evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach (0192T 66183) (A52432)
The anatomic modifiers left (-LT) or right (-RT) should be appended to the procedure code. The -50 modifier is not to be appended to this code as two eyes should not be done on the same day.Only CPT code 0192T should be reported for insertion of the anterior segment aqueous drainage device for dates of service July 1, 2008 thru December 31, 2013. Effective January 1, 2014 CPT code 66183 should be reported for insertion of the anterior segment aqueous drainage device. . Do not report CPT codes 66170, 66172, 66180 or other procedure codes formerly used for the insertion of this device.For claims submitted to the Part B MAC:Claims for 0192T/66183 are payable under Medicare Part B in the following places of service: office (11), inpatient hospital (21), outpatient hospital (22), ambulatory surgical center (24) and independent clinic (49).For claims submitted to the Part A MAC:Hospital Inpatient Claims:The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04.The principal diagnosis is the condition established after study to be chiefly responsible for this admission.The hospital enters ICD-10-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04,Medicare Claims Processing Manual,Chapter 25, Section 75 for additional instructions.)Hospital Outpatient Claims:The hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67.If no definitive diagnosis is made during the outpatient evaluation, the patients symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the providershould report an ICD-10-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9).
Article - Billing and Coding: Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach (0192T 66183) (A52432)
The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.
Article - Health and Behavior Assessment/Intervention – Medical Policy Article (A52434)
CMS National Coverage PolicyN/AArticle TextAbstract:"Health and Behavior Assessmentprocedures are used to identify the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment or management of physical health problems. The focus of the assessment is not on mental health but on the biopsychosocial factors important to physical health problems and treatments."1Health and Behavior Interventionprocedures are used to modify the psychological, behavioral, emotional, cognitive, and social factors directly affecting the patient's physiological functioning, health and well being, or specific disease-related problems.Health Behavior Assessment and Intervention (HBAI) services described by CPT codes 96156, 96158, 96159, 96164, 96165, 96167, and 96168, and any successor codes, are billed by clinical social workers, marriage and family therapists (MFTs), and mental health counselors (MHCs), in addition to clinical psychologists.Indications:The Health and Behavioral Assessment, initialand Reassessment and Intervention services may be considered reasonable and necessary for the patient who meetsallof the following criteria:The patient has an underlying physical illness or injury, andThere are indications that biopsychosocial factors may be significantly affecting the treatment or medical management of an illness or an injury, andThe patient is alert, oriented and has the capacity to understand and to respond meaningfully during the face-to-face encounter, andThe patient has a documented need for psychological evaluation or intervention to successfully manage his/her physical illness, and activities of daily living, andThe assessment is not duplicative of other provider assessmentsIn addition, for a reassessment to be considered reasonable and necessary, there must be documentation that there has been a sufficient change in the mental or medical status warranting re-evaluation of the patient's capacity to understand and cooperate with the medical interventions necessary to their health and well being.Health and Behavioral Intervention, individual or group (2 or more patients)require that:Specific psychological intervention(s) and patient outcome goal(s) have been clearly identified, andPsychological intervention is necessary to address:
Article - Health and Behavior Assessment/Intervention – Medical Policy Article (A52434)
Specific psychological intervention(s) and patient outcome goal(s) have been clearly identified, andPsychological intervention is necessary to address:Non-compliance with the medical treatment plan, orThe biopsychosocial factors associated with a new diagnosed physical illness, or an exacerbation of an established physical illness, when such factors affect symptom management and expression, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to medical illness.Health and Behavioral Intervention (with the family and patient present)is considered reasonable and necessary for the patient who meets all of the following criteria:The family representative* directly participates in the overall care of the patient, andThe psychological intervention with the patient and family is necessary to address biopsychosocial factors that affect compliance with the plan of care, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to medical illness.*For the purpose of this policy, all references to a family representative is defined as immediate family members only (i.e., husband, wife, siblings, children, grandchildren, grandparents, mother, and father), any primary caregiver who provides care on a voluntary, uncompensated, regular and sustained basis, or a guardian or healthcare proxy.Limitations:Health and Behavioral Assessment/Intervention will not be considered reasonable and necessary for the patient who:Does not have an underlying physical illness or injury, orFor whom there is no documented indication that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or injury (i.e., screening medical patient for psychological problems), orDoes not have the capacity to understand and to respond meaningfully during the face to face encounter, because of:
Article - Health and Behavior Assessment/Intervention – Medical Policy Article (A52434)
Dementia that has produced a severe enough cognitive defect for the psychological intervention to be ineffective.DeliriumSevere and profound mental retardationPersistent vegetative state/no discernible consciousness,Impaired mental status, e.g.,disorientation to person, time, place, purpose, orinability to recall current season, location of own room, names and faces, orinability to recall that he or she is in a nursing home or skilled nursing facilityDoes not require psychological support to successfully manage his/her physical illness through identification of the barriers to the management of physical disease and activities of daily living, orFor whom the conditions noted under the indications portion of this section are not met.Health and Behavioral Intervention with the family and patient present will not be considered reasonable and necessary for the patient if:It is not necessary to ensure patient compliance with the medical treatment plan, orThe family representative does not directly participate in the plan of care, orThe family representative is not present.There is no face to face encounter with the patient.Because it does not represent a diagnostic or treatment service to the patient, there is no coverage for CPT codes 96170, 96171.Health and Behavioral Intervention services are not considered reasonable and necessary to:Update or educate the family about the patient's conditionEducate family members, primary care-givers, guardians, the health care proxy, or other members of the treatment team, e.g., health aides, nurses, physical or occupational therapists, home health aides, personal care attendants and co-workers about the patient's care plan.Assist in treatment-planning with staffProvide family psychotherapy or mediationEducate diabetic patients and diabetic patients' family membersDeliver Medical Nutrition TherapyMaintain the patient's or family's existing health and overall well-beingProvide personal, social, recreational, and general support services. Although such services may be valuable adjuncts to care, they are not medically necessary psychological interventions.Examples of services not covered as health and behavioral interventions are:
Article - Health and Behavior Assessment/Intervention – Medical Policy Article (A52434)
Examples of services not covered as health and behavioral interventions are:Stress management for support staffReplacement for expected nursing home staff functionsMusic appreciation and relaxationCraft skill trainingCooking classesComfort care servicesIndividual social activitiesTeaching social interaction skillsSocialization in a group settingRetraining cognition due to dementiaGeneral conversationServices directed toward making a more dynamic personalityConsciousness raisingVocational or religious adviceGeneral educational activitiesTobacco or caffeine withdrawal supportVisits for loneliness reliefSensory stimulationGames, including bingo gamesProjects, including letter writingEntertainment and diversionary activitiesExcursions, including shopping outings, even when used to reduce a dysphoric stateTeaching grooming skillsGrooming servicesMonitoring activities of daily livingTeaching the patient simple self-careTeaching the patient to follow simple directivesWheeling the patient around the facilityOrienting the patient to name, date, and placeExercise programs, even when designed to reduce a dysphoric stateMemory enhancement trainingWeight loss managementCase management services including but not limited to planning activities of daily living, arranging care or excursions, or resolving insurance problemsActivities principally for diversionPlanning for milieu modificationsContributions to patient care plansMaintenance of behavioral logs
Article - Health and Behavior Assessment/Intervention – Medical Policy Article (A52434)
Biofeedback is coded as 90901 and will not be covered as a health and behavioral intervention.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 describe the patient's condition for which the service was performed.Advance Beneficiary Notice of Noncoverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04,Medicare Claims Processing Manual,Chapter 30, for complete instructions.If the initial health and behavior assessment or reassessment is unable to be completed during a single encounter, the date of service indicated on the claim should be the date on which the interview was finalized.For health and behavior assessment and/or intervention services performed by a physician, clinical nurse specialist (CNS), or nurse practitioner (NP), Evaluation and Management (E&M) or Preventive Medicine services codes should be used.Services to patients for evaluation and treatment of mental illnesses should be coded using a psychiatric services CPT code (90801-90899).For patients that require psychiatric services (CPT codes 90801-90899) as well as health and behavior assessment/intervention (96156, 96167, 96168), report the predominant service performed.The patient's medical record must contain documentation that fully supports the medical necessity for services included within this 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.Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned.
Article - Health and Behavior Assessment/Intervention – Medical Policy Article (A52434)
Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned.Because of the impact on the medical management of the patient's disease, documentation must show evidence of coordination of care with the patient's primary medical care providers or medical provider responsible for the medical management of the physical illness that the psychological assessment/intervention was meant to address.Documentation in the medical record must include:a. For the initial assessment, evidence to support that the assessment is reasonable and necessary, and must include, at a minimum, the following elements:
Article - Health and Behavior Assessment/Intervention – Medical Policy Article (A52434)
Date of initial diagnosis of physical illness, andClear rationale for why assessment is required, andAssessment outcome including mental status and ability to understand and respond meaningfully, andGoals and expected duration of specific psychological intervention(s), if recommended.b.For re-assessment, detailed progress notes to support that the reassessment is reasonable and necessary must include the following elements:Date of change in mental or physical statusSufficient rationale for why re-assessment is required, and,Clear indication of any precipitating events that necessitate re-assessmentc. For the intervention service, evidence to support that the intervention is reasonable and necessary must include, at a minimum, the following elements:Evidence that the patient has the capacity to understand and to respond meaningfullyClearly defined psychological intervention plannedThe goals of the psychological interventionThe expectation that the psychological intervention will improve compliance with the medical treatment planThe response to the interventionRationale for frequency and duration of servicesFor all claims, the time duration (stated in minutes) spent in the health and behavioral assessment or intervention encounter must be documented in the record.Documentation must be available to Medicare upon request.Sources of Information:This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.Current Procedural Terminology, CPT 2009Program Memorandum, Expanded Coverage of Diabetes Outpatient Self-Management Training, CR 1455, June 15, 2001Program Memorandum, Medical Nutrition Therapy for Beneficiaries with Diabetes or Renal Disease, CR 1776, August 7, 2001Carrier Advisory Committee Psychiatry Working GroupCPT Changes,"An Insider's View", 2002, American Medical Association, pages 218-220.
Article - Billing and Coding: Osteopathic Manipulative Treatment (A52435)
CMS National Coverage PolicyN/AArticle TextOsteopathic manipulative treatment (OMT) is a treatment employed, primarily by osteopathic physicians, to facilitate a patients recovery from somatic dysfunction, defined under the American Osteopathic Associations Glossary of Terminology as: impaired or altered function of related components of the somatic (body framework) system: skeletal, arthroidal and myofascial structures and related vascular, lymphatic and neuroelements. The positional and motion aspects of somatic dysfunction are best described using at least one of three parameters: 1. The position of a body part as determined by palpation and reference to its adjacent defined structure, 2. The direction in which motion is freer, and 3. The direction in which motion is restricted.Osteopathic manipulative treatment includes muscle energy, high velocity-low amplitude, counterstrain, myofascial release, visceral, and craniosacral. The chosen treatment will vary depending on patients age and clinical condition.Indications of CoverageOsteopathic Manipulative Treatment is covered when medically necessary and performed by a qualified physician, in patients whose history and physical examination indicate the presence of somatic dysfunction of one or more regions.Note:Osteopathic Manipulative Treatment(OMT) specifically encompasses only the procedure itself.Evaluation and management(E&M)services may be reported seperately using modifier -25 if the patient's condition requires a significant and identifiable E&M service which is above and beyond the usual pre and post service work associated with the OMT procedure; and it is appropriately documented.While the E&M service may be caused or prompted by the same symptoms or condition for which the OMT service was provided; documentation for the E&M must support this was a distinct and seperate purpose from the OMT evaluation and treatment.Different diagnoses are not required for the reporting of the OMT and E&M on the same date.Limitations of CoverageOsteopathic Manipulative Treatment is not covered when the indication of Coverage is not met, and conventional documentation of somatic dysfunction is not present in the patient's medical record
Article - Billing and Coding: Osteopathic Manipulative Treatment (A52435)
Limitations of CoverageOsteopathic Manipulative Treatment is not covered when the indication of Coverage is not met, and conventional documentation of somatic dysfunction is not present in the patient's medical recordNote: No E&M service is warranted for planned follow-up OMT treatments unless a new condition occurs or the patients condition has changed substantially, necessitating an overall reassessment.
Article - Billing and Coding: Sentinel Lymph Node Biopsy – Medical Policy Article (A52437)
CMS National Coverage PolicyN/AArticle TextSentinel lymph node biopsy involves the identification, removal, and evaluation of lymph nodes that drain the area of a malignant tumor. One or more lymphatic channels or basins, each of which has its own sentinel node, may drain any primary tumor site. When a sentinel node in a given chain is free of tumor cells, it may be assumed that the remainder of the lymph nodes in that lymphatic channel is also free of cancer. When tumor cells are identified in a sentinel node, it suggests that cancer has spread to other nodes, indicating that a regional lymph node dissection may be necessary to assess the extent of metastasis.Methods used to identify sentinel node include use of lymphoscintigraphy and/or direct visualization during surgery following an injection of vital dye (e.g., isosulfan blue). Lymphoscintigraphy is a nuclear medicine procedure performed prior to the surgical procedure to locate the sentinel node (s) for the surgeon. It is performed by injecting a radioactive tracer under the skin, which flows toward and into the sentinel node and its lymphatic channel and may be imaged by a gamma camera that produces a map of the path of the radioactive tracer and its first appearance in the sentinel node. This is injected several hours before surgery. A Gamma probe is used during surgery to locate the area of the sentinel node. A vital dye may be used during surgery to visualize the lymphatic channels, allowing more effective use of the gamma probe. Thus these techniques are complimentary.
Article - Billing and Coding: Sentinel Lymph Node Biopsy – Medical Policy Article (A52437)
The vital dye is selectively taken up by the lymphatic vessels that drain the tumor site and stains them blue. Multiple injections are usually made at equidistant points around the primary lesion shortly before surgery. If a radioactive tracer has not been injected and a gamma probe is not used, the dissection will begin along the blue-stained vessels that are closest to the primary dye injection site. When radioactive tracer has been injected pre-operatively, the surgeon may use a portable, hand-held gamma-ray detection instrument to aid in identification and confirmation of a sentinel node. When held to the sentinel node, the level of radioactivity registers at very high levels. (This process, called intraoperative lymphoscintigraphy, is included in the biopsy procedure and is not reported separately). Once located, the sentinel node is removed and sent to the pathology department for appropriate microscopic evaluation.Sentinel node biopsy can provide accurate staging information that can be used to determine and refine treatment options. It may also identify the presence of metastasis. An additional advantage of sentinel node biopsy is that if the sentinel node(s) is negative for tumor, a complete lymphadenectomy, with its increased morbidity, may be avoided.Coding Guidelines:General Guidelines for claims submitted to Part A or Part B MAC: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.The sentinel node excision is reported using the appropriate code from among CPT codes 38500, 38510, 38525 and 38530, and may be billed only with NOS of 001 regardless of the number of nodes excised.Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines