evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Non-Invasive Vascular Studies (A56758)
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 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.The HCPCS level II codes93985or 93986should be used for the initial autogenous access vessel mapping. The CPT codes 93970 and 93971 may be used for subsequent access mapping.If the service is done for monitoring purposes, it is not covered under Part B. No separate payment for non-invasive vascular studies for monitoring the access site of an ESRD patient, whether coded as the access site or peripheral site, is permitted to any entity.The technical component of HCPCS codes 93985 or 93986 and CPT code 93990 (modifier TC) performed in End-Stage Renal Disease (ESRD) facilities or for ESRD patients is included in the composite payment rate. This rate is a comprehensive payment that includes all services, equipment, supplies and certain laboratory tests and drugs that are necessary for dialysis treatment.The professional component for the procedure (modifier 26) is included in the monthly capitation payment (MCP) if billed by the MCP physician. Physicians other than the MCP provider (or a member of his/her group of the same specialty) may bill separately for interpretations of tests.Services performed on ESRD patients by entities outside the ESRD facility must bill the ESRD facility for payment of monitoring procedures.Definitions:Duplex scan:An ultrasonic scanning procedure with display of both two-dimensional structure and motion with time and Doppler ultrasonic signal documentation with spectrum analysis and/or color flow velocity mapping or imaging.Physiologic studies:Functional measurement procedures that include Doppler ultrasound studies, blood pressure measurements, transcutaneous oxygen tension measurement, or plethysmography.
Article - Billing and Coding: Non-Invasive Vascular Studies (A56758)
Physiologic studies:Functional measurement procedures that include Doppler ultrasound studies, blood pressure measurements, transcutaneous oxygen tension measurement, or plethysmography.Plethysmography:Plethysmography involves the measurement and recording (by one of several methods) of changes in the size of a body part as modified by the circulation of blood in that part. Plethysmography is of value as a noninvasive technique for diagnostic, preoperative and postoperative evaluation of peripheral artery disease in the internal medicine or vascular surgery practice. It is also a useful tool for the preoperative podiatric evaluation of the diabetic patient or one who has intermittent claudication or other signs or symptoms indicative of peripheral vascular disease which have a bearing on the patients candidacy for foot surgery. (CMS Publication 100-03, Medicare National Coverage Decisions Manual,Chapter 1, Section 20.14)
Article - Billing and Coding: Non-Invasive Vascular Studies (A56758)
Transcranial Doppler:Pulsed Doppler ultrasound is used to interrogate the intracranial vasculature of the Circle of Willis. Its value has been established in detecting severe stenosis in the major intracranial arteries, assessing patterns and extent of collateral circulation in patients with known regions of severe stenosis or occlusion and evaluating and following patients with vasoconstriction particularly after subarachnoid hemorrhage.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.It is the responsibility of the physician/provider to ensure the medical necessity of procedures and to maintain records in the event that records are requested for a post-payment audit.42 CFR 410.32 indicates that diagnostic tests, to be covered, must be ordered by the practitioner who treats the patient. The treating physician is the practitioner responsible for the treatment of the patient. He/she orders the test to use the results in the management of the beneficiarys specific medical problem(s). Consulting physicians may also order tests.A referral for one non-invasive study is not a blanket referral for all studies. A referral must be on record for each non-invasive study performed.Documentation must be provided supporting the need for more than one imaging study [Doppler flow (93990) or vessel mapping (93985, 93986) and arteriogram (75790/75820)].Providers of interpretations and the technical portion of the examination must be capable of demonstrating documented training and experience and maintain documentation for post-payment audit.Utilization Guidelines:Frequency of follow-up studies will be carefully monitored for medical necessity and it is the responsibility of the physician/provider to maintain documentation of medical necessity in the patients medical record. Guidelines for follow-up cerebrovascular arterial studies include:
Article - Billing and Coding: Non-Invasive Vascular Studies (A56758)
Stenosis of 20-49% (diameter reduction), an annual study;Stenosis of 50-79%, every six months;Stenosis of 80-99%, every 6 months if surgery not performed; and/orAfter carotid endarterectomy, repeat ipsilateral/unilateral examinations are allowable at six weeks, six months, and one year. During the first year, follow-up studies should be on the ipsilateral side unless signs and symptoms or previously identified disease in the contralateral carotid artery provide indications for a bilateral procedure.If patients become symptomatic of carotid disease repeat duplex scans are allowed without regard to the above schedule.Pre-surgical conduit mapping of the radial artery(ies) may be accompanied by vein-mapping studies when either study demonstrates that insufficient conduits are available for multiple bypass procedures.In the immediate post-operative period, patients may be studied if re-established pulses are lost, become equivocal, or if the patient develops related signs and/or symptoms of ischemia with impending repeat intervention.With regard to autogenous vein and synthetic lower extremity bypass surgeries, a study may be performed at three-month intervals during the first year, at six-month intervals during the second year, and annually thereafter. The frequency of medically necessary follow-up studies post-angioplasty is dictated by the vascular distribution treated.
Article - Billing and Coding: Incision and Drainage (I&D) of Abscess of Skin, Subcutaneous and Accessory Structures (A56766)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) forIncision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures.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. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Paronychia, when sufficiently treated with avulsion of the nail only, should be billed with CPT code 11730 and not as an incision and drainage. Permanent correction of recurring ingrown toenail by nail resection or wedge excision of the nail lip should be billed with CPT code 11750 or 11765 and not as an incision and drainage.Partial or complete avulsion of the toenail is a common treatment for paronychia in association with an ingrown nail. In fact, incision and drainage is not commonly performed for treatment of paronychia in the foot without avulsion of the toenail. This procedure usually effectively drains any associated infection. Therefore, the provider who performs this procedure to address a localized infection should bill the appropriate code 11730, and not one for an incision and drainage service.Billing for incision and drainage procedures (CPT codes 10060, 10061, 10160) for treatment of paronychia of the foot when avulsion or resection of the toenail has been performed to treat the same condition, is not appropriate.
Article - Billing and Coding: Incision and Drainage (I&D) of Abscess of Skin, Subcutaneous and Accessory Structures (A56766)
Pus-producing paronychia without ingrown toenail is relatively uncommon on the foot. Providers billing incision and drainage services for this condition must have medical record documentation available to Medicare on request. Then only CPT codes 10060, 10061, 10160 should be used and not combined with CPT codes 11750 or 11765.For Podiatry (Specialty 48):
Article - Billing and Coding: Incision and Drainage (I&D) of Abscess of Skin, Subcutaneous and Accessory Structures (A56766)
Claims for CPT codes 10060 or 10061 with diagnosis of furuncle/carbuncle (ICD-10-CM code L02.621, L02.622, L02.631, L02.632), suppurative hidradenitis (ICD-10-CM code L73.2) will be subject to review, as these diagnoses are not commonly found in the foot.CPT codes 10060, 10061 or 10160 are payable for ICD-10-CM codes L02.611, L02.612, L98.8 only.
Article - Billing and Coding: Incision and Drainage (I&D) of Abscess of Skin, Subcutaneous and Accessory Structures (A56766)
CPT code 10140 is payable only for ICD-10-CM codes L76.01, L76.02, L76.21, L76.22, S80.01XA, S80.01XD, S80.01XS, S80.02XA, S80.02XD, S80.02XS, S80.11XA*, S80.11XD*, S80.11XS*, S80.12XA*, S80.12XD*, S80.12XS*, S87.01XA, S87.01XD, S87.01XS, S87.02XA, S87.02XD, S87.02XS, S87.81XA*, S87.81XD*, S87.81XS*, S87.82XA*, S87.82XD*, S87.82XS*, S90.01XA, S90.01XD, S90.01XS, S90.02XA, S90.02XD, S90.02XS, S90.111A, S90.111D, S90.111S, S90.112A, S90.112D, S90.112S, S90.121A, S90.121D, S90.121S, S90.122A, S90.122D, S90.122S, S90.211A, S90.211D, S90.211S, S90.212A, S90.212D, S90.212S, S90.221A, S90.221D, S90.221S, S90.222A, S90.222D, S90.222S, S90.31XA, S90.31XD, S90.31XS, S90.32XA, S90.32XD, S90.32XS, S97.01XA, S97.01XD, S97.01XS, S97.02XA, S97.02XD, S97.02XS,
Article - Billing and Coding: Incision and Drainage (I&D) of Abscess of Skin, Subcutaneous and Accessory Structures (A56766)
S97.01XA, S97.01XD, S97.01XS, S97.02XA, S97.02XD, S97.02XS, S97.111A, S97.111D, S97.111S, S97.112A, S97.112D, S97.112S, S97.121A, S97.121D, S97.121S, S97.122A, S97.122D, S97.122S, S97.81XA, S97.81XD, S97.81XS, S97.82XA, S97.82XD, S97.82XS.
Article - Billing and Coding: Incision and Drainage (I&D) of Abscess of Skin, Subcutaneous and Accessory Structures (A56766)
*As allowed by State law.Anesthesia administered by or incident to the physician performing the incision and drainage service is included in the reimbursement for incision and drainage services and is not separately payable.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included withintheLCD. (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 patient's medical record must document the signs/symptoms exhibited by the patient that required the incision and drainage procedure. This information must be available in the patient's record, if requested for review purposes. Additional information such as photographs, operative reports, or progress notes may be required from any provider who demonstrates a pattern of billing repeated incision and drainage services of the same anatomical area.The pre-operative size, location and appearance of any abscess, hematoma or other lesion claimed to have undergone an incision and drainage service must be clearly documented in the medical record.The operative note must include a description of the procedure, e.g. equipment used, and the approximate quantity (e.g., 1 cc, 5 ml) and quality (e.g., serous, sero-sanguinous, bloody, exudative, frank pus, malodorous) of the material drained from the collection.Since the majority of hematomas, seromas and cysts do not require incision and drainage or aspiration, and since this procedure can actually increase the risk of infection, providers reporting these services must document the size, location and quantity of blood, material or serosanguinous fluid drained, as well as the medical necessity of the procedure, (e.g. severe pain or infection and failure to resolve with conservative measures).Pus-producing paronychia without ingrown toenail is relatively uncommon on the foot. Providers billing incision and drainage services for this condition must have medical record documentation available to Medicare on request.The Contractor retains the right to require of select providers photographic documentation of lesions prior to and/or after treatment if there are indications of abuse of any of the codes in this LCD.Providers will be notified of this requirement individually and prior to such a requirement being instituted.
Article - Billing and Coding: Incision and Drainage (I&D) of Abscess of Skin, Subcutaneous and Accessory Structures (A56766)
Providers will be notified of this requirement individually and prior to such a requirement being instituted.If a patient requires incision and drainage services repeatedly (more than once) for treatment of abscess in the same anatomic location, the medical record must clearly reflect the reason(s) for persistent or recurrent infection and what measures are being taken to avoid infections.Utilization Guidelines:A single drainage procedure for most abscesses, hematomas or other collections is often curative. It would be unusual for any individual lesion or collection to require more than two such services. Recurrent fluid or abscess collections or repeated need for incision and drainage services may indicate the need for additional medical or surgical measures to provide definitive treatment.Multiple abscesses or fluid collections in the same patient requiring drainage, more than two times per year in the same location is uncommon. Services exceeding this parameter will be considered not medically necessary. Any claims which include a diagnosis of hidradenitis (ICD-10-CM code L73.2) will be excluded from this parameter. However, the documentation must be clear as to the reason more definitive therapy is not appropriate.
Article - Billing and Coding: Heavy Metal Testing (A56767)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Heavy Metal Testing.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. 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: Somatosensory Testing (A56769)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claimCMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic TestsCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10.4 ICD Procedure Codes, 10.5 Coding for Outpatient Services and Physician Offices, 10.6 Relationship of Diagnosis Codes and Date of Service and 20 Description of Healthcare Common Procedure Coding SystemArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Somatosensory Testing L34433.
Article - Billing and Coding: Special Electroencephalography (A56771)
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 claimArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Special Electroencephalography L33447.Ambulatory electroencephalography (EEG) should always be preceded by a routine EEG. A routine EEG is described by Current Procedural Terminology (CPT) codes 95812, 95813, 95816, 95819 or 95822 and refers to a routine EEG recording of less than a 24-hour continuous duration.A routine resting(EEG) (as described by CPTcodes 95812, 95813, 95816, 95819 or 95822) must be performed prior to performing an ambulatory continuous EEG. A claim for the routine EEG must have been submitted to Medicare with a date of service (DOS) within 1 year of the DOS of the ambulatory EEG.The CPTcodes contained in this article are the codes that describe the services covered per the LCD language. Claims billed with EEG services represented by CPTcodes not contained in this article require the submission of documentation and will be reviewed on a claim-by-claim basis. Note that the codes for these services now have separate coding for the professional and the technical components. Providers should bill only the component of the service which they have provided.
Article - Billing and Coding: Virtual Colonoscopy (CT Colonography) (A56772)
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 claimCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, 30 Computerized Axial Tomography (CT) ProceduresCMS Internet-Only Manuals, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code RequirementsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Virtual Colonoscopy (CT Colonography) L33452.LimitationsCPTCode - 74263 Computed tomographic (CT) colonography (i.e., virtual colonoscopy), screening, including image postprocessing is never covered.
Article - Billing and Coding: Neurophysiology Evoked Potentials (NEPs) (A56773)
CMS National Coverage PolicySocial 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 TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L34975 (Neurophysiology Evoked Potentials [NEPs]). Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.CPT codes forSomatosensory Evoked Potentials and Responses (SEPs/SERs):95925, 95926, 95927, 95928, 95929, 95938, 95939.CPT codes forBrainstem Auditory Evoked Potentials and Responses (BAEPs/BAERs):92651, 92652, 92653.CPT code forVisual Evoked Potentials or Responses (VEPs/VERs):95930.
Article - Billing and Coding: Ophthalmic Angiography (Fluorescein and Indocyanine Green) (A56774)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forOphthalmic Angiography (Fluorescein and Indocyanine Green)L34426.
Article - Billing and Coding: Magnetic Resonance Angiography (A56775)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process that claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, 40.1.1 Magnetic Resonance Angiography (MRA) Coverage Summary and 40.1.2 HCPCS Coding Requirements.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forMagnetic Resonance Angiography L34424.
Article - Billing and Coding: Total Joint Arthroplasty (A56777)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code RequirementsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Total Joint Arthroplasty L33456.
Article - Billing and Coding: Intravenous Immune Globulin (A56779)
CMS National Coverage PolicyN/AArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy Intravenous Immune Globulin L35891.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.