evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
NOTE: Due to system requirement, the Fiscal Intermediary Standard System (FISS) has combined messages  15.19 and 15.20 so that, when  used for the same line item,  both messages will appear on the same MSN.  G. If denying claims for Cologuard multi- target sDNA screening test (HCPCS G0464 -  Effective  January 1, 2016, HCPCS  G0464 has been  discontinued and replaced  with CPT 81528) or Blood- based  Biomarker  test (HCPCS  G0327)  because  the beneficiary  is not between  the ages of 45 and 85, use:  15.19 - We used a Local  Coverage  Determination  (LCD) to decide coverage for your  claim.  To appeal, get a copy of the LCD at www.cms.gov/medicare -coverage- database (use the MSN Billing Code for the CPT/HCPCS Code) and send with information from your doctor."  Spanish Version -  Usamos una Determinacin de Cobertura Local (LCD) para decidir la cobertura  de su reclamo.  Para apelar,  obtenga  una copia  del LCD  en www.cms.gov/medicare - coverage- database (use el cdigo de facturacin de MSN para el cdigo "CPT/HCPCS") y envela con la informacin de su mdico.  15.20 - The following policies NCD  210.3 were  used when we  made this decision.  Spanish Version   Las  siguientes  polticas  NCD 210.3 fueron  utilizadas  cuando se tom  esta decision.  NOTE:  Due to system  requirement, FISS has combined messages  15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.  H. If denying claims for Cologuard multi- target sDNA screening test (HCPCS G0464 -  Effective  January 1, 2016, HCPCS  G0464 has been  discontinued and replaced  with CPT 81528) or Blood- based Biomarker test (HCPCS G0327) because the claim does not contain all of the ICD-10 diagnosis codes required, use:
(Medicare Claims Processing Manual)
15.19 - We used a Local  Coverage  Determination  (LCD) to decide coverage for your  claim.  To appeal, get a copy of the LCD at www.cms.gov/medicare -coverage- database (use the MSN Billing Code for the CPT/HCPCS Code) and send with information from your doctor."  Spanish Version -  Usamos una Determinacin de Cobertura Local (LCD) para decidir la cobertura  de su reclamo.  Para apelar,  obtenga  una copia  del LCD  en www.cms.gov/medicare - coverage- database (use el cdigo de facturacin de MSN para el cdigo "CPT/HCPCS") y envela con la informacin de su mdico.  15.20 - The following policies  210.3 were  used  when we  made this decision  Spanish Version   Las  siguientes  polticas  NCD210.3 fueron  utilizadas  cuando  se tom  esta decisin  NOTE:  Due to system  requirement, FISS has combined messages  15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.  I. If denying claims for Cologuard multi- target sDNA screening test (HCPCS G0464 -  Effective  January 1, 2016, HCPCS  G0464 has been  discontinued and replaced  with CPT 81528) or Blood- based Biomarker test (HCPCS G0327) on institutional claims when submitted on a TOB other than 13X, 14X, and 85X, use:   21.25 - This service was  denied  because Medicare only covers  this service in certain  settings.  Spanish Version:  El servicio  fue denegado  porque  Medicare solamente  lo cubre  en ciertas situaciones."
(Medicare Claims Processing Manual)
21.25 - This service was  denied  because Medicare only covers  this service in certain  settings.  Spanish Version:  El servicio  fue denegado  porque  Medicare solamente  lo cubre  en ciertas situaciones."   60.8 - Remittance Advice Codes (Rev. 12299; Issued:10 -12-23; Effective:01 -01-23; Implementation:11 -13-23) All messages  refer  to ANSI  X12N  835 coding.  A. If the claim  for a screening  FOBT, a  screening  flexible  sigmoidoscopy, or a screening barium enema is being denied because the patient is less than 45 years of age, use:  Claim Adjustment  Reason  Code  (CARC)  6 The procedure/revenue code  is inconsistent  with the patients age, at the line level; and, Remittance Advice Remark Code (RARC)  N129 Not eligible due to patients age  B. If the claim for a screening FOBT, a screening colonoscopy, a screening flexible sigmoidoscopy, or a screening  barium  enema is being denied  because the time period between the test/procedure has not passed, use:   CARC 119 Benefit  maximum for this time period or occurrence has been  reached at  the line level.  C. If the claim  is being denied  for a screening  colonoscopy (HCPCS  G0105)  or a screening barium enema (HCPCS G0120) because the patient is not at a high risk, use:   CARC 46 This  (these) service(s)  is (are)  not covered at  the line level;  and,   RARC M83 Service is not covered  unless  the patient  is classified  as a high risk.  at the line level.   D. If the service is being denied  because payment  has already  been  made for a similar procedure within the set time frame, use:   CARC 18, Duplicate claim/service  at the line level; and,    RARC M86 Service is denied  because payment  already  made for similar  procedure  within  a set timeframe. at the line level.
(Medicare Claims Processing Manual)
 RARC M86 Service is denied  because payment  already  made for similar  procedure  within  a set timeframe. at the line level.   E. If the claim  is being denied  for a non-covered  screening procedure  such as HCPCS  G0122, use: CARC 49, These are non-covered  services  because this is a routine  exam  or screening procedure done in conjunction with a routine exam.   F. If the claim  is being denied  because  the code is invalid, use  the following at the line level:   CARC B18 Payment  denied because  this procedure  code/modifier  was invalid  on the date of service or claim submission.  G. If denying claims for Cologuard multi- target sDNA screening test (HCPCS G0464 -  Effective January  1, 2016, HCPCS G0464 has been discontinued and replaced with CPT  81528) or Blood- based Biomarker test (HCPCS G0327) when furnished more than once in a 3- year period [at least 2 years and  11 full months  (35 months  total)  must  elapse from  the date of the last screening], use:    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  CO assigning financial  liability  to the provider, if a claim  is received  with a GZ modifier indicating no signed ABN is on file.   H. If denying claims for Cologuard multi- target sDNA screening test (HCPCS G0464 -  Effective January  1, 2016, HCPCS G0464 has been discontinued and replaced with CPT 81528) or Blood- based  Biomarker  test (HCPCS  G0327)  when  beneficiary  is not between  the ages  45-85, use:
(Medicare Claims Processing Manual)
 CARC 6:  The procedure/revenue code  is inconsistent  with  the patient's  age. Note:  Refer  to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.    RARC N129:  Not  eligible  due to the patients  age.   Group Code  CO assigning financial  liability  to the provider, if a claim  is received  with a GZ modifier indicating no signed ABN is on file.
(Medicare Claims Processing Manual)
 RARC N129:  Not  eligible  due to the patients  age.   Group Code  CO assigning financial  liability  to the provider, if a claim  is received  with a GZ modifier indicating no signed ABN is on file.   I. If denying claims for Cologuard multi- target sDNA screening test (HCPCS G0464 -  Effective  January 1, 2016, HCPCS  G0464 has been  discontinued and replaced  with CPT 81528) or Blood- based Biomarker test (HCPCS G0327) when the claim does not contain ICD-10 diagnosis codes Z12.12 OR Z12.11), use:   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.  Group Code  CO assigning financial  liability  to the provider, if a claim  is received  with a GZ modifier indicating no signed ABN is on file.  J. If denying claims for Cologuard multi- target sDNA screening test (HCPCS G0464 -  Effective January  1, 2016, HCPCS G0464 has been discontinued and replaced with CPT 81528) or  Blood- based  Biomarker  test (HCPCS  G0327)  when  claims  are submitted  on a TOB  other  than 13X, 14X, or 85X, use:   CARC 170: Payment is denied when performed/billed by this type of provider. Note: Refer to the 835 Healthcare Policy  Identification  Segment  (loop 2110 Service Payment  Information REF), if present.   RARC N95  This provider  type/provider  specialty  may not bill this service.  Group Code  CO assigning financial  liability  to the provider, if a claim  is received  with a GZ modifier indicating no signed ABN is on file.
(Medicare Claims Processing Manual)
70 - Glaucoma Screening Services  (Rev. 1, 10- 01-03)  B3-4184  Conditions of Medicare Part B coverage for glaucoma screening are located in the Medicare Benefit Policy Manual, Chapter 15.    70.1 - Claims Submission Requirements and Applicable HCPCS Codes  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  70.1.1 - HCPCS and Diagnosis Coding  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  The following HCPCS codes should be reported when billing for screening glaucoma services:   G0117 -  Glaucoma screening for high- risk patients furnished by an optometrist (physician for A/B MAC (B)) or ophthalmologist.   G0118 -  Glaucoma screening for high- risk patients furnished under the direct supervision of an optometrist (physician for A/B MAC (B) or ophthalmologist.   The A/B MAC (B) claims type of service for the above G codes is: TOS Q.   Glaucoma screening claims should be billed using screening (V) code V80.1 (Special Screening for Neurological, Eye, and Ear Diseases, Glaucoma), or if ICD -10-CM is applicable, diagnosis code Z13.5 (encounter for screening for eye and ear disorders).  Claims submitted without a screening diagnosis code may be returned to the provider as unprocessable (refer to chapter 1 of this manual for more information about incomplete or invalid claims).   70.1.1.1 - Additional Coding Applicable to Claims Submitted to A/B MACs (A)  (Rev. 371, Issued 11- 19-04, Effective: 04 -01-05, Implementation: 04- 04-05)  A. Type of Bill   The applicable A/B MAC (A) claim bill types for screening glaucoma services are 13X, 22X, 23X, 71X, 73X, 75X, and 85X.  (See instructions below for rural health clinics (RHCs) and federally qualified health centers (FQHCs).)   B. Revenue Coding
(Medicare Claims Processing Manual)
B. Revenue Coding   The following revenue codes should be reported when billing for screening glaucoma services:  Comprehensive outpatient rehabilitation facilities (CORFs), critical access hospitals (CAHs), and skilled nursing facilities (SNFs) bill for this service under re venue code 0770.  CAHs electing the optional method of payment for outpatient services also report this service under revenue codes 096X, 097X, or 098X.  Hospital outpatient departments bill for this service under any valid/appropriate revenue code.  They are not required to report revenue code 0770.  (See instructions below for RHCs and FQHCs.)   70.1.1.2 - Special Billing Instructions for RHCs and FQHCs  (Rev. 371, Issued 11- 19-04, Effective: 04 -01-05, Implementation: 04- 04-05)  Screening glaucoma services are considered RHC/FQHC services.  For claims with dates of service before April 1, 2005, RHCs and FQHCs bill the A/B MAC (A) under bill type 71X or 73X along with revenue code 0770 and HCPCS codes G0117 or G0118 and RHC/FQHC re venue code 0520 or 0521 to report the related visit.  Reporting of revenue code 0770 and HCPCS codes G0117 and G0118 in addition to revenue code 0520 or 0521 is required for this service in order for CWF to perform frequency editing.  Payment should not be  made for a screening glaucoma service unless the claim also contains a visit code for the service.  A/B MACs (A) must edit to assure payment is not made for revenue code 0770.  The claim must also contain a visit revenue code (0520 or 0521).  Payment is m ade for the screening glaucoma service under the all -inclusive rate for the line item reporting revenue code 0520 or 0521.  No payment is made on the line item reporting revenue code 0770.
(Medicare Claims Processing Manual)
Screening glaucoma services furnished within an RHC/FQHC by a physician or nonphysician are considered RHC/FQHC services.  For claims with dates of service on or after April 1, 2005, RHCs and FQHCs bill the A/B MAC (A) under bill type 71X or 73X for the se rvice.  Payment is made under the all -inclusive rate.  Additional revenue and HCPCS coding is no longer required for this service when RHCs/FQHCs are billing for the service.  Use revenue code 0520 or 0521, as appropriate.   70.1.2 - Edits  (Rev. 1, 10- 01-03)  B3-4184.4, A -01-132 (CR 1914), B3- 4184.5   A. Common Working File Edits   Effective January 1, 2002, CWF edits glaucoma screening claims for frequency and valid HCPCS codes for dates of service January 1, 2002, and later.   B. Claims Edits   Nationwide claims processing edits for pre or post payment review of claim(s) for glaucoma screening are not required at this time.  A/B MACs (A) and (B) monitor claims to assure that they are paid only for covered individuals and perform medical review as appropriate.  Local medical review policies and edits may be developed for such claims.   70.2 - Payment Methodology  (Rev. 1, 10- 01-03)  B3-4184.7, A -01-132 (CR 1914), A -01-105(CR 1783), B -01-46 (CR 1717)   A/B MACs (B) pay for glaucoma screening based on the Medicare Physician Fee Schedule.  Deductible and coinsurance apply.  Claims from physicians or other providers where assignment was not taken are subject to the Medicare limiting charge, which means they  cannot charge the beneficiary more than 115 percent of the allowed amount.   A/B MAC (A) pay the facility expense as follows:    Independent and provider -based RHC/free standing and provider -based FQHC receive payment under the all -inclusive rate for the screening glaucoma service based on the visit furnished to the RHC/FQHC patient;
(Medicare Claims Processing Manual)
 Independent and provider -based RHC/free standing and provider -based FQHC receive payment under the all -inclusive rate for the screening glaucoma service based on the visit furnished to the RHC/FQHC patient;   CAHs receive payment on a reasonable cost basis unless the CAH has elected the optional method of payment for outpatient services in which case, procedures outlined in Chapter 4 should be followed;    CORFs receive payment under the Medicare Physician Fee Schedule;    Hospital outpatient departments receive payment under the outpatient prospective payment system (OPPS);    Hospital inpatient Part B services are paid under OPPS;    SNF outpatient services are paid under the Medicare physician fee schedule (MPFS); and    SNF inpatient Part B services are paid under MPFS.   Deductible and coinsurance apply.   70.3 - Determining the 11 -Month Period  (Rev. 1, 10- 01-03)  A-01-132 (CR 1914), B3 -4184.3  Once a beneficiary has received a covered glaucoma screening procedure, the beneficiary may receive another procedure after 11 full months have passed.  To determine the 11- month period, start counts beginning with the month after the month in which the pr evious covered screening procedure was performed.   70.4 - Remittance Advice Notices  (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  Appropriate remittance advice(s) must be used by A/B MACs (A) and (B) when denying payment for glaucoma screening.  The following messages are used where applicable:    If the services were furnished before January 1, 2002, use existing ASC X12 835 remittance advice claim adjustment reason code 26 Expenses incurred prior to coverage at the line level.    If the claim for glaucoma screening is being denied because the minimum time period has not elapsed since the performance of the same Medicare covered procedure, use existing ASC X12 835 claim adjustment reason code 119 Benefit maximum for this time perio d has been reached at the line level.
(Medicare Claims Processing Manual)
 If the service is being denied because the individual is not an African -American age 50 or over, use existing remittance advice claim adjustment reason code 6, The procedure code is inconsistent with the patients age, and existing remark codes M83, Ser vice not covered unless the patient is classified as at high risk, and M82, Service not covered when patient is under age 50.  Report these codes at the line level.    If the service is being denied because the individual is not a Hispanic -American age 65 or over, use existing remittance advice claim adjustment reason code 96, Non -covered charge, and existing remark codes M83, Service not covered unless the patient is  classified as at high risk, and N129, "This amount represents the dollar amount not eligible due to patient's age."    If the service is being denied because the patient does not have diabetes mellitus, or there is no family history of glaucoma,  A/B MACs (B) use existing remittance advice claim adjustment reason code B5, Payment adjusted because coverage/program guidelin es were not met or were exceeded.  The zero payment for the service will indicate the denial.  In addition, report remark code M83, Service is not covered unless the patient is classified as at high risk at the line level.   70.5 - MSN Messages (Rev. 895, Issued:  03- 24-06; Effective:  01 -01-06; Implementation:  04 -03-06)  The following MSN messages where appropriate must be used.  If a claim for a screening for glaucoma is being denied because the service was performed prior to January 1, 2002, use the MSN message:   MSN Message 16.54:   This service is not covered prior to January 1, 2002.  The Spanish version of the MSN message should read:   Este servicio no est cubierto antes del 1 de enero de 2002.  If a claim for screening for glaucoma is being denied because the minimum time period has not elapsed since the performance of the same Medicare- covered procedure, use MSN message:   MSN Message 18.14:   Service is being denied because it has not been [12/24/48] months since your last [test/procedure] of this kind.
(Medicare Claims Processing Manual)
MSN Message 18.14:   Service is being denied because it has not been [12/24/48] months since your last [test/procedure] of this kind.   The Spanish version of this MSN message should read:   Este servicio est siendo denegado ya que no han transcurrido [12, 24, 48] meses desde el ltimo[examen/procedimiento] de esta clase.   If a claim for a screening for glaucoma is being denied because the age- related and/or ethnic -related coverage criteria are not met, use:   MSN Message 21.21:   This service was denied because Medicare only covers this service under certain circumstances.   The Spanish version of this MSN message should read:   Este servicio fue denegado porque Medicare solamente lo cubre bajo ciertas circunstancias.   80 - Initial Preventive Physical Examination (IPPE)  (Rev. 3096, Issued: 10- 17-14, Effective: 01 -27-14, Implementation: 11- 18-14)  (NOTE:  For billing and payment requirements for the Annual Wellness Visit, see chapter 18, section 140, of this chapter.)   Background :  Sections 1861(s)(2)(w) and 1861(ww) of the Social Security Act (and implementing regulations at 42 CFR 410.16, 411.15(a)(1), and 411.15(k)(11)) authorize coverage under Part B for a one -time initial preventive physical examination (IPPE) for new Medicare b eneficiaries that meet certain eligibility requirements.   Coverage :  As described in implementing regulations at 42 CFR 410.16, 411.15(a)(1), and 411.15(k)(11), the IPPE may be performed by a doctor of medicine or osteopathy as defined in section 1861 (r)(1) of the Social Security Act (the Act) or by a qualified nonphysicia n practitioner (NPP) (physician assistant, nurse practitioner, or clinical nurse specialist), not later than 12 months after the date the individuals first coverage begins under Medicare Part B. (See section 80.3 for a list of bill types of fac ilities that can bill A/B MACs for this service.)
(Medicare Claims Processing Manual)
The IPPE includes:   (1) review of the individuals medical and social history with attention to modifiable risk factors for disease detection,   (2) review of the individuals potential (risk factors) for depression or other mood disorders,   (3) review of the individuals functional ability and level of safety;   (4) an examination to include measurement of the individuals height, weight, body mass index, blood pressure, a visual acuity screen, and other factors as deemed appropriate, based on the beneficiarys medical and social history;   (5) end-of-life planning, upon agreement of the individual.  (6) education, counseling, and referral, as deemed appropriate, based on the results of the review and evaluation services described in the previous 5 elements, and  (7) education, counseling, and referral including a brief written plan (e.g., a checklist or alternative) provided to the individual for obtaining appropriate screening and other preventive services, which are separately covered under Medicare Part B.   Medicare will pay for only one IPPE per beneficiary per lifetime.  The Common Working File (CWF) will edit for this benefit.   The IPPE does not include other preventive services that are currently separately covered and paid under Medicare Part B.  (That is: pneumococcal, influenza and hepatitis B vaccines and their administration, screening mammography, screening pap smear and screening pelvic examinations, prostate cancer screening tests, colorectal cancer screening tests, diabetes outpatient self -management training services, bone mass measurements, glaucoma screening, medical nut rition therapy for individuals with diabetes or renal disease, cardiovascular screening blood tests, diabetes screening tests, screening ultrasound for abdominal aortic aneurysms, an electrocardiogram, and additional preventive services covered under Medic are Part B through the Medicare national coverage determination process.)   For the physician/practitioner billing correct coding and payment policy, refer to chapter 12, section 30.6.1.1, of this manual.  80.1 - Healthcare Common Procedure Coding System (HCPCS) Coding for the IPPE  (Rev. 2159, Issued: 02 -15-11, Effective: 01 -01-11, Implementation: 04- 04-11)