evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Sentinel Lymph Node Biopsy – Medical Policy Article (A52437)
Advance Beneficiary Notice of Noncoverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary, and theydo havean ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections1862(a)(1), 1862(a)(9), 1879(e), or 1879(g)of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisionsotherthan medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, FI and Part A MAC systems will automatically deny the services.The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and theyhave nothad an ABN signed by the beneficiary.
Article - Billing and Coding: Sentinel Lymph Node Biopsy – Medical Policy Article (A52437)
If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.For claims submitted to the Part B MAC:Claims for sentinel lymph node biopsy services are payable under Medicare Part B in the following places of service:CPT codes 38500, 38510, 38525 and 38530 are payable in the following places of service: inpatient hospital (21), outpatient hospital (22) and ambulatory surgical center (24).CPT codes 38792, 38900 and 78195 (26) are payable in the following places of service: office (11), inpatient hospital (21), outpatient hospital (22), ambulatory surgical center (24) and independent clinic (49).CPT code 78195 (global/TC) is payable in the office (11) and independent clinic (49).Lymphoscintigraphy should be coded as CPT code 78195 and reported separately when performed prior to the surgical procedure. The injection of the radioactive tracer, when performed by the same provider, is included in the CPT code 78195 and should not be billed separately.CPT code 38792 can be billed for both the injection of radioactive tracer when performed without lymphoscintigraphy; and for the injection of vital dye (Isosulfan Blue Dye or a similar product) to visualize the sentinel node, by the surgeon/physician who performs the injection.The NOS for CPT code 38792 may only be reported with units of one (001), for each use, regardless of the number of injections for each substance.If one physician is billing for the injection of the tracer and the injection of the dye, CPT code 38792 should be billed on 2 lines of coding, using modifier 59 on the second line.Scintigraphy performed intraoperatively using a hand-held device is not separately reimbursable, and is included in the fee for the surgical procedure.
Article - Billing and Coding: Sentinel Lymph Node Biopsy – Medical Policy Article (A52437)
Scintigraphy performed intraoperatively using a hand-held device is not separately reimbursable, and is included in the fee for the surgical procedure.If the sentinel node is not identified at the time of surgery or is found to be positive for metastatic carcinoma, and additional lymphadenectomy is performed, then the CPT codes appropriate for the location and extent of lymphadenectomy should be used. The injection and scintigraphy codes may still be billed, regardless of the results.For claims submitted to the Part A MAC:HOSPITAL INPATIENT CLAIMS:The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04.The principal diagnosis is the condition established after study to be chiefly responsible for this admission.The hospital enters ICD-10-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-08,Medicare Program Integrity Manual,Chapter 25, Section 75 for additional instructions.)HOSPITAL OUTPATIENT CLAIMSThe hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67.If no definitive diagnosis is made during the outpatient evaluation, the patients symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the providershould report an ICD-10-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9).The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.When lymphoscintigraphy is performed in the radiology department prior to surgery to locate the sentinel node(s), lymphoscintigraphy procedures should be coded and reported separately as a radiology procedure under the appropriate revenue code.
Article - Billing and Coding: Sentinel Lymph Node Biopsy – Medical Policy Article (A52437)
When injection of radioactive tracer is performed without lymphoscintigraphy, CPT code 38792 should be used for the injection procedure under the appropriate revenue code.The injection of the radioactive tracer should be billed with units or number of services (NOS) of 001 regardless of the number of injections around the lesion.When performed in the operating room, the injection of vital dye (Isosulfan Blue Dye or a similar product) to visualize the sentinel node is not reported as a separate operative procedure.Scintigraphy performed intraoperatively using a hand-held device is not separately billable.If the sentinel node is not identified at the time of surgery or is found to be positive for metastatic carcinoma, and additional lymphadenectomy is performed, then the CPT codes appropriate for the location and extent of lymphadenectomy should be used.If the surgery necessitating the lymphoscintigraphy is limited to inpatients only, then it is anticipated that the lymphoscintigraphy and related radiopharmaceutical will be either provided during the inpatient stay or bundled into the inpatient DRG payment.The radiopharmaceutical tracer is billed as a drug with a revenue code appropriate to the place of administration. Radiopharmaceuticals commonly used for lymphoscintigraphy:A9541 - Technetium Tc-99m Sulfur Colloid, Diagnostic, per study dose, up to 20 mCi'sA4641 - TechnetiumTc-99m Human Serum AlbuminVital Dye is billed as part of the surgical supplies. In the case of inpatient claims it is bundled into the DRG payment. In the case of outpatient claims it is part of the APC payment for the specific surgery.
Article - Billing and Coding: Tetanus Immunization (A52438)
CMS National Coverage PolicyN/AArticle TextAbstractTetanus is a neurologic syndrome caused by a neurotoxin elaborated at the site of injury by Clostridium tetani. Nearly all cases of tetanus occur in nonimmunized or inadequately immunized individuals. Available evidence indicates that complete primary vaccination with tetanus toxoid provides long-lasting protection; 10 years for most recipients. To maintain adequate protection a booster dose every 10 years is recommended. Consequently, after complete primary tetanus vaccination, boosters, even for wound management, need to be given only every 10 years when wounds are minor and uncontaminated. For other wounds, a booster is appropriate if the patient has not received tetanus toxoid within the preceding five years. (MMWR 40: No. RR-10, 1991) Immunizations are generally excluded from coverage under Medicare unless they are directly related to the treatment of an injury or direct exposure to a disease or condition. In the absence of injury or direct exposure, preventive immunization is not covered. This medical policy coverage article documents CGS coverage and coding guidelines for the administration of tetanus toxoids.Indications:One booster injection of tetanus toxoids is covered in a patient who has had primary immunization, has sustained a high-risk wound (a wound which affords anaerobic conditions or which has been incurred in a circumstance with probability of exposure to tetanus spores), and has not received the booster within the last 5 years.(MMWR Aug 8, 1991/40(RR10:1-28)These injections are also covered when given for an acute injury (clean, minor injury or high-risk wound) when a patient has not received primary immunization or the primary immunization status is not known, and the patient has sustained a high-risk wound. Patients with unknown or uncertain previous immunization histories should be considered to have no previous tetanus toxoid doses. For inadequately vaccinated patients of all ages, completion of primary vaccination at the time of discharge or at follow-up visits should be ensured. (MMWR 40: No. RR-10, 1991)Limitations:
Article - Billing and Coding: Tetanus Immunization (A52438)
Limitations:When a tetanus booster is given to a patient in the absence of an injury/potential exposure, the injection does not meet the coverage criteria for Medicare (even though it may be appropriate preventative treatment). Preventative services should not be billed to Medicare.If a medication is determined not to be reasonable and necessary for diagnosis or treatment of an illness or injury, the entire charge will be excluded (i.e., for both the drug and its administration). Also excluded from payment is any charge for other services (such as office visits) which are primarily for the purpose of administering a noncovered injection (i.e., an injection that is not reasonable and necessary for the diagnosis or treatment of an illness or injury).Coding Guidelines:General Guidelines for claims submitted to Part A or Part B MAC: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 ICD-10-CM 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.Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines (for outpatient services):An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 30, revised 09/05/2008, for complete instructions.Services not meeting medical necessity guidelines should be billed with modifier -GA or -GZ as appropriate.
Article - Billing and Coding: Tetanus Immunization (A52438)
Services not meeting medical necessity guidelines should be billed with modifier -GA or -GZ as appropriate.The GA modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a specific service as not reasonable and necessary and theydo havean ABN signed by the beneficiary on file. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and theyhave nothad an ABN signed by the beneficiary.If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier.For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same day.Claims for CPT codes 90702, 90714, J1670 are payable under Medicare Part B in the following places of service: office (11), urgent care facility (20) , nursing facility (32), and independent clinic (49).For claims submitted to the Part A MAC:Hospital Inpatient Claims:The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04.The principal diagnosis is the condition established after study to be chiefly responsible for this admission.The hospital enters ICD-10-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.)
Article - Billing and Coding: Tetanus Immunization (A52438)
For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.)Hospital Outpatient Claims:The hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67.If no definitive diagnosis is made during the outpatient evaluation, the patients symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the providershould report an ICD-10-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9).The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.
Article - Laparoscopic Sleeve Gastrectomy (LSG) – Medical Policy Article (A52447)
CMS National Coverage PolicyN/AArticle TextAbstract:The sleeve gastrectomy (SG) involves excision of the lateral aspect of the stomach, leaving a much reduced, lesser-curve based, tubular stomach (Hutter, 2011). When this procedure is performed laparoscopically the term laparoscopic sleeve gastrectomy (LSG) is used. Presently, LSG is commonly used as a stand-alone approach to bariatric surgery; however, initially, the procedure served to reduce gastric capacity and initiate short-term weight loss while the malabsorptive component of the operation (biliopancreatic diversion) provided the long-term weight loss (Brethauer, 2011). A stand-alone sleeve gastrectomy is sometimes referred to as an isolated sleeve gastrectomy. A laparoscopic approach to sleeve gastrectomy was later developed. There are variations in the detail of the sleeve gastrectomy procedure itself. Although LSG has been gaining popularity over the last few years and the number of bariatric surgery units that offer it is increasing, there is not yet a standard technique for this procedure (Ferrer-Mrquez, 2012).Obesity, defined as a body mass index (BMI)  30 kg/m2, is recognized as an important risk factor for morbidity and mortality associated with a number of chronic diseases such as heart disease and diabetes (Flegal, 2010). The Centers for Disease Control and Prevention (CDC) reported that obesity rates in the U.S. have increased dramatically over the last 30 years, and obesity is now epidemic in the United States (Kahn, 2009). For adults 60 years and older, the prevalence of obesity is about 37% among men and 34% among women (NHANES - National Health and Nutrition Examination Survey). Obesity may be further classified according to the National Institutes of Health (NIH):Class I Obesity = BMI 30.0-34.9 kg/mClass II Obesity = BMI 35.0-39.9 kg/mClass III (Extreme) Obesity = BMI  40.0 kg/mIndications and Limitations:National Government Services, Inc. will cover stand-alone laparoscopic sleeve gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions A-C are satisfied.
Article - Laparoscopic Sleeve Gastrectomy (LSG) – Medical Policy Article (A52447)
A. The beneficiary has a body-mass index (BMI)  35 kg/m2,B.The beneficiary has at least one co-morbidity related to obesity, andC. The beneficiary has been previously unsuccessful with medical treatment for obesity.Documentation of outcomes for all bariatric procedures is required for the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accredited hospitals.Coding Information: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 ICD-10-CM 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.Claims must include three (primary, secondary and tertiary) ICD-10-CM codes as indicated below:The primary ICD-10-CM code of E66.01 for morbid obesity;A secondary ICD-10-CM code Z68.35, Z68.36, Z68.37, Z68.38, Z68.39, Z68.41, Z68.42, Z68.43 Z68.44, Z68.45 describing a body mass index; andA tertiary ICD-10-CM code describing the co-morbid condition.For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.CMS has determined the evidence is sufficient to conclude that continuing the requirement for certification for bariatric surgery facilities would not improve health outcomes for Medicare beneficiaries.For claims submitted to the Part A MAC:For inpatient hospital claims, ICD-10-CM procedure code 0DB64Z3 should be reported when conditions A-C (specified above in the Indications and Limitations section) are satisfiedCMS National Coverage Policy:Title XVIII of the Social Security Act (SSA):
Article - Laparoscopic Sleeve Gastrectomy (LSG) – Medical Policy Article (A52447)
CMS National Coverage Policy:Title XVIII of the Social Security Act (SSA):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.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Publications:CMS Transmittal 158, Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Change Request 8484, December 23, 2013 and CMS Transmittal 2841, Publication 100-04,Medicare Claims Processing Manual,Change Request 8484, December 23, 2013 advises effective for dates of service on and after September 24, 2013, facility certification shall no longer be required for coverage of covered bariatric surgery procedures.CMS Transmittal 157, Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Change Request 8484, November 15, 2013 and CMS Transmittal, Publication 100-04,Medicare Claims Processing Manual,Change Request 8484, November 15, 2013 advises effective for dates of service on and after September 24, 2013, facility certification shall no longer be required for coverage of covered bariatric surgery procedures.CMS Transmittal No. 2590, Publication 100-04,Medicare Claims Processing Manual,Change Request #8028, November 9, 2012 advises that effective for claims with dates on or after June 27, 2012, Medicare Administrative Contractors (MACs) acting within their respective jurisdictions may determine coverage of stand-alone laparoscopic sleeve gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only when all three of the conditions are satisfied.Sources of Information:This bibliography presents those sources that were obtained during the development of this article. National Government Services is not responsible for the continuing viability of Web site addresses listed below.Brethauer SA. Sleeve gastrectomy.Surg Clin North Am.2011;91(6):1265-1279.Decision Memo for Bariatric Surgery for the Treatment of Morbid Obesity (CAG-00250R2.)
Article - Laparoscopic Sleeve Gastrectomy (LSG) – Medical Policy Article (A52447)
Decision Memo for Bariatric Surgery for the Treatment of Morbid Obesity (CAG-00250R2.)Ferrer-Marquez M, Belda-Lozano R, Ferrer-Ayza M. Technical controversies in laparoscopic sleeve gastrectomy.Obes Surg.2012;22(1):182-187.Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008.JAMA.2010;303:235-421.Hutter MM, Schirmer BD, Jones DB, et al. First report from the American College of Surgeons Bariatric Surgery Center Network: laparoscopic sleeve gastrectomy has morbidity and effectiveness positioned between the band and the bypass.Ann Surg.2011;254:410-420.