evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers (A58998)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Minimal Residual Disease Testing for Cancer L38822.A Minimal Residual Disease (MRD) test, as defined in the related policy, is aservicethat may include multiple components and/or multiple timepoints (i.e., serial assays).Testing schedules are set based on the validity established for the individual test comprising the service.Each component and timepoint of the service must be reasonable and necessary and adhere to the criteria set forth in the policy. The medical record must contain clear documentation of the medical necessity of this test, as per the conditions outlined in the policy.The following tests have met the criteria for coverage under the policyManufacturerTestIndicated Uses and LimitationsAdaptive BiotechnologiesClonoSeqNote:An episode of testing typically requires a baseline assay and multiple follow-up assays.Acute lymphoblastic leukemia (ALL), Multiple myeloma (MM), and Chronic lymphocytic leukemia (CLL). Refer to CPT/HCPCS Group 2 for additional instructions and select the appropriate ICD-10 code listed under ICD-10 Codes that Support Medical Necessity Group 2 Codes.
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers (A58998)
This Table will be updated to reflect revisions and additions of newly covered tests.Coverage of CLONOSEQfor other cancer indications and episodes of care, and modifications to the definition of an episode of care will be evaluated as needed.Additional process requirements for coverage and billing:MolDX may make available specific forms to assist with test Technical Assessments (TAs). Please follow the instructions on the MolDX website to assist with this process. If such forms are available that pertain to the test type in question, these forms are required for successful coverage determinations.Single-gene PCR tests:For patients with or without cancer (as defined in the policy),established standard-of-careMRD tests using single-genePCR(i.e., BCR-ABL1)may be billed on an individual basis according to testing schedules outlined in national (i.e., NCCN) or society guidelines, with 1 UOS for each date of service.Refer to CPT/HCPCS Group 3 for additional instructions and select the appropriate ICD-10 code listed under ICD-10 Codes that Support Medical Necessity Group 3 Codes.Regarding single-gene and panel testing of genes  Refer to definitions and instructions in Billing and Coding: MolDX: Testing of Multiple Genes A57503 and Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) A56853
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers (A58998)
Regarding single-gene and panel testing of genes  Refer to definitions and instructions in Billing and Coding: MolDX: Testing of Multiple Genes A57503 and Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) A56853Other tests (i.e., ClonoSeq):For patients with cancer, the unit of service for this type of test is 1. Billing should occur at the start of the episode of testing. Regarding the use of NGS-based MRD tests (i.e., ClonoSeq) in patients with cancer Theservicemay be performed once per patient per cancer diagnosis, unless there is clinical evidence ofa priorichange in genetic content.For patients without cancer (as defined in the policy), a second kind of test may exist wherein asingletimepointmay constitute a single test (i.e., 1 UOS for a given date of service). Testing in these patients will be accompanied by the appropriate Personal history of cancer ICD-10 code. Testing may not be performed more than once in a month; the testing schedule is set based on the validity established of the individual test for the given indication.Refer to additional instructions outlined in the relevant Group sections below.Regarding NGS panels:To submit a claim for MRD analysis by NGS that measures multiple analytes, use CPT 81479 and one (1) UOS with the assigned DEX Z-Code.Billing instructions:Billing requires a Z-identifier code to be submitted with the claim. All tests must be registered with the DEX Diagnostic Exchange application.To report an episode of testing, please submit the following claim information:Select the appropriate CPTcode.If no specific CPT code exists for the test submitted, bill with the NOC code 81479.Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claim
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers (A58998)
Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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 formSelect the appropriate ICD-10-CM codeNOTE:When entering the DEX Z-Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers (A59004)
CMS National Coverage PolicyTitle XVIII of the Social Security Act 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Minimal Residual Disease Testing for Cancer L38835.A Minimal Residual Disease (MRD) test, as defined in the related policy, is a service that may include multiple components and/or multiple timepoints (i.e., serial assays).Testing schedules are set based on the validity established for the individual test comprising the service.Each component and timepoint of the service must be reasonable and necessary and adhere to the criteria set forth in the policy. The medical record must contain clear documentation of the medical necessity of this test, as per the conditions outlined in the policy.The following tests have met the criteria for coverage under the policyManufacturerTestIndicated Uses and LimitationsAdaptive BiotechnologiesClonoSeqNote:An episode of testing typically requires a baseline assay and multiple follow-up assays.Acute lymphoblastic leukemia (ALL), Multiple myeloma (MM), and Chronic lymphocytic leukemia (CLL) and Diffuse Large B-Cell Lymphoma (DLBCL). Refer to CPT/HCPCS Group 2 for additional instructions and select the appropriate ICD-10 code listed under ICD-10 Codes that Support Medical Necessity Group 2 Codes.This Table will be updated to reflect revisions and additions of newly covered tests.Coverage of CLONOSEQfor other cancer indications and episodes of care, and modifications to the definition of an episode of care will be evaluated as needed.Additional process requirements for coverage and billing:MolDX may make available specific forms to assist with test Technical Assessments (TAs). Please follow the instructions on the MolDX website to assist with this process. If such forms are available that pertain to the test type in question, these forms are required for successful coverage determinations.Single-gene PCR tests:
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers (A59004)
For patients with or without cancer (as defined in the policy), established standard-of-care MRD tests using single-gene PCR (i.e., BCR-ABL1) may be billed on an individual basis according to testing schedules outlined in national (i.e., NCCN) or society guidelines, with 1 UOS for each date of service. Refer to CPT/HCPCS Group 3 for additional instructions and select the appropriate ICD-10 code listed under ICD-10 Codes that Support Medical Necessity Group 3 Codes.Regarding single-gene and panel testing of genes  Refer to definitions and instructions in Billing and Coding: MolDX: Testing of Multiple Genes A57880 and Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) A57772.Other tests (i.e., ClonoSeq):For patients with cancer, the unit of service for this type of test is 1. Billing should occur at the start of the episode of testing. Regarding the use of NGS-based MRD tests (i.e., ClonoSeq) in patients with cancer. Theservicemay be performed once per patient per cancer diagnosis, unless there is clinical evidence ofa priorichange in genetic content.For patients without cancer (as defined in the policy), a second kind of test may exist wherein asingle timepointmay constitute a single test (i.e., 1 UOS for a given date of service). Testing in these patients will be accompanied by the appropriate Personal history of cancer ICD-10 code. Testing may not be performed more than once in a month; the testing schedule is set based on the validity established of the individual test for the given indication.Refer to additional instructions outlined in the relevant Group sections below.Regarding NGS panels:To submit a claim for MRD analysis by NGS that measures multiple analytes, use CPT81479 and one (1) UOS with the assigned DEX Z-Code.Billing instructions:Billing requires a Z-identifier code to be submitted with the claim. All tests must be registered with the DEX Diagnostic Exchange application.To report an episode of testing, please submit the following claim information:
Article - Billing and Coding: MolDX: Minimal Residual Disease Testing for Hematologic Cancers (A59004)
Select the appropriate CPTcode. If no specific CPT code exists for the test submitted, bill with the NOC code 81479.Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A 837PBox 19 for paper claimEnter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode 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 formSelect the appropriate ICD-10-CM codeNOTE:When entering the DEX Z-Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Off-Label Use of Chemotherapeutic Drugs and Biologicals for Non-Cancer Indications (A59006)
CMS National Coverage PolicyN/AArticle TextOff-label (unlabeled) drug is defined as a use for a non-FDA approved indication that is not listed on the drug's official label/prescribing information. Off-label use is further defined as giving the drug in a way that deviates significantly from the labeled prescribing information for a particular indication. This includes but is not necessarily limited to, dosage, route of administration, duration, and frequency of administration, and population to whom the drug would be administered.Indication is defined as a diagnosis, illness, injury, syndrome, condition, or other clinical parameter for which a drug may be given.For the off-label (unlabeled) use of drugs and biologicals for indications that are not part of an anti-cancer chemotherapeutic regime CGS will consider coverage on case to case basis per CMS IOM 100-02, Chapter 15, 50.4.2 Unlabeled Use of Drugs. Inclusion of these drugs and biologicals in a compendium does not guarantee coverage, but the compendium recommendation will be considered as part of the review.The following may be submitted to support the coverage with the claim:Submission of compendium reference if availableFull text support articles for use of the agent for the indicationSocietal recommendations
Article - Off-Label Use of Chemotherapeutic Drugs and Biologicals for Non-Cancer Indications (A59006)
Submission of compendium reference if availableFull text support articles for use of the agent for the indicationSocietal recommendationsThe medical records must document the rationale for the off-label use of the agent.If a cancer chemotherapy drug /biologic use is identified as not indicated by the Centers for Medicare and Medicaid Services (CMS) or the FDA or if CGS determines that peer-reviewed medical literature does not support the off-label usage, the drug/biologic is not covered.List the appropriate J or Q to indicate the drug name. When a specific HCPCS code does not exist, list the appropriate NOC code J3490, J3590, or J9999 with the drug name, and dose in the remarks field of the claim Item 19 of the CMS-1500 form for claims billed to the Part B MAC.For Part A, claims with C9399 are suspended, and remarks should be placed on the claim in field locator 80 for the UB04 claim form or SV202-7 for 837I electronic claim.Facilities under the hospital OPPS may use code C9399, billed as one unit, if it does not have an assigned HCPCS or the assigned HCPCS is not yet effective.Note:Claims billed to the Part B MAC with C9399 will be rejected.Claims billed with a NOC drug code are suspended and the following should be provided on the claim in the following fields:Field locator 80 for paper claims /line SV202-7 for electronic claims for Part A.Box 19 for paper claims/loop 2400 or SV101-7 for Part B.Claims billed for Not Otherwise Classified (NOC) codes need to include the following information in the fields listed above:Name of the drugDose administered (mg, cc, etc.)Route of administration (IV, IM, SC, PO, etc.)NDC number if availableThe invoice price (for new drugs if the wholesale acquisition cost (WAC) is unavailable, or for compounded drugs).
Article - Off-Label Use of Chemotherapeutic Drugs and Biologicals for Non-Cancer Indications (A59006)
The JW modifier is required for wastage in single-dose vials; this modifier does not apply to multi-dose vials per CMS Internet-Only Manual, Pub 100-04, Chapter 17, Section 40 Discarded Drugs and Biologicals (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c17.pdf).
Article - Billing and Coding: MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia (A59015)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia.To receive a denial, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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 formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: Surgical Treatment of Nails (A59028)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 20.9 National Correct Coding Initiative (NCCI)Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) forSurgical Treatment of Nails L39258.Coding GuidelinesWhen billing for non-covered services, use the appropriate modifier.When CPTcode 11730, 11732 or 11750 is reported, it represents all services performed on that nail for that date of service (DOS).When lateral and medial sides of a nail are involved, do not report a separate code for each border.Reporting CPTcodes 11730 or 11732 (avulsion) with CPTcode 11750 (excision) and/or 11765 (wedge resection) for the same digit on the same DOS is not correct coding.Reporting CPTcode 11750 (excision) with CPTcode 11765 (wedge resection) for the same digit on the same DOS is not correct coding.Reporting CPTcode 11765 for the removal of a small piece of the skin and/or the nail without local anesthesia is not correct coding.If CPTprocedure codes 11730, 11750, or 11765 are performed on different nails, report the procedure performed with 1 unit of service (UOS) and append with the appropriate identifying digit modifiers.For every subsequent avulsion, CPTcode 11732 is reported as the add-on code with 1 UOS and the appropriate identifying digit modifier appended.CPT codes 11730 and 11732 for partial or complete nail avulsion, if billed for the same finger less than 16 weeks or the same toe less than 32 weeks, must include the following criteria:For a medically reasonable and necessary repeat nail excision on the same finger or toe. The medical record documentation must be specific as to the indication, such as ingrown nail of the opposite border or new significant pathology on the same border recently treated;
Article - Billing and Coding: Surgical Treatment of Nails (A59028)
For a medically reasonable and necessary repeat nail avulsion of the same toenail or fingernail performed more often than every 32 weeks (8 months) for toenails or every 16 weeks (4 months) for fingernails. The medical record documentation must be specific as to the indication, such as ingrown nail of the opposite border or new significant pathology on the same border recently treated.
Article - Billing and Coding: Hyaluronic Acid Injections for Knee Osteoarthritis (A59030)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claimCMS Internet-Only Manual, Pub. 100-04, Medicare ClaimsProcessing Manual,Chapter 12,30.6.7(D) Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201-99215) -Drug Administration Services and E/M Visits Billed on Same Day of ServiceCMS Internet-Only Manual, Pub. 100-04, Medicare ClaimsProcessing Manual,Chapter 17,40 Discarded Drugs and Biologicals and90.2 Drugs, Biologicals, and RadiopharmaceuticalsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Hyaluronic Acid Injections for Knee OsteoarthritisL39260.*Note:The prescribing information for the dose and frequency of administration should be consistent with theUnited States (U.S.) Food and Drug Administration (FDA) approved labeling.Billing subsequent injections in a series (EJ modifier):Use EJ modifier with the HCPCS code for the drug administered to indicate subsequent injections of a series. Do not use this modifier for the first injection of each series. A series is defined as a set of injections for each joint and each treatment.JW Modifier Requirement:Effective January 1, 2017, the Centers for Medicare and Medicaid Services (CMS) issued CR 9603, regarding the use of the JW modifier for discarded Part B drugs and biologicals. Providers are required to use the JW modifier for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded (except those provided under the CAP for Part B drugs and biologicals). Document the discarded drug or biological in the patients medical record when submitting claims with unused Part B drugs or biologicals from single use vials or single use packages that are appropriately discarded.Billing the injection procedure:
Article - Billing and Coding: Hyaluronic Acid Injections for Knee Osteoarthritis (A59030)
The CPTcode (procedure code) 20610 or 20611 (with ultrasound guidance) may be billed for the intra-articular injection in addition to the drug.If an aspiration and an injection procedure are performed at the same session, bill only 1 unit for CPTcode 20610 or 20611.When additional substances simultaneously administer (e.g., cortisone, anesthetics) with viscosupplementation, only 1 injection service is allowed per knee.The appropriate site modifier (RT or LT) must be appended to CPTcode 20610 or CPTcode 20611 to indicate if the service was performed unilaterally and modifier (50) must be appended to indicate if the service was performed bilaterally.An Evaluation and Management (E&M) service may be appropriate if the decision to start the series of injections is made after an evaluation during the same visit. Indicate this by using an E&M code with modifier -25.An E&M service should not be reported for subsequent injections unless there was a separately identifiable problem for which the E&M service was required and rendered.
Article - Billing and Coding: MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia (A59032)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia.To receive a denial, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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-Code identifier adjacent to the CPTcode 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 formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia (A59034)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia.To receive a denial, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode 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-Code identifier adjacent to the CPTcode 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 formSelect the appropriate ICD-10-CM code