evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Cardiac Catheterization and Coronary Angiography (A52850)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the local coverage determination (LCD) forCardiac Catheterization and Coronary Angiography.Coding Guidelines: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 patients condition for which the service was performed.Specific coding guidelines:Diagnosis CodingA primary diagnosis of ICD-10-CM code Z09 (encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm); and a secondary diagnosis of ICD-10-CM code Z94.1 (heart transplant status); should be used for patients post-heart transplant requiring follow-up cardiac catheterization and not showing evidence of rejection.Add the ICD-10-CM code for the underlying disorder (cause) for ICD-10-CM codes I25.82 (chronic total occlusion of coronary artery) and I31.4 (cardiac tamponade).The CPT code(s) for the cardiac catheterization procedure(s), coronary angiography, and injection procedure(s) should be linked to the appropriate ICD-10-CM diagnosis code(s) that describes the indication for the procedure on the claim.Modifier GuidelinesWhen billing for CPT codes 92978, 92979, 93571 and 93572, use the coronary artery modifier to identify which vessel is undergoing a specific procedure. The modifiers are RC: right coronary artery, LC: left circumflex coronary artery, LD: left anterior descending coronary artery, LM: left main coronary artery, and RI: ramus intermedius.Claims for these services billed without the major artery modifier will be returned to the provider as unprocessable.
Article - Billing and Coding: Cardiac Catheterization and Coronary Angiography (A52850)
Claims for these services billed without the major artery modifier will be returned to the provider as unprocessable.Coronary angiography procedures, performed during a therapeutic coronary artery procedure, that are integral parts of the procedure (e.g., guiding arteriograms), are considered to be part of the percutaneous coronary intervention and not separately reportable diagnostic procedures. However, when billing for a diagnostic cardiac catheterization or angiography, which has not been previously performed, but now is performed on the same day as a separate procedure prior to percutaneous coronary intervention, then the 59 modifier should be appended to the codes 93454  93461 as appropriate.Not Separately Billable ServicesThe following services are included in cardiac catheterization and coronary angiography, and should not be separately billed to Medicare:sedation;local anesthesia;positioning, repositioning, and removal of catheter(s);recording of intravascular and intracardiac pressures;obtaining blood samples for blood gas determinations;cardiac output measurements at rest, or at rest and during exercise, with or without electrode catheter placement;monitoring services, such as ECG and arterial oxygen saturation;final evaluation;written report;administration of medications during catheterization to treat acute symptoms or adverse events (e.g., angina, congestion, arrhythmias, etc);post-procedure evaluation.Medicare Part B covers only the professional component of cardiac catheterization and coronary angiography procedures, when they are performed in hospital inpatient and outpatient facility settings. The technical component is covered under the Part A benefit. Diagnostic cardiac catheterization performed in an office setting (where permitted) is covered under Part B for both the professional and technical components.CPT and Units of Service GuidelinesCatheterization for anomalous coronary arteries, patent foramen ovale, mitral valve prolapse and bicuspid aortic valve should be reported with the non-congenital catheterization codes (93451-93464 and 93566-93568).
Article - Billing and Coding: Cardiac Catheterization and Coronary Angiography (A52850)
Use CPT code 93541 or other appropriate right heart catheterization code (93453, 93456, 93457, 93460 or 93461) when right heart catheterization is done in a cardiac catheterization laboratory or in an interventional radiology laboratory and the procedure is done as part of a formal cardiac catheterization study.The CPT codes for right heart catheterization are to be reported only when they pertain to diagnostic studies. Therefore, they should not be separately coded when a flow-directed catheter (e.g., Swan-Ganz) is placed in the right heart for monitoring purposes or when an endomyocardial biopsy is performed without obtaining hemodynamic data not previously available.When an endomyocardial biopsy (CPT code 93505) is performed during cardiac catheterization, bill only one unit of service regardless of the number of biopsies taken.CPT codes 93454 and 93455 (catheter placement, angiography) should be billed, as appropriate, when coronary or bypass angiography without left heart catheterization is performed. CPT codes 93454 and 93455 may be billed only once per catheterization.CPT codesfor Cardiac Catheterization include all dye injections for angiography, catheter insertion/replacement and repositioning, and the supervision and interpretation. Component services are no longer separately billable. Codes may be billed once per catheterization encounter.CPT code 93598 may not be billed with catheterization codes.When a catheterization involving multiple components is performed, the single CPT code including all of the components should be billed. Services for the individual component parts may not be billed. CPT codes 93563-93565 may only be billed with CPT codes 93593, 93594, 93595, 93596, and 93597. Codes for right atrial/ventricular angiography, supravalvular aortography and pulmonary angiography may be billed as add-on codes with any of the catheterization codes.
Article - Billing and Coding: Cardiac Catheterization and Coronary Angiography (A52850)
The transeptal/transapical left heart catheterization (93462) may be billed with 93452-93453, 93458-93461, 93595, 93596 and 93597. This code may only be billed when there is a puncture of an intact septum and should not be billed if the catheter is advanced into the left atrium through a patent foramen ovale or atrial septal defect.Pharmacologic agent administration (93463) and Physiologic exercise study (93464) may only be coded when performed with pre-, intra- and post-intervention hemodynamic and function measures as a diagnostic test or to evaluate potential therapeutic interventions.Percutaneous insertion of an intra-aortic balloon catheter may be coded separately when performed during the same encounter that cardiac catheterization or coronary angiography is performed.The CPT codes for repair of blood vessel, direct (35201, 35206 and 35226) and repair of blood vessel with graft other than vein (35261, 35266 and 35286) are codes for open repairs of these vessels, and should not be used to bill for the use of percutaneous vascular closure devices (G0269) with angiographic, cardiac catheterization and interventional cardiology or radiology procedures.Selective extra-cardiac angiography performed during cardiac catheterization, when medically necessary, should be billed using the appropriate codes from the 36140-36254 and 75625-75716 series. These codes should also be billed when these angiographic services are performed unrelated to cardiac catheterization.Codes from 36140 through 36254 and 75625 through 75716 should only be coded if they are used to code selective studies and were medically necessary for diagnostic purposes as described in the LCD.For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.The insertion of the percutaneous closure device (G0269) is a bundled service and not separately billable by the physician.
Article - Billing and Coding: Cardiac Catheterization and Coronary Angiography (A52850)
The insertion of the percutaneous closure device (G0269) is a bundled service and not separately billable by the physician.The name and NPI of the treating physician who specifically requested/ordered extra-cardiac angiographic services must be submitted in items 17 and 17a of the CMS 1500 form or in the electronic equivalent of the claim for these services.Supervision CriteriaThe global and technical component [TC] procedures are covered under part B when performed under personal physician supervision (the physician would have to be present in the room while the entire cardiac catheterization is being performed) in the following circumstances:The procedure is performed in an IDTF or free-standing facility;The cardiac catheterization is performed in an entity set up as a physician office or physician directed clinic;The professional components (-26) and professional services are reimbursable in any approved site of service when performed under personal physician supervision (the physician would have to be present in the room while the entire cardiac catheterization is being performed).For claims submitted to the Part A MAC:Cardiac catheterizations for which an overnight stay is anticipated, for routine recovery, should not be billed as inpatient services. Furthermore, the routine recovery period should not be billed as observation hours in addition to the catheterization unless the patient has sustained untoward complications necessitating the continued monitoring. An inpatient or observation stay following a routine outpatient cardiac catheterization would be considered not medically necessary and denied.
Article - Billing and Coding: Cardiac Catheterization and Coronary Angiography (A52850)
The insertion of the percutaneous closure device (G0269) is not a reimbursable service although it should be billed on the UB-92 claim but as a non-reimbursable supply (Nstatus).Documentation Requirements:Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned.The patients medical record should contain documentation that fully supports the medical necessity for cardiac catheterization and coronary angiography as it is covered by Medicare. This documentation includes, but is not limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or procedures.The medical record should contain a formal procedure report and interpretation for each procedure performed.The record must include documentation of the medical decision making when interventional procedures are not performed during the same session as the diagnostic procedures.The medical record must include documentation of the medical necessity for each procedure when multiple catheterization and angiographic procedures are performed during the same session.The medical record must include an interpretation and report of all angiograms. Imaging for each angiographic procedure (film, video or digital) must be retained in the medical record and be available for review by the Medicare contractor.The medical record must include documentation of request for extra-cardiac angiography from the referring/ordering provider treating the patient.Medical records must be made available to Medicare upon request.Utilization Guidelines:Diagnostic coronary angiography may not be billed when performed during percutaneous coronary intervention, if it has been previously performed within the past six months resulting in the decision for the beneficiary to undergo the specific interventional procedure.
Article - Billing and Coding: Drugs and Biologicals (A52855)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) forDrugs and Biologicals, Coverage of, for Label and Off-Label Uses.Coding Information:General InformationProcedure 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.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.Intravenous in Lieu of Oral FormulationWhen billing for an IV drug which has an available oral form, please also report an additional ICD-10-CM code to indicate that the oral route is not appropriate, for example:K91.2POSTSURGICAL MALABSORPTION, NOT ELSEWHERE CLASSIFIEDK90.9INTESTINAL MALABSORPTION UNSPECIFIEDT50.995AADVERSE EFFECT OF OTHER DRUGS, MEDICAMENTS AND BIOLOGICAL SUBSTANCES, INITIAL ENCOUNTERY63.6UNDERDOSING AND NONADMINISTRATION OF NECESSARY DRUG, MEDICAMENT OR BIOLOGICAL SUBSTANCEY63.8FAILURE IN DOSAGE DURING OTHER SURGICAL AND MEDICAL CAREZ87.19PERSONAL HISTORY OF OTHER DISEASES OF THE DIGESTIVE SYSTEMDocumentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.The medical record must include the following information:The name of the drug or biological administered;The route of administration;The dosage (e.g., mgs, mcgs, cc's or IU's);The duration of the administration (for CPT codes that are time based); and
Article - Billing and Coding: Drugs and Biologicals (A52855)
When modifier JW is used to report that a portion of the drug or biological is discarded, from single use vials, the medical record must clearly document the amount administered and the amount wasted or discarded. Effective July 1, 2023 (CR 13056) JZ Modifier is required on all claims that bill for drugs separately payable under Medicare Part B when there are no discarded amounts from single-dose containers or single-use packages.For claims submitted to the Part B MAC:Drugs with No ChargesEffective for dates of service on or after 05/07/2018,when a drug is purchased by the beneficiary, or when the drug was supplied without charge by the manufacturer, the drug should be billed using the appropriate HCPCS code with a billed amount of $0.01.Fordates of service prior to 05/07/2018,drugs with no charge will be accepted by Medicare even with a submitted charge of $0.00. However, the name and dosage of the drug should be listed in the narrative record of the claim, to avoid requests for additional information on the claim.
Article - Billing and Coding: Pain Management - injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels (A52863)
CMS National Coverage PolicyN/AArticle TextThis article containscoding and other guidelinesthat complement the Local Coverage Determination (LCD) for Pain Management.Coding Information: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.All procedures related to pain management procedures performed by the physician/provider performed on the same day must be billed on the same claim.Acupuncture, a non-covered service, prior to January 21, 2020, is reported with CPT codes 97810  97814. Effective January 21, 2020, Medicare will cover all types of acupuncture including dry needling for chronic low back pain within specific guidelines in accordance with NCD 30.3.3.Injection of separate sites (tendon sheath, ligament or ganglion cyst) during the same encounter as trigger point injections should be reported on a separate line of coding and must have the modifier 59 appended. Multiple surgical rules will apply. Modifier 50 should not be reported with CPT codes 20551 or 20612, but may be reported, when appropriate, with CPT codes 20550 and 20526. For an Ambulatory Surgical Center (ASC), the appropriate site modifier (RT and/or LT) should be appended to indicate if the service was performed unilaterally or bilaterally. Bilateral services must be reported on separate lines using an RT and LT modifier (50 modifier should not be used).Multiple injections per day, at the same site, are considered one injection and should be coded with one unit of service (NOS 001).For claims submitted to the Part B MAC
Article - Billing and Coding: Pain Management - injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels (A52863)
Multiple injections per day, at the same site, are considered one injection and should be coded with one unit of service (NOS 001).For claims submitted to the Part B MACHCPCS DRUG CODESA claim for services rendered in the off-campus-outpatient hospital (19), inpatient hospital (21), on campus-outpatient hospital (22) or emergency room, hospital (23), ambulatory surgery center (24), skilled nursing facility for patients in a part A stay (31), comprehensive inpatient rehabilitation facility (61), and comprehensive outpatient rehabilitation facility (62) must indicate the name of the drug and dosage in item 19 or the electronic equivalent. The HCPCS drug code and dose is not required when CPT 20612 is reported for aspiration and not for injection or when the ICD-10-CM codes reported are M77.11 or M77.12 and there is no injection.The medication being injected, designated by an appropriate HCPCS drug code must be submitted on the same claim, same day of service as the claim for the procedure. Claims for local anesthetic should not be reported. The exceptions to this guideline are:When services are rendered in places of services 19, 21, 22, 23, 61, and 62 there should be no claim for the HCPCS drug code. In addition, drugs packaged in ASC payments should not be separately reported.
Article - Billing and Coding: Pain Management - injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels (A52863)
When services are rendered in places of services 19, 21, 22, 23, 61, and 62 there should be no claim for the HCPCS drug code. In addition, drugs packaged in ASC payments should not be separately reported.A claim for services rendered in the office or independent clinic, when the physician does not bill for the injectables, must include the name of the drug and dosage in item 19 or the electronic equivalent.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.A procedure note must be legible and include sufficient detail to allow reconstruction of the procedure. Required elements of the note include a description of the techniques employed, and sites(s) of injections, drugs and doses with volumes and concentrations as well as pre- and post-procedural pain assessments.Forinjections of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels, the medical record must include a procedural note documenting the reason for the injection at any particular site. If multiple sites are injected, documentation to substantiate that all the injections are reasonable and necessary must be present.Utilization Guidelines:Injection Tendon Sheath, Ligament, Ganglion Cyst, Carpal and Tarsal Tunnel:Most conditions that require injections into the tendon sheaths, ligaments or ganglion cysts should be resolved with one to three injections.Frequency and Number of Injections or Interventions:
Article - Billing and Coding: Pain Management - injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels (A52863)
Most conditions that require injections into the tendon sheaths, ligaments or ganglion cysts should be resolved with one to three injections.Frequency and Number of Injections or Interventions:In the diagnostic phase, a patient may receive injections at intervals of no sooner than one week or preferably, two weeks.The number of injections in the diagnostic phase should be limited to no more than two times.Once a structure is proven to be negative, no repeat interventions should be directed at that structure unless there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and validity that implicate the structure.The effect of injected corticosteroids may remain for several weeks. The benefit is attributed to a decrease of local inflammation and perhaps some local anesthetic effect. It is usually not necessary to repeat an injection if there has been a satisfactory response to the first injection. Patients who relapse after a satisfactory response may be candidates for another trial after an appropriate interval. Consideration should be given to the cumulative dose injected and limitations made to avoid steroid complications.In the therapeutic phase (after the diagnostic phase is completed), the frequency should be two months or longer between each injection, provided that there is initial pain relief with diagnostic injections of greater than or equal to (>/=) 75% - 100% with the ability to perform previously painful maneuvers, and a persistent pain relief of greater than or equal to (>/=) 50% with the continued ability to perform previously painful maneuvers is maintained for at least six weeks. The therapeutic frequency must remain at least two months or longer.In the treatment or therapeutic phase, the injections should be repeated only as medically necessary. No more than four per patient per year are anticipated for the majority of patients.