evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
 SNF inpatient Part B - payment is made under MPFS.  Deductible and coinsurance apply.  E.  Special Billing Instructions for RHCs and FQHCs   Screening glaucoma services are considered RHC/FQHC services.  RHCs and FQHCs bill the contractor under bill type 71X or 73X along with revenue code 770 and HCPCS codes G0117 or G0118 and RHC/FQHC revenue code 520 or 521 to report the related visit.  Reporting of revenue code 770 and HCPCS codes G0117 and G0118 in addition to revenue code 520 or 521 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.  Therefore, the contractor installs an edit in its system to assure payment is not made for revenue code 770 unless the claim also cont ains a visit revenue code (520 or 521).  280.2 - Colorectal Cancer Screening  (Rev. 1, 10-01-03) B3-4180  280.2.1 - Covered Services and HCPCS Codes  See Business Requirements at http://cms.hhs.gov/manuals/pm_trans/R3BP.pdf  (Rev. 3, 12-19-03) B3-4180.1  Medicare covers colorectal cancer screening test/procedures for the early detection of colorectal cancer for the HCPCS codes indicated.   A. Effective for Services Furnished On or After January 1, 1998:   G0107 - Colorectal cancer screening; fecal -Occult blood test, 1-3 simultaneous determinations;  G0104 - Colorectal cancer screening; flexible sigmoidoscopy;  G0105 - Colorectal cancer screening; colonoscopy on individual at high risk;  G0106 - Colorectal cancer screening  barium enema ; alternative to GO104, screening sigmoidoscopy;  G0120 -  Colorectal cancer screening  barium enema ; alternative to GO105, screening sigmoidoscopy.  B. Effective for Services Furnished On or After July 1, 2001:   G0121 -  Colorectal Cancer Screening; Colonoscopy on Individual Not Meeting Criteria for High Risk
(Medicare Benefit Policy Manual)
B. Effective for Services Furnished On or After July 1, 2001:   G0121 -  Colorectal Cancer Screening; Colonoscopy on Individual Not Meeting Criteria for High Risk   C. Effective for Services Furnished On or After January 1, 2004:   G0328 - Colorectal cancer screening; fecal -occult blood test, immunoassay, 1- 3 simultaneous determinations.   280.2.2 - Coverage Criteria  (Rev. 12299; Issued:10- 12-23; Effective:01 -01-23; Implementation:11 -13-23)  The following are the coverage criteria for these screenings:   A. Screening  Fecal -Occult  Blood  Tests  (FOBT)  (Codes  82270 &  G0328)
(Medicare Benefit Policy Manual)
The following are the coverage criteria for these screenings:   A. Screening  Fecal -Occult  Blood  Tests  (FOBT)  (Codes  82270 &  G0328)   Effective for services furnished on or after January 1, 2004, one screening FOBT (code 82270 or G0328)  is covered  for beneficiaries  who have  attained  age 50, at  a frequency  of once every  12 months (i.e., at least 11 months have passed following the month in which the last covered screening FOBT was done). Screening FOBT means: (1) a guaiac- based test for peroxidase activity in which the beneficiary completes it by taking samples from two different sites of three consecutive stools or , (2) an immunoassay (or immunochemical)  test for antibody activity  in which  the beneficiary  completes  the test by taking the appropriate number of samples according to the specific manufacturers instructions.  This expanded coverage is in accordance with revised regulations at 42 CFR 410.37(a)(2) that includes  other tests determined by the Secretary through a national coverage determination.  This screening requires a written order from the beneficiarys attending physician or for claims with dates of service on or after January 27, 2014, from the beneficiarys attending physician assistant, nurse practitioner, or clinical nurse specialist.  (The term attending physician is defined to mean a doct or of medicine  or osteopathy (as defined in 1861(r)(1) of  the Act)  who is fully knowledgeable about the beneficiarys medical condition, and who would be responsible for using the results of any examination performed in the overall management of the beneficiarys specific medical problem.)  NOTE:  For claims  with dates  of service prior to January  1, 2007, physicians, suppliers, and providers report HCPCS code G0107. Effective January 1, 2007, code G0107, is discontinued and replaced with CPT code 82270. For complete claims processing information refer to Pub. 100- 04, Medicare Claims Processing Manual, chapter 18, section 60.
(Medicare Benefit Policy Manual)
Effective January 1, 2023, the minimum age for FOBT screening tests is reduced to 45 years and older. For complete claims processing information, refer to Pub 100- 04, Medicare Claims Processing Manual, chapter 18, section 60.  B. Screening  Flexible  Sigmoidoscopies  (code G0104)   For claims with dates of service on or after January 1, 2002, A/B MACs (B) pay for screening  flexible  sigmoidoscopies  (Code  G0104)  for beneficiaries  who have attained  age 50 when these services were performed by a doctor of medicine or osteopathy, or by a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in  1861(aa)(5)  of the Act and at 42 CFR  410.74, 410.75, and 410.76)  at the frequencies noted below. For claims with dates of service prior to January  1, 2002, pay for these services under the conditions noted only when they are performed by a doctor of medicine or osteopathy.   For services  furnished from  January 1, 1998,  through  June  30, 2001, inclusive   Once every  48 months  (i.e., at least 47 months  have passed  following the month in which the last covered screening flexible sigmoidoscopy was done).   For services  furnished on or after  July 1, 2001   Once every 48 months as calculated above unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer (refer to 280.2.3) and the beneficiary  has had a screening  colonoscopy (code G0121)  within  the preceding  10 years. If such a  beneficiary  has had  a screening  colonoscopy  within  the preceding  10 years, then he or she can have covered a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that he/she received the screening colonoscopy (code G0121).   NOTE:  If during the course of a screening  flexible sigmoidoscopy a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure  classified  as a flexible  sigmoidoscopy with biopsy or removal  should be billed and paid rather than code G0104.
(Medicare Benefit Policy Manual)
Effective January 1, 2023, the minimum age for Screening Flexible Sigmoidoscopies is reduced to 45 years and older. For complete claims processing information, refer to Pub 100- 04, Medicare Claims Processing Manual, chapter 18, section 60.   C. Screening  Colonoscopies  for Beneficiaries  at High  Risk  of Developing  Colorectal Cancer (Code G0105)   The A/B MAC  (B) must  pay for screening  colonoscopies  (code  G0105)  when  performed by a doctor of medicine  or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed  following the month in which  the last covered  G0105 screening  colonoscopy was performed).  Refer to 280.2.3 for the criteria to use in determining whether or not an individual is at high risk for developing colorectal cancer.   NOTE:  If during the course of the screening  colonoscopy, a  lesion  or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than code G0105.   Effective January 1, 2023, colorectal cancer screening tests include a follow -on Screening Colonoscopy for Beneficiaries at High Risk of Developing Colorectal Cancer after a Medicare covered non -invasive stool -based colorectal cancer screening test returns  a positive result. Non- invasive stool -based colorectal cancer screening tests include:    Screening Guaiac- based Fecal Occult Blood Test (gFOBT) (82270)   Screening Immunoassay -based Fecal Occult Blood Test (iFOBT) (G0328)   Screening The Cologuard  Multi- target Stool DNA (sDNA) Test (81528)
(Medicare Benefit Policy Manual)
The frequency limitations described for Screening Colonoscopies for Beneficiaries at High Risk of Developing Colorectal Cancer in this section shall not apply in the instance of a follow -on Screening Colonoscopy for Beneficiaries at High Risk of Developing Colorectal Cancer after a Medicare covered non -invasive stool -based colorectal cancer screening test returns a positive result. For complete claims processing information, refer to Pub 100- 04, Medicare Claims Processing Manual, chapter 18, section 60.   D. Screening  Colonoscopies  Performed  on Individuals  Not Meeting  the Criteria  for Being at High -Risk for Developing Colorectal Cancer (Code G0121)   Effective  for services  furnished on or after July 1, 2001, screening  colonoscopies  (code G0121) are covered when performed under the following conditions:   1. On individuals  not meeting  the criteria  for being at high risk for developing colorectal cancer (refer to 280.2.3);   2. At a frequency of once every 10 years (i.e., at least 119 months have passed following the month in which  the last covered  G0121 screening  colonoscopy was performed); and   3. If the individual would otherwise qualify to have covered a G0121 screening colonoscopy based on the  above  (see 280.2.2.D.1 and 2)  but has had a covered screening flexible sigmoidoscopy (code G0104), then the individual may have a covered G0121 screening colonoscopy only after at least 47 months have passed following the month in which  the last covered  G0104 flexible  sigmoidoscopy was performed.   NOTE:  I f during the course of the screening  colonoscopy, a  lesion  or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than code G0121.   Effective January 1, 2023, colorectal cancer screening tests include a follow -on Screening Colonoscopy Performed on Individuals Not Meeting the Criteria for Being at High -Risk for Developing Colorectal Cancer after a Medicare covered non -invasive stool -based colorectal cancer screening test returns a positive result. Non-invasive stool -based colorectal cancer screening tests include:
(Medicare Benefit Policy Manual)
 Screening Guaiac- based Fecal Occult Blood Test (gFOBT) (82270)   Screening Immunoassay -based Fecal Occult Blood Test (iFOBT) (G0328)   Screening The Cologuard  Multi- target Stool DNA (sDNA) Test (81528)   The frequency limitations described for Colonoscopies Performed on Individuals Not Meeting the Criteria for Being at High -Risk for Developing Colorectal Cancer in this section shall not apply in the instance of a follow -on Screening Colonoscopy Performed o n Individuals Not Meeting the Criteria for Being at High- Risk for Developing Colorectal Cancer after a Medicare covered non -invasive stool -based colorectal cancer screening test returns a positive result. For complete claims processing information, refer t o Pub 100- 04, Medicare Claims Processing Manual, chapter 18, section 60.   E. Screening  Barium  Enema  Examinations  (codes  G0106 and G0120)   Screening  barium  enema  examinations  are covered  as an alternative  to either  a screening sigmoidoscopy (code G0104) or a screening colonoscopy (code G0105) examination.  The same frequency  parameters  for screening  sigmoidoscopies  and screening colonoscopies above apply.
(Medicare Benefit Policy Manual)
In the case of an individual aged 50 or over, payment may be made for a screening barium  enema examination  (code  G0106)  performed  after at least 47 months  have  passed following the month in which the last screening barium enema or screening flexible sigmoidoscopy was performed.  For example, the beneficiary received a screening barium enema examination as an alternative to a screening flexible sigmoidoscopy in January 1999. The count starts beginning February 1999. The beneficiary  is eligible for another screening barium enema in January 2003.  In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination (code G0120) performed after at least 23 months  have  passed  following the month in which  the last screening  barium  enema or the last screening colonoscopy was performed. For example, a beneficiary at high risk for developing colorectal cancer received a screening barium enema examination (code G0120) as an alternative to a screening colonoscopy (code G0105) in January  2000. The count starts beginning February 2000. The beneficiary is eligible for another screening barium enema examination (code G0120) in January 2002.   The screening  barium  enema must  be ordered  in writing  after a determination  that the test is the appropriate screening test. Generally, it is expected that this will be a screening double contrast enema unless the individual is unable to withstand such an exam. This means that in the case of a particular individual, the attending physician must determine that the estimated screening  potential for the barium enema is equal to or greater than the screening  potential that has been estimated for a screening flexible sigmoidoscopy, or for a screening colonoscopy, as appropriate, for the same individual. The screening single contrast barium enema also requires a written order from the beneficiarys attending physician in the same manner as described above for the screening double contrast barium enema examination.  Effective January 1, 2023, the minimum age for Screening Barium Enema Examinations is reduced to 45 years and older. For complete claims processing information, refer to Pub 100- 04, Medicare Claims Processing Manual, chapter 18, section 60.
(Medicare Benefit Policy Manual)
280.2.3 - Determining Whether or Not the Beneficiary is at High Risk for Developing Colorectal Cancer  (Rev. 194, Issued: 09- 03-14, Effective: Upon Implementation of ICD -10, Implementation: Upon Implementation of ICD -10)  A.  Characteristics of the High Risk Individual   An individual at high risk for developing colorectal cancer has one or more of the following:   A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;  A family history of familial adenomatous polyposis;  A family history of hereditary nonpolyposis colorectal cancer;  A personal history of colorectal cancer;  A personal history of adenomatous polyps;  Inflammatory bowel disease, including Crohns Disease, and ulcerative colitis.   B.  Partial List of ICD -9-CM Codes Indicating High Risk (for Services before Implementation of ICD -10)  Listed below are some examples of diagnoses that meet the high risk criteria for colorectal cancer.  This is not an all -inclusive list.  There may be more instances of conditions which may be coded and could be at the medical directors discretion.   Personal History   o V10.05 -  Personal history of malignant neoplasm of large intestine  o V10.06 -  Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus    Chronic Digestive Disease Condition   o 555.0 -  Regional enteritis of small intestine  o 555.1 -  Regional enteritis of large intestine  o 555.2 -  Regional enteritis of small intestine with large intestine  o 555.9 -  Regional enteritis of unspecified site  o 556.0 -  Ulcerative (chronic) enterocolitis  o 556.1 -  Ulcerative (chronic) ileocolitis  o 556.2 -  Ulcerative (chronic) proctitis  o 556.3 -  Ulcerative (chronic) proctosigmoiditis  o 556.8 -  Other ulcerative colitis  o 556.9 -  Ulcerative colitis, unspecified (nonspecific PDX on the MCE)
(Medicare Benefit Policy Manual)
 Inflammatory Bowel   o 558.2 -  Toxic gastroenteritis and colitis  o 558.9 -  Other and unspecified noninfectious gastroenteritis and colitis   C.  Partial List of ICD -10-CM Codes Indicating High Risk (for Services after Implementation of ICD -10)
(Medicare Benefit Policy Manual)
Code  Description  K50.00  Crohn's  disease  of small  intestine  without  complications  K50.011  Crohn's  disease  of small  intestine  with rectal  bleeding  K50.012  Crohn's  disease  of small  intestine  with intestinal  obstruction  K50.013  Crohn's  disease  of small  intestine  with fistula  K50.014  Crohn's  disease  of small  intestine  with abscess  K50.018  Crohn's  disease  of small  intestine  with other  complication  K50.019  Crohn's  disease  of small  intestine  with unspecified  complications  K50.10  Crohn's  disease  of large  intestine  without  complications  K50.111  Crohn's  disease  of large  intestine  with rectal  bleeding  K50.112  Crohn's  disease  of large  intestine  with intestinal  obstruction  K50.113  Crohn's  disease  of large  intestine  with fistula  K50.114  Crohn's  disease  of large  intestine  with abscess  K50.118  Crohn's  disease  of large  intestine  with other  complication  K50.119  Crohn's  disease  of large  intestine  with unspecified  complications  K50.80  Crohn's  disease  of both small  and large  intestine  without  complications  K50.811  Crohn's  disease  of both small  and large  intestine  with rectal  bleeding  K50.812  Crohn's  disease  of both small  and large  intestine  with intestinal  obstruction  K50.813  Crohn's  disease  of both small  and large  intestine  with fistula  K50.814  Crohn's  disease  of both small  and large  intestine  with abscess  K50.818  Crohn's  disease  of both small  and large  intestine  with other  complication  K50.819  Crohn's  disease  of both small  and large  intestine  with unspecified  complications  K50.90  Crohn's  disease,  unspecified,  without  complications  K50.911  Crohn's  disease,  unspecified,  with rectal  bleeding  K50.912  Crohn's  disease,  unspecified,  with intestinal  obstruction  Code  Description  K50.913  Crohn's  disease,  unspecified,  with fistula  K50.914
(Medicare Benefit Policy Manual)
disease,  unspecified,  with rectal  bleeding  K50.912  Crohn's  disease,  unspecified,  with intestinal  obstruction  Code  Description  K50.913  Crohn's  disease,  unspecified,  with fistula  K50.914  Crohn's  disease,  unspecified,  with abscess  K50.918  Crohn's  disease,  unspecified,  with other  complication  K50.919  Crohn's  disease,  unspecified,  with unspecified  complications  K51.80  Other  ulcerative  colitis  without  complications  K51.80  Other  ulcerative  colitis  without  complications  K51.20  Ulcerative  (chronic)  proctitis  without  complications  K51.211  Ulcerative  (chronic)  proctitis  with rectal  bleeding  K51.212  Ulcerative  (chronic)  proctitis  with intestinal  obstruction  K51.213  Ulcerative  (chronic)  proctitis  with fistula  K51.214  Ulcerative  (chronic)  proctitis  with abscess  K51.218  Ulcerative  (chronic)  proctitis  with other  complication  K51.219  Ulcerative  (chronic)  proctitis  with unspecified  complications  K51.30  Ulcerative  (chronic)  rectosigmoiditis  without  complications  K51.311  Ulcerative  (chronic)  rectosigmoiditis  with rectal  bleeding  K51.312  Ulcerative  (chronic)  rectosigmoiditis  with intestinal  obstruction  K51.313  Ulcerative  (chronic)  rectosigmoiditis  with fistula  K51.314  Ulcerative  (chronic)  rectosigmoiditis  with abscess  K51.318  Ulcerative  (chronic)  rectosigmoiditis  with other  complication  K51.319  Ulcerative  (chronic)  rectosigmoiditis  with unspecified  complications  K51.80  Other  ulcerative  colitis  without  complications  K51.811  Other  ulcerative  colitis  with rectal  bleeding  K51.812  Other  ulcerative  colitis  with intestinal  obstruction  K51.813  Other ulcerative colitis with fistula  K51.814  Other ulcerative colitis with abscess  K51.818  Other ulcerative colitis with other complication  K51.819  Other ulcerative colitis with unspecified complications  K51.90  Ulcerative colitis, unspecified, without complications  Code  Description  K51.911  Ulcerative colitis, unspecified
(Medicare Benefit Policy Manual)
ulcerative colitis with other complication  K51.819  Other ulcerative colitis with unspecified complications  K51.90  Ulcerative colitis, unspecified, without complications  Code  Description  K51.911  Ulcerative colitis, unspecified with rectal bleeding  K51.912  Ulcerative colitis, unspecified with intestinal obstruction  K51.913  Ulcerative colitis, unspecified with fistula  K51.914  Ulcerative colitis, unspecified with abscess  K51.918  Ulcerative colitis, unspecified with other complication  K51.919  Ulcerative colitis, unspecified with unspecified complications  K52.1  Toxic gastroenteritis and colitis  K52.89  Other specified noninfective gastroenteritis and colitis  K52.9  Noninfective gastroenteritis and colitis, unspecified  Z85.038  Personal history of other malignant neoplasm of large intestine  Z85.048  Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus  D12.6  Benign neoplasm of colon, unspecified  Z12.11  Encounter for screening for malignant neoplasm of colon  Z12.12  Encounter for screening for malignant neoplasm of rectum  Z15.09  Genetic susceptibility to other malignant neoplasm  Z80.0  Family history of malignant neoplasm of digestive organs  Z83.71  Family history of colonic polyps
(Medicare Benefit Policy Manual)
280.2.4 - Determining Frequency Standards  (Rev. 1, 10- 01-03) B3-4180.4  To determine the 11, 23, 47, and 119- month periods, the count starts beginning with the month after the month in which a previous test/procedure was performed.   EXAMPLE:  The beneficiary received a fecal -occult blood test in January 2000.  The A/B MAC (B) starts its count beginning with February 2000.  The beneficiary is eligible to receive another blood test in January 2001 (the month after 11 full months have passed).   280.2.5 - Noncovered Services  (Rev. 1, 10- 01-03) B3-4180.5  The following noncovered HCPCS codes are used to allow claims to be billed and denied for beneficiaries who need a Medicare denial for other insurance purposes for the dates of service indicated:   A.  From January 1, 1998 Through June 30, 2001, Inclusive  Code G0121 (colorectal cancer screening; colonoscopy on an individual not meeting criteria for high risk) should be used when this procedure is performed on a beneficiary who does NOT meet the criteria for high risk.  This service should be denied as noncovered because it fails to meet the requirements of the benefit for these dates of service.  The beneficiary is liable for payment. Note that this code is a covered service for dates of service on or after July 1, 2001.  B.  On or After January 1, 1998  Code G0122 (colorectal cancer screening; barium enema) should be used when a screening barium enema is performed NOT as an alternative to either a screening colonoscopy (code G0105) or a screening flexible sigmoidoscopy (code G0104).  This service should be denied as noncovered because it fails to meet the requirements of the benefit.  The beneficiary is liable for payment.   280.3 - Screening Mammography (Rev. 1, 10-01-03) A3-3660.10, B3-4601.1  Section 4163 of the Omnibus Budget Reconciliation Act of 1990 added 1834(c)