evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Ambulance Services (A56468)
Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forAmbulance Services L34549.Physician Certification & Order:The ambulance supplier is responsible for obtaining the signed written order and certification with the appropriate signatures as expeditiously as possible, and must obtain the signed order before billing for the service.If the ambulance supplier is unable to obtain the written order and certification with appropriate signatures within 21 calendar days following the date of the service, the supplier may bill only if there is documentation of good faith effort to obtain the order and certification.When the transport involves a ground ambulance and an air ambulance, both services may be reimbursed if both are medically necessary.The ambulance provider or supplier must meet all coverage criteria in order for payment to be made.Medicare requires the signature of the beneficiary, or that of his or her representative, for both the purpose of accepting assignment and submitting a claim to Medicare.Ambulance services that are not Medicare benefits because some other form of transportation is not contraindicated, is an exclusion from Medicare benefits under the statutory definition of that benefit at 1861(s)(7). An Advance Beneficiary Notice of Noncoverage (ABN) is not needed and should not be used in the following situations:Any denial where the patient could be transported safely by other means (these are denials under 1861(s)(7) of the Social Security Act (SSA)).Any denial that is based on not meeting an origin or destination requirement (these denials are inconsistent with 42 CFR 410.40 and generally also constitute 1861(s)(7) denials).A denial for mileage that is beyond the nearest appropriate facility (for the same reason as b. above).A denial where the physician certification statement or accepted alternative (e.g., certified mail) is not obtained (for the same reason as b. above).A convenience discharge, e.g., where the beneficiary is an inpatient at one hospital that can care for their needs, but wants to be transferred to a second hospital to be closer to family (for the same reason as b. above).
Article - Billing and Coding: Ambulance Services (A56468)
Not obtaining an ABN in these technical denial situations does not prevent the supplier or provider from collecting denied charges from the beneficiary.CMS developed the Beneficiary Notices Initiative web page to assist suppliers and providers in informing beneficiaries that the services they are receiving are excluded from Medicare benefits. Ambulance suppliers may develop their own process to communicate to beneficiaries that they will be billed for excluded services for which the ABN is not appropriate.Multiple patient transports - a single payment allowance for mileage will be prorated by the number of beneficiaries onboard.Downcoding from air to ground is an 1862(a)(1)(A) denial.Multiple arrivals - when multiple units respond to a call for services the entity that provides the transport for the beneficiary should be the only provider billing the service.
Article - Billing and Coding: Bladder/Urothelial Tumor Markers (A56471)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Bladder/Urothelial Tumor Markers (L36975).CGS Administrators, LLCwill only cover bladder tumor marker fluorescence in situ hybridization (FISH) testing services when performed using validated assays. To date, UroVysion Bladder Cancer Kit is the only Federal Drug Administration (FDA) approved assay that is designed to detect aneuploidy for chromosomes 3, 7, 17 and loss of the 9p21 locus via FISH. The assay is performed on urine specimens from persons with hematuria suspected of having bladder cancer as an aid for initial diagnosis of bladder carcinoma and subsequent monitoring for tumor recurrence in patient previously diagnosed with bladder cancer. UroVysion Bladder Kit services may only be billed by a CLIA certified lab.To bill UroVysion Bladder Kit services, submit the following claim information:Select CPTcode 88120 or 88121 as appropriateEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/typesLoop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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 formLaboratories reporting only the technical component for a UroVysion service should append the appropriate code 88120 or 88121 with the TC modifier.All other services that meet the code 88120 or 88121 definition performed by any provider type MUST bill the following claim information.
Article - Billing and Coding: Bladder/Urothelial Tumor Markers (A56471)
All other services that meet the code 88120 or 88121 definition performed by any provider type MUST bill the following claim information.Select CPTcode 88120 or 88121 as appropriateEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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 formTo register a test for a DEX Z-Code identifier, follow the registration process outlined in the MolDX Test Registration article located on the MolDX site. Once an identifier has been assigned, submit a Technical Assessment (TA) request as documented on the MolDX site TA Process.Note:Physicians may NOT submit claims for a code 88120 and 88121 professional component when the interpretive information is provided by a lab technician or scientist. Per Chapter 10 in the NCCI Policy Manual for Medicare Services, Version 16.3, the physician work component requires a physician to read, quantitate and interpret the tissues/cells stained with the probes(s). Physicians who knowingly report and interpretation based on the documented results of another professional may be subject to additional corrective action including Recovery Audit Contractor (RAC) or fraud referrals.To report a Bladder/Urothelial Tumor Marker service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Select the appropriate ICD-10 code
Article - Billing and Coding: Botulinum Toxins (A56472)
CMS National Coverage PolicySection 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 8:50.5 Drugs and Biologicals [Coverage of SNF services]70 Medical and Other Health Services Furnished to SNF Patients.CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 12:40.10 Drugs and Biologicals [Coverage of Comprehensive Outpatient Rehabilitation Facility services]CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15:50.150.5 Drugs and Biologicals 120 Ambulatory Surgical Center ServicesCMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 16:260 Non-coverage for Cosmetic ProceduresCMS Publication 100-04;Medicare Claims Processing Manual,Chapter 17:40 Discarded Drugs and BiologicalsCMS Publication 100-04;Medicare Claims Processing Manual,Chapter 30:20.2.1 Categorical DenialsArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy Botulinum Toxins L33949.General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Article - Billing and Coding: Botulinum Toxins (A56472)
Advance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier 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 is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.
Article - Billing and Coding: Botulinum Toxins (A56472)
The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)For coverage of botulinum toxin treatment by Medicare, the medical record should include:documentation of the medical necessity for this treatment. For spastic conditions other than upper limb spasticity, blepharospasm, hemifacial spasm, cervical dystonia or other focal dystonias, documentation should include a statement that the spastic condition has been unresponsive to conventional treatment;a covered diagnosis;dosage(s), site(s) and frequency(ies) of injection;documentation of the medical necessity for associated electromyography when used; anddescription of the effectiveness of this treatment.Due to the short life span of the drug once it is reconstituted, Medicare will reimburse the unused portions of Botulinum toxins. However, the documentation in the medical records must show the precise amount of the drug administered and the amount discarded.Documentation must be available upon request of the contractor. Peer-reviewed medical literature may be requested for case-by-case determinations.Utilization GuidelinesIt is generally not considered medically necessary to give Botulinum toxin injections for spastic or excess muscular contraction conditions more frequently than every 90 days.Other Comments:For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS to process their claims.
Article - Billing and Coding: Botulinum Toxins (A56472)
For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS to process their claims.Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.
Article - Billing and Coding: Cardiac Radionuclide Imaging (A56476)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Cardiac Radionuclide Imaging L33457.Claims submitted for stress tests performed as preoperative evaluation of patients without symptoms of coronary artery disease (CAD) who are deemed to be at moderate risk must document 1 of the following at-risk conditions in the medical record: diabetes mellitus (DM) with complications, peripheral vascular disease (PVD), aortic aneurysm or cerebrovascular disease.
Article - Billing and Coding: Hemophilia Factor Products (A56482)
CMS National Coverage PolicyInternet-Only Manuals (IOMs):CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 17, Section 80.4 Billing for Hemophilia Clotting Factors, Section 80.4.1 Clotting Factor Furnishing FeeSocial 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: Hemophilia Factor Products (A56482)
This Billing and Coding Article provides coding guidance for Hemophilia Factor Products.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered as if they are covered. When billing for non-covered services, use the appropriate modifier.The Centers for Medicare & Medicaid Services (CMS) provided CR4229 to clarify billing practices for providers to ensure that units of service for blood clotting factor are reported accurately. Some Medicare providers have been billing units of drugs and biologicals incorrectly on outpatient bills as well as on inpatient claims for hemophilia clotting factors. The erroneous reporting of units of service has resulted in Medicare overpayments (reference Medicare Learning Network [MLN] Matters Number: 4229).General Billing InstructionsThe provider determines the dosage of hemophilia factor furnished to the beneficiary and using the definition of the appropriate HCPCS code, translates the dosage into units of service(s). See example below on translating the dosage administered into units of service.Note:Not all short version descriptions of HCPCS codes define units for the HCPCS code. Providers are reminded to refer to the long descriptors of the HCPCS codes in their HCPCS book.When submitting claims for hemophilia clotting factors it is essential to submit the correct Quantity Billed (QB) to receive the correct reimbursement. Some of the codes are based on international unit (IU) and some may be per milligram (mg) or microgram (mcg) as specified in the code descriptor. Therefore, the units of service(s) reported should reflect the number of IU, mg, or mcg being administered.JW and JZ ModifiersWhen billing for Part B drugs and biologicals (except those provided under a competitive acquisition program [CAP]), the use of the JW modifier to identify unused drugs or biologicals from single-dose containers or single-use packages that are appropriately discarded is required. The discarded amount shall be billed on a separate claim line using the JW modifier. Providers are required to document the discarded drug or biological in the patients medical record.Any amount wasted must be clearly documented in the medical record and should include the date and time, amount of medication wasted, and the reason for the wastage.
Article - Billing and Coding: Hemophilia Factor Products (A56482)
Any amount wasted must be clearly documented in the medical record and should include the date and time, amount of medication wasted, and the reason for the wastage.The use of the JZ modifier (attesting that there were no discarded amounts) is required on claims to report there are no discarded amounts of unused drugs or biologicals from single-dose containers or single-use packages.Claims for drugs separately payable under Medicare Part B from single-dose containers are required to report either the JW or JZ modifier, to identify any discarded amounts or to attest that there are no discarded amounts, respectively.
Article - Billing and Coding: Hemophilia Factor Products (A56482)
The JW and JZ modifier policy does not apply for drugs that are not separately payable, such as packaged OPPS or ASC drugs, or drugs administered in the FQHC or RHC setting.The JW and JZ modifiers do not apply to drugs assigned status indicator N (Items and Services Packaged into APC Rates) under the OPPS. Similarly, the JW and JZ modifiers do not apply to drugs assigned payment indicator N1 (ASC).Example of Translating the Dosage Administered into Units of ServiceHCPCS CodeShort DescriptorBilling UnitDosage AdministeredUnits of ServiceJ7189Factor viiaPer mcg (1mcg)13,365 mcg13,365
Article - Billing and Coding: Hemophilia Factor Products (A56482)
Example of Translating the Dosage Administered into Units of ServiceHCPCS CodeShort DescriptorBilling UnitDosage AdministeredUnits of ServiceJ7189Factor viiaPer mcg (1mcg)13,365 mcg13,365The provider would calculate the units of service with this equation: 13,365 mcg divided by 1 mcg equals 13,365. Note that the process for calculations based on one IU or one mg is the same as the process for calculations based on one mcg.After the dosage administered has been translated into the total number of units of service, then the provider determines if multiple claim lines should be billed. See Role of Medically Unlikely Edits (MUE) in Proper Billing.Role of Medically Unlikely Edits (MUE) in Proper BillingWhen billing for units of service on the same date of service for the same HCPCS code, MUEs play a role in proper billing and coding. The number of units of service reported on the same date of service for the same HCPCS code cannot have a claim line quantity that exceeds the MUE value for that HCPCS code or that exceeds 9,999 units per claim line.Refer to the CMS.gov website to verify the MUE for each HCPCS code being billed. The units to bill per claim line can be determined by dividing the total number of units of service by the MUE value. However, if this amount is greater than 9,999 then an additional limitation will apply. See examples below.Billing Instructions when MUE is Less than 9,999 Units Per LineIn the below example, the HCPCS code J7193 has a MUE Value of 4,000 units per line. This is the maximum number of units which can be billed per claim line (as per MUE Adjudication Indicator [MAI]). HCPCS code J7193 appears on the CMS.gov MUE spreadsheet as follows:HCPCSMUE ValueMUE Adjudication Indicator (MAI)MUE RationaleJ71934,0001 Line EditClinical: Data
Article - Billing and Coding: Hemophilia Factor Products (A56482)
HCPCSMUE ValueMUE Adjudication Indicator (MAI)MUE RationaleJ71934,0001 Line EditClinical: DataIf more than one line needs to be billed on the claim, the repeat service modifier (-76) must be appended to the second and subsequent lines.Example:Using the HCPCS code J7193 from above, the MUE Value is 4,000 units per line. If 12,500 IUs were administered to a beneficiary on the same date of service, then the total number of units of service would be translated to 12,500 (based on the long descriptor, HCPCS code J7193 is per IU). The minimum number of claim lines to report this amount would be calculated as 4 lines (12,500  4,000 = 3.125, requiring 4 lines as shown below).LineDate of Service (From - To)Procedure Code/ModifierUnit of ServiceBilled Amount105 02 2022 - 05 02 2022J71934,000$4,520.00205 02 2022 - 05 02 2022J7193-764,000$4,520.00305 02 2022 - 05 02 2022J7193-764,000$4,520.00405 02 2022 - 05 02 2022J7193-76500$565.00
Article - Billing and Coding: Hemophilia Factor Products (A56482)
305 02 2022 - 05 02 2022J7193-764,000$4,520.00405 02 2022 - 05 02 2022J7193-76500$565.00Do not report a date range as the date of service. Indicate date span in the narrative of the claim. If the claim is for a monthly supply of clotting factor distributed to the beneficiary on the date of service, indicate monthly supply and the date span in the narrative of the claim or the EDI equivalent. For additional information on reporting DOS, see section below titled Date of Service (DOS).Billing Instructions when MUE is Greater than 9,999 Units Per LineDue to system limitations, a maximum of 9,999 units of service may be billed on any one claim line. This limitation is applicable in addition to the established MUE limit for the HCPCS code. If the total number of units of service exceeds 9,999 divide the total number of units of service by the maximum number of units that can be billed on a claim line to determine the minimum number of claims lines to bill.Example:The MUE for HCPCS code J7192 is 22,000 units per line, which exceeds the system limit of 9,999 units per line. If 22,000 IUs were administered to a beneficiary on the same date of service, then the total number of units of service would be translated to 22,000 (based on the long descriptor, HCPCS code J7192 is per IU). The minimum number of claim lines to report this amount would be calculated as 3 lines (22,000  9,999 = 2.20, requiring 3 lines as shown below).LineDate of Service (From - To)Procedure Code/ModifierUnit of ServiceBilled Amount105 11 2022 - 05 11 2022J71929,999$13,489.65205 11 2022 - 05 11 2022J7192-769,999$13,489.65305 11 2022 - 05 11 2022J7192-762,002$2,702.70