evekhm/cms_iom_500 huggingface dataset:
Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)
The allowance for the labor involved in replacing an orthotic component that is coded with a specific L-code is included in the allowance for that component. The allowance for the labor involved in replacing an orthotic component that is coded with the miscellaneous code L4210 is separately payable in addition to the allowance for that component.Addition codes L4002, L4010, L4020, L4030, L4040, L4045, L4050, L4055, L4060, L4070, L4080, L4090, L4100, L4110,L4130, and L4392 are for billing of replacement components and are not payable at initial issue of a base orthosis. When claims for code(s) L4002, L4010, L4020, L4030, L4040, L4045, L4050, L4055, L4060, L4070, L4080, L4090, L4100, L4110,L4130, and L4392 are billed at the time of initial issue of a base orthosis, the addition code(s) will be rejected as incorrect coding.
Article - Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (A52457)
Suppliers should contact the Pricing, Data Analysis, and Coding (PDAC) contractor for guidance on the correct coding of these items.HCPCS codes L4050 and L4055 do not describe replacement soft interfaces used with contracture orthoses.Some replacement items have unique Healthcare Common Procedure Coding System (HCPCS) codes. Replacement components that do not have a unique HCPCS code must be billed with a "not otherwise specified" code - L2999. Items that have unique codes must not be billed using a NOC code.CODING VERIFICATION REVIEWThe only products which may be billed using the following list of HCPCS codes are those for which a written coding verification review (CVR) has been made by the PDAC contractor and subsequently published on the Product Classification List (PCL). Information concerning the documentation that must be submitted to the PDAC for a CVR can be found on the PDAC web site or by contacting the PDAC. A PCL with products which have received a coding verification can be found on the PDAC web site. The effective date of the CVR is included for each code.Effective for claims with dates of service on or after April 1, 2012:L1906Effective for claims with dates of service on or after January 1, 2020:L2006If a product is billed to Medicare using a HCPCS code that requires written CVR, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.
Article - Automatic External Defibrillators - Policy Article (A52458)
CMS National Coverage PolicyN/AArticle Text
Article - Automatic External Defibrillators - Policy Article (A52458)
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Automatic external defibrillators are covered under the Durable Medical Equipment benefit (Social Security Act 1861(s)(6). In order for a beneficiarys DME to be eligible for reimbursement, the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter andWritten Order Prior to DeliveryList is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD prior to delivery, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.
Article - Automatic External Defibrillators - Policy Article (A52458)
POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.The diagnosis code that justifies the need for these items must be included on the claim.MODIFIERSKX, GA, GZ AND KF MODIFIERS:Suppliers must add a KX modifier to a code only if all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD have been met.If all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a denial as not reasonable and necessary, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.Claim lines billed without a GA, GZ, or KX modifier will be rejected as missing information.Devices coded K0606 and E0617 are classified by the Food and Drug Administration as Class III devices; therefore, all claims for code K0606 and E0617 must include the KF modifier. Claim lines billed without a KF modifier will be rejected as missing information.CODING GUIDELINESAutomatic defibrillators are devices that are capable of monitoring cardiac rhythms, detecting dysrhythmias, and delivering a defibrillation shock to the heart when appropriate without any user decision-making.Non-wearable, automatic external defibrillators with integrated electrocardiogram capability are coded using HCPCS code E0617.Wearable, automatic, external defibrillators with integrated electrocardiogram analysis are coded using HCPCS code K0606.Other types of defibrillators are coded as A9270. No separate payment is made for carrying cases or mounting hardware.
Article - Automatic External Defibrillators - Policy Article (A52458)
Other types of defibrillators are coded as A9270. No separate payment is made for carrying cases or mounting hardware.Replacement supplies and accessories for use with K0606 are coded using K0607, K0608, and K0609 as appropriate.Replacement supplies and accessories for use with E0617 are coded using A9999.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Article - Canes and Crutches - Policy Article (A52459)
CMS National Coverage PolicyN/AArticle TextNON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Canes and Crutches are covered under the Durable Medical Equipment benefit (Social Security Act 1861(s)(6)). In order for a beneficiarys equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.A white cane for a blind person is noncovered since it is more of an identifying and self-help device than an item which makes a meaningful contribution in the treatment of an illness or injury (see CMSNational Coverage Determinations Manual(CMS Pub. 100-03), Chapter 1, Part 4, Section 280.2).REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.
Article - Canes and Crutches - Policy Article (A52459)
Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD prior to delivery, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS.CODING GUIDELINESCode A9270 must be used for a white cane for a blind person.All canes and crutches are billed using the specific codes listed in the Local Coverage Determination regardless of their stated weight capacity. Do not use code E1399 (DME, miscellaneous) to code any type of cane or crutch regardless of special features or weight capacity.Code E0117 describes an articulating crutch which has two crutch legs connected by a bar between them which helps propel the beneficiary forward.Code E0118 describes a crutch substitute which can be either a device strapped to the lower leg with a platform or a device with wheels and a platform the beneficiary propels with their sound limb.Canes or crutches which contain a spring that reduces impact and vibration against the ground should not be billed with E1399. These types of canes or crutches should be coded with the existing codes for canes or crutches.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Article - Cold Therapy - Policy Article (A52460)
CMS National Coverage PolicyN/AArticle Text
Article - Cold Therapy - Policy Article (A52460)
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Cold therapy devices are covered under the Durable Medical Equipment benefit (Social Security Act 1861(s)(6)). In order for a beneficiarys equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD prior to delivery, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.
Article - Cold Therapy - Policy Article (A52460)
POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS.CODING GUIDELINESCode A9270 is used for billing non DME items such as:
Article - Cold Therapy - Policy Article (A52460)
disposable single use fluid packs which generate cold temperature by a chemical reaction,devices in which ice water is put in a reservoir and then circulated through a pad by means of gravity orself-made containers used to administer cold therapy.Code A9273 describes products such as insulated cold or hot bottles, ice caps or collars, heat and/or cold wraps of any type that are reusable.Code E0218 describes a device which has an electric pump that circulates cold fluid through a pad.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Article - Commodes - Policy Article (A52461)
CMS National Coverage PolicyN/AArticle Text
Article - Commodes - Policy Article (A52461)
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Commodes are covered under the Durable Medical Equipment benefit (Social Security Act 1861(s)(6)). In order for a beneficiarys equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.A raised toilet seat (E0244) is noncovered; therefore, a commode chair that is used as a raised toilet seat by positioning it over the toilet is also noncovered. When a commode chair is provided for use in this manner, the GY modifier must be added to the code for the commode chair and the KX modifier must not be used.Toilet seat lift mechanisms (E0172) are not primarily medical in nature; therefore do not meet the statutory definition of durable medical equipment. They are non-covered.A footrest (E0175) is non-covered because it is not medical in nature.Bidets and bidet toilet seats are non-covered because they are not primarily medical in nature.REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.
Article - Commodes - Policy Article (A52461)
Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD prior to delivery, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.The diagnosis code that justifies the need for these items must be included on the claim.KX, GA, GY, AND GZ MODIFIERS:For commodes (E0163, E0165, E0168, E0170, and E0171) used as a raised toilet seat by positioning it over the toilet, the GY modifier must be added to the code, and the KX, GA, or GZ modifier must not be used.For commodes (E0163, E0165, E0168, E0170, and E0171) not used as a raised toilet seat, the KX modifier must be added to the code only if all of the coverage criteria as described in the Coverage Indication, Limitations and/or Medical Necessity section of the related LCD have been met.For commode chairs with seat lift mechanism (E0170 and E0171), the KX modifier must be added to the code only if the beneficiary meets all of the criteria for a seat lift mechanism.
Article - Commodes - Policy Article (A52461)
For commode chairs with seat lift mechanism (E0170 and E0171), the KX modifier must be added to the code only if the beneficiary meets all of the criteria for a seat lift mechanism.If all of the criteria in the Coverage Indication, Limitations and/or Medical Necessity section of the related LCD have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter a GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or a GZ modifier if they have not obtained a valid ABN.Claim lines billed without a GA, GY, GZ or KX modifier will be rejected as missing information.CODING GUIDELINESA commode with seat lift mechanism (E0170, E0171) is a free-standing device that has a commode pan and that has an integrated seat that can be raised with or without a forward tilt while the beneficiary is seated. An integrated device is one which is sold as a unit by the manufacturer and in which the lift and the commode cannot be separated without the use of tools.A toilet seat lift mechanism is a device with a seat that can be raised with or without a forward tilt while the beneficiary is seated, allowing the beneficiary to stand and ambulate once he/she is in an upright position. It may be manually operated or electric. It is attached to the toilet. These devices are coded as E0172.A raised toilet seat (E0244) is a device that adds height to the toilet seat. It is either fixed height or adjustable. It is either attached to the toilet or is unattached, resting on the bowl.Note: A freestanding raised toilet seat supported by legs on the floor is coded as a commode.Bidets, bidets incorporated into toilet seats and similar genitalia/perineum/buttocks cleansing devices are products that utilize a stream of water to irrigate and wash the buttocks and perineal area. Bidets and similar devices are coded A9270 (NONCOVERED ITEM OR SERVICE).
Article - Commodes - Policy Article (A52461)
Extra wide/heavy duty commode chairs (E0168) have a width of greater than or equal to 23 inches and are also capable of supporting a beneficiary who weighs 300 pounds or more.A Column II code is included in the allowance for the corresponding Column I code when provided at the same time.
Article - Commodes - Policy Article (A52461)
Column IColumn IIE0163E0167E0165E0167E0168E0167E0170E0167, E0627, E0629E0171E0167, E0627, E0629Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Article - Eye Prostheses - Policy Article (A52462)
CMS National Coverage PolicyN/AArticle TextNON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Eye prostheses are covered under the Medicare Artificial Legs, Arms and Eyes benefit (Social Security Act 1861(s)(9)). In order for a beneficiarys equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.Trial scleral cover shells are not separately payable. They are included in the allowance for scleral cover shells, V2627.The following services and items are included in the allowance for an eye prosthesis and, therefore, are not separately billable to or payable by Medicare under the prosthetic device benefit:Evaluation of the beneficiaryPre-operative planningCost of materialsLabor involved in the fabrication and fitting of the prosthesisModifications to the prosthesis made at the time delivery of the prosthesis or within 90 days thereafterRepair due to normal wear or tear within 90 days of deliveryFollow-up visits within 90 days of delivery of the prosthesis