evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
380.1 -  Leadless Pacemaker Coding and Billing Requirements for Professional   Claims   380.1.1 -  Leadless Pacemaker Place of Service Restrictions   380.1.2 -  Leadless Pacemaker Modifier   380.1.3 -  Leadless Pacemaker Additional Claim Billing Information  380.2 -  Leadless Pacemaker Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Medicare Summary Notice (MSN) Messages  390  Supervised exercise therapy (SET) of Symptomatic Peripheral Artery Disease   390.1 -  General Billing Requirements   390.2 -  Coding Requirements for SET   390.3 -  Special Billing Requirements for Institutional Claims    390.4 -  Common Working File (CWF) Requirements  390.5 -  Applicable Medicare Summary Notice (MSN), Remittance Advice Remark Codes (RARC) and Claim Adjustment Reason Code (CARC) Messaging  400 -  Chimeric Antigen Receptor (CAR) T - cell Therapy   400.1 -  Coverage Requirements  400.2 -  Billing Requirements  400.2.1-  A/B Medicare Administrative Contractor (MAC) (A) Bill Types  400.2.2 -  A/B MAC (A) Revenue Codes  400.2.3 -  A/B MAC Billing Healthcare Common Procedural Coding System (HCPCS) Codes     400.2.3.1  A/B MAC (B) Places of Service (POS)  400.2.4 -  A/B MAC Diagnosis Requirements  400.2.5  Billing Information for Professional Claims  400.3 -  Payment Requirements  400.4 -  Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs),Group Codes, and Medicare Summary Notice (MSN) Messages  400.5 -  Claims Editing  410 -  Acupuncture for Chronic Low Back Pain (cLBP)  410.1 -  Coverage Requirements  410.2 -  Claims Processing General Information  410.3 -  Institutional Claims Bill Type and Revenue Coding Information  410.4  Messaging  410.5  Common Working File (CWF) Editing
(Medicare Claims Processing Manual)
411  Home Infusion Therapy Services  411.1  Policy   411.2  Coverage Requirements  411.3  Home Infusion Drugs: Healthcare Common Procedural Coding System (HCPCS) Drug Codes   411.4  Billing and Payment Requirements  411.5  Return as Un -Processable, Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Group Codes, and Medicare Summary Notice Messages  411.6  CWF and MCS Editing Requirements      10 - Diagnostic Blood Pressure Monitoring  (Rev. 109, 02-27-04)  10.1 - Ambulatory Blood Pressure Monitoring (ABPM) Billing Requirements  (Rev. 11021; Issued: 10-01- 21; Effective: 10 -29-21; Implementation: 10-29-21)  A. Coding Applicable to A/B MACs (A and B)   Effective April 1, 2002, a National Coverage Decision was made to allow for Medicare coverage of ABPM for those beneficiaries with suspected "white coat hypertension" (WCH). ABPM involves the use of a non-invasive device, which is used to measure blood pressure in 24-hour cycles. These 24- hour measurements are stored in the device and are later interpreted by a physician. Suspected "WCH" is defined as: (1) Clinic/office blood pressure >140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit; (2) At least two documented separate blood pressure measurements taken outside the clinic/office which are < 140/ 90 mm Hg; and (3) No evidence of end -organ damage. ABPM is not covered for any other uses. Coverage policy can be found in Medicare National Coverage Determinations Manual, Chapter 1, Part 1, 20.19. ( http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp).  The ABPM must be performed for at least 24 hours to meet coverage criteria. Payment is not allowed for institutionalized beneficiaries, such as those receiving Medicare covered skilled nursing in a facility. In the rare circumstance that ABPM needs to be performed more than once for a beneficiary, the qualifying criteria described above must be met for each subsequent ABPM test.
(Medicare Claims Processing Manual)
Effective dates for applicable Common Procedure Coding System (HCPCS) codes for ABPM for suspected WCH and their covered effective dates are as follows:   HCPCS  Definition  Effective Date  93784 ABPM, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; including recording, scanning analysis, interpretation and report. 04/01/2002 93786 ABPM, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; recording only. 04/01/2002 93788 ABPM, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; scanning analysis with report. 01/01/2004    HCPCS  Definition  Effective Date  93790  ABPM, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; physician review with interpretation and report. 04/01/2002   In addition, one of the following diagnosis codes must be present:    Diagnosis  Code  Description  If ICD -10-CM is applicable  R03.0  Elevated blood pressure reading without diagnosis of hypertension   B. A/B MAC (A) Billing Instructions   The applicable types of bills acceptable when billing for ABPM services are 13X, 23X, 71X, 73X, 75X, and 85X. Chapter 25 of this manual provides general billing instructions that must be followed for bills submitted to A/B MACs (A). The A/B MACs (A) pay for hospital outpatient ABPM services billed on a 13X type of bill with HCPCS 93786 and/or 93788 as follows: (1) Outpatient Prospective Payment System (OPPS) hospitals pay based on the Ambulatory Payment Classification (APC); (2) non- OPPS hospitals (Indian H ealth Services Hospitals, Hospitals that provide Part B services only, and hospitals located in American Samoa, Guam, Saipan and the Virgin Islands) pay based on reasonable cost, except for Maryland Hospitals which are paid based on a percentage of cost. E ffective 4/1/06, type of bill 14X is for non- patient laboratory specimens and is no longer applicable for ABPM.
(Medicare Claims Processing Manual)
The A/B MACs (A) pay for comprehensive outpatient rehabilitation facility (CORF) ABPM services billed on a 75x type of bill with HCPCS code 93786 and/or 93788 based on the Medicare Physician Fee Schedule (MPFS) amount for that HCPCS code.  The A/B MACs (A) pay for ABPM services for critical access hospitals (CAHs) billed on a 85x type of bill as follows: (1) for CAHs that elected the Standard Method and billed HCPCS code 93786 and/or 93788, pay based on reasonable cost for that HCPCS code; and (2) for CAHs that elected the Optional Method and billed any combination of HCPCS codes 93786, 93788 and 93790 pay based on reasonable cost for HCPCS 93786 and 93788 and pay 115% of the MPFS amount for HCPCS 93790.  The A/B MACs (A) pay for ABPM services for skilled nursing facility (SNF) outpatients billed on a 23x type of bill with HCPCS code 93786 and/or 93788, based on the MPFS.  The A/B MACs (A) accept independent and provider -based rural health clinic (RHC) bills for visits under the all -inclusive rate when the RHC bills on a 71x type of bill with revenue code 052x for providing the professional component of ABPM services. The A/ B MACs  (A) should not make a separate payment to a RHC for the professional component of ABPM services in addition to the all -inclusive rate. RHCs are not required to use ABPM HCPCS codes for professional services covered under the all -inclusive rate.   The A/B MACs (A) accept free- standing and provider -based federally qualified health center (FQHC) bills for visits under the all- inclusive rate when the FQHC bills on a 73x type of bill with revenue code 052x for providing the professional component of ABP M services.
(Medicare Claims Processing Manual)
The A/B MACs (A) should not make a separate payment to a FQHC for the professional component of ABPM services in addition to the all -inclusive rate. FQHCs are not required to use ABPM HCPCS codes for professional services covered under the all -inclusive ra te.  The A/B MACs (A) pay provider -based RHCs/FQHCs for the technical component of ABPM services when billed under the base providers number using the above requirements for that particular base provider type, i.e., a OPPS hospital based RHC would be paid for the ABPM technical component services under the OPPS using the APC for code 93786 and/or 93788 when billed on a 13x type of bill.  Independent and free -standing RHC/FQHC practitioners are only paid for providing the technical component of ABPM services when billed to the A/B MAC (B) following the MACs instructions.   A/B MAC (B)  Claims   A/B MACs (B) pay for ABPM services billed with ICD -10-CM diagnosis code R03.0 (if ICD-10 is applicable) and HCPCS codes 93784 or for any combination of 93786, 93788 and 93790, based on the MPFS for the specific HCPCS code billed.   Coinsurance and Deductible   The A/B MACs (A and B) shall apply coinsurance and deductible to payments for ABPM services except for services billed to the A/B MAC (A) by FQHCs. For FQHCs only co - insurance applies.    11 - Wound Treatments  (Rev 124a, 03-19-04)  11.1 - Electrical Stimulation  (Rev. 371, Issued 11-19- 04, Effective: 04 -01-05, Implementation: 04-04-05)  A.  Coding Applicable to Carriers & Fiscal Intermediaries (FIs)
(Medicare Claims Processing Manual)
A.  Coding Applicable to Carriers & Fiscal Intermediaries (FIs)   Effective April 1, 2003, a National Coverage Decision was made to allow for Medicare coverage of Electrical Stimulation for the treatment of certain types of wounds.  The type of wounds covered are chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers.  All other uses of electrical stimulation for the treatment of wounds are not covered by Medicare.  Electrical stimulation will not be covered as an initial treatment modality.   The use of electrical stimulation will only be covered after appropriate standard wound care has been tried for at least 30 days and there are no measurable signs of healing. If electrical stimulation is being used, wounds must be evaluated periodically by the treating physician but no less than every 30 days by a physician. Continued treatment with electrical stimulation is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.  Additionally, electrical stimulation must be discontinued when the wound demonstrates a 100% epithelialzed wound bed.  Coverage policy can be found in Pub. 100- 03, Medicare National Coverage Determinations Manual, Chapter 1, Section 270.1 (http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp)  The applicable Healthcare Common Procedure Coding System (HCPCS) code for Electrical Stimulation and the covered effective date is as follows:   HCPCS  Definition  Effective Date  G0281 Electrical Stimulation, (unattended), to one or more areas for chronic Stage III and 04/01/2003 HCPCS  Definition  Effective Date  Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care.   Medicare will not cover the device used for the electrical stimulation for the treatment of wounds.  However, Medicare will cover the service. Unsupervised home use of electrical stimulation will not be covered.   B.  FI Billing Instructions
(Medicare Claims Processing Manual)
Medicare will not cover the device used for the electrical stimulation for the treatment of wounds.  However, Medicare will cover the service. Unsupervised home use of electrical stimulation will not be covered.   B.  FI Billing Instructions   The applicable types of bills acceptable when billing for electrical stimulation services are 12X, 13X, 22X, 23X, 71X, 73X, 74X, 75X, and 85X.  Chapter 25 of this manual provides general billing instructions that must be followed for bills submitted to FIs .  FIs pay for electrical stimulation services under the Medicare Physician Fee Schedule for a hospital, Comprehensive Outpatient Rehabilitation Facility (CORF), Outpatient Rehabilitation Facility (ORF), Outpatient Physical Therapy (OPT) and Skilled Nursing Facility (SNF).   Payment methodology for independent Rural Health Clinic (RHC), provider -based RHCs, free-standing Federally Qualified Health Center (FQHC) and provider based FQHCs is made under the all -inclusive rate for the visit furnished to the RHC/FQHC patient to obta in the therapy service.  Only one payment will be made for the visit furnished to the RHC/FQHC patient to obtain the therapy service.  As of April 1, 2005, RHCs/FQHCs are no longer required to report HCPCS codes when billing for these therapy services.  Payment Methodology for a Critical Access Hospital (CAH) is on a reasonable cost basis unless the CAH has elected the Optional Method and then the FI pays115% of the MPFS amount for the professional component of the HCPCS code in addition to the technical component.  In addition, the following revenues code must be used in conjunction with the HCPCS code identified:  Revenue Code  Description  420 Physical Therapy  430 Occupational Therapy  520 Federal Qualified Health Center *  521 Rural Health Center *  977, 978 Critical Access Hospital - method II CAH professional services only  * NOTE:   As of April 1, 2005, RHCs/FQHCs are no longer required to report HCPCS codes when billing for these therapy services.   C.  Carrier Claims
(Medicare Claims Processing Manual)
* NOTE:   As of April 1, 2005, RHCs/FQHCs are no longer required to report HCPCS codes when billing for these therapy services.   C.  Carrier Claims   Carriers pay for Electrical Stimulation services billed with HCPCS codes G0281 based on the MPFS.  Claims for Electrical Stimulation services must be billed on Form CMS -1500 or the electronic equivalent following instructions in chapter 12 of this manual (http://www.cms.hhs.gov/manuals/104_claims/clm104c12.pdf).  D.  Coinsurance and Deductible   The Medicare contractor shall apply coinsurance and deductible to payments for these therapy services except for services billed to the FI by FQHCs.  For FQHCs, only co- insurance applies.   11.2 - Electromagnetic Therapy  (Rev.  2998, Issued: 07- 25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD -10)  A. HCPCS Coding Applicable to A/B MACs (A and B)   Effective July 1, 2004, a National Coverage Decision was made to allow for Medicare coverage of electromagnetic therapy for the treatment of certain types of wounds.  The type of wounds covered are chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers.  All other uses of electromagnetic therapy for the treatment of wounds are not covered by Medicare.  Electromagnetic therapy will not be covered as an initial treatment modality.
(Medicare Claims Processing Manual)
The use of electromagnetic therapy will only be covered after appropriate standard wound care has been tried for at least 30 days and there are no measurable signs of healing.  If electromagnetic therapy is being used, wounds must be evaluated periodically by the treating physician but no less than every 30 days.  Continued treatment with electromagnetic therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.  Additionally, electromagnetic ther apy must be discontinued when the wound demonstrates a 100% epithelialzed wound bed.  Coverage policy can be found in Pub. 100- 03, Medicare National Coverage Determinations Manual, Chapter 1 section 270.1. (http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp)  The applicable Healthcare Common Procedure Coding System (HCPCS) code for Electrical Stimulation and the covered effective date is as follows:   HCPCS  Definition  Effective Date  G0329 ElectromagneticTherapy, to one or more areas for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy  plan of care.  07/01/2004  Medicare will not cover the device used for the electromagnetic therapy for the treatment of wounds.  However, Medicare will cover the service.  Unsupervised home use of electromagnetic therapy will not be covered.   B. A/B MAC (A) Billing Instructions
(Medicare Claims Processing Manual)
B. A/B MAC (A) Billing Instructions   The applicable types of bills acceptable when billing for electromagnetic therapy services are 12X, 13X, 22X, 23X, 71X, 73X, 74X, 75X, and 85X.  Chapter 25 of this manual provides general billing instructions that must be followed for bills submitted to A/B MACs (A).  A/B MACs (A) pay for electromagnetic therapy services under the Medicare Physician Fee Schedule for a hospital, CORF, ORF, and SNF.  Payment methodology for independent (RHC), provider- based RHCs, free -standing FQHC and provider based FQHCs is made under the all-inclusive rate for the visit furnished to the RHC/FQHC patient to obtain the therapy service.  Only one payment will be made f or the visit furnished to the RHC/FQHC patient to obtain the therapy service.  As of April 1, 2005, RHCs/FQHCs are no longer required to report HCPCS codes when billing for the therapy service.   Payment Methodology for a CAH is payment on a reasonable cost basis unless the CAH has elected the Optional Method and then the A/B MAC (A) pays pay 115% of the MPFS amount for the professional component of the HCPCS code in addition to the technical component. In addition, the following revenues code must be used in conjunction with the HCPCS code identified:  Revenue Code  Description  420 Physical Therapy  430 Occupational Therapy  520 Federal Qualified Health Center *  521 Rural Health Center *  977, 978 Critical Access Hospital - method II CAH professional services only  * NOTE:  As of April 1, 2005, RHCs/FQHCs are no longer required to report HCPCS codes when billing for the therapy service.  C. A/B MAC (B) Claims   A/B MACs (B) pay for Electromagnetic Therapy services billed with HCPCS codes G0329 based on the MPFS.  Claims for electromagnetic therapy services must be billed using the ASC X12 837 professional claim format or Form CMS-1500 following instructions in chapter 12 of this manual ( www.cms.hhs.gov/manuals/104_claims/clm104index.asp).
(Medicare Claims Processing Manual)
Payment information for HCPCS code G0329 will be added to the July 2004 update of the Medicare Physician Fee Schedule Database (MPFSD).   D.  Coinsurance and Deductible   The Medicare contractor shall apply coinsurance and deductible to payments for electromagnetic therapy services except for services billed to the A/B MAC (A) by FQHCs.  For FQHCs only co- insurance applies.   11.3  Autologous Platelet -Rich Plasma (PRP) for Chronic Non -Healing Wounds  (Rev. 11214, Issued: 01-20-22, Effective:04-13-21, Implementation: 01-03-22 Shared Systems Contractors, 02-14- 22 MACs)   11.3.1  Policy  (Rev. 11214, Issued: 01-20-22, Effective:04 -13-21, Implementation: 01-03-22 Shared Systems Contractors, 02-14- 22 MACs)   Effective for claims with dates of service on or after April 13, 2021, contractors shall accept and pay for autologous platelet-rich plasma (PRP) for the treatment of chronic non-healing diabetic wounds for a duration of 20 weeks, when prepared by devices whose Food and Drug Administration -cleared indications include the management of exuding cutaneous wounds, such as diabetic ulcers, in accordance with the coverage criteria outlined in Publication 100-03, chapter 1, section 270.3, of the National Coverage Determinations (NCD) Manual.   NOTE: Coverage of PRP services for the treatment of chronic non -healing diabetic wounds that are performed more than 20 weeks after the date of the first PRP service shall be determined by the local Medicare Administrative Contractor (MAC).    Coverage of autologous PRP for the treatment of all other chronic non-healing wounds (non-diabetic) will be determined by local MACs under section 1862(a)(1)(A) of the Social Security Act.   11.3.2  Healthcare Common Procedure Coding System (HCPCS) Codes and Diagnosis Coding (Rev. 11214, Issued: 01-20-22, Effective:04-13-21, Implementation: 01-03-22 Shared Systems Contractors, 02-14- 22 MACs)
(Medicare Claims Processing Manual)
Healthcare Common Procedure Coding System (HCPCS) Code  Effective for claims with dates of service on or after April 13, 2021, Medicare providers shall report HCPCS code G0460 for PRP services for the treatment of chronic non-healing non-diabetic wounds.  Effective for claims with dates of service on or after April 13, 2021, Medicare providers shall report HCPCS code G0465 for PRP services for the treatment of chronic non- healing diabetic wounds under the conditions and criteria outlined in NCD Manual Section 270.3.  If ICD -10 Diagnosis coding is applicable  For claims with dates of service on or after April 13, 2021, PRP, for the treatment of chronic non-healing diabetic wounds must be billed reporting both an ICD-10 diagnosis code for diabetes mellitus and an ICD -10 diagnosis code for chronic ulcers.  - Two diagnosis codes are required - Diabetic Mellitus plus Chronic Ulcer   Diabetes Mellitus    E08.621  Diabetes mellitus due to underlying condition with foot ulcer  E08.622  Diabetes mellitus due to underlying condition with other skin ulcer  E09.621  Drug or chemical induced diabetes mellitus with foot ulcer  E09.622  Drug or chemical induced diabetes mellitus with other skin ulcer  E10.621  Type 1 diabetes mellitus with foot ulcer  E10.622  Type 1 diabetes mellitus with other skin ulcer  E11.621  Type 2 diabetes mellitus with foot ulcer  E11.622  Type 2 diabetes mellitus with other skin ulcer  E13.621  Other specified diabetes mellitus with foot ulcer  E13.622  Other specified diabetes mellitus with other skin ulcer    Chronic Ulcer
(Medicare Claims Processing Manual)
L97.111  Non-pressure chronic ulcer of right thigh limited to breakdown of skin  L97.112  Non-pressure chronic ulcer of right thigh with fat layer exposed  L97.113  Non-pressure chronic ulcer of right thigh with necrosis of muscle  L97.115  Non-pressure chronic ulcer of right thigh with muscle involvement without evidence of  necrosis  L97.116  Non-pressure chronic ulcer of right thigh with bone involvement without evidence of  necrosis  L97.118  Non-pressure chronic ulcer of right thigh with other specified severity  L97.114  Non-pressure chronic ulcer of right thigh with necrosis of bone  L97.121  Non-pressure chronic ulcer of left thigh limited to breakdown of skin  L97.122  Non-pressure chronic ulcer of left thigh with fat layer exposed  L97.123  Non-pressure chronic ulcer of left thigh with necrosis of muscle  L97.124  Non-pressure chronic ulcer of left thigh with necrosis of bone  L97.125  Non-pressure chronic ulcer of left thigh with muscle involvement without evidence of  necrosis  L97.126  Non-pressure chronic ulcer of left thigh with bone involvement without evidence of necros  L97.128  Non-pressure chronic ulcer of left thigh with other specified severity  L97.211  Non-pressure chronic ulcer of right calf limited to breakdown of skin  L97.212  Non-pressure chronic ulcer of right calf with fat layer exposed  L97.213  Non-pressure chronic ulcer of right calf with necrosis of muscle  L97.214  Non-pressure chronic ulcer of right calf with necrosis of bone  L97.215  Non-pressure chronic ulcer of right calf with muscle involvement without evidence of  necrosis  L97.216  Non-pressure chronic ulcer of right calf with bone involvement without evidence of necros  L97.218  Non-pressure chronic ulcer of right calf with other specified severity  L97.221  Non-pressure chronic ulcer of left calf limited to breakdown of skin  L97.222  Non-pressure chronic ulcer of left calf with fat layer exposed  L97.223  Non-pressure chronic ulcer of left calf with necrosis of muscle  L97.224  Non-pressure chronic ulcer of left calf with necrosis of bone  L97.225  Non-pressure chronic ulcer of left calf