evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A57385)
Major depressive disorder, recurrent, moderateMDDF33.2Major depressive disorder, recurrent severe without psychotic featuresMDDF33.3Major depressive disorder, recurrent, severe with psychotic symptomsMDDF33.41Major depressive disorder, recurrent, in partial remissionNeuropsychiatricF20.0Paranoid schizophreniaNeuropsychiatricF20.1Disorganized schizophreniaNeuropsychiatricF20.2Catatonic schizophreniaNeuropsychiatricF20.3Undifferentiated schizophreniaNeuropsychiatricF20.5Residual schizophreniaNeuropsychiatricF20.81Schizophreniform disorderNeuropsychiatricF20.89Other schizophreniaNeuropsychiatricF31.0Bipolar disorder, current episode hypomanicNeuropsychiatricF31.11Bipolar disorder, current episode manic without psychotic features, mildNeuropsychiatricF31.12Bipolar disorder, current episode manic without psychotic features, moderateNeuropsychiatricF31.13Bipolar disorder, current episode manic without psychotic features, severeNeuropsychiatricF31.2Bipolar disorder, current episode manic severe with psychotic featuresNeuropsychiatricF31.31Bipolar disorder, current episode depressed, mildNeuropsychiatricF31.32Bipolar disorder, current episode depressed, moderateNeuropsychiatricF31.4Bipolar disorder, current episode depressed, severe, without psychotic featuresNeuropsychiatricF31.5Bipolar disorder, current episode depressed, severe, with psychotic featuresNeuropsychiatricF31.61Bipolar disorder, current episode mixed, mildNeuropsychiatricF31.62Bipolar disorder, current episode mixed, moderateNeuropsychiatricF31.63Bipolar disorder, current episode mixed, severe, without psychotic featuresNeuropsychiatricF31.64Bipolar disorder, current episode mixed, severe, with psychotic featuresNeuropsychiatricF31.71Bipolar disorder, in partial remission, most recent episode hypomanicNeuropsychiatricF31.73Bipolar disorder, in partial remission, most recent episode manicNeuropsychiatricF31.75Bipolar disorder, in partial remission, most recent episode depressedNeuropsychiatricF31.77Bipolar disorder, in partial remission, most recent episode mixedNeuropsychiatric
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A57385)
NeuropsychiatricF31.75Bipolar disorder, in partial remission, most recent episode depressedNeuropsychiatricF31.77Bipolar disorder, in partial remission, most recent episode mixedNeuropsychiatricF40.11Social phobia, generalizedNeuropsychiatricF41.0Panic disorder [episodic paroxysmal anxiety]NeuropsychiatricF41.1Generalized anxiety disorderNeuropsychiatricF41.3Other mixed anxiety disordersNeuropsychiatricF41.8Other specified anxiety disordersNeuropsychiatricF43.11Post-traumatic stress disorder, acuteNeuropsychiatricF43.12Post-traumatic stress disorder, chronicNeuropsychiatricF60.5Obsessive-compulsive personality disorderNeuropsychiatricF90.0Attention-deficit hyperactivity disorder, predominantly inattentive typeNeuropsychiatricF90.1Attention-deficit hyperactivity disorder, predominantly hyperactive typeNeuropsychiatricF90.2Attention-deficit hyperactivity disorder, combined typeNeuropsychiatricF90.8Attention-deficit hyperactivity disorder, other type
Article - Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment (A57386)
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 claimCMS 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 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 MolDX: Biomarkers in Cardiovascular Risk AssessmentL36139.
Article - Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (A57414)
CMS National Coverage PolicySocial 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) L35350, Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic). 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.Documentation RequirementsAll documentation must be maintained in the patients 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.
Article - Billing and Coding: MolDX: Envisia™, Veracyte™, Idiopathic Pulmonary Fibrosis Diagnostic Test (A57419)
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, 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, 60.1.2 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 following coding and billing guidance is to be used with its associated Local coverage determination.To report anEnvisia Genomic Classifier service, please submit the following claim information:Select CPT codeEnter 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: Envisia™, Veracyte™, Idiopathic Pulmonary Fibrosis Diagnostic Test (A57420)
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, 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, 60.1.2 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 following coding and billing guidance is to be used with its associated Local coverage determination.To report anEnvisia Genomic Classifierservice, please submit the following claim information:Select CPTcodeEnter 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: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease (A57421)
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 100-04,Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual, Publication 100-04 Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure Codes.CMS Internet-Only Manual, Publication 100-04 Medicare Claims Processing Manual, Chapter 12, 30 Correct Coding Policy.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease L36180. For single genes performed by NGS, these tests must demonstrate compliance with L38123 MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies and its accompanying billing and coding article, A55624 Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Next-Generation Sequencing Testing in Cancer.To report Genetic Testing for BCR-ABL Negative Myeloproliferative Disease service, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier 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 codeNOTE:When entering the DEX Z- Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease (A57422)
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 100-04,Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual, Publication 100-04 Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure Codes.CMS Internet-Only Manual, Publication 100-04 Medicare Claims Processing Manual, Chapter 12, 30 Correct Coding Policy.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease L36186. For single genes performed by NGS, these tests must demonstrate compliance with L38125 MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies and its accompanying billing and coding article, A56518 Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Next-Generation Sequencing Testing in Cancer.To report Genetic Testing for BCR-ABL Negative Myeloproliferative Disease service, please submit the following claim information:Select appropriate CPTcodeEnter 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 codeNOTE:When entering the DEX Z- Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) (A57423)
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 Manuals, 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 following coding and billing guidance is to be used with its associated Local coverage determination.To report a Genetic Testing for Hypercoagulability/Thrombophilia service, please submit the following claim information:Select appropriate CPT codeEnter 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 SV010-7 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
Article - Billing and Coding: MolDX: Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) (A57424)
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, 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 CodesArticle TextThe following coding and billing guidance is to be used with its associated Local coverage determination.To report a Genetic Testing for Hypercoagulability / Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) service, please submit the following claim information:Select appropriate CPTcodeEnter 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: Transrectal Ultrasound (A57427)
CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: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 Publication 100-03,Medicare National Coverage Determinations Manual (NCD) Manual,Chapter 1:220.5 Ultrasound Diagnostic ProceduresCMS Publication 100-04,Medicare Claims Processing Manual,Chapter 9:100 General Billing RequirementsCMS Publication 100-04,Medicare Claims Processing Manual,Chapter 12:70 Payment Conditions for Radiology ServicesArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD)for Transrectal Ultrasound.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. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Documentation Requirements:
Article - Billing and Coding: Transrectal Ultrasound (A57427)
The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Documentation must be available to Medicare upon request.Utilization Guidelines:CPT code 76872 will be covered only 2 (two) times in a year. Services exceeding this parameter will be considered not medically necessary.
Article - Billing and Coding: Total Joint Arthroplasty (A57428)
CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be 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.Code of Federal Regulations:Title 21 CFR, Chapter 1, Subchapter H, Part 888 orthopedic devices, arthroscope.Title 42 CFR 482.24 documentation for medical records.IOM:CMS Publication 100-08,Medicare Program Integrity Manual:Chapter 6, 6.5.2, Medical Review of Acute IPPS Hospital or LTCH.Chapter 13, 3.4.1.3, diagnosis code requirement.CMS Publication 100-02,Medicare Benefit Policy Manual:Chapter 7- Home Health Services, 40.2.1 - General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy, defines activities of daily living (ADLs).Article Text
Article - Billing and Coding: Total Joint Arthroplasty (A57428)
Article TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD)for Total Joint Arthroplasty.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. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Documentation RequirementsIn order to qualify for coverage of both Medicare Part A inpatient services and Part B provider services the medical record must contain documentation that fully supports the medical necessity and justification of the procedure performed and must be made available to National Government Services upon request. When the documentation does not meet the criteria for the service(s) rendered or the documentation does not establish the medical necessity for the service(s), such service(s) will be denied as not reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act.A history and physical, discharge summary, physician progress notes and an operative report are typically in the hospital record for the procedures in the related LCD.Other relevant information addressing coverage criteria related to the patients episode of care prior to the hospitalization, should be included in the hospital record (see below).Failure to include this information in the hospital record may result in denial of coverage for Part A services and trigger a review of the Part B provider claim to determine whether the Part B service rendered was reasonable and necessary.When the procedure is indicated for advanced joint disease, the following should be documented in the medical record:Arthritis of the knee or hip supported by X-ray or MRI. The X-ray or MRI should demonstrate one of the following:subchondral cysts,subchondral sclerosis,periarticular osteophytes,joint subluxation,joint space narrowing,avascular necrosis, orbone on bone articulations