evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Psychological and Neuropsychological Testing (A57481)
CMS National Coverage PolicySocial Security Act 1861(s) Medical And Other Health ServicesSocial Security Act 1862(a)(7) does not extend coverage to screening procedures.42 CFR (Code of Federal Regulations):410.73 Clinical social worker services410.74 Physician assistants services410.75 Nurse practitioners services410.76 Clinical nurse specialists servicesMLN Matters Number SE0441 Incident to Services.CMS Publication 100-02:Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services:80.2 Psychological and Neuropsychological Tests160 Clinical Psychological Services170 Clinical Social Worker (CSW) Services210 Clinical Nurse Specialist (CNS) ServicesCMS Publication 100-03:Medicare National Coverage Determinations (NCD)Manual, Chapter 1- Coverage Determination, Part 1, Sections 10-80:30.1 Biofeedback TherapyCMS Publication 100-04:Medicare Claims Processing Manual, Chapter 12 - Physicians/Nonphysician Practitioners:120 Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) Services Payment Methodology120.1 Limitations for Assistant-at-Surgery Services Furnished by Nurse Practitioners and Clinical Nurse Specialist150 Clinical Social Worker (CSW) Services160 Independent Psychologist Services170 Clinical Psychologist Services170.1 PaymentArticle Text
Article - Billing and Coding: Psychological and Neuropsychological Testing (A57481)
Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L34646 Psychological and Neuropsychological Testing.Psychological and Neuropsychological Testing are diagnostic procedures that must be used as an important tool in making specific diagnoses or prognoses to aid in treatment planning and to address questions regarding treatment goals, efficacy, and patient disposition. Diagnostic procedures that have no impact on a patients plan of care or have no effect on treatment are not medically necessary. The CPT Codes discussed in this Billing and Coding Article are used to report the services provided during testing of the cognitive function of the central nervous system. The testing of cognitive processes, visual motor responses and abstractive abilities is accomplished by the combination of several types of testing procedures.Coding GuidelinesReferences to providers throughout this policy include non-physicians, such as clinical psychologists, independent psychologist, nurse practitioners, clinical nurse specialists and physician assistants when the services performed are within the scope of their clinical practice/education, licensed and authorized under the state law.A minimum of 31 minutes must be provided to report any per hour code.Psychological or neuropsychological testing includes selection, administration and scoring of the tests, directly by the psychologist, neuropsychologist, physician or other qualified health care professional, by a technician under the clinician's direct supervision, by computerized test administration, or via some combination of these three approaches.Typically, testing requires 4-8 hours to perform, including administration andscoring. If the testing is performed over several days, the time for all testing should be combined and reported on the last day of service.Psychological and Neuropsychological testing is medically necessary for multiple reasons. The medical record must document the reason the tests are being performed. The LCD does not define coverage for either the medical or psychiatric diagnosis that may require the services.Psychological and neuropsychological testing is not covered for Alzheimers diseases once a diagnosis has been made.Billing Guidelines
Article - Billing and Coding: Psychological and Neuropsychological Testing (A57481)
For assessment of aphasia and cognitive performance testing use code 96105 and 96125, respectively.For developmental/behavioral screening and testing use codes 96110, 96112, 96113, and 96127.For neurobehavioral status examinations (includes test administration, scoring, interpretation and report) use codes 96116 and 96121.For test administration and scoring for psychological/neuropsychological testing use codes 96136, 96137, 96138 and 96139.For automated testing and results for psychological/neuropsychological testing use code 96146.To bill these services to Medicare the practitioner providing the testing must have a Medicare provider number and be appropriately licensed in the State where the services are performed.
Article - Billing and Coding: Removal of Benign Skin Lesions (A57482)
CMS National Coverage PolicyCMS Pub.100-02 Medicare Benefit Policy Manual, Chapter 16 - General Exclusions From Coverage, Section 120 - Cosmetic SurgeryCMS Pub. 100-03 Medicare National Coverage Determinations Manual-Chapter 1, Coverage Determinations, Part 4, Section 250.4 - Treatment of Actinic KeratosisCMS Pub.100-04 Medicare Claims Processing Manual, Ch. 23 Fee Schedule Administration and Coding Requirements, Section 10.1-10.6  Reporting ICD Diagnosis and Procedure CodesTitle XVIII of the Social Security Act, section 1862 (a)(1)(A). This section allows coverage and payment of those services that are considered to be medically reasonable and necessary.CMS Transmittal No, 863, effective date October 3, 2018 Change Request 10901 Local Coverage Determinations (LCDs) Implementation date January 8, 2019.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L35498 Removal of Benign Skin Lesions.Coding InformationUse the CPT code that best describes the procedure, the location and the size of the lesion. If there are multiple lesions treated, multiple codes may be reported but you must follow National Correct Coding Initiative guidelines.CPT code 11200 should be reported with one unit of service. CPT code 11201 should be reported with 1 unit for each additional group of 10 lesions.CPT code 17110 should be reported with one unit of service for removal of benign lesions other than skin tags or cutaneous vascular lesions, up to 14 lesions. CPT code 17111 should be reported with one unit of service for removal of benign lesions other than skin tags or cutaneous vascular lesions, representing 15 or more.CPT codes 11400-11446 should be used when the excision is a full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure.
Article - Billing and Coding: Removal of Benign Skin Lesions (A57482)
The provider should use the appropriate CPT code and the diagnosis code should match the CPT code. If a provider bills a benign skin lesion CPT code, it is not correct to use a malignant diagnosis code.If a beneficiary wishes to have one or more benign asymptomatic lesions removed that pose no threat to health or function, and for cosmetic purposes:The physician should explain to the patient, in advance, that Medicare will not cover cosmetic cutaneous surgery and that the beneficiary will be liable for the cost of the service. Charges should be clearly stated. A claim for cosmetic services does not need to be submitted to the Medicare Contractor unless the patient requests that the claim be submitted on his/her behalf.When the patient requests the claim for cosmetic services be submitted on his/her behalf, the services should be reported with modifier GY (items or services statutorily excluded or does not meet the definition of any Medicare benefit)anddiagnosis codeZ41.1.Evaluation and management services provided on the day, or the day before a dermatological procedure, for the purpose of making the decision to perform the procedure, are not payable. The modifier -57 cannot be used since the decision to perform the dermatological procedure is considered a routine preoperative service and a visit or consultation should not be billed. (Modifier -57 is only applicable for major procedures that have a 90-day global period.)Please refer to Modifier-57 Fact Sheet on WPS GHA website.An E&M service reported on the same day as a dermatological surgery is subject to the Medicare global surgery rules and will only be payable if a significant and separately identifiable medical service is rendered and clearly documented in the patient's medical record. A modifier-25 should be appended to the appropriate visit code to indicate the patient's condition required a significant, separately identifiable visit service in addition to the procedure that was performed.Please refer to Modifier-25 Fact Sheet on WPS GHA website.
Article - Billing and Coding: Removal of Benign Skin Lesions (A57482)
Removal of benign lesions is elective surgery and generally pre-scheduled. It is inappropriate to report an E&M service with a -25 modifier on the same date of service as these surgeries for the usual pre/post-operative care associated with these surgeries.When billing the destruction of multiple other benign lesions use CPT 17110 or 17111 with a 1 in the unit box. CPT 17110 and CPT 17111 may not be reported together.Providers should bill the appropriate CPT code and match the diagnosis code to the procedure code.
Article - Billing and Coding: Visual Fields (A57483)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.CMS Pub 100-02,Medicare Benefit Policy Manual, Chapter 16  General Exclusions From Coverage, Section 90  Routine Services and Appliances.42 CFR Section 410.32 Diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) and diagnostic tests payable under the Physicians Fee Schedule must be furnished under the appropriate level of supervision by the physician.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L34615 Visual Fields.Taped and un-taped visual field testing is considered one unit of service for MUE (medically unlikely edits) purposes. MUEs are established by a separate CMS contractor, not WPS GHA.If the claim contains a separate charge for gross visual fields, it will be denied as an incidental service.If the service is performed in a hospital inpatient or outpatient setting, the modifier -26 should be used to indicate the professional component.The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.Claims submitted for visual field examinations performed at unusually frequent intervals may be reviewed in order to verify that the services were medically reasonable and necessary.For claims submitted to the Contractor or Part B MAC:Claims for Visual Fields Testing services are payable under Medicare Part B in the following places of service:The global services (technical plus professional) may be billed in the following places of service:Office (11), nursing facility (32) and independent clinic (49).The technical component may be billed in the following places of service:Office (11), nursing facility (32), independent clinic (49), federally qualified health center (50) and rural health clinic (72).
Article - Billing and Coding: Visual Fields (A57483)
The technical component may be billed in the following places of service:Office (11), nursing facility (32), independent clinic (49), federally qualified health center (50) and rural health clinic (72).The professional component may be billed at the following places of service:Office (11), off-campus outpatient hospital (19), inpatient hospital (21), on-campus outpatient hospital (22), emergency room (23), skilled nursing facility (31), nursing facility (32), independent clinic (49) and comprehensive outpatient rehabilitation facility (62).
Article - Billing and Coding: Vitamin D Assay Testing (A57484)
CMS National Coverage PolicyTitle XVIII of Social Security Act, Section 1861 Act provides for payment of clinical laboratory services under Medicare Part B. Clinical laboratory services involve the biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the diagnosis, prevention, or treatment of a disease or assessment of a medical condition.Title XVIII of Social Security Act, Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of Social Security Act, Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.42 CFR part 493, laboratory services must meet all applicable requirements of the Clinical Laboratory Improvement Amendments of 1988 (CLIA), as set forth. Section 1862(a)(1)(A) provides that Medicare payment may not be made for services that are not reasonable and necessary.42 CFR 410.32(a), clinical laboratory services must be ordered and used promptly by the physician who is treating the beneficiary.42 CFR 410.32(a) (3), or by a qualified nonphysician practitioner.CMS Pub 100-02,Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Care Services, 80.1  Clinical Laboratory Services and 80.6  Requirements for Ordering and Following Orders for Diagnostic Tests.CMS Pub. 100-04,Medicare Claims Processing Manual, Chapter 1- General Billing Requirements, Sections 60  Provider Billing of Non-covered Charges on Institutional Claims  60.1.1 - Basic Payment Liability Conditions.CMS Pub 100-04,Medicare Claims Processing Manual, Chapter 25  Completing and Processing the Form CMS-1450 Data Set, Section 75.5  From Locators 43-81, FL-67 Principal Diagnosis Codes.CMS Transmittal No, 857, effective date October 3, 2018 Change Request 10901 Local Coverage Determinations (LCDs) Implementation date January 8, 2019.Italicized font- represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording.
Article - Billing and Coding: Vitamin D Assay Testing (A57484)
Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD Vitamin D Assay Testing.A. General Guidelines for claims submitted to MAC A/B contractors:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise, the symptoms prompting the performance of the test should be reported.For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order, and establish the plan of care for Vitamin D Assay Testing services as authorized by State law.B. Billing Guidelines:Bill type codes only apply to providers billing these services to Part A. Bill type codes do not apply to physicians, other professionals, and suppliers who bill these services to Part B. (See CMS Publication 100-04,Medicare Claims Processing Manual,Chapter 25  Completing and Processing the Form CMS-1450 Data Set, Section 75.5  From Locators 43-81, FL-67 Principal Diagnosis Codes, for additional instructions.)All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.Claims for Vitamin D Assay Testing services are payable under Medicare Part B in the following places of service: office (11), independent clinic (49), Federally Qualified health Center (50) and independent lab (81).
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Medicare Claims Processing Manual  Chapter 1 - General Billing Requirements   Table of Contents  (Rev. 1 2448, Issued: 01 -11-24)    Transmittals for Chapter 1
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01 - Foreword  01.1 - Remittance Advice Coding Used in this Manual  02 - Formats for Submitting Claims to Medicare  02.1 - Electronic Submission Requirements  02.1.1 - HIPAA Standards for Claims  02.1.2 - Where to Purchase HIPAA Standard Implementation Guides  02.2 - Paper Claims  02.2.1 - Paper Formats for Institutional Claims  02.2.2 - Paper Formats for Professional and Supplier Claims  02.3 - Remittance Advices  10 - Jurisdiction for Claims  10.1 - A/B MACs (Part B) and DME MACs Jurisdiction of Requests for Payment  10.1.1 - Payment Jurisdictions Among A/B MACs (B) for Services Paid Under the Physician Fee Schedule and Anesthesia Services  10.1.1.1 - Claims Processing Instructions for Payment Jurisdiction  10.1.1.2 - Payment Jurisdiction for Services Subject to the Anti-Markup Payment Limitatio n 10.1.1.3 - Payment Jurisdiction for Reassigned Services  10.1.3 - Exceptions to Jurisdictional Payment  10.1.5 - Domestic Claims Processing Jurisdictions  10.1.5.1 - Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, Supplies, Parental and Enteral Nutrition (PEN)  10.1.5.2 - Supplier of Portable X- Ray, EKG, or Similar Portable Services  10.1.5.3 - Ambulance Services Submitted to Carriers  10.1.5.4 - Independent Laboratories  10.1.5.4.1 - Cases Involving Referral Laboratory Services  10.1.6 - Railroad Retirement Beneficiary Carrier  10.1.7 - Welfare Carriers  10.1.9 - Disposition of Misdirected Claims to the B/MAC/ Carrier /DME MAC  10.1.9.1 -  An A/B MAC (B) Receives a Claim for Services that are in Another A/B MAC (B)s Payment Jurisdiction 10.1.9.2  An A/B MAC (B) Receives a Claim for Services that are in a DME MACs Payment Jurisdiction  10.1.9.3  A DME MAC Receives a Claim for Services that are in A Local B/MAC/Carriers Payment Jurisdiction  10.1.9.4 -  An A/B MAC (B) Receives a Claim for an RRB Beneficiary  10.1.9.5 -  An
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that are in A Local B/MAC/Carriers Payment Jurisdiction  10.1.9.4 -  An A/B MAC (B) Receives a Claim for an RRB Beneficiary  10.1.9.5 -  An A/B MAC (B) or DME MAC Receives a Claim for a UMWA Beneficiary  10.1.9.6 -  Medicare Carrier or RRB -Named Carrier to Welfare Carrier  10.1.9.7 -  Protests Concerning Transfer of Requests for Payment to Carrier  10.1.9.8 -  Transfer of Claims Material Between Carrier and Intermediary (FI) 10.1.9.9 -  A DME MAC receives a Paper Claim with Items or Services that are in Another DME MAC's Payment Jurisdiction 10.2 -  FI Jurisdiction of Requests for Payment  10.2.1 -  FI Payment for Emergency and Foreign Hospital Services  10.3 -  Payments Under Part B for Services Furnished by Suppliers of Services to Patients of a Provider  10.4 -  Claims Submitted for Items or Services Furnished to Medicare Beneficiaries in State or Local Custody Under a Penal Authority 10.5  Claims Processing Requirements for Deported Beneficiaries  10.5.1  Implementation of Payment Policy for Deported Beneficiaries  20 - Provider Assignment to FIs and MACs  20.1 -  FI Service to HHAs and Hospices  20.2 -  Provider Change of Ownership (CHOW)  20.3 -  CMS No Longer Accepts Provider Requests to Change Their FI  30 - Provider Participation  30.1 -  Content and Terms of Provider Participation Agreements  30.1.1 -  Provider Charges to Beneficiaries  30.1.1.1 -  Charges to Hold a Bed During SNF Absence  30.1.2 -  Provider Refunds to Beneficiaries  30.1.3 -  Provider Treatment of Beneficiaries  30.2 -  Assignment of Providers Right to Payment  30.2.1 -  Exceptions to Assignment of Providers Right to Payment -  Claims Submitted to A/B MACs  30.2.2 -  Background and Purpose of Reassignment Rules -  Claims Submitted to B/MACs  30.2.2.1 -  Reassignments by Nonphysician Suppliers -  Claims Submitted to FIs  30.2.3 - Effect of Payment to Ineligible Recipient  30.2.4 - Payment to Agent - Claims Submitted to Carriers  30.2.5 - Payment to Bank
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Reassignments by Nonphysician Suppliers -  Claims Submitted to FIs  30.2.3 - Effect of Payment to Ineligible Recipient  30.2.4 - Payment to Agent - Claims Submitted to Carriers  30.2.5 - Payment to Bank 30.2.6 - Payment to Employer of Physician - Carrier Claims Only  30.2.7 - Payment for Services Provided Under a Contractual Arrangement - Carrier Claims Only  30.2.8.2 - University -Affiliated Medical Faculty Practice Plans  - Claims Submitted to Carriers  30.2.8.3 - Indirect Payment Procedure (IPP) - Payment to Entities that Provide Coverage Complementary to Medicare Part B  30.2.9 - Payment to Physician or Other Supplier for Purchased Diagnostic Tests Subject to the Anti- Markup Payment Limitation -Claims Submitted to A/B MACs  (Part B)  30.2.10 -  Payment Under Reciprocal Billing Arrangements - Claims Submitted to A/B MACs Part B  30.2.11 -  Payment Under Fee -For-Time Compensation Arrangements (formerly referred to as Locum Tenens Arrangements) - Claims Submitted to A/B MACs Part B
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30.2.12 - Establishing That a Person or Entity Qualifies to Receive Payment on Basis of Reassignment - for Carrier Processed Claims  30.2.13 - Billing Procedures for Entities Qualified to Receive Payment on Basis of Reassignment - for A/B MAC Part B Processed Claims  30.2.14 - Correcting Unacceptable Payment Arrangements  30.2.14.1 - Questionable Payment Arrangements  30.2.15 - Sanctions for Prohibited Payment Arrangement  30.2.16 - Prohibition of Assignments by Beneficiaries  30.3 - Physician/Practitioner/Supplier Participation Agreement and Assignment - Carrier Claims  30.3.1 - Mandatory Assignment on Carrier Claims  30.3.1.1 - Processing Claims for Services of Participating Physicians or Suppliers  30.3.2 - Nature and Effect of Assignment on Carrier Claims  30.3.3 - Physicians Right to Collect From Enrollee on Assigned Claim Submitted to Carriers  30.3.4 - Effect of Assignment Upon Rental or Purchase of Durable Medical Equipment on Claims Submitted to Carriers  30.3.5 - Effect of Assignment Upon Purchase of Cataract Glasses From Participating Physician or Supplier on Claims Submitted to Carriers  30.3.6 - Mandatory Assignment Requirement for Physician Office Laboratories on Claims Submitted to Carriers  30.3.7 -  Billing for Diagnostic Tests (Other Than Clinical Diagnostic Laboratory Tests) Subject to the Anti -Markup Payment Limitation -  Claims Submitted to A/B MACs (B)  30.3.8 -  Mandatory Assignment and Other Requirements for Home Dialysis Supplies and Equipment Paid Under Method II on Claims Submitted to Carriers  30.3.9 -  Filing Claims to a Carrier for Nonassigned Services  30.3.10 -  Carrier Submitted Bills by Beneficiary  30.3.11 -  Carrier Receipted Bill -  Definition  30.3.12 -  Carrier Annual Participation Program  30.3.12.1 -  Annual Open Participation Enrollment Process  30.3.12.1.2 -  Annual Medicare Physician Fee Schedule File Information  30.3.12.2 -  Carrier/MACs Participation Agreement 30.3.12.3 -  Carrier Rules for Limiting Charge  30.3.13 -  Charges for Missed Appointments  40 - Termination of Provider Agreement  40.1 -  Voluntary Termination 40.1.1 -  Close of Business  40.1.2 -  Change of Ownership 40.1.3 -  Expiration and Renewal -Nonrenewal of SNF Term Agreements  40.2 -  Involuntary Terminations  40.2.1