evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Immune Globulin (A57778)
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) L34007 (Immune Globulin). 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.The use of the JA and JB modifiers is required for drugs which have one HCPCS Level II (J or Q) code but multiple routes of administration. Drugs that fall under this category must be billed with the JA modifier for the intravenous infusion of the drug or billed with the JB modifier for the subcutaneous injection of the drug.HCPCS codes J1561 and J1569 must be billed with either modifier JA for the intravenous formulation or modifier JB for the subcutaneous formulation.Not Otherwise Classified (NOC) Drug BillingOffice/ClinicProviders submit NOC codes (e.g., J1599) in the 2400/SV101-2 data element in the 5010 professional claim transaction (837P). When billing an NOC code, providers are required to provide a description in the 2400/SV101-7 data element. The 5010 TR3 Implementation Guide instructs: "Use SV101-7 to describe non-specific procedure codes." (Do not use the 2400 NTE segment to describe non-specific procedure codes with 5010). The SV101-7 data element allows for 80 bytes (i.e., characters, including spaces) of information.In order for the A/B MAC to correctly reimburse NOC drugs and biologicals, providers must indicate the following in the 2400/SV101-7 data element, or Item 19 of the CMS 1500 form:
Article - Billing and Coding: Immune Globulin (A57778)
In order for the A/B MAC to correctly reimburse NOC drugs and biologicals, providers must indicate the following in the 2400/SV101-7 data element, or Item 19 of the CMS 1500 form:The name of the drug,The total dosage (plus strength of dosage, if appropriate), andThe method of administration.Important:Listoneunit of service in the 2400/SV1-04 data element or in item 24G of the CMS 1500 form. Do not quantity-bill NOC drugs and biologicals even if multiple units are provided. Medicare determines the proper payment of NOC drugs and biologicals by the narrative information, not the number of units billed.Claims for NOC drugs and biologicals will reject as unprocessable if any of the information listed above is missing, or if the NOC code is billed with more than one unit of service. (Note: The remittance notice will include remark code M123, "Missing/incomplete/invalid name, strength, or dosage of the drug furnished," even if the rejection is due to the number of units billed).Ambulatory Surgical Centers (ASCs) and Hospital Outpatient DepartmentsHCPCS code C9399, Unclassified drug or biological, should be used for new drugs and biologicals that are approved by the United States (U.S.) Food and Drug Administration (FDA) on or after January 1, 2004, for which a specific HCPCS code has not been assigned.Drug WastageWhen 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 use vials 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.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 use vials or single use packages.
Article - Billing and Coding: Immune Globulin (A57778)
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 use vials 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.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).Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.The medical record documentation must support the medical necessity of the services as stated in the LCD.The information contained in the medical record should include all relevant diagnostic laboratory studies, prior history of bleeding, infection, disease progression, prior medical/surgical therapies, vaccination response, and any other information essential in establishing that the patient meets the coverage indications as set forth in the NCD and LCD.An accurate weight in kilograms should be documented prior to the infusion since the dosage is based on mg/kg/dosage.
Article - Billing and Coding: Magnetic Resonance Angiography (MRA) (A57779)
CMS National Coverage PolicyN/AArticle TextThis First Coast Billing and Coding Article for Local Coverage Determination (LCD) L34372 Magnetic Resonance Angiography (MRA) provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.Refer to the LCD for reasonable and necessary requirements and limitations.The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.Coding GuidelinesNotice: 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.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.If the provider of the magnetic resonance angiography study is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physicians order for the studies. The physician must state the reason for the MRA in his order for the test. (CFR, Title 42, Volume 2,Chapter IV, Part 410.32(a) Ordering diagnostic tests.)Utilization GuidelinesIn accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.Compliance with the provisions in LCD L34372, Magnetic Resonance Angiography (MRA) may be monitored and addressed through post payment data analysis and subsequent medical review audits.
Article - Billing and Coding: Psychological and Neuropsychological Tests (A57780)
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) L34520 Psychological and Neuropsychological Tests. 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.Codes 96132, 96133, 96136, 96137, 96138, and 96139 describe testing which is intended to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain.Neuropsychological testing does not rely on self-report questionnaires such as the Minnesota Multiphasic Personality Inventory 2 (MMPI-2), rating scales such as the Hamilton Depression Rating Scale, or projective techniques such as the Rorschach or Thematic Apperception Test (TAT). In circumstances when additional time is necessary to integrate other sources of clinical data including previously completed and reported technician- and/or computer-administered tests, the neuropsychological testing may include time spent integrating self-report questionnaires.Typically, psychological testing/neuropsychological testing may require four (4) to six (6) hours to perform (including administration, scoring, and interpretation.) If the testing is done over several days, the testing time should be combined and reported all on the last date of service.Documentation Requirements
Article - Billing and Coding: Psychological and Neuropsychological Tests (A57780)
All documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.The medical record must indicate testing is necessary as an aid in the diagnosis and therapeutic planning. The record must show the tests performed, scoring and interpretation, as well as the time involved for services that are time- based.The medical record should include all of the following information:Reason for referral.Tests administered, scoring/interpretation, and time involved.Present evaluation.Diagnosis (or suspected diagnosis that was the basis for the testing if no mental/ neurocognitive illness was found).Recommendations for interventions, if necessary.Identity of person performing service.
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A57787)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 12, Section 40.7 Claims for Bilateral SurgeriesChapter 13, Section 10.1 Billing Part B Radiology Services and Other Diagnostic Procedures, Section 20 Payment Conditions for Radiology Services, and Section 30 Computerized Axial Tomography (CT) ProceduresSocial 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) L33930, Facet Joint Interventions for Pain Management. 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.Diagnostic and Therapeutic Procedures:Each paravertebral facet level refers to either the facet joint, also called the zygapophyseal jointORthe two medial branch nerves that innervate each zygapophyseal joint.Each facet level has a pair of facet joints (one on the right side and one on the left side of the spine). Unilateral or bilateral facet interventions may be performed during the facet joint procedure (a diagnostic nerve block, a therapeutic facet joint [intraarticular] injection, or a medial branch block) injection, in one session. A bilateral facet nerve intervention is still considered a single level intervention.For paravertebral spinal nerves and branch injections, image guidance (fluoroscopy or computed tomography [CT]) is required for the performance of CPT codes 64490, 64491, 64493, and 64494 with any injection contrast, which is an included component of the code.
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A57787)
As defined by the Current Procedural Terminology (CPT) Professional edition code book, there are two distinct anatomic spinal regions for paravertebral facet injections: cervical /thoracic (codes 64490, 64491) and lumbar/sacral (codes 64493, 64494).For each initial, single level injection, diagnostic or therapeutic, performed with image guidance (fluoroscopy or CT), use code 64490 (cervical or thoracic) or code 64493 (lumbar or sacral).For any additional diagnostic or therapeutic procedures on the same day, use add-on codes 64491 (cervical/thoracic) or 64494 (lumbar/sacral) to report second level injections performed with image guidance (fluoroscopy or CT) in addition to the primary procedure codes 64490 or 64493.Note:Each unilateral or bilateral intervention at any level should be reported as one unit of service (UOS).If an initial (64490 or 64493) or second level add-on (64491 or 64494) paravertebral facet injection procedure is performed bilaterally, report the procedure with modifier -50 as a single line item using one UOS. Do not use modifier RT or LT when performing these procedures bilaterally (modifier -50).For unilateral paravertebral facet injection of the T12-L1 and L1-L2 levels or nerves innervating that joint, use 64490 and 64494 once.For bilateral paravertebral facet injection of the T12-L1 and L1  L2 levels or nerves innervating that joint, use 64490 with modifier 50 and 64494 with modifier 50.For services performed in the Ambulatory Surgical Center (ASC), do not use modifier 50. Report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each line.For CPT codes 64492 and 64495, the need for a three-level procedure may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal.KX modifier requirements:
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A57787)
For CPT codes 64492 and 64495, the need for a three-level procedure may be considered under unique circumstances and with sufficient documentation of medical necessity on appeal.KX modifier requirements:The KX modifier should be appended to the line for all diagnostic injections. In most cases the KX modifier will only be used for the two initial diagnostic injections. If the initial diagnostic injections do not produce a positive response as defined by the LCD and are not indicative of identification of the pain generator, and it is necessary to perform additional diagnostic injections, at a different level, append the KX modifier to the line. Aberrant use of the KX modifier may trigger focused medical review.Neurolytic Destruction Procedures (Radiofrequency Ablation):For destruction of paravertebral facet joint medial branch nerves, image guidance and localization (fluoroscopy or CT) are required and inclusive in codes 64633, 64634, 64635, and 64636.Per the current CPT Professional edition code book, codes 64633, 64634, 64635, and 64636 are reported per joint, not per nerve. Although two nerves innervate each facet joint, only one unit per code may be reported for each joint denervated, regardless of the number of nerves treated. There are two distinct anatomic spinal regions for paravertebral facet destruction: cervical/thoracic (codes 64633, 64634) and lumbar/sacral (codes 64635, 64636). For each initial, single level thermal radiofrequency destruction performed with image guidance (fluoroscopy or CT), use code 64633 (cervical or thoracic) or code 64635 (lumbar or sacral).For any additional thermal radiofrequency destruction performed on the same day, use add-on codes 64634 (cervical/thoracic) or 64636 (lumbar/sacral) in addition to the primary procedure codes 64633 or 64635.Note:Each unilateral or bilateral intervention at any level should be reported as one UOS.
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A57787)
Note:Each unilateral or bilateral intervention at any level should be reported as one UOS.If initial (64633 or 64635) or each additional add-on (64634 or 64636) paravertebral neurolytic destruction procedure is performed bilaterally, report the procedure with modifier -50 as a single line item using one UOS. Do not use modifier RT or LT when performing these services bilaterally (modifier -50).For services performed in the Ambulatory Surgical Center (ASC), do not use modifier 50. Report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each line.Non-thermal facet joint denervation (including chemical, low grade thermal energy [<80 degrees Celsius] or any other form of pulsed radiofrequency) should not be reported with CPT codes 64633, 64634, 64635 or 64636. These services should be reported with CPT code 64999. CPT code 64999 is non-covered when used to report non-thermal facet joint denervation.Note:CPT code 64999 is non covered when used to report non thermal facet joint denervation including chemical, low grade thermal energy (less than 80 degrees Celsius) or any form of pulsed radiofrequency.Note:When reporting CPT code 64999 ensure that the description of the service is included on the claim.If facet joints are injected with biologicals or other substances not designated for this use the entire claim may deny per CMS IOMMedicare Benefit Policy Manual, Chapter 16, Section 180-Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare.Utilization ParametersNote:A session is defined as all procedures (i.e., MBB, IA, facet cyst ruptures, and destruction by a neurolytic agent (e.g., RFA) performed on the same date of service.CPT codes 64490 through 64494 will be limited to no more than four (4) sessions, per region, per rolling 12 months.
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A57787)
CPT codes 64490 through 64494 will be limited to no more than four (4) sessions, per region, per rolling 12 months.CPT code 64490 through 64494 with the KX modifier will be limited to no more than four (4) sessions, per region, per rolling 12 months.CPT codes 64633 through 64636 will be limited to no more than two (2) sessions, per region, per rolling 12 months.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.The medical record must include the assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit, relevant medical history, and the results of any pertinent tests/procedures.Documentation of why the patient is not a candidate for radiofrequency ablation (RFA) must be submitted for therapeutic injection procedures.The scales used to assess the measurement of pain and/or disability must be documented in the medical record. Acceptable scales include but are not limited to: verbal rating scales, Numerical Rating Scale (NRS), Visual Analog Scale (VAS) for pain assessment, Pain Disability Assessment Scale (PDAS), Oswestry Disability Index (ODI), Oswestry Low Back Pain Disability Questionnaire (OLBPDQ), Quebec Back Pain Disability Score (QBPDS), Roland Morris Pain Scale, Back Pain Functional Scale (BPFS), and the Patient-Reported Outcomes Measurement Information System (PROMIS) profile domains to assess function.