evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Treatment of Males with Low Testosterone (A57616)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made for items or services that 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 the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.42 Code of Federal Regulations (CFR) 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.CMSInternet Online Manual Pub. 100-02(Medicare Benefit Policy Manual), Chapter 15, Section 80, Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic TestsCMS Internet-Only Manuals, Publication 100-04,Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.12 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet Online Manual Pub. 100-04 (Medicare Claims Processing Manual), Chapter 23 (Section 10) Reporting ICD Diagnosis and Procedure Codes.CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 12, 30-Correct Coding PolicyArticle TextThe following coding and billing guidance is to be used with its associated Local coverage determination.
Article - Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A57618)
CMS National Coverage PolicyInternet-Only Manuals (IOMs):CMS IOM Publication, 100-04,Medicare Claims Processing Manual,Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)National Correct Coding Initiative (NCCI):Medicare NCCI Policy Manual,Chapter 8, Section D. OphthalmologySocial 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.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35004 Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Effective October 1, 2017, The Center for Medicare & Medicaid Services (CMS) revised policy may allow payment to be made for a medically necessary upper eyelid blepharoptosis when performed with (noncovered) cosmetic blepharoplasty on the same eye during the same visit.For correct coding guidelines and specific applicable code combinations prior to billing Medicare, refer to the Medicare NCCI Policy Manual, Chapter 8, Section D. Ophthalmology.Correct coding dictates that removal of malignant and benign lesions requires a different set of codes than the codes listed in this article.Removal of malignant lesions should be reported with CPT codes 11640-11646.Removal of benign lesions should be reported with CPT codes 11440-11446, 67840 or 67850.Mohs surgery should be reported with CPT codes 17311-17315.Documentation Requirements
Article - Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A57618)
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.The submitted medical recordmust includeresults of pertinent diagnostic tests and operative reportsas appropriate,documentation to support the medical necessity of blepharoptosis repair, brow ptosis repair, and blepharoplasty procedures:Clinical notes, supporting a decrease in visual field (peripheral vision and/or upper field vision) demonstrating a 12 to 15 degree superior loss or 24% to 30% superior visual field impairment, near or far visual impairment, or difficulty reading.Patient complaints and physical findings, for example:Interference with vision or visual field, related to activities such as, difficulty reading due to upper eyelid drooping, looking through the eyelashes, seeing the upper eyelid skin, or brow fatigue.Chronic eyelid dermatitis due to redundant eyelid skin.Lower eyelid ectropion resulting in eye irritation and inflammation and excessive tearing.Entropion where the eyelashes are contacting the cornea resulting in discomfort, redness, tearing, and foreign body sensation.Difficulty wearing prosthesis.Margin reflex distance (MRD1) of 2 mm or less.A palpebral fissure height on down-gaze of 1 mm or less, (measured with the patient fixating on an object in downgaze with the ipsilateral brow relaxed and the contralateral lid elevated).The presence of Herings Law meeting one of the above criteria in bullets 3 or 4. Herings Law of equal innervation to both upper eyelids may be considered in the documentation to perform bilateral ptosis repair in which the position of one upper eyelid has marginal criteria and the other eyelid had good supportive documentation for ptosis surgery.Visual field testing demonstrating a 12 to 15 degree superior field loss or 24% to 30% superior visual field impairment.
Article - Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A57618)
Preoperative photographs in the form of prints or slides are required to be submitted with the medical record to support medical necessity of blepharoptosis repair, brow ptosis repair and blepharoplasty procedures if the record is not sufficient to determine medical necessity. If photographs are requested to support the documentation, photograph guidelines that support medical necessity include:The photographs must be frontal view, canthus to canthus with the head perpendicular to the plane of the camera (not tilted) to demonstrate a skin rash or position of the true lid margin or the pseudo-lid margin.For CPT codes 15820-15823 or 67901-67908: If redundant skin coexists with true lid ptosis, additional photos taken with the upper lid skin retracted to show the actual position of the true lid margin are supportive of medical necessity.Oblique photos are only needed to demonstrate redundant skin on the upper eyelashes when this is the only indication for surgery.Separate from the photographs, documentation in the medical record of the indicated distance thresholds (e.g., 2 mm or less from the central corneal reflex to the upper eyelid margin or skin that overhangs the eyelid margin [pseudoptosis]) is helpful to demonstrate medical necessity.NOTE:If both a blepharoplasty and a blepharoptosis repair are planned, both must be individually documented. The medical necessity criteria for each procedure must be met and the additional required testing criteria demonstrate visual impairment that cannot be addressed by one procedure alone. This may require two sets of photographs showing the effect of drooping of redundant skin (drooping of brows and its correction by taping), and the actual presence of blepharoptosis with drooping of the upper eyelid.
Article - Billing and Coding: MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) (A57619)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual Publication 100-04 Medicare Claims Processing Manual, Chapter 23 Section 10 "Reporting ICD Diagnosis and Procedure Codes"Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Oncotype DXBreast Cancer for DCIS (Genomic Health)To report an Oncotype DXBreast Cancer for DCISservice, please submit the following claim information:Select PLA code 0045UEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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 claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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 code
Article - Billing and Coding: MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) (A57620)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual Publication 100-04 Medicare Claims Processing Manual, Chapter 23 Section 10 "Reporting ICD Diagnosis and Procedure Codes"Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Oncotype DX Breast Cancer for DCIS (Genomic Health)To report an Oncotype DXBreast Cancer for DCISservice, please submit the following claim information:Select PLA code 0045UEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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 claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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 code
Article - Billing and Coding: MolDX: DecisionDx-UM (Uveal Melanoma) (A57621)
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 Laboratories.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure Codes.Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) MolDX: DecisionDx-UM (Uveal Melanoma) L37070.To report a DecisionDx-UM (Uveal Melanoma) service, please submit the following claim information:Select CPT code 81552Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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 claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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 code
Article - Billing and Coding: MolDX: DecisionDx-UM (Uveal Melanoma) (A57622)
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 Laboratories.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure Codes.Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) MolDX: DecisionDx-UM (Uveal Melanoma) L37072.To report a DecisionDx-UM (Uveal Melanoma) service, please submit the following claim information:SelectCPTcode 81552Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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 claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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 code
Article - Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (A57630)
CMS National Coverage PolicyTitle 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 Publication 100-04;Medicare Claims Processing Manual, Chapter 13:80 Supervision and Interpretation (S & I) Codes and Interventional RadiologyCMS Transmittal No. 423, Publication 100-04,Medicare Claims Processing Manual, Change Request #3632, January 6, 2005. Update of the Hospital Outpatient Prospective Payment, includes Kyphoplasty.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD L38213 Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF).Coding GuidelinesNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Article - Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (A57630)
Percutaneous vertebral augmentation including cavity creation using mechanical device of one vertebral body must be reported with CPT codes 22513 (thoracic), 22514 (lumbar) and 22515 (each additional thoracic or lumbar vertebral body [list separately in addition to code for the primary procedure]).Modifiers 50, LT/RT are not required for CPT codes 22510, 22511, 22512, 22513, 22514, and 22515. The CPT descriptor is per vertebral body, unilateral or bilateral.Standard payment adjustment rules for multiple procedures will apply if performed at more than one level on the same date of service.Bone biopsy (CPT code 20225, 20250 or 20251) is considered integral to both percutaneous vertebroplasty and percutaneous vertebral augmentation procedures and should not be billed separately unless the biopsy is at a different site or performed during a different session.If bone biopsy is performed on a separate site, modifier 59 or modifier XS  Separate Structure, must be reported with the CPT code submitted and documentation must clearly support a separate and distinct procedure from the procedure performed. Identify the site (example: L1) in the item 19 of the CMS 1500 form or its electronic equivalent.Payment of vertebroplasty and vertebral augmentation will be all-inclusive for the entire procedure (i.e. injection, intraosseous venography, etc.).No separate payment for venography performed during the operative session may be allowed and it should not be separately billed.The assistant at surgery" Medicare Physician Fee Schedule Database indicator for percutaneous vertebroplasty and percutaneous vertebral augmentation (kyphoplasty) procedures is "1." Therefore, a statutory payment restriction for assistants at surgery applies to this procedure and an assistant at surgery may not be paid.The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in the associate LCD.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
Article - Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (A57630)
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.It is the providers responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.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.An Advance Beneficiary Notice of Non-coverage (ABN) may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.
Article - Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF) (A57630)
Specific Coding Guidelines:No separate payment for venography performed during the operative session may be allowed and it should not be separately billed.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD L38213. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, specific signs, symptoms of diagnosis, other non-invasive corrective medical treatment previously provided/failed, results of pertinent diagnostic tests or procedures and support the use of x-ray guidance, either fluoroscopy or CT scan in all settings, including an office setting. This information must be available to the contractor upon request.
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