evekhm/cms_iom_500 huggingface dataset:
Article - Eye Prostheses - Policy Article (A52462)
Modifications to the prosthesis made at the time delivery of the prosthesis or within 90 days thereafterRepair due to normal wear or tear within 90 days of deliveryFollow-up visits within 90 days of delivery of the prosthesisModifications to a prosthesis are separately payable when they occur more than 90 days after delivery of the prosthesis and they are required because of a change in the beneficiarys condition.Repairs are covered when there has been accidental damage or extensive wear to the prosthesis that can be repaired. If the expense for repairs exceeds the estimated expense for a replacement prosthesis, no payments can be made for the amount of the excess.Follow-up visits which occur more than 90 days after delivery and which do not involve modification or repair of the prosthesis are noncovered services.Physicians who are enrolled as a DMEPOS supplier are to submit claims for eye prostheses provided in an office or nursing home setting by nonphysicians or physicians to the DME MAC. Claims for eye prostheses provided in an outpatient hospital setting are submitted to the applicable A/B MAC. Eye prostheses provided in an inpatient hospital setting are included in the payment made to the hospital; therefore, claims should not be submitted to the DME MAC.Claims for implanted components (e.g., titanium studs, magnets, etc.) and procedures used to affix the ocular prosthesis to the beneficiary are not the jurisdiction of the DME MAC. Claims for these items and services will be denied as wrong jurisdiction.Replacement of an ocular prosthesis because of loss or irreparable damage may be reimbursed without a treating practitioner's order when it is determined that the prosthesis as originally ordered still fills the beneficiary's medical needs.
Article - Eye Prostheses - Policy Article (A52462)
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD prior to delivery, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS.When billing for an item or service at a greater frequency than that described in the policy, there must be documentation in the beneficiarys medical records that corroborates the order and supports the medical necessity of the items and quantities billed. This information must be available upon request.The treating practitioner's records must contain information which supports the medical necessity of the item ordered. The ocularist's documentation of the necessity for a replacement prosthesis is appropriate documentation for that claim if the replacement is necessitated by other than medical reasons.
Article - Eye Prostheses - Policy Article (A52462)
MODIFIERSThe right (RT) and/or left (LT) modifiers must be used with all HCPCS codes in this policy. Effective for claims with dates of service (DOS) on or after 3/1/2019, when the same code for bilateral items (left and right) is billed on the same date of service, bill each item on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line and billed with 2 UOS. Claims billed without the RT and/or LT modifiers, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.CODING GUIDELINESTrial scleral shells must be billed with code L9900.PROSE DevicePROSE (BostonSight, Needham, MA) devices are designed to rest on the sclera or white part of the eye and are used to treat ocular surfaces diseases, including some types of "dry eye." For Medicare billing purposes the correct HCPCS coding for this item is determined based upon the condition(s) being treated. When the PROSE device is used as a treatment for either of the following indications listed below, the correct HCPCS code to use is V2627 (SCLERAL COVER SHELL):Treatment of an eye rendered sightless and shrunken by inflammatory disease; or,Treatment of "dry eye" where the PROSE device serves as a substitute for the function of the diseased lacrimal gland.When the PROSE device is used for any conditions other than those listed above, the device must be coded with HCPCS code V2531(CONTACT LENS, SCLERAL, GAS PERMEABLE, PER LENS (FOR CONTACT LENS MODIFICATION, SEE 92325))and is subject to the Medicare refractive lens statutory coverage exclusion.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Article - Facial Prostheses - Policy Article (A52463)
CMS National Coverage PolicyN/AArticle TextNONMEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Facial prostheses are covered under the Medicare Artificial Legs, Arms and Eyes benefit (Social Security Act 1861(s)(9)). In order for a beneficiary to be eligible for reimbursement, the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition to meeting the benefit policy, there are specific statutory payment policy requirements, discussed below, that also must be met.Adhesives, adhesive remover, skin barrier wipes, and tape used in conjunction with a facial prosthesis are covered.The following services and items are included in the allowance for a facial prosthesis and, therefore, are not separately billable to or payable by Medicare under the prosthetic device benefit:Evaluation of the beneficiaryPre-operative planningCost of materialsLabor involved in the fabrication and fitting of the prosthesisModifications to the prosthesis made at the time delivery of the prosthesis or within 90 days thereafterRepair due to normal wear or tear within 90 days of deliveryFollow-up visits within 90 days of delivery of the prosthesis
Article - Facial Prostheses - Policy Article (A52463)
Modifications to a prosthesis are separately payable when they occur more than 90 days after delivery of the prosthesis and they are required because of a change in the beneficiarys condition.Repairs are covered when there has been accidental damage or extensive wear to the prosthesis that can be repaired. If the expense for repairs exceeds the estimated expense for a replacement prosthesis, no payments can be made for the amount of the excess.Follow-up visits which occur more than 90 days after delivery and which do not involve modification or repair of the prosthesis are noncovered services.Replacement of a facial prosthesis is covered in cases of loss or irreparable damage or wear or when required because of a change in the beneficiarys condition that cannot be accommodated by modification of the existing prosthesis. When replacement involves a new impression/moulage rather than use of a previous master model, the reason for the new impression/moulage must be clearly documented in the supplier's records and available upon request.Physicians who are enrolled as a DMEPOS supplier are to submit claims for facial prostheses provided in an office or nursing home setting by nonphysicians or physicians to the DME MAC.Claims for facial prostheses provided in an outpatient hospital setting are submitted to the applicable A/B MAC. Facial prostheses provided in an inpatient hospital setting are included in the payment made to the hospital; and, therefore should not be submitted to the DME MAC.Claims for implanted components (e.g., titanium studs, magnets, etc.) and procedures used to affix the external facial prosthesis to the beneficiary are not the jurisdiction of the DME MAC. Claims for these items and services will be denied as wrong jurisdiction.If an ocular prosthesis is dispensed to the beneficiary as an integral part of a facial prosthesis, the ocular prosthesis component must be billed by the supplier of the facial prosthesis. (For information on ocular prostheses that are not part of orbital prostheses, refer to the Eye Prostheses LCD.)Skin care products related to the prosthesis, including but not limited to cosmetics, skin cream, cleansers, etc., are noncovered.
Article - Facial Prostheses - Policy Article (A52463)
Skin care products related to the prosthesis, including but not limited to cosmetics, skin cream, cleansers, etc., are noncovered.Claims for tape and adhesive (A4450, A4452, A5120) that are billed without an AV modifier or another modifier indicating coverage under a different policy will be rejected as missing information.
Article - Facial Prostheses - Policy Article (A52463)
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD prior to delivery, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS.When either code V2629 or L8048 is billed, the claim must be accompanied by a brief description of the item in the narrative field. When L8048 is provided, a drawing/photograph of the item provided must be available upon request.The treating practitioner's records must contain information which supports the medical necessity of the item ordered. The prosthetists documentation of the necessity for a replacement prosthesis is appropriate documentation for that claim if the replacement is necessitated by other than medical reasons.
Article - Facial Prostheses - Policy Article (A52463)
MODIFIERSAV, KM, KN, RT and LT MODIFIERS:Claims for tape and adhesive (A4450, A4452, A5120) that are submitted without AV modifier will be rejected as missing information.When a replacement prosthesis is fabricated starting with a new impression/moulage, the KM modifier should be added to the code. When a replacement prosthesis is fabricated using a previous master model, the KN modifier should be added to the code.The right (RT) and/or left (LT) modifiers must be used with facial prosthesis codes when applicable. Effective for claims with dates of service (DOS) on or after 3/1/2019, if bilateral prostheses using the same code are billed on the same date of service, bill each item on two separate claim lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the same claim line and billed with 2 UOS. Claims billed with codes L8042, L8043 and L8045, L8046, without modifiers RT and/or LT, or with RTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.
Article - Facial Prostheses - Policy Article (A52463)
CODING GUIDELINESCodes for a facial prosthesis (L8040, L8041, L8042, L8043, L8044, L8045, L8046, L8047) describe a complete prosthesis, except as noted below for the use of code L8048 (UNSPECIFIED MAXILLOFACIAL PROSTHESIS, BY REPORT, PROVIDED BY A NON-PHYSICIAN).A nasal prosthesis (L8040) is a removable superficial prosthesis, which restores all or part of the nose. It may include the nasal septum.A midfacial prosthesis (L8041) is a removable superficial prosthesis, which restores part or all of the nose plus significant adjacent facial tissue/structures, but does not include the orbit or any intraoral maxillary component. Adjacent facial tissue/structures include one or more of the following: soft tissue of the cheek, upper lip, or forehead.An orbital prosthesis (L8042) is a removable superficial prosthesis, which restores the eyelids and the hard and soft tissue of the orbit. It may also include the eyebrow. This code does not include the ocular prosthesis component.An upper facial prosthesis (L8043) is a removable superficial prosthesis, which restores the orbit plus significant adjacent facial tissue/structures, but does not include the nose or any intraoral maxillary component. Adjacent facial tissue/structures include one or more of the following: soft tissue of the cheek or forehead. This code does not include the ocular prosthesis component.A hemi-facial prosthesis (L8044) is a removable superficial prosthesis, which restores part or all of the nose plus the orbit plus significant adjacent facial tissue/structures, but does not include any intraoral maxillary component. This code does not include the ocular prosthesis component.An auricular prosthesis (L8045) is a removable superficial prosthesis, which restores all or part of the ear.A partial facial prosthesis (L8046) is a removable superficial prosthesis which restores a portion of the face but which does not specifically involve the nose, orbit, or ear.
Article - Facial Prostheses - Policy Article (A52463)
A partial facial prosthesis (L8046) is a removable superficial prosthesis which restores a portion of the face but which does not specifically involve the nose, orbit, or ear.A nasal septal prosthesis (L8047) is a removable prosthesis, which occludes a hole in the nasal septum but does not include superficial nasal tissue.Code L8048 is a miscellaneous code. There are limited scenarios where the use of miscellaneous code L8048 is appropriate:
Article - Facial Prostheses - Policy Article (A52463)
If a facial prosthesis is not described by a specific code, L8040, L8041, L8042, L8043, L8044, L8045, L8046, or L8047.If a facial prosthesis has a component which is used to attach it to a bone-anchored implant or to an internal prosthesis (e.g., maxillary obturator), that component should be billed separately using code L8048. This code should not be used for implanted prosthesis-anchoring components.Covered modifications or repairs are billed using code L8048 for any materials used and code L8049 for the labor components.
Article - Facial Prostheses - Policy Article (A52463)
Code V2623 describes an ocular prosthesis, which is custom fabricated.Code V2629 is used for an ocular prosthesis that is not custom fabricated (i.e., stock prosthesis).When a new ocular prosthesis component is provided as an integral part of an orbital, upper facial or hemi-facial prosthesis, it should be billed using code V2623 or V2629 on a separate claim line. When a replacement facial prosthesis utilizes an ocular component from the prior prosthesis, the ocular prosthesis code should not be billed.When a prosthesis is needed for adjacent facial regions, a single code must be used to bill for the item whenever possible. For example, if a defect involves the nose and orbit, this should be billed using the hemi-facial prosthesis code and not separate codes for the orbit and nose. This would apply even if the prosthesis is fabricated in two separate parts.When codes A4450, A4452 and A5120 are used with a facial prosthesis, they must be billed with the AV modifier. For this policy, codes A4450, A4452 and A5120 are the only codes for which the AV modifier may be used.Covered modifications or repairs are billed using code L8049 for the labor components and code L8048 for any materials used. Time reported using code L8049 should only be for laboratory modification/repair time and associated prosthetic evaluation used only for services after 90 days from the date of delivery of the prosthesis. Evaluation not associated with repair or modification is noncovered and should not be coded as L8049.
Article - Facial Prostheses - Policy Article (A52463)
Adhesives, adhesive remover, and tape used in conjunction with a facial prosthesis should be billed using codes A4364, A4455, A4456, A4450, or A4452. The unit of service is specified for each code. For tape, one unit of service is 18 square inches. Therefore, a roll of tape 1/2" X 3 yds. would be 3 units; 1" x 3 yds. would be 6 units. Other skin care products related to the prosthesis should generally not be billed; but, if they are billed at the beneficiary's request, code A9270 (noncovered item or service) should be used.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Article - Glucose Monitor - Policy Article (A52464)
CMS National Coverage PolicyN/AArticle Text
Article - Glucose Monitor - Policy Article (A52464)
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Home blood glucose monitors (BGMs) and continuous glucose monitors (CGMs) are covered under the Durable Medical Equipment (DME) benefit [Social Security Act 1861(s)(6)]. In order for a beneficiarys DME to be eligible for reimbursement, the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination (LCD) must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.Effective for claims with dates of service on or after January 12, 2017, Medicare began coverage of therapeutic (non-adjunctive) CGM devices under the DME benefit. CGM devices covered by Medicare were defined in CMS Ruling 1682R as therapeutic (non-adjunctive) CGMs.A non-adjunctive CGM can be used to make treatment decisions without the need for a stand-alone BGM to confirm testing results. An adjunctive CGM requires the user verify their glucose levels or trends displayed on a CGM with a BGM prior to making treatment decisions. On February 28, 2022, CMS determined that both non-adjunctive and adjunctive CGMs may be classified as DME. CGM devices that solely display results on a smartphone and do not have a stand-alone receiver or integration into an insulin infusion pump do not meet the definition of DME and will be denied as non-covered (no benefit).
Article - Glucose Monitor - Policy Article (A52464)
The supply allowance for supplies used with a CGM system (A4238, A4239) encompassesall itemsnecessary for the use of the device and includes but is not limited to, CGM sensors and transmitters. For non-adjunctive CGMs, the supply allowance (A4239) also includes a home BGM and related supplies (test strips, lancets, lancing device, calibration solution, and batteries), if necessary. Supplies or accessories billed separately will be denied as unbundling.For adjunctive CGMs, the supply allowance (A4238) encompassesall itemsnecessary for the use of the device and includes but is not limited to, CGM sensors and transmitters. Separate billing of CGM sensors and transmitters will be denied as unbundling. Code A4238 does not include a home BGM (HCPCS codes E0607, E2100, E2101) and related BGM testing supplies (HCPCS codes A4233, A4234, A4235, A4236, A4244, A4245, A4246, A4247, A4250, A4253, A4255, A4256, A4257, A4258, A4259). These items may be billed separately, in addition to code A4238.Coverage of a CGM system supply allowance (code A4238 or A4239) is available for CGM systems when the beneficiary uses a stand-alone receiver or insulin infusion pump classified as DME to display glucose data. In addition, Medicare coverage is available for a CGM system supply allowance if a non-DME device (watch, smartphone, tablet, laptop computer, etc.) is usedin conjunctionwith the durable CGM receiver (code E2102 or E2103). The following are examples of this provision:
Article - Glucose Monitor - Policy Article (A52464)
Medicare coverage of a CGM supply allowance is available when a beneficiary uses a durable CGM receiver to display their glucose data and also transmits that data to a caregiver through a smart phone or other non-DME receiver.Medicare coverage of a CGM system supply allowance is available when a beneficiary uses a durable CGM receiver on some days to review their glucose data but uses a non-DME device on other days.