, must be billed using ICD -9 code 185 (malignant neoplasm of prostate) and at least one of the following ICD -9 codes: