evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Complex Drug Administration Coding (A58527)
The name of the drug,The total dosage (plus strength of dosage, if appropriate), and;The method of administration.Important: List1unit of service in the 2400/SV1-04 data element or in item 24G of the CMS 1500 form. Do not quantity-bill NOC drugs and biologicals even if multiple units are provided. Medicare determines the proper payment of NOC drugs and biologicals by the narrative information, not the number of units billed.Medicare will reject as unprocessable claims for NOC drugs and biologicals if any of the information above is missing, or if the NOC code is billed with more than one unit of service. (Note: The remittance notice will include remark code M123, "Missing/incomplete/invalid name, strength, or dosage of the drug furnished," even if the rejection is due to the number of units billed.)For further information, see Palmetto GBA's Website Topic Article:Unclassified or Not Otherwise Classified (NOC) Drug Codes: Rejected if Not Submitted CorrectlyASC and Hospital Outpatient DepartmentsHCPCS code C9399, Unclassified drug or biological, should be used for new drugs and biologicals that are approved by the United States (U.S.) Food and Drug Administration (FDA) on or after January 1, 2004, for which a specific HCPCS code has not been assigned.JW ModifierJW Modifiereffective January 1, 2017. Claims for discarded drugs or biologicals amount not administered to any patient shall be submitted using the JW modifier.Unused drugs or biologicals from single use vials or single use packages that are opened, and the entire dose/quantity is not administered, and the remainder is discarded. (Except those provided under the Competitive Acquisition Program (CAP) for Part B drugs and biologicals.)Providers must document the discarded drugs or biologicals in the patient's medical record.This modifier, billed on a separate line, will provide payment for the amount of discarded drugs or biologicals.
Article - Billing and Coding: Complex Drug Administration Coding (A58527)
A situation in which the JW modifier is not permitted is when the actual dose of the drug or biological administered is less than the billing unit. For example, 1 billing unit for a drug is equal to 10mg of the drug in a single use vial. A 7mg dose is administered to a patient while 3mg of the remaining drug is discarded. The 7mg dose is billed using 1 billing unit that represents 10mg on a single line item. The single line item of 1 unit would be processed for payment of the total 10mg of drug administered and discarded. Billing another unit on a separate line item with the JW modifier for the discarded 3mg of drug is not permitted because it would result in overpayment. Therefore, when the billing unit is equal to or greater than the total actual dose and the amount discarded, the use of the JW modifier is not permitted.(SeeCMS Internet Only-Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, 40 Discarded Drugs and Biologicals)Route of Administration ModifierThe use of the JA and JB modifiers is required for drugs which have 1 HCPCS Level II (J or Q) code but multiple routes of administration. Drugs that fall under this category must be billed with JA Modifier for the intravenous infusion of the drug or billed with JB Modifier for subcutaneous injection of the drug.The lists below are not an all-inclusive list and may be subject to further revision.Subcutaneous and Intramuscular Injection Non-ChemotherapyThe administration of the following drugs should not be billed using a chemotherapy administration code. Instead, the administration of the following drugs in their subcutaneous or intramuscular forms should be billed using CPTcode 96372, (therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular).To avoid unnecessary rejections, claims for these types of drugs and their non-chemotherapy administration should be billed as a pair on a separate claim from any chemotherapy.Generic/Trade NamesGeneric NameTrade NameHCPCS CodebenralizumabFasenraJ0517canakinumabIlarisJ0638certolizumab pegolCimziaJ0717denosumabProlia/XgevaJ0897
Article - Billing and Coding: Complex Drug Administration Coding (A58527)
canakinumabIlarisJ0638certolizumab pegolCimziaJ0717denosumabProlia/XgevaJ0897filgrastim (g-csf) excludes biosimilars**Neupogen**J1442**tbo-filgrastimGranixJ1447filgrastim-sndz biosimilar**Zarxio**Q5101**filgrastim-aafi**Nivestym**Q5110**luspatercept-aamtReblozylJ0896mepolizumabNucalaJ2182octreotide acetate depotSandostatinLAR depotJ2353omalizumabXolairJ2357pegfilgrastim excludes biosimilar*Neulasta*J2506*pegfilgrastim-jmbd, biosimilarFulphilaQ5108pegfilgrastim-cbqvUdenycaQ5111pegfilgrastim-bmezZiextenzoQ5120pegfilgrastim-apgf, biosimilarNyvepriaQ5122pegfilgrastim-fpgkStimufendQ5127pegfilgrastim-pbbkFylnetraQ5130rilonaceptArcalystJ2793tildrakizumab-asmnIlumyaJ3245
Article - Billing and Coding: Complex Drug Administration Coding (A58527)
Q5127pegfilgrastim-pbbkFylnetraQ5130rilonaceptArcalystJ2793tildrakizumab-asmnIlumyaJ3245*Note: Effective 01/01/2018 providers are instructed to use 96377 for the on body application injector for NeulastaOnpro Kit.**When billing filgrastim (HCPCS codes J1442, Q5101, or Q5110), append the JA modifier for the intravenous (IV) formulation or the JB modifier for the subcutaneous formulation.Infusions Non-ChemotherapyThe administration of the following drugs should not be billed using a chemotherapy administration code. The IV administration of the drugs below should be billed with the appropriate IV injection/infusion CPTcodelisted under Therapeutic Prophylactic, and Diagnostic Injections and Infusions.To avoid unnecessary rejections, claims for chemotherapy drugs and their chemotherapy administration should be billed as a pair on a separate claim. In this circumstance, the Medicare Claims Processing System will still allow the add-on codes 96367 and 96368 if billed appropriately on a separate claim from the initial claim for the chemotherapy drug and administration codes with the same date of service.Generic/Trade NamesGeneric NameTrade NameHCPCS Codeabatacept****Orencia****J0129****Anifrolumab-fniaSaphneloJ0491belataceptNulojixJ0485bezlotoxumabZinplavaJ0565eculizumabSolirisJ1300edaravoneRadicavaJ1301filgrastim (g-csf) excludes biosimilars***Neupogen***J1442***filgrastim-sndz, biosimilar***Zarxio***Q5101***filgrastim-aafi***Nivestym***Q5110***golimumabSimponi AriaJ1602natalizumabTysabriJ2323
Article - Billing and Coding: Complex Drug Administration Coding (A58527)
filgrastim-aafi***Nivestym***Q5110***golimumabSimponi AriaJ1602natalizumabTysabriJ2323octreotide acetate non-depot**Sandostatin**J2354**patisiranOnpattroJ0222remdesivirVekluryJ0248reslizumabCinqairJ2786ustekinumab*Stelara*J3358*vedolizumabEntyvioJ3380*Effective September 23, 2016, IV ustekinumab (Stelara) should be billed with HCPCS J3590 (OPPS: C9399 for dates of service (DOS)before04/01/2017; C9487 for DOS from 04/01/2017 to 06/30/17, Q9989 for DOS from 07/01/2017-12/31/17 and J3358 for DOS 01/01/2018 and after) for the initial IV dose of Stelarawhen used for Crohns disease and Ulcerative Colitis. Each subsequent subcutaneous dosemustbe billed with J3357. This IV formulation is now FDA approved for Crohns disease and Ulcerative Colitis. On and after July 31, 2017, both the drug and administration should be billed on the same claim with no other drugs or administration to prevent inappropriate claim rejection.**When billing octreotide acetate (HCPCS code J2354), append the JA modifier for the IV formulation or the JB modifier for the subcutaneous formulation. The subcutaneous (SQ) form is on the Self-Administered Drug Exclusion List (SAD List).***When billing filgrastim (HCPCS codes J1442, Q5101, Q5110), append the JA modifier for the IV formulation or the JB modifier for the subcutaneous formulation.****When billing abatacept (HCPCS code J0129), append the JA modifier for the IV formulation or the JB modifier for the subcutaneous formulation. The SQ form is on the SAD List.
Article - Billing and Coding: Urodynamic Services - Non-invasive (A58541)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Section 230.2 Uroflowmetric EvaluationsCMS IOM Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60 Services and Supplies, Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic TestsCMS Publication 100-08,Medicare Program Integrity Manual,Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCDFederal Register References:42 Code of Federal Regulations, 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions42 Code of Federal Regulations, 410.33 Independent diagnostic testing facility42 Code of Federal Regulations, 410.74 Physician assistants services42 Code of Federal Regulations, 410.75 Nurse practitioners services42 Code of Federal Regulations, 410.76 Clinical nurse specialists servicesSocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Title XVIII of the 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.Article TextUrodynamic tests include: Cystometry, Electromyography, Urethral Pressure Profile, Uroflowmetry and Voiding Pressure Study; which are used to define the functional status of the lower urinary tract and to assist in the diagnosis of signs and symptoms of lower urinary tract problems or to guide further medical and/or surgical decision-making for urologic dysfunction.
Article - Billing and Coding: Urodynamic Services - Non-invasive (A58541)
The penile cuff is a non-invasive diagnostic test for male urinary disorders, also known as lower urinary tract symptoms (LUTS) such as urgency, frequency, nocturia and incomplete emptying. The test uses an external penile cuff (resembling a blood pressure cuff) instead of a catheter to measure bladder pressure while also calculating urine flow rate. This Billing and Coding Article provides billing and coding guidance for Urodynamic testing performed when using a penile pressure cuff for a urethral pressure study.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire Billing and Coding Article) as if they are covered. When billing for non-covered services, use the appropriate modifier.When there is no CPT/HCPCS code available to describe the service(s) performed, the appropriate CPT/HCPCS Not Otherwise Classified (NOC) code must be submitted.Non-invasive urodynamic studies, i.e., those performed without catheterization are to be reported using the CPT code 55899 with non-invasive urodynamic studies (e.g. UroCuff) noted in the narrative portion of the claim.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.Documentation includes signs and symptoms of voiding dysfunction, a relevant medical history, physical exam, urinalysis with urine microscopy and effectiveness of treatment when there is a diagnosis of urinary tract infection.Printouts from the electronic equipment are considered part of the documentation and should be included in the patients official medical record in addition to the professional interpretation and supervision report.
Article - Billing and Coding: Urodynamic Services - Non-invasive (A58543)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Section 230.2 Uroflowmetric EvaluationsCMS IOM Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60 Services and Supplies, Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic TestsCMS Publication 100-08,Medicare Program Integrity Manual,Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCDFederal Register References:42 Code of Federal Regulations, 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions42 Code of Federal Regulations, 410.33 Independent diagnostic testing facility42 Code of Federal Regulations, 410.74 Physician assistants services42 Code of Federal Regulations, 410.75 Nurse practitioners services42 Code of Federal Regulations, 410.76 Clinical nurse specialists servicesSocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Title XVIII of the 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.Article TextUrodynamic tests include: Cystometry, Electromyography, Urethral Pressure Profile, Uroflowmetry and Voiding Pressure Study; which are used to define the functional status of the lower urinary tract and to assist in the diagnosis of signs and symptoms of lower urinary tract problems or to guide further medical and/or surgical decision-making for urologic dysfunction.
Article - Billing and Coding: Urodynamic Services - Non-invasive (A58543)
The penile cuff is a non-invasive diagnostic test for male urinary disorders, also known as lower urinary tract symptoms (LUTS) such as urgency, frequency, nocturia and incomplete emptying. The test uses an external penile cuff (resembling a blood pressure cuff) instead of a catheter to measure bladder pressure while also calculating urine flow rate. This Billing and Coding Article provides billing and coding guidance for Urodynamic testing performed when using a penile pressure cuff for a urethral pressure study.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire Billing and Coding Article) as if they are covered. When billing for non-covered services, use the appropriate modifier.When there is no CPT/HCPCS code available to describe the service(s) performed, the appropriate CPT/HCPCS Not Otherwise Classified (NOC) code must be submitted.Non-invasive urodynamic studies, i.e., those performed without catheterization are to be reported using the CPT code 55899 with non-invasive urodynamic studies (e.g. UroCuff) noted in the narrative portion of the claim.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.Documentation includes signs and symptoms of voiding dysfunction, a relevant medical history, physical exam, urinalysis with urine microscopy and effectiveness of treatment when there is a diagnosis of urinary tract infection.Printouts from the electronic equipment are considered part of the documentation and should be included in the patients official medical record in addition to the professional interpretation and supervision report.
Article - Billing and Coding: Independent Diagnostic Testing Facilities (IDTF) (A58559)
CMS National Coverage PolicyCMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.2 Psychological and Neuropsychological Tests and 80.6 Requirements for Ordering and Following Orders for Diagnostic TestsCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 1, 30.2 Assignment of Providers Right to PaymentCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 35, Independent Diagnostic Testing Facility (IDTF)Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Title XVIII of the Social Security Act, 1861(aa)(6) NPs and CNSs perform tests in collaboration with a physician.42 CFR 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions42 CFR 410.33Independent diagnostic testing facilityArticle Text
Article - Billing and Coding: Independent Diagnostic Testing Facilities (IDTF) (A58559)
42 CFR 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions42 CFR 410.33Independent diagnostic testing facilityArticle TextThis article provides information regarding CPT/HCPCS codes that describe diagnostic procedures (and some materials required to perform the diagnostic procedures, i.e., radioactive tracers) that may be performed in an independent diagnostic testing facility (IDTF).Coding GuidelinesIn order for an IDTF to be reimbursed by Medicare for any procedure or material included in this article, that specific IDTF must be credentialed and approved by Palmetto GBA provider enrollment to bill for that specific service when provided to a Medicare beneficiary.The information in this article may not be all-inclusive and may be subject to change as CPT/HCPCS codes are updated. The codes included in this article are based on the latest coding updates. The effective date of this article is the date of the most recent update.With these updates certain codes may be deleted but will still be appropriate for billing up to 1 year after the procedure date. A listing of these codes that may still be valid are located in theOther Coding Informationsection of this article.The listing of a procedure code does not guarantee that Medicare will reimburse the service. All services are subject to Medicare medical necessity and coverage policies, including National Coverage Decisions, Local Coverage Decisions, statutory exclusions and instructions in interpretive manuals.It is not appropriate to bill Medicare for services that are not covered as if they are covered. When billing for non-covered services, use the appropriate modifier.Additional Services/SuppliesAdditional services/items (e.g., radiopharmaceutical agents, special contrast agents, medications, etc.) are considered supplies and are also payable to an IDTF if they are commonly separately reimbursed to a physician in a physicians office setting. They are not listed in this article, in that if the test is payable, the supplies will be also.Physician Supervision of Diagnostic Procedures
Article - Billing and Coding: Independent Diagnostic Testing Facilities (IDTF) (A58559)
The following list defines the numeric level of physician supervision for diagnostic procedures assigned to each CPT/HCPCS code and is located in theMedicare Physician Fee Schedule Database (MPFSDB).1 = General supervision of a physician2 = Direct supervision of a physician3 = Personal supervision of a physician4 = Physician supervision does not apply if performed by a qualified independent psychologist or a clinical psychologist; otherwise general supervision of a physician is required5 = Physician supervision does not apply if performed by a qualified audiologist; otherwise general supervision of a physician is required6 = Must be personally performed by a physician or by a physical therapist (PT) who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiologic clinical specialist and is permitted to provide the service under state law66 = May be performed by a physician or a physical therapist with ABPTS certification and certification in this specific procedure6A = Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may supervise another PT, but only the PT with ABPTS certification may bill21 = Procedure may be performed by a technician with certification under general supervision of a physician; otherwise must be performed under the direct supervision of a physician22 = May be performed by a technician with on-line real-time contact with a physician77 = Procedure must be performed by a PT with ABPTS certification (TC & PC) or by a PT without certification under direct supervision of a physician (TC & PC), or by a technician with certification under general supervision of a physician (TC only; PC always physician)7A = Must be personally performed by a physical therapist (PT) who is certified by the American Board of Physical Therapy Specialties (ABPTS) or by a PT without certification under direct supervision of a physician, or by a technician with certification under general supervision; in addition, the PT with ABPTS certification may supervise another PT, but only the PT with ABPTS certification may bill9 = 26 /TC indicator not applicable - concept of a professional/technical component does not applyQualification requirements: IDTF Supervising PhysicianLicensed to practice in the state(s) in which the diagnostic tests he or she supervises will be performedEnrolled in MedicareMeets the proficiency standards for any tests he or she is supervisingNot currently excluded or barredProvides general supervision for no more than three IDTF sitesQualification requirements: IDTF Interpreting Physician