evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Home PT/INR Monitoring (G0249) Billing and Coding (A55754)
CMS National Coverage PolicyN/AArticle TextNoridian is issuing this coding and billing guidance as it relates to the National Coverage Determination for Home Prothrombin Time/International Normalized Ration (PT/INR) Monitoring for Anticoagulation Monitoring (NCD 190.11) and is in no way a change in coverage as outlined in the NCD and MLN Matters articles.This NCD provides coverage for home testing of the PT/INR for those beneficiaries who meet the criteria for coverage in the NCD language.For the purpose of billing and coding the following guidelines are promulgated and are effective immediately.The coverage is for one home test per week. For the purpose of this direction a week is considered a calendar week, Sunday through Saturday.Providers may only bill Noridian for this service when the fourth test is completed and the results submitted to the treating physician. In the event the beneficiary either withdraws from home testing, dies or transfers to a Medicare Advantage or similar program, a claim for partial billing is allowed when appended with a -52 modifier. Noridian will pay a pro-rated amount based on the number of tests fully completed and reported to the treating physician. No payment is available for unused tests. As use of this code G0249 is for completion of four INR services, in the rare event that it is known services will not continue and a claim must be filed for fewer, use the code with the modifier -52 appended and decrement the charge in direct proportion to the number that have been completed (75%, 50% or 25%). For such partial billings submit the following claim information:The number of tests completed shall be 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 claimThe number of tests completed shall be 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: Home PT/INR Monitoring (G0249) Billing and Coding (A55754)
The number of tests completed shall be 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 form2. Noridian realizes that on rare occasions a beneficiary may inadvertently test twice in one week or may elect to test early for the next week due to personal situations. These exceptions may be allowed as long as the clinical records indicate a reasonable cause for the early testing and no more than four tests in four weeks are submitted. Such early testing is not expected to be the norm and does not allow for payment for more than 4 tests (one unit of service (UOS) in four weeks.3. Should a situation occur where the beneficiary needs additional testing, for example an abnormal INR on a home test, such added home testing is not covered using the G0249 code. The beneficiary may be tested in the physicians office or a clinical lab in the usual manner for outpatient testing. If they prefer to do a repeat home test(s) and such is approved by their provider and a written order received, payment for such extra tests are the responsibility of the beneficiary. Noridian recommends that an ABN be given to the patient and the appropriate ABN modifier appended to any claim with the extra tests.4. A Unit of Service is four tests. One unit of G0249 is therefore four tests which have been completed and reported to the provider over a period of four weeks or greater. The billing date of service is either on or after the completion and reporting of the fourth test.Sources:CMS Internet Only Manual (IOM), Publication Medicare National Coverage Determination (NCD); Part 2,Section 190.11.CMSChange Request 6397, Dated March 4, 2009-April Update to the 2009 Medicare Physician Fee Schedule Database (MPFSDB)
Article - Billing and Coding: Home PT/INR Monitoring (G0249) Billing and Coding (A55756)
CMS National Coverage PolicyN/AArticle TextNoridian is issuing this coding and billing guidance as it relates to the National Coverage Determination for Home Prothrombin Time/International Normalized Ration (PT/INR) Monitoring for Anticoagulation Monitoring (NCD 190.11) and is in no way a change in coverage as outlined in the NCD and MLN Matters articles.This NCD provides coverage for home testing of the PT/INR for those beneficiaries who meet the criteria for coverage in the NCD language.For the purpose of billing and coding the following guidelines are promulgated and are effective immediately.1. The coverage is for one home test per week. For the purpose of this direction a week is considered a calendar week, Sunday through Saturday.Providers may only bill Noridian for this service when the fourth test is completed and the results submitted to the treating physician. In the event the beneficiary either withdraws from home testing, dies or transfers to a Medicare Advantage or similar program, a claim for partial billing is allowed when appended with a -52 modifier. Noridian will pay a pro-rated amount based on the number of tests fully completed and reported to the treating physician. No payment is available for unused tests. As use of this code G0249 is for completion of four INR services, in the rare event that it is known services will not continue and a claim must be filed for fewer, use the code with the modifier -52 appended and decrement the charge in direct proportion to the number that have been completed (75%, 50% or 25%). For such partial billings submit the following claim information:The number of tests completed shall be 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 claimThe number of tests completed shall be 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: Home PT/INR Monitoring (G0249) Billing and Coding (A55756)
The number of tests completed shall be 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 form2. Noridian realizes that on rare occasions a beneficiary may inadvertently test twice in one week or may elect to test early for the next week due to personal situations. These exceptions may be allowed as long as the clinical records indicate a reasonable cause for the early testing and no more than four tests in four weeks are submitted. Such early testing is not expected to be the norm and does not allow for payment for more than 4 tests (one unit of service (UOS) in four weeks.3. Should a situation occur where the beneficiary needs additional testing, for example an abnormal INR on a home test, such added home testing is not covered using the G0249 code. The beneficiary may be tested in the physicians office or a clinical lab in the usual manner for outpatient testing. If they prefer to do a repeat home test(s) and such is approved by their provider and a written order received, payment for such extra tests are the responsibility of the beneficiary. Noridian recommends that an ABN be given to the patient and the appropriate ABN modifier appended to any claim with the extra tests.4. A Unit of Service is four tests. One unit of G0249 is therefore four tests which have been completed and reported to the provider over a period of four weeks or greater. The billing date of service is either on or after the completion and reporting of the fourth test.Sources:CMS Internet Only Manual (IOM), Publication Medicare National Coverage Determination (NCD); Part 2,Section 190.11.CMSChange Request 6397, Dated March 4, 2009-April Update to the 2009 Medicare Physician Fee Schedule Database (MPFSDB).
Article - Wound care (L37166): Medicare Part A/B local coverage determination (LCD) comment summary (A55757)
CMS National Coverage PolicyN/AArticle Text
Article - Wound care (L37166): Medicare Part A/B local coverage determination (LCD) comment summary (A55757)
Comments received:Comment #1:A common issue was on the proposed noncoverage of disposable negative pressure wound therapy (dNPWT) devices (CPT codes 97607 and 97608) and how one reference was omitted from the local coverage determinations (LCD) Sources of Information section: Armstrong et al. 2012 study. There were multiple comments expressing disagreement with the noncoverage of the disposable NPWT devices. Even though the available literature is not of good quality since it has sponsor bias, for appropriately-selected patients, these devices are highly effective and achieve better patient compliance since they allow more mobility to the patient and are more convenient than NPWT that utilizes durable medical equipment (DME).Also, there were several comments stating that disposable NPWT (97607/8) has been a covered benefit for Medicare beneficiaries under First Coast Service Options (First Coast) jurisdiction since 2014 when NPWT was removed from the Noncovered Services LCD (L33777).Contractor response:First Coast agrees that the available literature is not of high quality due to some of the reasons identified in comment #1. The Armstrong 2012 reference was inadvertently left off of the draft, but it was evaluated by First Coast Medical Policy staff in 2013 and was considered low in quality of evidence for several factors (e.g., small sample size, lack of comparator, numerous patients lost to follow-up, author bias two of the authors received funding by the sponsors of the study: Spiracur (manufacturer at the time) for the SNAP device and KCI for the VAC device.) The Armstrong 2012 study will be added to the LCD when it is finalized. The Contractor also recognizes studies show disposable NPWT may be just as effective as the traditional NPWT, and it has been determined that there will be access to coverage for NPWT utilizing durable medical equipment or non-durable medical equipment in appropriately selected patients.In response to the removal of disposable NPWT codes from the Noncovered Services LCD, CPT codes 97607-97608 were removed from the LCD in 2013 to gather more data on these services. A service or procedure that is removed from noncoverage or not addressed in the Noncovered Services LCDdoes
Article - Wound care (L37166): Medicare Part A/B local coverage determination (LCD) comment summary (A55757)
notprovide positive coverage and is given individual consideration on a case-by-case basis. Thus, dNPWT was not given positive coverage by the First Coast jurisdiction when it was removed from the Noncovered Services LCD.Comment #2:A few commenters requested clarification of the use of wet-to-dry and dry-to-dry dressings as they state are no longer the standard of care.Contractor response:Clarification is provided on judicious use and efficacy of wet-to-dry and dry-to-dry dressings.Comment #3:When Unna Boot is applied and a wound debridement is performed, the LCD does not allow for both, but CCI allows for both if an appropriate modifier/different site is applicable. If for a separate condition and same anatomical site, this should be allowed.Contractor response:The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services Chapter 4, section G states that debridement codes (11042-7, 97597) should not be reported with a strapping code (29580, 29581) for the same anatomic area. After consideration, this language would be more appropriate for a coding article rather than the LCD since it relates more to billing and coding information and does not address reasonable and necessary considerations for coverage. A coding article will be developed for provider guidance and posted when the policy becomes effective.Comment #4:A number of commenters suggested clarification regarding paring or cutting of corns / non-plantar calluses. Commenters stated that regardless of pathology, when an ulcer is present, appropriate wound care is indicated and should be covered.Contractor response:This language in the Limitations section was taken directly from our existing wound debridement services LCD (L33566). There have not been any reconsideration requests to remove or revise this limitation. However, we appreciate the comment and agree that once there is skin breakdown underneath a corn or non-plantar callus, it becomes an ulcer and may require debridement. Therefore, the limitations addressing ulcers which may arise after paring or cutting of corns or non-plantar calluses as not reasonable and necessary wound debridement services have been removed from the finalized LCD.
Article - Wound care (L37166): Medicare Part A/B local coverage determination (LCD) comment summary (A55757)
Comment #5:Numerous comments were submitted requesting removal of debridement frequency limitation. Commenters stated that patients may require more than eight services in a year depending on many different factors. Commenters stated current literature does not support a specific number of debridements for proper wound care but rather debridements should be specific to the wound to encourage healing.Contractor response:Data analysis illustrates that a minority of patients receiving wound care actually receive more than eight debridements involving debridement of subcutaneous tissue, muscle/ fascia or bone in a rolling 360 day period. While it is recognized that some patients have an unusual and prolonged course of wound healing and / or palliation, debridements of an unusually excessive number should be accompanied by meticulous documentation illustrating that the service performed is both medically reasonable and necessary. It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. Utilization of more than eight debridements in a rolling 360 day period may be subject to pre or post payment medical review (records requested).Comment #6:Several comments were received requesting removal of the documentation requirement regarding photographs. Commenters requested clarification on whether photographs are required. Commenters stated requiring photographs could become an unnecessary burden to providers.Contractor response:Photographic documentation for wounds has been amended to suggestions for best practices in wound care. First Coast recognizes that photographic submission is not possible in many cases but may be particularly beneficial as an adjunct to document wound healing, particularly in wounds which are more extensive in nature or require prolonged or repetitive services.Comment #7:While there is an agreement that the initial debrided bone sample should have a pathology report, subsequent bone removal would not necessitate additional pathology, which is increasing costs without a medical benefit. Only the initial pathology is required.Contractor response:Pathology requirements mandating reporting of debridement codes of fascia and bone have been amended to guidelines for documentation. Submission of pathology codes may be particularly beneficial in initial debridements of muscle/ fascia or bone and in wounds requiring prolonged or excessive care.Comment #8:Comments were submitted requesting removal of the frequency limitation for Negative Pressure Wound Therapy (NPWT). Comments reflected concern that the frequency limitations were arbitrary, and the draft policy bibliography did not support the clinical or scientific basis for the limitation.
Article - Wound care (L37166): Medicare Part A/B local coverage determination (LCD) comment summary (A55757)
Comment #8:Comments were submitted requesting removal of the frequency limitation for Negative Pressure Wound Therapy (NPWT). Comments reflected concern that the frequency limitations were arbitrary, and the draft policy bibliography did not support the clinical or scientific basis for the limitation.Contractor response:Wounds heal at varying degrees and are affected by various factors. While the frequency of application of NPWT is generally recommended at two to three times per week, data analysis of application of NPWT illustrates that a minority of beneficiaries of wound care will actually receive more than six applications in a four month period in order to achieve the desired objective in the care of the wound. Wounds which require prolonged and excessive application of NPWT devices should be accompanied by meticulous documentation illustrating that the service is both medical necessary and reasonable. It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. Utilization of more than six NPWT applications in a four month period may be subject to pre or post payment medical review (records requested).Comment #9:A number of commenters requested clarification regarding wound care dressing changes and skills of physicians, podiatrist, physical therapists, occupational therapists, or wound care nurses. Commenters stated the policy implied that providers listed in the following statement would not be reimbursed for services should they remove and perform a subsequent reapplication of a dressing: Dressing changes (removal and subsequent reapplication) alone do not require the skills of physicians, podiatrists, physical therapists, occupational therapists or wound care nurses and in fact are usually performed by non-physician providers.Contractor response:Dressing changes (removal and subsequent reapplication) alone generally do not require the skills of physicians. They may be performed by physical therapists, occupational therapists, licensed professional nurses, or wound care nurses. The LCD has been amended to provide clarification.Comment #10:All references in the LCD should refer to Podiatrists as physicians and not distinguish between the two.Contractor response:Podiatrists are defined as physicians alongside doctors of medicine and osteopathy. The final LCD was amended to remove the reference about podiatrists.
Article - Wound care (L37166): Medicare Part A/B local coverage determination (LCD) comment summary (A55757)
Contractor response:Podiatrists are defined as physicians alongside doctors of medicine and osteopathy. The final LCD was amended to remove the reference about podiatrists.Comment #11:A number of commenters requested clarification of what would be considered experimental or investigational since the policy states, Wound debridement utilizing experimental or investigational methods is considered not reasonable and necessary. Therefore, it would not be reasonable and necessary to report these services with any CPT code.Contractor response:As stated under the History/Background section of the LCD, any method which is unproven by valid scientific literature would be considered not reasonable and necessary.Comment #12:Multiple comments were received requesting rewording of language pertaining to palliative wound care. Commenters offered concern that the language in the draft policy suggests abandonment of patients who require palliative care.Contractor response:The language in the policy has been changed to clarify that the optimal objective for wound therapy is progressive healing of the wound. Multiple factors, etiologies, and co-morbid conditions affect healing, and wound care for palliation may serve a role in avoiding prolonged hospitalizations.Comment #13:Several commenters requested clarification of language in the History section regarding wound care performed by the patient or the patients caregiver. Commenters said the draft policy is correct in most cases but asked for clarification regarding patients for whom it is not the case that, a wound will reach a state at which its care should be performed primarily by the patient and/or the patients caregiver with periodic physician assessment and supervision.Contractor response:The LCD will be clarified as follows: While complete healing of the wound may be the primary objective, a secondary desired objective is that, with appropriate management, a wound may reach a state at which its care may be performed primarily by the patient and/or the patients caregiver with periodic physician assessment and supervision.
Article - Wound care (L37166): Medicare Part A/B local coverage determination (LCD) comment summary (A55757)
Comment #14:The Documentation Requirements section states that a patients expected restoration potential must be significant in relation to the extent and duration of treatment required in achieving this potential. If wound closure is not a reasonable goal, then the expectation is to optimize recovery and establish an appropriate non-skilled maintenance program. This requirement appears to violate the American Disability Act for patients with spinal cord injuries, motor neuron disease, demyelinating disease, visual impairment from diabetic retinopathy, severe arthritis, strokes, mild dementia, etc. All of these patients would be incapable of caring for their wounds and recognizing serious events. In other words, a non-skilled maintenance program is not possible in the absence of a Federal mandate, which compels family members to provide this care. This assumes the patient has an immediate family to compel.Contractor response:Medicare coverage is defined by reasonable and necessary criteria per Social Security Act section 1862 (a) 1(A).This statement is an expectation; it does not preclude a skilled maintenance program or palliative wound care when reasonable and necessary.Comment #15:Several commenters requested the following specific requirements pertaining to wound healing be removed from the policy because even though the concept of a wound healing trajectory has been popularized, it cannot be generalized to all clinical scenarios: Wound volume or surface dimension should decrease by at least ten percent per month or Wounds will demonstrate granulation tissue advancement of no less than one mm/week.Contractor response:Wounds heal at varying rates and are affected by various factors. An allusion referring to the rate of healing of the wound will be removed from the LCD.Comment #16:Several commenters requested clarification regarding the following statement regarding the use of anesthesia for CPT codes 97597-97598: This procedure typically requires no anesthesia and there is generally no bleeding associated with it. Commenters stated there is no need to include statements about bleeding in this policy.Contractor response:Medically reasonable and necessary use of the various anesthesia modalities, if needed, is at the discretion of the provider. Also, the reference about bleeding tissue has been clarified.Comment #17:A number of commenters requested removal of dermatologic conditions under Wound Care Surgical Debridements (eczema, bullous skin diseases, etc.) as these are not related to wounds.