evekhm/cms_iom_500 huggingface dataset:
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
For the purposes of reasonable useful lifetime and calculation of continuous use, the first day of the first rental month in which Medicare payments are made for the item (i.e., DOS) serves as the start date of the reasonable useful lifetime and period of continuous use. In these cases, the POD documentation serves as evidence that the beneficiary is already in possession of the item.FACE-TO-FACE ENCOUNTERAs a condition for payment, 42 CFR 410.38 and Final Rule 1713 (84 Fed. Reg Vol 217) require that a treating practitioner have a face-to-face encounter with a beneficiary within the six (6) months prior to prescribing items that appear on the Required List.The face-to-face encounter must support payment for the item(s) ordered/prescribed, and be documented in the pertinent portion of the medical record (for example, history, physical examination, diagnostic tests, summary of findings, progress notes, treatment plans or other sources of information that may be appropriate). The supporting documentation must include subjective and objective beneficiary specific information used for diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered.This face-to-face requirement also includes examinations conducted via the CMS-approved use of telehealth examinations, which must meet the requirements of 42 CFR  410.78 and 414.65 for purposes of DMEPOS coverage.A WOPD must be completed within six (6) months after the required face-to-face encounter.Refer to the applicable LCD-related Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section for more information regarding documentation requirements.The 6-month timing requirement does not supplant other coverage or documentation requirements.There must be sufficient medical information included in the medical record to demonstrate that all other applicable coverage criteria are met. Refer to the applicable Local Coverage Determination for information about the medical necessity criteria for the item(s) being ordered.For items other than PMDs that appear on the Required List, thetreating practitioner that conducted the face-to-face encounter does not need to be the prescriber for the DMEPOS item; however, the prescriber must:
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
Verify that a qualifying face-to-face encounter occurred within the 6-months prior to the date of their prescription; and,Have documentation of the qualifying face-to-face encounter that was conducted.A qualifying face-to-face encounter is required each time a new order/prescription for one of the specified items on the Required List is ordered.CMS and the DME MACs will post on their websites the Required List of selected HCPCS codes, which will be published through the Federal Register Notice, and periodically updated.Upon request by a contractor, all DMEPOS suppliers must provide documentation of the face-to-face encounter.REPAIRS/REPLACEMENTGENERALFor the purposes of Medicare reimbursement, repairs are not synonymous with replacements. Repairs (parts and labor) of DMEPOS items are performed on the base item. The replacement of parts or components that make up the base item is considered to be a repair. Conversely, the furnishing of new separately payable accessories that were not part of the initial base item is considered to be replacement, which is addressed in the section below.Replacement of a beneficiary owned DMEPOS item typically involves providing an identical or nearly identical item.REPAIRSThe definition of a repair is found in the Medicare Benefit Policy Manual (CMS Pub. 100-02), Chapter 15, Section 110.2.A. That section generally defines repair as to fix or mend and to put the item back in good condition after damage or wear.Repairs to items which a beneficiary owns are covered when necessary to make the items serviceable. However, routine periodic maintenance, such as testing, cleaning, regulating, and checking is not covered.Medicare does not separately reimburse for repairs of:Items in the frequent and substantial servicing payment category; or,Oxygen equipment; or,Items in the capped rental payment category during the capped rental period; or,Items covered under a manufacturers or suppliers warranty; or,Previously denied items.A new treating practitioners order is not needed for repairs.In the case of repairs to a beneficiary-owned DMEPOS item, if Medicare paid for the base item initially, medical necessity for the base item has been established. With respect to Medicare reimbursement for the repair, there are two documentation requirements:
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
The treating practitioner must document that the DMEPOS item being repaired continues to be reasonable and necessary (see Continued Medical Need section above); and,Either the treating practitioner or the supplier must document that the repair itself is reasonable and necessary.
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
The supplier must maintain detailed records describing the need for and nature of all repairs including a detailed explanation of the justification for any component or part replaced as well as the labor time to restore the item to its functionality.REPLACEMENTThe definition of replacement is found in the Medicare Benefit Policy Manual (CMS Pub. 100-02), Chapter 15, Section 110.2.C. That section generally defines replacement as the provision of an entirely identical or nearly identical item when it is lost, stolen or irreparably damaged.Beneficiary owned items or a capped rental item may be replaced in cases of loss or irreparable damage. Irreparable damage may be due to a specific accident or to a natural disaster (e.g., fire, flood). Contractors may request documentation confirming details of the incident (e.g., police report, insurance claim report).Replacement of items due to irreparable wear takes into consideration the Reasonable Useful Lifetime (RUL) of the item. The RUL of DME is determined through program instructions. In the absence of program instructions, carriers may determine the RUL, but in no case can it be less than 5 years. If the item has been in continuous use by the beneficiary on either rental or purchase basis for its RUL, the beneficiary may elect to obtain a replacement.Medicare does not cover replacement for items in the frequent and substantial servicing payment category, oxygen equipment, or inexpensive or routinely purchased rental items.A treating practitioners order, when required, is needed to reaffirm the medical necessity for replacement of an item.There are special rules for the replacement of artificial arms, legs and eyes.Adjustments and repairs of prostheses and prosthetic components are covered under the original order for the prosthetic device.Medicare payment may be made for the replacement of prosthetic devices, which are artificial limbs, or for the replacement of any part of such devices, without regard to continuous use or useful lifetime restrictions if a treating practitioner determines that the replacement device, or replacement part of such a device, is necessary.
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
Claims involving the replacement of a prosthesis or major component (foot, ankle, knee, socket etc.) must be supported by a new treating practitioner's order and documentation supporting the reason for the replacement. The reason for replacement must be documented by the treating practitioner, either on the order or in the medical record, and must fall under one of the following:
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
A change in the physiological condition of the patient resulting in the need for a replacement. Examples include but are not limited to, changes in beneficiary weight, changes in the residual limb, beneficiary functional need changes; or,An irreparable change in the condition of the device, or in a part of the device resulting in the need for a replacement; or,The condition of the device, or the part of the device, requires repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replaced.The prosthetist must retain documentation of the prosthesis or prosthetic component replaced, the reason for replacement, and a description of the labor involved irrespective of the time since the prosthesis was provided to the beneficiary. This information must be available upon request. It is recognized that there are situations where the reason for replacement includes but is not limited to changes in the residual limb; functional need changes; or irreparable damage or wear/tear due to excessive beneficiary weight or prosthetic demands of very active amputees.SIGNATURE REQUIREMENTSAll signatures must comply with the CMS signature requirements outlined in the Medicare Program Integrity Manual (CMS Pub. 100-08), Chapter 3, Section 3.3.2.4.
Article - Billing and Coding: MolDX: VEGFR2 Tests (A55468)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) statutory exclusion covers diagnostic testing "except for items and 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".Article TextVascular endothelial growth factor, subtype 2, (VEGFR2) receptor has been found to be oncogenic. Current studies have targeted VEGFR2 as a potential therapeutic option. However, at present there is insufficient evidence to establish a clear association between VEGFR2 mutations and treatment response. Therefore, the MolDX Team has determined VEGFR2 testing is a statutorily excluded service. MolDX will also deny panels of tests that include the VEGFR2 receptor.To receive a VEGFR2 service denial, please submit the following claim information:CPTcode 81479An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierEnter the appropriate DEX Z-Codeidentifier 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 claimEnter the appropriate DEX Z-Codeidentifier 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 form
Article - Billing and Coding: MolDX: VEGFR2 Tests (A55469)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) statutory exclusion covers diagnostic testing "except for items and 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".Article TextVascular endothelial growth factor, subtype 2, (VEGFR2) receptor has been found to be oncogenic. Current studies have targeted VEGFR2 as a potential therapeutic option. However, at present there is insufficient evidence to establish a clear association between VEGFR2 mutations and treatment response. Therefore, the MolDX Team has determined VEGFR2 testing is a statutorily excluded service. MolDX will also deny panels of tests that include the VEGFR2 receptor.To receive a VEGFR2 service denial, please submit the following claim information:CPTcode 81479An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientEnter the appropriate DEX Z-Codeidentifier 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 claimEnter the appropriate DEX Z-Codeidentifier 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 form
Article - Billing and Coding: Abbreviated Daytime Sleep Study (e.g. PAP-NAP) (A55478)
CMS National Coverage PolicyN/AArticle TextAn abbreviated daytime sleep study (PAP NAP) has been used by some to address poor compliance and enhance individual comfort and tolerance of CPAP/BiPAP. PAP NAP combines psychological and physiological treatments into one procedure during an abbreviated daytime nap session (100-120 minutes). Sleep technicians employ various coaching and monitoring techniques including mask and pressure desensitization, emotion focused therapy to overcome aversive responses to CPAP, mental imagery to divert the individuals attention from the sensations associated with CPAP and physiological exposure to CPAP.An Abbreviated daytime sleep study (PAP-NAP) used as a supplement to standard sleep studies for all indications, including but not limited to, the following are considered integral to the primary procedure and (are) not separately reimbursable.correcting non-compliance, or improving compliance with prescribed CPAPdecreasing anxiety/claustrophobia associated with CPAPpatient educationmask and pressure desensitizationcognitive behavioral therapy (CBT)Limited data from a single study of PAP-NAP is insufficient evidence to form conclusions on the efficacy of this approach in improving compliance with CPAP. No professional guidelines currently recommend use of PAP NAP as a compliance enhancement.Split StudiesIt is not appropriate to bill diagnostic and titration studies separately when performing a split night study.  This is considered one service.Sources of Information
Article - Billing and Coding: Abbreviated Daytime Sleep Study (e.g. PAP-NAP) (A55478)
Split StudiesIt is not appropriate to bill diagnostic and titration studies separately when performing a split night study.  This is considered one service.Sources of InformationBlueCross BlueShield Association. Medical Policy Reference Manual. (11:2015).Diagnosis and medical management of obstructive sleep apnea syndrome.(2.01.18). Retrieved June 29, 2016 from BlueWeb. (61 articles and/or guidelines reviewed)Centers for Medicare & Medicaid Services. CMS.gov.NCD for sleep testing for obstructive sleep apnea (OSA) (240.4.1).Retrieved June 29, 2016 fromMCPMKrakow, B., Ulibarri, V., Melendrez, D., Kikta, S., Togami, L., & Haynes, P. (2008). A daytime, abbreviated cardio-respiratory sleep study (CPT 95807-52) to acclimate insomnia patients with sleep disordered breathing to positive airway pressure (PAP-NAP).Journal of Clinical Medicine,4 (3), 212-222. (Level 4 evidence)FREQUENTLY ASKED QUESTIONS ABOUT SLEEP CODINGAmerican Academy of Sleep Medicine,March, 2014
Article - Billing and Coding: Abbreviated Daytime Sleep Study (e.g. PAP-NAP) (A55479)
CMS National Coverage PolicyN/AArticle TextAn abbreviated daytime sleep study (PAP NAP) has been used by some to address poor compliance and enhance individual comfort and tolerance of CPAP/BiPAP. PAP NAP combines psychological and physiological treatments into one procedure during an abbreviated daytime nap session (100-120 minutes). Sleep technicians employ various coaching and monitoring techniques including mask and pressure desensitization, emotion focused therapy to overcome aversive responses to CPAP, mental imagery to divert the individuals attention from the sensations associated with CPAP and physiological exposure to CPAP.An Abbreviated daytime sleep study (PAP-NAP) used as a supplement to standard sleep studies for all indications, including but not limited to, the following are considered integral to the primary procedure and (are) not separately reimbursable.correcting non-compliance, or improving compliance with prescribed CPAPdecreasing anxiety/claustrophobia associated with CPAPpatient educationmask and pressure desensitizationcognitive behavioral therapy (CBT)Limited data from a single study of PAP-NAP is insufficient evidence to form conclusions on the efficacy of this approach in improving compliance with CPAP. No professional guidelines currently recommend use of PAP NAP as a compliance enhancement.Split StudiesIt is not appropriate to bill diagnostic and titration studies separately when performing a split night study.  This is considered one service.Sources of Information
Article - Billing and Coding: Abbreviated Daytime Sleep Study (e.g. PAP-NAP) (A55479)
Split StudiesIt is not appropriate to bill diagnostic and titration studies separately when performing a split night study.  This is considered one service.Sources of InformationBlueCross BlueShield Association. Medical Policy Reference Manual. (11:2015).Diagnosis and medical management of obstructive sleep apnea syndrome.(2.01.18). Retrieved June 29, 2016 from BlueWeb. (61 articles and/or guidelines reviewed)Centers for Medicare & Medicaid Services. CMS.gov.NCD for sleep testing for obstructive sleep apnea (OSA) (240.4.1).Retrieved June 29, 2016 fromMCPMKrakow, B., Ulibarri, V., Melendrez, D., Kikta, S., Togami, L., & Haynes, P. (2008). A daytime, abbreviated cardio-respiratory sleep study (CPT 95807-52) to acclimate insomnia patients with sleep disordered breathing to positive airway pressure (PAP-NAP).Journal of Clinical Medicine,4 (3), 212-222. (Level 4 evidence)FREQUENTLY ASKED QUESTIONS ABOUT SLEEP CODINGAmerican Academy of Sleep Medicine,March, 2014
Article - Billing and Coding: MolDX: STAT3 Gene Testing (A55480)
CMS National Coverage PolicyN/AArticle TextSTAT3 gene testing may be performed during the diagnosis of Autosomal Dominant Hyper IgE Syndrome (AD-HIES). Since management is not determined by the presence or absence of a STAT3 mutation in patients with a probable clinical diagnosis, the MolDX Contractor has determined STAT3 analysis is a statutorily excluded test.To receive a STAT3 analysis service denial, please submit the following claim information:CPT code 814058 - STAT3, targeted sequence analysisAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientEnter the appropriate DEX Z-Codeidentifier 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 claimEnter the appropriate DEX Z-Codeidentifier 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 form
Article - Billing and Coding: MolDX: STAT3 Gene Testing (A55481)
CMS National Coverage PolicyN/AArticle TextSTAT3 gene testing may be performed during the diagnosis of Autosomal Dominant Hyper IgE Syndrome (AD-HIES). Since management is not determined by the presence or absence of a STAT3 mutation in patients with a probable clinical diagnosis, the MolDX Contractor has determined STAT3 analysis is a statutorily excluded test.To receive a STAT3 analysis service denial, please submit the following claim information:CPT code 81405  STAT3, targeted sequence analysisAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientEnter the appropriate DEX Z-Codeidentifier 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 claimEnter the appropriate DEX Z-Codeidentifier 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 form
Article - Billing and Coding: MolDX: TP53 Gene Tests (A55484)
CMS National Coverage PolicyN/AArticle TextTP53 gene testing may be performed during the diagnosis of Li-Fraumeni syndrome (LFS), a cancer predisposition syndrome associated with the development of specific tumors. Clinical symptoms and diagnosis usually occur prior to Medicare eligibility and carrier testing is not a covered benefit.To receive a TP53 gene sequencing service denial, please submit the following claim information:Select the appropriate CPT codeAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN,append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifier.Select the appropriate diagnosis for the patientEnter the appropriate DEX Z-Codeidentifier 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 claimEnter DEX Z-Codeidentifier 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 form
Article - Billing and Coding: MolDX: TP53 Gene Tests (A55487)
CMS National Coverage PolicyN/AArticle TextTP53 gene testing may be performed during the diagnosis of Li-Fraumeni syndrome (LFS), a cancer predisposition syndrome associated with the development of specific tumors. Clinical symptoms and diagnosis usually occur prior to Medicare eligibility and carrier testing is not a covered benefit.To receive a TP53 gene sequencing service denial, please submit the following claim information:Select the appropriate CPT codeAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientEnter the appropriate DEX Z-Codeidentifier 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 claimEnter DEX Z-Codeidentifier 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 form