evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
Follow -up services billed by a physician other than the operating physician for up to 3 months following donation surgery should be billed under the recipients Medicare beneficiary identifier .  Regarding donor complications:   Expenses incurred for complic ations that arise with respect to the donor are covered only if they are directly attributable to the donation surgery.  Complications that arise after the date of the donors discharge will be billed under the recipients Medicare beneficiary identifier .  This is true of both facility cost and physician services.  Billings for donor complications will be reviewed.    In all of these situations, the donor is not responsible for co- insurance or deductible.   140.10 - Coverage After Recipient Has Exhausted Part A  (Rev. 1, 10- 01-03)  A3-3178.11   If the recipient has exhausted Part A benefits while the donor still requires and receives inpatient hospital care, the program continues to pay for such donor care under Part A at 100 percent reimbursement.  140.11 - Cada ver Kidneys  (Rev. 1, 10- 01-03)  A3-3178.12   Costs incurred by the provider in connection with the acquisition of a cadaver kidney are reimbursable by the program through the kidney acquisition cost center.  Typical covered costs involved in excising the ca daver kidney include: surgeons service, operating room, anesthetist, donor evaluation and support, preservation supplies (perfusion materials and equipment), preservation technician, telephone consultation charge, intensive care costs, pathology, central supply costs, organ transportation costs, and transportation costs for a technician.  There is no provision in the law for coverage of charges by an agent transporting a kidney for transplant into an eligible beneficiary, if the agent bills the program or the patient directly.  However, reimbursement may be made to hospitals and included in kidney acquisition costs.   140.12 - Services Involved  (Rev. 1, 10- 01-03)  A3-3178.13, RDF -232
(Medicare Benefit Policy Manual)
140.12 - Services Involved  (Rev. 1, 10- 01-03)  A3-3178.13, RDF -232  When there is no suitable living donor, a patient with renal failure may be considered for a cadaveric transplant.  In such cases, the services provided to recipients of live donor kidneys (i.e., tissue typing and other related tests) are also provided to potential recipients of cadaver kidneys.  However, because a kidney may  not be available for a long period of time, additional services may be provided in the form of direct physician care for the patients renal condition, and certain tests may be performed on a regular basis to allow the physician to have current informatio n regarding the status of the patient and his or her suitability for transplant.  In addition, the number of mixed lymphocyte cultures which are prepared whenever a kidney is procured that may suit the recipient depends on the number of kidneys which becom e available for transplant.  The cost of registering a potential recipient with a kidney transplant registry is also covered, as well as the services furnished to maintain organ viability after excision, i.e., preservation, and transporting the kidney to t he place of transplantation.   140.13 - Tissue Typing Services for Cadaver Kidney  (Rev. 1, 10- 01-03)  A3-3178.14   Tissue typing services for cadaveric kidney recipients are treated in a similar manner to the way in which such services are covered and reimbursed in live donor cases.  Tissue typing of the cadaveric organ by the excising hospital becomes an organ acquisition cost that is included in the charges for organs, which are supplied by the hospital.  140.14 - Cadaver Excision Yielding Two Kidneys  (Rev . 1, 10- 01-03)  A3-3178.15   When two kidneys are obtained from a cadaver, and both kidneys are shipped to the same transplant hospital or organ procurement agency, the hospital should adjust its normal charges to reflect any increased perfusion, preservati on, and shipping costs due to the additional kidney.  On the other hand, when the kidneys are sent to separate organizations or transplant hospitals, the excising hospital should prorate its charges to the receiving organizations so that the total charges do not exceed the amount that would have been billed if one transplant hospital or agency had received both kidneys.
(Medicare Benefit Policy Manual)
140.15 - Provider Costs Related to Cadaver Kidney Excisions  (Rev. 1, 10- 01-03)  A3-3178.16   Typical provider costs involved in excising a cadaver kidney whether or not it is eventually transplanted include:    Intensive care costs;    Surgeons services -  anesthetist services, operating room, preservation supplies (perfusion materials and equipment), preservation technicians services, donor evaluation and support, pathology, central exchange costs (transportation and packaging), and administration costs (overhead items).  140.16 - Noncovered Transplant Related Items and Services  (Rev. 1, 10- 01-03)  A3-3178.17   The following list represents so me of the transplant related items and services which are not covered and for which no program payment can be made:     Travel, room, and board expenses incurred by a live donor;    Travel, room, and board expenses (to any transplant center) incurred by the recipient;    Reimbursement for the kidney itself when the live donor or the cadaver donors next of kin sells the kidney;    Transportation of the potential cadaveric donor to the transplant hospital (only transportation of the organ is reimbursable as part of t he organ procurement charge); or    Pronouncement of death and burial expenses for the cadaveric donor.   140.17 - Other Covered Services  (Rev. 1, 10- 01-03)  A3-3178.18   A.  Tissue Typing   Tissue typing of the recipient, as well as tissue typing and tests to determine the suitability of a living donor or a cadaveric kidney, are covered as medical expenses, necessary for the treatment of an eligible recipient.  The costs of these services are covered under the hospital insurance or medical insurance programs (P art B coverage after recipient has exhausted Part A), and are reflected in the kidney acquisition costs.  B.  Preservation Laboratories   The services performed by preservation laboratories are medically necessary for the treatment of a beneficiarys illness.  A participating hospital is reimbursed for the reasonable cost of such services which its own laboratory performs or which the hospital purchases from a freestanding preservation laboratory or organ procurement agency.   C.  Registration Fees
(Medicare Benefit Policy Manual)
C.  Registration Fees   A participating hospital which expects to perform a kidney transplant will be reimbursed for the reasonable cost incurred in listing the patient and the patients blood characteristics with a professionally recognized organization that maintains a registry of  potential transplant candidates, and which provides a regular listing of such patients to hospitals engaged in kidney procurement.   140.18 - Hospitals that Excise but Do Not Transplant Kidneys  (Rev. 1, 10- 01-03)  A3-3178.19, PR 1- 2772    The excising hospit al plays an important part in the national organ procurement effort.  Most of these hospitals are community hospitals and neither excise kidneys on a regular basis nor perform transplants.  A hospital that excises but does not transplant kidneys must be certified to participate in the Medicare program.  Where the hospital is not participating in the Medicare program, organs may be accepted from it only if they cannot be obtained from any other source.   A hospital that excises but does not transplant kidneys  may perform excisions on cadavers or on live donors; however, regardless of the vital status of the donor, most of the hospital services utilized in the excision are the same.      Transmittals Issued for this Chapter    Rev #  Issue Date  Subject  Impl Date  CR#  R257BP  03/01/2019 Update to Publication 100- 02 Provide Language -Only Changes for the New Medicare Card Project  04/01/2019  11170  R254BP  12/13/2018 Implementation of Changes in the End -Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2019
(Medicare Benefit Policy Manual)
01/07/2019  11021  R250BP  10/25/2018 Implementation of Changes in the End -Stage Renal Disease (ESRD) Prospective Payment System (PPS) and Payment for Dialysis Furnished for Acute Kidney Injury (AKI) in ESRD Facilities for Calendar Year (CY) 2019 01/07/2019  11021  R245BP  08/03/2018 System Changes to Implement Epoetin Alfa Biosimilar, Retacrit for End Stage Renal Disease (ESRD) and Acute Kidney Injury (AKI) Claim s 01/07/2019  10839  R244BP  07/20/2018 Internet Only Manual (IOM) Update to Publication 100- 02, Chapter 11 -  End Stage Renal Disease (ESRD), Section 100 10/23/2018  10809  R240BP  01/19/2018 Internet Only Manual (IOM) Update to Pub. 100-02, Chapter 11 -  End Stage Renal Disease (ESRD), Section 100 02/20/2018  10366  R224BP  06/03/2016 Update to Pub. 100- 02, Chapter 11 End- Stage Renal Disease (ESRD) for Calendar Year (CY) 2016  09/06/2016  9541 R219BP  01/13/2016 Calendar Year (CY) 2016 Eligibility Changes to the End- Stage Renal Disease (ESRD) Prospective Payment System (PPS) Low -Volume Payment Adjustment (LVPA)  01/22/2016  9478  R218BP  01/08/2016 Calendar Year (CY) 2016 Eligibility Changes to the End- Stage Renal Disease (ESRD) Prospective Payment System (PPS) Low -Volume Payment Adjustment (LVPA)  Rescinded and replaced by Transmittal 219 01/22/2016  9478 R200BP  12/02/2014 Implementation o f Changes in the End -Stage Renal Disease Prospective Payment System (ESRD PPS) for Calendar Year (CY) 2015  01/05/2015  8978 R199BP  11/14/2014 Implementation of Changes in the End -Stage Renal Disease Prospective Payment System (ESRD PPS) for Calendar Year (CY) 2015  Rescinded and replaced by Transmittal 200 01/05/2015  8978 R197BP  10/24/2014 Clarification of the End Stage Renal Disease (ESRD) Prospective Payment System
(Medicare Benefit Policy Manual)
Calendar Year (CY) 2015  Rescinded and replaced by Transmittal 200 01/05/2015  8978 R197BP  10/24/2014 Clarification of the End Stage Renal Disease (ESRD) Prospective Payment System (PPS) Low Volume Adjustment  01/05/2015  8898 R195BP  10/102014 Clarification of the End Stage Renal Disease (ESRD) Prospective Payment System (PPS) Low Volume Adjustment  Rescinded and replaced by Transmittal 197  01/12/2015  8898 R177BP  12/13/2013 Implementation of Changes in the End -Stage Renal Disease Prospective Payment System (ESRD PPS) for Calendar Year (CY) 2014  01/06/2014  8472 R174BP  11/29/2013 Implementation of Changes in the End -Stage Renal Disease Prospective Payment System (ESRD PPS) for Calendar Year (CY) 2014  Rescinded and replaced by Transmittal 177 01/06/2014  8472 R171BP  06/07/2013 Implementation of the End Stage Renal Disease (ESRD) Prospective Payment Sys tem (PPS)  09/09/2013  8261 R148BP  01/28/2011 Billing for Donor Post -Kidney Transplant Complication Services  04/02/2012  7523  R136BP  01/28/2011 Clarification of Existing Policy Regarding Items and Services Included Under End Stage Renal Disease (ESRD) Composite Payment Rate 02/25/ 2011  7312 R98BP  12/12/2008 Implementation of Changes in End Stage Renal Disease (ESRD) Payment for Calendar Year 2009  01/05/2009  6216 R83BP  02/15/2008 Clinical Lab: New Automated Test for the AMCC Panel Payment Algorithm 07/07/2008  5874 R67BP  03/09/2007 2007 Update to the End Stage Renal Disease Composite Payment Rates  04/02/2007  5535 R61BP  11/24/2006 Implementation of Changes in End Stage Renal Disease (ESRD) Payment for Calendar Year (CY) 2007  01/02/2007  5407 R50BP  06/02/2006 Immunosuppressive Therapy For Kidney Transplant  07/03/2006  4143 R44BP  02/10/2006 Update to the ESRD Composite Payment Rate 02/13/2006  4291
(Medicare Benefit Policy Manual)
R50BP  06/02/2006 Immunosuppressive Therapy For Kidney Transplant  07/03/2006  4143 R44BP  02/10/2006 Update to the ESRD Composite Payment Rate 02/13/2006  4291 R35BP  06/03/2005 Automated Multi- Channel Chemistry (AMCC) for Continuous Ambulatory Peritoneal Dialysis (CAPD) and Non -CAPD Patients  07/05/2005  3802 R27BP  11/23/2004 New ESRD Composite Payment Rates Effective January 1, 2005 01/03/2005  3554 R08BP  03/05/2004 Policy Changes to Reflect Billing for Darbepoetin Alfa and Epoetin  04/05/2004  2984 R07BP  02/20/2004 Restoring Composite Rate Exceptions for Pediatric Facilities Under the ESRD Composite Rate System  04/01/2004  3119 R01BP  10/01/2003 Introduction to the Benefit Policy Manual  N/A N/A Back to top of Chapter
Article - Billing and Coding: Lab: Coenzyme Q10 (CoQ10) (A55709)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e). Prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.0 Requirements for Diagnostic X-ray, Diagnostic Laboratory, and Other Diagnostic Tests, 80.1.1 Certification Changes, 80.1.2 A/B MAC (B) Contacts with Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Coenzyme Q10 (CoQ10) L37022.Coenzyme Q10 (CoQ10 or Q10) supplementation is purported to prolong life and prevent age-related functional declines; inhibit the development and/or progression of atherosclerosis; have value as an adjunct to conventional medical therapy in the treatment of congestive heart failure, conventional angina therapy, and cancer; provide protection against myocardial damage during ischemia-reperfusion during cardiac surgery; provide benefit in the treatment of hypertension, CV disease and diabetes; play a role in neurodegenerative diseases such as Parkinsons disease, Huntingtons disease and Friedreichs ataxia; enhance athletic performance and enhance fertility. As such, serum or other body fluid testing for Q10 levels has been advocated. However, the scientific evidence to support coverage for Q10 testing for any purpose is controversial and/or limited for all diseases. Consequently, Q10 testing is not reasonable and necessary (LCD L37022), and claims for testing will be denied.To receive a Q10 service denial, please submit the following claim information:CPTcode 82542For a voluntary issued Advanced Beneficiary Notice (ABN), append with GX modifier
Article - Lymphedema Decongestive Treatment (A55710)
CMS National Coverage PolicyN/AArticle TextWe are providing clarification of coverage and documentation requirements for lymphedema decongestive treatment based on Noridian medical review findings. The two basic types of decongestive treatment are: Manual Lymphatic Drainage (MLD) which stimulates the movement of fluids in the tissues using gentle massage and; Comprehensive Decongestive Therapy (CDT) which is a combination of MLD, bandaging, skin care and exercises.Coverage RequirementsMedicare will reimburse for necessary components of decongestive treatment when the medical record supportsA diagnosis of lymphedema (not tissue edema due to other etiologies e.g., chronic venous insufficiency, congestive heart failure, acute infection).Recent changes in the patients conditionPrior unsuccessful therapies (e.g., elevation, bandaging, diuresis) reported to justify the need for skilled services.Services were provided by a qualified clinician (i.e., physician, non-physician practitioner (NPP), qualified therapist, or appropriately supervised therapist assistant).Services must be under accepted standards of medical practice and considered to be specific and effective treatment for the patients condition.Limitations
Article - Lymphedema Decongestive Treatment (A55710)
LimitationsThe goal of therapy is not to achieve maximum volume reduction but to ultimately transfer the responsibility for the care from the provider to the patient and/or caregiver, generally within a 1-3 week time period. There is only temporary benefit from the treatment unless the patient and/or caregiver are able to complete treatments at home on an ongoing basis. The end of treatment is not when the edema resolves or stabilizes but when the patient and/or caregiver are able to continue the treatments at home.Skilled Level of CareThe key issue is whether the skills of a therapist are needed, or whether the services can be carried out by the patient and/or caregiver after sufficient training. The medical record must clearly indicate the patients condition before, during, and after the therapy episode to support that the patient significantly benefitted from ongoing therapy services and that the progress was sustainable and of practical value when measured against the patients condition at the start of treatment. Documentation should indicate clear objective evidence of improvement generally within the first week or 10 days of therapy (e.g., changes in weight, extremity circumference).Maintenance Level of CareWhen it is reasonable to assume that ongoing services could reasonably be carried out by the patient and/or appropriately trained caregiver(s), then the services are considered to be at a maintenance level of care and no longer require the skills of a qualified clinician. It is the patient's responsibility to acquire caregiver assistance for carrying out the of the home maintenance program when necessary. Generally, it is anticipated that an efficient home maintenance program will be effective for a lifetime. However, in the rare instance, when additional treatment for the same condition is necessary, then the documentation must support reasonableness and medical necessity for the additional services. For additional information, see the Noridian article titled "Medical Necessity of Therapy Services".Coding Considerations
Article - Lymphedema Decongestive Treatment (A55710)
Medically necessary hands-on MLD is a covered Medicare service and is coded using CPT 97140 for manual therapy.There is no Medicare coverage for lymphedema compression bandage application as this is considered to be an unskilled service. This non-coverage extends to the application of high compression, multi-layered, sustained bandage systems (e.g., Profore, Dynaflex, Supress, coded with CPT 29581 or 29584.Minutes spent applying compression bandaging without patient/caregiver education should not be billed as skilled therapy services.However, Medicare will cover a brief period (e.g. three or fewer sessions if no new specific issues are identified), of patient/caregiver instruction in compression bandaging home management. Medical necessity for this education must be clearly documented and meet the code descriptor requirements for CPT 97535.Note that high compression bandage application used for treatment of wounds may be appropriately coded with CPT 29581 or 29584. However, these codes should not be billed for unskilled lymphedema compression bandage application. For additional information, see the Noridian article titled "High Compression Bandage System Clarification."Sources:Federal Register (FR), Volume 76, Number 228, Part III, Section C-5Internet Only Manual (IOM)Medicare National Coverage Determinations Manual,Publication 100-03, Chapter 1, Part 4, Sections 270.5, 280.1, 280.6IOMMedicare Benefit Policy Manual,Publication 100-02, Chapter 15, Sections 220-230IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 5, Section 20(B)Current Procedural Terminology Coding ManualSocial Security Act (SSA), Title 18, Section 1862(a)(1)(A)
Article - Billing and Coding: MolDX: Abbott RealTime IDH1 and IDH2 testing for Acute Myeloid Leukemia (AML) (A55711)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle Text
Article - Billing and Coding: MolDX: Abbott RealTime IDH1 and IDH2 testing for Acute Myeloid Leukemia (AML) (A55711)
Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.TheAbbott RealTimeIDH1by Abbott Molecular is the only test that has received FDA approval to be used as an aid in identifying acute myeloid leukemia (AML) patients with an isocitrate dehydrogenase-1 (IDH1)mutation for treatment with TIBSOVO(ivosidenib).TIBSOVOis an isocitrate dehydrogenase-1 (IDH1) inhibitor indicated for the treatment of adult patients with relapsed or refractory acute myeloid leukemia (AML) with a susceptible IDH1 mutation as detected by an FDA-approved test.Abbott RealTime IDH1by Abbott Molecular meets the reasonable and necessary criteria for Medicare reimbursement, effective 7/20/2018.TheAbbott RealTimeIDH2by Abbott Molecular is the only test thathas received FDA approval to be used as an aid in identifying acute myeloid leukemia (AML) patients with an isocitrate dehydrogenase-2 mutation for treatment with enasidenib (IDHIFA).IDHIFA is an isocitrate dehydrogenase-2 inhibitor indicated for the treatment of adult patients with relapsed or refractory acute myeloid leukemia (AML) with an isocitrate dehydrogenase-2 (IDH2) mutation as detected by an FDA-approved test.Abbott RealTime IDH2by Abbott Molecular meets the reasonable and necessary criteria for Medicare reimbursement, effective 8/1/2017.To report anAbbott RealTime IDH1service, please submit the following claim information:Select the CPT 81120 for claims on or after 7/20/2018.To report anAbbott RealTime IDH2service, please submit the following claim information:Select the CPT code 81121 for claims on or after 1/1/2018.Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claim
Article - Billing and Coding: MolDX: Abbott RealTime IDH1 and IDH2 testing for Acute Myeloid Leukemia (AML) (A55711)
Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM codeNote:This MolDX coverage determination and coding guideline ONLY applies to the UNMODIFIED, IDH2 test kit by Abbott Molecular for patients with acute myeloid leukemia. If a lab modifies these tests, a MolDX Technical Assessment, outlined in the MolDx section onwww.PalmettoGBA.com/medicare, must be submitted and a determination assessed prior to claims submission.This article reflects the FDA-approved indications on article creation date. MolDX will allow future FDA approved and amended indications for these tests.