evekhm/cms_iom_500 huggingface dataset:
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All MACs should use the following guidelines in planning training sessions.   Limit the training sessions to a manageable size to encourage questions and answers.   A/B MACs (B) should limit sessions to office staffs of homogenous medical specialties, e.g., do not include DME suppliers with staff from physicians offices.    Invite office personnel who complete bills and claims to attend.    In conducting the training, emphasize the use of the new HCPCS/CPT -4 manuals and the proper completion of the claim forms using the new codes.   Be alert to a specific physician/supplier/provider having difficulty with HCPCS.  Provide follow up training focused to the individual situation.  Review and discuss specific billing problems over the phone or by mail.  If many problems develop with a spec ific provider, the MAC schedules a visit to provide the specific training needed.  Training is the A/B MACs (A)s, (B)s, (HHH)s, and DME MACs responsibility.   20.6 - Professional/Public Relations for HCPCS  (Rev. 1, 10- 01-03)  A/B MACs (A), (B), (HHH), and DME MACs must perform the following professional/public relations activities:  Designate a knowledgeable person as a focal point for physician, supplier and provider inquiries.  This person must be able to address coding and payment questions.   Notify physicians, suppliers and providers by newsletter and Web site at least 30 days before codes are changed, added or deleted.  Also, notify them when general problems arise including coding issues.   A/B MACs (B) should share Level III codes/modifiers with the Medicaid State agency in the A/B MAC (B)s jurisdiction.   Advise physicians and providers to obtain new copies of CPT -4 annually from the AMA.  Orders can be placed by calling 1- 800-621-8335 or order online at www.ama -assn.org/catalog   A/B MACs (A) and (HHH) supply providers with CMS alpha -numeric code updates and with any local codes.  See 20 for sources.  A/B MACs (B) supply the current HCPCS local codes/modifiers (alpha -numeric W -Z) since they are the only source.
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 A/B MACs (A), (B), (HHH), and DME MACs inform physicians, suppliers, and providers when the annually and quarterly updated HCPCS codes become available and effective in the claims processing system.    All codes/modifiers contained in the current version of the HCPCS will be recognized and processed unless they have been deleted or are indicated as not valid for Medicare.    It is important for physicians, practitioners, suppliers, and providers to note that code/modifier recognition does not imply that a service is covered by Medicare.  In addition, a separate code does not mean that the payment level will be different from similar services identified by different codes.    Since local changes can occur throughout the year, continue professional relations activities to provide as much information as possible to providers.   20.7 - Use of the American Medical Associations (AMAs) Physicians Current Procedural Terminology (CPT) Fourth Edition Codes, and Use of the American Dental Associations (ADAs) Current Dental Terminology-Fourth Edition (CDT) Codes, on A/B MACs (A)s, (B)s, (HHH)s, and DME MACs  Web Sites and Other Electronic Media  (Rev. 10211, Issued: 07- 10-2020, Effective: 08 -10-2020, Implementation: 08- 10-2020)   See Business Requirements at http://www.cms.hhs.gov/manuals/pm_trans/R43CP.pdf  CMS AMA- ADA-AHA Medical Codes Overview  The Centers for Medicare & Medicaid Services (CMS) staff may access the following copyright protected medical codes and descriptors:   American Medical Associations Current Procedural Terminology  AMA/CPT   American Dental Associations Current Dental Terminology  ADA/CDT   American Hospital Associations National Uniform Billing Codes  AHA/NUBC UB-04   CMS signed licensing agreements with the AMA, ADA, and AHA giving staff limited use of CPT, CDT, and NUBC data codes and descriptors.
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CMS signed licensing agreements with the AMA, ADA, and AHA giving staff limited use of CPT, CDT, and NUBC data codes and descriptors.   Access the CPT, CDT, or NUBC codes  Prior to accessing the codes, CMS staff must accept the terms and conditions of an association's licensing agreement.   American Medical Associations Current Procedural Terminology  AMA/CPT  o     AMA Terms and Conditions  o    AMA CPT Exhibits Directory   American Dental Associations Current Dental Terminology  ADA/CDT  o     ADA Terms and Conditions  o     ADA CDT Exhibits Directory   American Hospital Associations National Uniform Billing Codes  AHA/NUBC  o     AHA Terms and Conditions  o    AHA NUBC Exhibits Directory    Any proposed usage not covered by the current agreement requires the completion of a CPT-CDT -NUBC New Use Application . CMS, then, will negotiate your new use with the appropriate association.   20.8 - Payment, Utilization Review (UR), and Coverage Information on CMS Annual HCPCS Codes Update File  (Rev. 10320, Issued: 08- 28-2020, Effective: 12 -01-2020, Implementation: 12- 01-2020)   The file CMS provides for the quarterly update of HCPCS codes contains fields for payment, UR, and coverage information to assist in developing front -end edit screens.  Coverage information is not all inclusive, but should be used mainly as a guide in establishing specific review limits.  A/B MACs (B) must establish reasonable developmental guidelines, review screens, and relative value units, as appropriate.  A/B MACs (B) must assure that their system processes claims in accordance with CMS policies and pr ocedures, including changes that may occur between HCPCS codes updates.    Where CMS determines that nationally uniform temporary codes/modifiers are needed to implement policy/legislation between HCPCS codes updates, the codes/modifiers, definitions and policy are issued as Level II codes/modifiers prefixed with Q or K or G.  Questions may arise in updating that require A/B MAC (B) staff to refer to a physicians or suppliers pricing history.  Therefore, keep an electronic backup of HCPCS codes for the two prior years with linkages to pricing profiles.  Perform required computer analysis as necessary.
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The HCPCS terminology seldom includes a place of service designation.  Where place of service affects pricing, pricing is obtained from the place of service field on the claim record.   A/B MACs (A) and (HHH) also develop editing screens using HCPCS based on payment and coverage policies from CMS.  A/B MACs (A) and (HHH) must assure that system claims processing complies with CMS policy and procedures.   20.9 - National  Correct Coding Initiative (NCCI)                                    (Rev.  10878, Issued: 07 -15-2021, Effective:08 -16-2021; Implementation:08 -16-2021)
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The CMS developed the National Correct Coding Initiative (NCCI) program to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Associations CPT manual, CMS national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. An overview of the NCCI program for both the Procedure -to-Procedure (PTP), Medically Unlikely Edits (MUEs), Add- on Code (AOC) Edits and additional information sources are found on the CMS NCCI Website . The National Correct Coding Initiative Policy Manual for Medicare Services (also known as the Coding Policy Manual) shall be used by Medicare Administrative Contractors (MACs) as a general reference tool that explains the rationale for NCCI edits.  The purpose of the NCCI PTP edits is to prevent improper payment when incorrect code combinations are reported. The NCCI webpage contains separate tables of edits for physicians / practitioners, outpatient hospital services, and durable medical equipment. Additional information regarding types of tables is available in the How to Use The National Correct Coding Initiative (NCCI) Tools MLN booklet. The purpose of the NCCI MUE program is to prevent improper payments when services are reported with incorrect units of service (UOS). The CMS developed MUEs to reduce the paid claims error rate for Part B claims. An MUE for a Healthcare Common Procedure Coding System (HCPCS) /  Current Procedural Terminology (CPT) code is the maximum  UOS that a provider or supplier would report under most circumstances for a single beneficiary on a single date of service.  An AOC is a HCPCS / CPT code that describes a service that , with rare exception, is performed in conjunction with another primary service by the same practitioner. An AOC is rarely eligible for payment if it is the only procedure reported by a practitioner. CMS posted the Correspondence Language Manual for Medicare Services on the NCCI Website for use by the Medicare Contractors to answer routine correspondence inquiries about the NCCI PTP and MUE edits. The general correspondence language paragraphs explain the rationale for the edits. The section- specific examples add further explanation to the PTP or MUE edits and are sorted by edit rationale and HCPCS
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and MUE edits. The general correspondence language paragraphs explain the rationale for the edits. The section- specific examples add further explanation to the PTP or MUE edits and are sorted by edit rationale and HCPCS / CPT code section (00000, 10000, 20000, etc.). Please refer to the Introduction of the Correspondence Language Manual for additional guidance about its use.
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20.9.1 - Correct Coding Modifier Indicators (CCMI) and HCPCS Codes Modifiers                                                                                                       (Rev . 10878, Issued: 07 -15-2021, Effective:08- 16-2021; Implementation:08- 16-2021)           The National Correct Coding Initiative (NCCI) File Formats continue to include a Correct Coding Modifier Indicator (CCMI) for the Column One / Column Two Correct Coding edit file. This indicator determines whether an NCCI PTP-associated modifier causes the code pair to bypass the edit. The CCMI will be either a 0, 1, or a 9. The definitions of each are:  0 = an NCCI PTP -associated modifier is not allowed and will not bypass the edit. 1 = an NCCI PTP -associated modifier is allowed and will bypass the edit. 9 = The use of NCCI PTP -associated modifiers is not specified. This indicator is used for all code pairs that have a deletion date that is the same as the effective date. This indicator prevents blank spaces from appearing in the indicator field. 20.9.1.1 - Instructions for Codes With Modifiers ( A/B MACs (B)  Only)  (Rev. 10878, Issued: 07- 15-2021, Effective:08 -16-2021; Implementation:08- 16-2021)
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A. General  Medicare Administrative Contractors (MACs) subject all line items for the same beneficiary, same NPI, and same date of service to National Correct Coding Initiative (NCCI) edits.  All line items for the same beneficiary, same NPI, and same date of service shall be subject to NCCI Procedure -to-Procedure (PTP) edits. If the CCMI of a PTP edit is 0, the Column Two code is not eligible for payment even if an NCCI PTP -associated modifi er is appropriately appended to one of the codes. If the CCMI of a PTP edit is 1, the edit may be bypassed and the Column Two code of the edit may be eligible for payment if an NCCI PTP-associated modifier is appropriately appended to one of the codes. I f the 2 codes of a code pair edit have the same NCCI PTP -associated anatomic modifier, the edit will not be bypassed unless an additional NCCI PTP -associated modifier is appended to 1 of the codes indicating the reason to bypass the edit. The use of modifiers that are not NCCI PTP -associated modifiers shall not bypass an NCCI PTP edit.  NCCI PTP -associated modifiers are the following:        Anatomic modifiers: E1 -E4, FA, F1- F9, TA, T1- T9, LT, RT,             LC, LD, RC, LM, RI     Global surgery modifiers: 24, 25, 57, 58, 78, 79  Other modifiers: 27, 59, 91, XE, XS, XP, XU
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LC, LD, RC, LM, RI     Global surgery modifiers: 24, 25, 57, 58, 78, 79  Other modifiers: 27, 59, 91, XE, XS, XP, XU     B. Modifiers 59 or -  X{EPSU}  Modifiers 59 or -  X{EPSU} and other NCCI PTP -associated modifiers shall not be used to bypass a PTP edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI -associated modifier that is used. Find further information on modifiers 59 or - X{EPS U} in the Coding Policy Manual available on the CMS website.  Use of modifiers 59 or -X{EPSU} does not require a different diagnosis for each HCPCS/CPT coded procedure. Conversely, different diagnoses are not adequate criteria for use of modifiers - 59 or - X{EPSU}.   Modifiers 59 or - X{EPSU} shall not be used with the following codes:   77427 Radiation treatment management, 5 treatments   Evaluation & Management (E&M) services  When a provider or supplier submits a claim for any of the codes specified above with the 59 modifier, the A/B MAC must process the claim as if the modifier were not present. In addition to those messages specified in 20.9.1 above, A/B MACs shall convey a dditional messaging per instructions in Pub. 100- 09, Chapter 6 and Pub. 100- 04, Chapter 22.  Examples of appropriate use of modifiers 59 and -X{EPSU} can be found in the Fact Sheet Proper Use of Modifiers 59 & - X{EPSU}.  1. Modifier 59 or XE are used appropriately when the procedures are performed in     different encounters on the same day.   2. Modifier 59 or XP are used appropriately when the procedures are performed by    different practitioners,   3. Modifier 59 or XS are used appropriately for different anatomic sites during the same     encounter only when procedures are performed on different organs, or different     anatomic regions, or in limited situations on different, non- contiguous lesions in different     anatomic regions of the same organ.
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encounter only when procedures are performed on different organs, or different     anatomic regions, or in limited situations on different, non- contiguous lesions in different     anatomic regions of the same organ.   4. Other specific appropriate uses of modifiers 59 or - X{EU}  There are 3 other limited situations in which 2 services may be reported as separate and distinct because they are separated in time and describe non -overlapping services even though they may occur during the same encounter.  a. Modifier 59 or XE is used appropriately for 2 services described by timed codes provided during the same encounter only when they are performed sequentially. There is an appropriate use for modifiers 59 or XE that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 minutes, per hour). If 2 timed services are provided in blocks of time that are separate and distinct (i.e., the same time block is not used to determine t he unit of service for both codes), modifier 59 may be used to identify the services.   b. Modifier 59 or XU is used appropriately for a diagnostic procedure, which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.  When a diagnostic procedure precedes a surgical procedure or on -surgical therapeutic procedure and is the basis on which the decision to perform the surgical procedure is made, that diagnostic test may be considered to be a separate and distinct procedure as long as (a) it occurs before the therapeutic procedure and is  not interspersed with services that are required for the therapeutic intervention; (b) it clearly provides the information needed to decide whether to proceed with the therapeutic procedure; (c) it does not constitute a service that would have otherwise been required during the therapeutic intervention; and d) it is not specifically prohibited. If the diagnostic procedure is an inherent component of the surgical procedure, it should not be reported separately.
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c. Modifier 59 or XU is used appropriately for a diagnostic procedure, which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow -up to the therapeutic procedure. When a diagnostic procedure follows the surgical procedure or non- surgical therapeutic procedure, that diagnostic procedure may be considered to be a separate and distinct procedure as long as (a) it occurs after the completion of the therapeutic procedure  and is not interspersed with or otherwise commingled with services that are only required for the therapeutic intervention, and (b) it does not constitute a service that would have otherwise been required during the therapeutic intervention. If the post -procedure  diagnostic procedure is an inherent component or otherwise included (or not separately payable) post -procedure service of the surgical procedure or non -surgical therapeutic procedure, it should not be reported separately.   5. Modifiers 59 or X{EPSU} are used inappropriately if the basis for their use is that the     narrative description of the 2 codes is different.
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C. Modifier 91 Modifier 91 may be appended to laboratory procedure(s) or service(s) to indicate a repeat test or procedure on the same day when appropriate. If a HCPCS/CPT code has an MUE that is adjudicated as a claim line edit, (i.e., MAI equal to 1) appropriate use of CPT modifiers (i.e., 59 or - X{EPSU}, 76, 77, 91, anatomic) may be used to report the same HCPCS/CPT code on separate lines of a claim. This modifier indicates to the Medicare contractors that the physician had to perform a repeat clinical diagnostic lab oratory test that was distinct or separate from a lab panel or other lab services performed on the same day, and was performed to obtain medically necessary subsequent reportable test values. This modifier must not be used to report repeat laboratory testi ng due to laboratory errors, quality control, or confirmation of results. For example, if a laboratory performs all tests included in a panel of laboratory tests and repeats one of these component tests as a medically reasonable and necessary service on the same date of service, the HCPCS code corresponding to the repeat laborat ory test may be reported with modifier 91 appended.  D. Reserved for future use  E. Coding for Noncovered Services and Services Not Reasonable and Necessary  For information on this topic, see the Claims Processing Manual Chapter 1 and MLN Booklet: Medicare Advance Written Notices of Noncoverage ICN 006266 found on the CMS website at: MLN Booklet: Medicare Advance Written Notices of Noncoverage ICN 006266. Use of the A9270  A9270, Noncovered item or service, will not be accepted under any circumstances for services or items billed to A/B MACs. However, in cases where there is no specific procedure code for an item or supply and no appropriate NOC code available, the A9270 must continue to be used by suppliers to bill DME MACs for statutorily non- covered items or supplies and items or supplies that do not meet the definition of a Medicare benefit. Claims Processing Instructions  At A/B MAC and DME MAC discretion, claims submitted using the GY modifier may be auto-denied. If the GZ and GA modifiers are submitted for the same item or
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the definition of a Medicare benefit. Claims Processing Instructions  At A/B MAC and DME MAC discretion, claims submitted using the GY modifier may be auto-denied. If the GZ and GA modifiers are submitted for the same item or service, treat the item or service as having an invalid modifier and therefore unprocessable. Effective for dates of service on and after July 1, 2011, A/B MACs shall automatically deny claim line(s) items submitted with a GZ modifier. A/B MACs shall not perform complex medical review on claim line(s) items submitted with a GZ modifier. All MACs shall make all language published in educational outreach materials, articles, and on their Web sites, consistent to state all claim line(s) items submitted with a GZ modifier shall be denied automatically and will not be subject to complex medical review.  20.9.2 - Reserved for future use  (Rev. 4465; Issued: 11- 15-19, Effective: 01 -30-19, Implementation: 01- 30-19) 20.9.3  Appeals     (Rev. 10878, Issued: 07 -15-2021, Effective:08- 16-2021; Implementation:08 -16-2021)
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When a request for review is received as a result of an initial determination based on a correct coding initiative edit, and after determining that the reviews were coded correctly, the reviewer must come to the same conclusion as the initial determination  (i.e., the review does not result in an increase in payment). If the review determines that a correct coding modifier not submitted with the initial claim could have been appended to either code of an edit code pair, the reviewer may change the initial determination only if the correct coding initiative edit has a modifier indicator of 1. If the correct coding initiative edit modifier indicator is a 0, the reviewer must come to the same conclusion as the initial determination. If the conclusion is the same as the initial determination, the review determination must repeat the generic language that appears in the Medicare Summary Notice (MSN) or remittance advice notice pertaining to the correct coding edit. In addition, Medicare Administrative Contractors (MACs) must include the more detailed explanation of the correct coding initiative edit which can be found in the standard correspondence language for MACs in the Medicare Correspondence Language Manual  on the CMS NCCI Website.  20.9.3.1- Procedure -to-Procedure  (PTP) Edits                                                     (Rev. 10878, Issued: 07 -15-2021, Effective:08 -16-2021; Implementation:08 -16-2021)