evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Please refer to the National Coverage Determinations Manual (Publication 100 -03, Section 20.35) for more information.   390.1  General Billing Requirements   (Rev. 4049, Issued: 05-  11-18, Effective: 05 -25-17, Implementation: 07- 02-18)  Effective for claims with date of services on or after May 25, 2017, contractors shall pay claims for SET for beneficiaries with IC for the treatment of symptomatic PAD, with a referral from the physician responsible for PAD treatment.    Medicare Administrative Contractors (MACs) have the discretion to cover SET beyond 36 sessions over 12 weeks and may cover an additional 36 sessions over an extended period of time.  Contractors shall accept the inclusion of the KX modifier on the claim line(s) as an attestation by the provider of the services that documentation is on file verifying that further treatment beyond the 36 sessions of SET over a 12 week period meets the requirements of the medical policy.   390.2  Coding Requirements for SET  (Rev. 4049, Issued: 05-  11-18, Effective: 05 -25-17, Implementation: 07- 02-18)    CPT 93668   Under Peripheral Arterial Disease Rehabilitation    ICD-10 Codes   I70.211  right leg   I70.212  left leg   I70.213  bilateral legs   I70.218  other extremity   I70.311  right leg   I70.312  left leg   I70.313  bilateral legs   I70.318  other extremity    I70.611  right leg   I70.612  left leg   I70.613  bilateral legs   I70.618  other extremity   I70.711  right leg   I70.712  left leg   I70.713  bilateral legs   I70.718  other extremity    390.3 Special Billing Requirements for Institutional Claims  (Rev.4049, Issued: 05-  11-18, Effective: 05 -25-17, Implementation: 07- 02-18)  Contractors shall pay claims for SET services containing CPT code 93668 on Types of Bill (TOBs) 13X under OPPS and 85X based on reasonable cost.
(Medicare Claims Processing Manual)
Contractors shall pay claims for SET services containing CPT code 93668 on Types of Bill (TOBs) 13X under OPPS and 85X based on reasonable cost.   Contractors shall pay claims for SET services containing CPT 93668 with revenue codes 096X, 097X, or 098X when billed on TOB 85X Method II based on 115% of the lesser of the fee schedule amount or the submitted charge.   390.4 Common Working File (CWF) Requirements  (Rev.4049, Issued: 05-  11-18, Effective: 05 -25-17, Implementation: 07 -02-18)  CWF shall create a new edit for CPT 93668 to reject claims when a beneficiary has reached 36 SET sessions within 84 days after the date of the first SET session and the KX modifier is not included on the claim or to reject any SET session provided after 84 days from the date of the first session and the KX modifier is not included on the claim.  CWF shall determine the remaining SET sessions.   The CWF determination, to parallel claims processing, shall include all applicable factors including:    Beneficiary entitlement status   Beneficiary claims history   Utilization rules  CWF shall update the determination when any changes occur to the beneficiary master data or claims data that would result in a change to the calculation.   CWF shall display the remaining SET sessions on all CWF provider query screens.   The Multi -Carrier System Desktop Tool (MCSDT) shall display the remaining SET sessions in a format equivalent to the CWF HIMR screen(s).   390.5 Applicable Medicare Summary Notice (MSN), Remittance Advice Remark Codes and Claim Adjustment Reason Code Messaging  (Rev.4049, Issued: 05-  11-18, Effective: 05 -25-17, Implementation: 07- 02-18)   Contractors shall deny claims for SET when services are provided on other than TOBs 13X and 85X using the following messages:  MSN 15.20: The following policies NCD 20.35 were used when we made this  decision.
(Medicare Claims Processing Manual)
 Contractors shall deny claims for SET when services are provided on other than TOBs 13X and 85X using the following messages:  MSN 15.20: The following policies NCD 20.35 were used when we made this  decision.   Spanish Version  Las siguientes polticas NCD 20.35 fueron utilizadas cuando se tom esta decisin.  (Part A only) MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call  1-800-MEDICARE (1 -800-633-4227) for a copy of the LCD.    Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto. Un LCD se us para su reclamacin. Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si piens a que puede cambiar nuestra decisin. Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1800- 633-4227).   Claim Adjustment Reason Code (CARC) 58:   Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. NOTE: Refer to the 832 Healthcare Policy Identification Segment (loop 2110 Service payment Information REF), if present.   Remittance advice remark code (RARC) N386:  This decision was based on a National Coverage Determination (NCD) 20.35. An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www. cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.  Contractors shall use Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.   Contractors deny/reject claim lines for CPT 93668 without one of the diagnosis codes listed in 390.2 and use the following messages:
(Medicare Claims Processing Manual)
MSN 15.20: The following policies NCD 20.35 were used when we made this  decision.   Spanish Version  Las siguientes polticas NCD 20.35 fueron utilizadas cuando se tom esta decisin.   (Part A only) MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call  1-800-MEDICARE (1 -800-633-4227) for a copy of the LCD.  Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto. Un LCD se us para su reclamacin. Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si piens a que puede cambiar nuestra decisin. Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1800- 633-4227).   CARC 167  This (these) diagnosis(es) is (are) not covered. 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  www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.
(Medicare Claims Processing Manual)
Contractors shall use Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary if a claim is received with a GA modifier indicating a signed ABN is on file.    Contractors shall use Group CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.   Contractors shall reject claims with CPT 93668 which exceed 36 sessions within 84 days from the date of the first session when the KX modifier is not included on the claim line OR any SET session provided after 84 days from the date of the first session an d the KX modifier is not included on the claim and use the following messages:   96- Non -covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason [sic] Code, or Remittance Advice Remark Code that is not an ALERT.)   Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.    N640 Exceeds number/frequency approved/allowed within time period.     Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim line -item is received with a GZ modifier indicating no signed ABN is on file and occurrence code 32 is not present).     Contractors shall deny/reject claim lines with CPT 93668 when sessions have reached 73 sessions using the following messages:  MSN 15.20: The following policies NCD 20.35 were used when we made this decision.     Spanish Version  Las siguientes polticas NCD 20.35 fueron utilizadas cuando se tom esta decisin.   (Part A only) MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call  1-800-MEDICARE (1 -800-633-4227) for a copy of the LCD.
(Medicare Claims Processing Manual)
Spanish Version -  Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto. Un LCD se us para su reclamacin. Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si piens a que puede cambiar nuestra decisin. Para obtener una copia del LCD, llame al 1 -800-MEDICARE (1800- 633-4227).   CARC 119: Benefit maximum for this time period or occurrence has been reached.   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 www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.    Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is received with occurrence code 32 with or without a GA modifier or a claim -line is received with a GA modifier indicating a signed ABN is on file)   Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim line -item is received with a GZ modifier indicating no signed ABN is on file and occurrence code 32 is not present   Contractors shall deny claim line -items for SET, CPT 93668, when sessions have reached 73 sessions with or without the KX Modifier present using the following messages:   MSN 15.20: The following policies NCD 20.35 were used when we made this decision.   Spanish Version  Las siguientes polticas NCD 20.35 fueron utilizadas cuando se tom esta decisin.   (Part A only) MSN 15.19: Local Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800- MEDICARE (1 -800-633-4227) for a copy of the LCD.
(Medicare Claims Processing Manual)
Spanish Version - Las Determinaciones Locales de Cobertura (LCDs en ingls) le ayudan a decidir a Medicare lo que est cubierto. Un LCD se us para su reclamacin. Usted puede comparar su caso con la determinacin y enviar informacin de su mdico si piensa que puede cambiar nuestra decisin. Para obtener una copia del LCD, llame al 1 -800- MEDICARE (1800-633-4227).  CARC 119: Benefit maximum for this time period or occurrence has been reached.    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 www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.  Group Code PR (Patient Responsibility) assigning financial responsibility to the beneficiary (if a claim is received with occurrence code 32 with or without a GA modifier or a claim -line is received with a GA modifier indicating a signed ABN is on file)  Group Code CO (Contractual Obligation) assigning financial liability to the provider (if a claim line- item is received with a GZ modifier indicating no signed ABN is on file and occurrence code 32 is not present).  400 - Chimeric Antigen Receptor (CAR) T -cell Therapy  (Rev. 11721; Issued: 11-28-22; Effective: 01 -01-23; Implementation: 01-03-23)  T-cells employ a number of mechanisms to fight abnormal cells such as cancer. One type of therapy that leverages the immune system, immunotherapy, is Chimeric Antigen Receptor (CAR) T-cell therapy. CAR T- cells have been genetically altered in order to impr ove the ability of the T- cells to fight cancer.  400.1 - Coverage Requirements  (Rev. 11721; Issued: 11-28-22; Effective: 01 -01-23; Implementation: 01-03-23)
(Medicare Claims Processing Manual)
Effective for services performed on or after August 7, 2019, the Centers for Medicare & Medicaid Services (CMS) covers autologous treatment for cancer with T- cells expressing at least one CAR when administered at healthcare facilities enrolled in the Food and Drug Administration (FDA) risk evaluation and mitigation strategies (REMS) and used for a medically accepted indication as defined at Social Security Act (the Act) section 1861(t)(2), i.e., is used for either an FDA -approved indication (according to the FDA-approved label for that product), or for other uses when the product has been FDA-approved and the use is supported in one or more CMS-approved compendia. See Publication 100-03, National Coverage Determination (NCD) Manual 110.24 for complete coverage criteria. See the following websites  for specific REMS facility information:  Kymriah https://www.us.kymriah.com/treatment- center -locator   Yescarta https://www.yescarta.com/find -a-treatment -center    Tecartus  https://www.tecartus.com/hcp/treatment- center -locator   Breyanzi https://www.celltherapy360.com/locations   ABECMA https://www.celltherapy360.com/locations   CARVYKTI  https://www.carvyktihcp.com/treatment- centers    NOTE:  The use of allogenic  T-cells from healthy donors are not autologous CAR T- cell treatments and shall not be billed as autologous CAR T- cell treatments.    400.2 - Billing Requirements (Rev. 11721; Issued: 11- 28-22; Effective: 01 -01-23; Implementation: 01 -03-23)  Effective for dates of service on or after August 7, 2019, contractors shall pay for line -item professional claims from approved providers for the administration of autologous treatment for cancer with T -cells expressing at least one CAR with Current Proce dural Terminology (CPT) code 0540T.
(Medicare Claims Processing Manual)
Contractors shall not require the NCD 110.24 - KX modifier and diagnosis codes for clinical trials under NCD 310.1. These claims shall be billed with the NCT number for the specific trial, the -Q0 clinical trial modifier, and the Z00.6 clinical trial diagno sis code on the 0540T claim line effective for dates of service on or after August 7, 2019.   For Part A Outpatient (OPPS) contractors shall not require NCD 110.24 REMS facility and diagnosis codes for CAR T -cell therapy CPT code 0540T in clinical trials under NCD 310.1 billed with the NCT number for the specific trial, the -Q0 clinical trial modifier, condition code 30, value code D4, and the Z00.6 clinical trial diagnosis code effective for dates of service on or after August 7, 2019.  400.2.1 - A/B Medicare Administrative Contractor (MAC) (A) Bill Types  (Rev. 10891, Issued: 07- 20-21, Effective: 08 -07-19, Implementation: 09- 20-21)   Valid type of bills (TOBs) for billing inpatient CAR T -cell therapy services may include (but are not necessarily limited to): 011x  Inpatient Hospital 012x  Inpatient Ancillary Hospital  Valid TOBs for billing outpatient CAR T -cell therapy services may include (but are not necessarily limited to):   013x  Outpatient Hospital 085x  Critical Access Hospital   400.2.2 - A/B MAC (A) Revenue Code  (Rev. 11721; Issued: 11- 28-22; Effective: 01 -01-23; Implementation: 01 -03-23)  The following Revenue Codes are used for billing inpatient and outpatient CAR T -cell therapy services:
(Medicare Claims Processing Manual)
The following Revenue Codes are used for billing inpatient and outpatient CAR T -cell therapy services:   0871  Cell Collection w/CPT code 0537T  0872  Specialized Biologic Processing and Storage  Prior to Transport w/CPT code 0538T  0873  Storage and Processing after Receipt of Cells from Manufacturer w/CPT code 0539T  0874  Infusion of Modified Cells w/CPT code 0540T  0891  Special Processed Drugs  FDA Approved Cell Therapy w/ Healthcare Common Procedure Coding System (HCPCS) codes Q2041, Q2042, C9073 (replaced with Q2053 April 1, 2021), C9076 (replaced with Q2054 October 1, 2021), C9081 (replaced with Q2055 January 1, 2022), C9098 (replaced with Q2056 October 1, 2022), or C9399  400.2.3 - A/B MAC Billing HCPCS Codes  (Rev. 11721; Issued: 11- 28-22; Effective: 01 -01-23; Implementation: 01 -03-23)  The following HCPCS/CPT procedure codes are used for billing outpatient CAR T -cell therapy services:
(Medicare Claims Processing Manual)
The following HCPCS/CPT procedure codes are used for billing outpatient CAR T -cell therapy services:   HCPCS Code Q2041 for Axicabtagene Ciloleucel  HCPCS Code Q2042 for Tisagenlecleucel  HCPCS Code Q2053 for Brexucabtagene Autoleucel (effective April 1, 2021)  HCPCS Code Q2054 for Lisocabtagene Maraleucel (effective October 1, 2021)  HCPCS Code Q2055 for Idecabtagene Vicleucel (effective January 1, 2022)  HCPCS Code Q2056 for Ciltacabtagene Autoleucel (effective October 1, 2022)  HCPCS Code C9073 for Brexucabtagene Autoleucel (prior to April 1, 2021)  HCPCS Code C9076 for Lisocabtagene maraleucel (prior to October 1, 2021)  HCPCS Code C9081 for Idecabtagene Vicleucel (prior to January 1, 2022)  HCPCS Code C9098 for Ciltacabtagene Autoleucel (prior to October 1, 2022)  HCPCS Code C9399, J3490, J3590, or J9999 for unclassified drugs or biologicals when dose of CAR T -cell therapy exceeds code descriptor or when other CAR T -cell therapy obtains FDA approval but has not yet received a specific HCPCS code  CPT Code 0537T collection/handling* CPT Code 0538T preparation for transport*  CPT Code 0539T receipt and preparation*  CPT Code 0540T the provider (physician/NPP) procedure to administer CAR T -cells  * Procedure represents the various steps required to collect and prepare the genetically modified T -cells, and these steps are not paid separately under the Outpatient Prospective Payment System (OPPS)/Medicare Physician Fee Schedule (MPFS).   400.2.3.1  A/B MAC (B) Places of Service (POS)  (Rev. 11721; Issued: 11- 28-22; Effective: 01 -01-23; Implementation: 01 -03-23)
(Medicare Claims Processing Manual)
The following places of service (POS) are covered for CAR T -cells product HCPCS codes (Q2041, Q2042, Q2053-Q2056, J3490, J3590, and J9999):   11 (Office)  49 (Independent clinic)   Professional claims for the procedure to administer CAR T -cells (0540T) may include (but are not necessarily limited to):  11 (Office)  19 (Off Campus -Outpatient Hospital)  21 (Inpatient Hospital)  22 (On Campus -Outpatient Hospital)  49 (Independent Clinic)   400.2.4 - A/B MAC Diagnosis and Procedure Code Requirements  (Rev. 11721; Issued: 11- 28-22; Effective: 01 -01-23; Implementation: 01 -03-23)  Please see NCD spreadsheet for the applicable International Classification of Disease (ICD) -10-CM diagnosis codes for CAR T -cell therapy coverage.   The following are the applicable ICD -10-PCS procedure codes for CAR T -cell therapy coverage for inpatient claims:    For dates of service on or after October 1, 2021:   CARVYKTI  - XW033A7: Introduction of Ciltacabtagene Autoleucel into Peripheral Vein, Percutaneous Approach, New Technology Group 7  CARVYKTI  - XW043A7: Introduction of Ciltacabtagene Autoleucel into Central Vein, Percutaneous Approach, New Technology Group 7   When other CAR T -cell therapy obtains FDA approval but has not yet received a specific PCS code, and for use in clinical trials FDA -approved under NCD 310.1  XW033C7: Introduction of Autologous Engineered Chimeric Antigen Receptor T -cell Immunotherapy int o Peripheral Vein, Percutaneous Approach, New Technology Group 7  When other CAR T -cell therapy obtains FDA approval but has not yet received a specific PCS code, and for use in clinical trials FDA -approved under NCD 310.1  XW043C7: Introduction of Autologous Engineered Chimeric Antigen Receptor T -cell Immunotherapy int o Central Vein, Percutaneous Approach, New Technology Group 7
(Medicare Claims Processing Manual)
Yescarta -  XW033H7: Introduction of Axicabtagene Ciloleucel Immunotherapy into Peripheral Vein, Percutaneous Approach, New Technology Group 7   Yescarta -  XW043H7: Introduction of Axicabtagene Ciloleucel Immunotherapy into Central Vein, Percutaneous Approach, New Technology Group 7   Kymriah -  XW033J7: Introduction of Tisagenlecleucel Immunotherapy into Peripheral Vein, Percutaneous Approach, New Technology Group 7   Kymriah -  XW043J7: Introduction of Tisagenlecleucel Immunotherapy into Central Vein, Percutaneous Approach, New Technology Group 7  ABECMA -  XW033K7: Introduction of Idecabtagene Vicleucel Immunotherapy into Peripheral Vein, Percutaneous Approach, New Technology Group 7   ABECMA -  XW043K7: Introduction of Idecabtagene Vicleucel Immunotherapy into Central Vein, Percutaneous Approach, New Technology Group 7   Tecartus  - XW033M7: Introduction of Brexucabtagene Autoleucel Immunotherapy into Peripheral Vein, Percutaneous Approach, New Technology Group 7   Tecartus  - XW043M7: Introduction of Brexucabtagene Autoleucel Immunotherapy into Central Vein, Percutaneous Approach, New Technology Group 7   Breyanzi -  XW033N7: Introduction of Lisocabtagene Maraleucel Immunotherapy into Peripheral Vein, Percutaneous Approach, New Technology Group 7   Breyanzi -  XW043N7: Introduction of Lisocabtagene Maraleucel Immunotherapy into Central Vein, Percutaneous Approach, New Technology Group 7   For dates of service prior to October 1, 2021:   Yescarta, ABECMA, Kymriah -  XW033C3: Introduction of Engineered Autologous Chimeric Antigen  Receptor T -cell Immunotherapy into Peripheral Vein, Percutaneous Approach, New Technology Group 3
(Medicare Claims Processing Manual)
Yescarta, ABECMA, Kymriah -  XW043C3: Introduction of Engineered Autologous Chimeric Antigen  Receptor T -cell Immunotherapy into Central Vein, Percutaneous Approach, New Technology Group 3   Tecartus  - XW23346 - Transfusion of Brexucabtagene Autoleucel Immunotherapy into Peripheral Vein,  Percutaneous Approach, New Technology Group 6   Tecartus  - XW24346 - Transfusion of Brexucabtagene Autoleucel Immunotherapy into Central Vein, Percutaneous Approach, New Technology Group 6   Breyanzi -  XW23376   Transfusion of lisocabtagene maraleucel immunotherapy into peripheral vein, percutaneous approach, new technology group 6   Breyanzi - XW24376  Transfusion of lisocabtagene maraleucel immunotherapy into central vein, percutaneous approach, new technology 6   NOTE:  Since allogenic T -cells are by definition not autologous CAR T -cells, it is inappropriate to use any of the above autologous CAR T -cell ICD -10 PCS procedure codes for allogenic T -cell treatments.   For Part A Inpatient contractors shall not require NCD 110.24 REMS facility and diagnosis codes for autologous CAR T-cell therapy ICD -10-PCS codes XW033A7/XW043A7, XW033H7/XW043H7, XW033J7/XW043J7, XW033K7/XW043K7, XW033M7/XW043M7, and XW033N7/XW043N7 in c linical trials under NCD 310.1 billed with the NCT number for the specific trial, condition code 30, value code D4, and the Z00.6 clinical trial diagnosis code effective for dates of service on or after August 7, 2019.  400.2.5  Billing Information for Professional Claims  (Rev. 11721; Issued: 11- 28-22; Effective: 01 -01-23; Implementation: 01 -03-23)