evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Lab: Cystatin C Measurement (A56948)
Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Cystatin C Measurement L37581.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.The medical record documentation must support the medical necessity of the services as directed in the related LCD.The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition (ICD-10-CM code) that warrants the test(s).Examples of documentation requirements of the ordering physician/non-physician practitioner (NPP) include, but are not limited to, history and physical or exam findings that support the decision making, problems/diagnoses, relevant data (e.g., lab testing).Medical record documentation must support cystatin C test was performed on an adult patient with creatinine based eGFR 4559 ml/min/1.73 m2 who does not have markers of kidney damage.Medical record documentation must clearly indicate the rationale which supports the medical necessity for performing eGFR by measurement of cystatin C (i.e., support GFR estimates based on serum creatinine are thought to be inaccurate and what decisions depend on more accurate knowledge of the GFR) and must reflect how the test results were used in the patients plan of care.To report a cystatin C service, please submit the following claim information:Select CPTcode 82610Enter 1 unit of service (UOS)Select the appropriate ICD-10-CM code
Article - Billing and Coding: Lab: Cystatin C Measurement (A56948)
To report a cystatin C service, please submit the following claim information:Select CPTcode 82610Enter 1 unit of service (UOS)Select the appropriate ICD-10-CM codeNote: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this article. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
Article - Billing and Coding: MolDX: Breast Cancer Assay: Prosigna® (A56949)
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 LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Breast Cancer Assay: ProsignaL36125.To report a Prosignaservice, please submit the following claim information:Select CPTcode 81520Enter 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: Cardiology Non-emergent Outpatient Stress Testing (A56952)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Title XVIII of the Social Security Act, Section 1834(e)(1)(B). Claims for the technical component of advanced diagnostic imaging services.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38396 Cardiology Non-Emergent Outpatient Stress Testing. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Current Procedural Terminology (CPT) code 78434 should be reported in conjunction with CPT code 78431 or 78492.Evaluation of the individuals left ventricular wall motion and ejection fractions are routinely performed during SPECT MPI and are included in the codes definition.Attenuation correction, when performed, is included in the MPI service.Documentation Requirements
Article - Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing (A56952)
Attenuation correction, when performed, is included in the MPI service.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.If the provider of the service is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physicians order for the studies.The ordering physician must state the clinical indication/medical necessity for the study in the order for the test.Documentation must be maintained by the referring physician in the beneficiarys medical record that the required conditions (as indicated in the Coverage Indications, Limitations and/or Medical Necessity section of the LCD) for the stress test performed have been met.The rationale for selecting pharmacologic stress testing rather than exercise stress testing must be documented in the medical record.In the instance where regional wall motion abnormalities and ejection fraction have been assessed during the same episode of care by other testing modalities (e.g., echocardiography), the medical necessity of repeating this assessment through the use of nuclear imaging modalities must be clearly documented in the medical record.All segments of the service must have a formal interpretation and report.
Article - Billing and Coding: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (A56953)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38398, Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Implantationof a Hypoglossal Nerve Stimulator (HNS) for treatment of Obstructive Sleep Apnea (OSA) is reported with:CPT code 64582 -Open implantation of both the neurostimulator and its corresponding electrode array.Revision or Replacementof HNS for treatment of OSA is reported with:CPT code 64583- Revision or replacement of chest wall respiratory sensor electrode or electrode array, including connection to existing pulse generator.Replacementof HNS for treatment of OSA is reported with:Per AMA CPT, useCPT code 61886for the Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays.Removalof HNS for treatment of OSA is reported with:CPT code 64584- Removal of chest wall respiratory sensor electrode or electrode array.Documentation Requirements
Article - Billing and Coding: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (A56953)
Removalof HNS for treatment of OSA is reported with:CPT code 64584- Removal of chest wall respiratory sensor electrode or electrode array.Documentation RequirementsAll documentation must be maintained in the patients medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
Article - Billing and Coding: Osteopathic Manipulative Treatment (A56954)
CMS National Coverage PolicyN/AArticle TextThis article contains codingandother guidelines that complement the local coverage determination (LCD) for Osteopathic Manipulative Treatment.Coding Guidelines: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 patients condition for which the service was performed.
Article - Billing and Coding: Osteopathic Manipulative Treatment (A56954)
Specific Coding Guidelines:According to the NCCI Policy Manual for Medicare Services, Chapter I, General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services, E&M services are only separately payable with OMT services when there is a significant, separately identifiable E&M service.Documentation RequirementsThe medical record should support the medical necessity of osteopathic manipulative treatment as taught in the United States Osteopathic Medical Schools and made available to Medicare upon request.The documentation should clearly identify the body regions affected and treated with OMT in order to justify the procedure code billed and the medical necessity of the service being performed. Medical records must be made available upon request.Documentation of examination findings of somatic dysfunction should describe pathology in the areas of the skeletal, arthrodal and myofascial structures as well as related vascular, lymphatic and neural elements when present. One or more of the elements of TART (see above) should be documented in each region of somatic dysfunction treated with OMT. The selection of body regions to which OMT is applied should reflect the regions of documented somatic dysfunction.There may be instances when multiple regions are treated due to the presence of compensatory changes. When this occurs, the documentation should describe the compensatory changes and the rationale for treating this area. The type, frequency and duration of OMT should be consistent with current standards of medical practice.Functional improvement or decline should be documented using objective measures. This is especially true for the treatment of somatic dysfunction in patients with chronic, persistent conditions.If a significant, separately identifiable evaluation and management service above and beyond the osteopathic manipulation service is provided, this must be indicated by reporting modifier 25 to the E&M service code. OMT utilized at a follow-up visit is not the same as follow-up OMT. A follow-up visit for OMT is a predetermined service and a follow-up visit where OMT is utilized is not necessarily predetermined unless the preceding progress note denoted it to be an OMT visit.Utilization Guidelines
Article - Billing and Coding: Osteopathic Manipulative Treatment (A56954)
Utilization GuidelinesThe number of regions treated during any one session will depend upon the history, examination and medical decision-making utilized to determine medical necessity of the most appropriate intervention. Each OMT service billed must include an indication of the patients pre and post treatment status.Only one OMT service should be billed per day, based on the description of the procedure code.The type, frequency and duration of services must be reasonable and consistent with the standards of practice in the medical community.Medicare defines the reasonableness of therapies based on the ability to "treat illness and improve function". If a response is not noted within a reasonable timeframe, by the physician, then other treatment options should be considered. The following are treatment guidelines and not rules:Acute phase OMT should be individualized and performed as necessary during the first month, but will typically be no more than once per week. If there is failure to progress then a re-evaluation of the patient and assessment of treatment and diagnostic considerations may lead to modifications.Subacute phase OMT should be performed as necessary to maintain the improvement trend but at less frequent intervals unless there are extenuating circumstances that are documented in the medical record. Once the patients condition has plateaued, any further treatment enters the chronic phase.Chronic phase OMT involves chronic illness or conditions (such as chronic pain syndrome with depression, postCVA spasticity, post-polio syndrome, progressive neurodegenerative disorders and malignant disease), and should be provided as necessary, for functional benefit, but is not expected to be more than one or two times per month unless explained in the medical record. It is the expectation that the patients ongoing symptomatology is adequately medically investigated if the treatment is protracted.It is understood that there can be exacerbations of chronic conditions, which can and should be treated to return the patient to a level of maximum functioning.It is appropriate to perform OMT on a patient who is hospitalized when the physician determines it is medically necessary to the patients treatment. The medical record should support this treatment decision.
Article - Billing and Coding: ProMark® Risk Score (A56957)
CMS National Coverage PolicyCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims,60.1.2 Independent Laboratory Specimen Drawing,60.2 Travel AllowanceTitle 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. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for ProMarkRisk Score L36665.To report a ProMarkassay service, please submit the following claim information:Select CPTcode 81479Enter 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 ICD-10-CM code C61
Article - Billing and Coding: MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease (A56959)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual, Publication 100-04 Medicare Claims Processing Manual, Chapter 23, 10 "Reporting ICD Diagnosis and Procedure Codes"CMS Internet-Only Manual, Publication 100-04 Medicare Claims Processing Manual, Chapter 12, 30 Correct Coding PolicyArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Genetic Testing for BCR-ABL Negative Myeloproliferative Disease L36044. For single genes performed by NGS, these tests must demonstrate compliance with L38047 MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies and its accompanying billing and coding article, A54795 Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Next-Generation Sequencing Testing in Cancer.To report Genetic Testing for BCR-ABL Negative Myeloproliferative Disease service, please submit the following claim information:Select appropriate CPTcodeEnter 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 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 - Billing and Coding: MolDX: Melanoma Risk Stratification Molecular Testing (A56961)
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, 10 Reporting ICD Diagnosis and Procedure CodesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Melanoma Risk Stratification Molecular Testing L37725.To report a molecular diagnostic service, please submit the following claim information:Select the 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: MolDX: NRAS Genetic Testing (A56962)
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 claimCMSInternet-Only Manual, Pub.100-08, Medicare Benefit Policy Manual, Chapter 3,  3.4.1.3, Diagnosis Code RequirementsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: NRAS Genetic Testing L35073.To report a NRAS Genetic Testing service, 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: MolDX: EndoPredict Breast Cancer Gene Expression Test (A56963)
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 Manuals, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: EndoPredict Breast Cancer Gene Expression Test L37264.To report an EndoPredict service, please submit the following claim information:Select CPTcode 81522Enter 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