evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea (A57149)
CMS National Coverage PolicyN/AArticle TextRefer to the Local Coverage Determination (LCD) L38307, Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, for reasonable and necessary requirements.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.Coding GuidelinesImplantationof a Hypoglossal Nerve Stimulator (HSN) for treatment of OSA utilizes 2 CPT codes:Beginning 01/01/2022use single code:CPT 64582Open implantation of hypoglossal nerve stimulator array, pulse generator, and distal respiratory sensor electrode or electrode arrayCoding InformationEffective 1/1/22 CPT code 64568 is no longer used for hypoglossal nerve stimulator due to development of specific CPT codes for this technology 64582-64584Documentation 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 diagnosis code(s).Informational Only:Removal, revisions and replacements related to implantable devices are addressed inMedicare Benefit Policy Manual, Chapter 16, Section 180, Services Related to and Required as a Result of Services Which Are Not Covered Under MedicareEffective 1/1/22 0466T, 0467T and 0468T are deleted codes. Services for revision, replacement or removal of hypoglossal nerve stimulator components should be billed with:CPT 64583Revision or replacement of hypoglossal nerve stimulator array and distal respiratory sensor electrode or electrode array, including connections to existing pulse generatorCPT 64584removal of hypoglossal nerve rose stimulator array pulse generator, and distal respiratory sensor electrode or electrode array
Article - Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea (A57149)
Utilization GuidelinesIn accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Draft Article - Billing and Coding: MolDX: SelectMDx for Prostate Cancer (DA57153)
CMS National Coverage PolicyN/AArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: SelectMDx for Prostate Cancer(DL38247).To report a SelectMDX for Prostate 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: Blood Product Molecular Antigen Typing (A57155)
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: Blood Product Molecular Antigen Typing L38249.Blood product antigen typing is a germline test and the use of panels 0001U and 0084U will be limited to once in a beneficiary lifetime.The individual codes 0180U-0201U, 0221U and 0222U and codes 81105-81112 are also germline tests. These will be noncovered as multiple antigens must be utilized as part of a comprehensive antigen evaluation and will be considered only as part of a panel.To report aBlood Product Molecular Antigen Typingservice, please submit the following claim information:Select the appropriate CPTor PLA codeEnter unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPT code 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 CPT code 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: Immune Thrombocytopenia (ITP) Therapy (A57160)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Immune Thrombocytopenia (ITP) Therapy (A57160)
This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L38268-Immune Thrombocytopenia (ITP) Therapy.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. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Advance Beneficiary Notice of Non-coverage (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.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.
Article - Billing and Coding: Immune Thrombocytopenia (ITP) Therapy (A57160)
Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.
Article - Billing and Coding: Immune Thrombocytopenia (ITP) Therapy (A57160)
Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
Article - Billing and Coding: Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs) (A57161)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A). Allows coverage and payment for only those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act, 1833(e). Prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.CMS Manual System, Pub. 100-03,Medicare National Coverage Determinations Manual,Chapter 1, Part 4, 250.4.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.1) CPT codes 17106, 17107 and 17108 describe treatment of lesions that are usually cosmetic. When using these CPT codes the clinical records should clearly document the medical necessity of such treatment and why the procedure is not cosmetic.2) CPT codes 11055, 11056 and 11057 describe treatment of hyperkeratotic lesions (e.g., corns and calluses). Coverage for these three codes is described in the Medicare Internet Only Manual.
Article - Billing and Coding: Benign Skin Lesion Removal (Excludes Actinic Keratosis, and Mohs) (A57162)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A). Allows coverage and payment for only those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act, 1833(e). Prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.CMS Manual System, Pub. 100-03,Medicare National Coverage Determinations Manual,Chapter 1, Part 4, 250.4.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.1) CPT codes 17106, 17107 and 17108 describe treatment of lesions that are usually cosmetic. When using these CPT codes the clinical records should clearly document the medical necessity of such treatment and why the procedure is not cosmetic.2) CPT codes 11055, 11056 and 11057 describe treatment of hyperkeratotic lesions (e.g., corns and calluses). Coverage for these three codes is described in the Medicare Internet Only Manual.
Article - Billing and Coding: MolDX: Melanoma Risk Stratification Molecular Testing (A57165)
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 Codes.CMS 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) forMolDX: Melanoma Risk Stratification Molecular Testing DL38016.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
Draft Article - Billing and Coding: MolDX: Razor 14-Gene Lung Cancer Assay (DA57171)
CMS National Coverage PolicyN/AArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: Razor 14-Gene Lung Cancer Assay(DL38284).To report a Razor 14-Gene Lung Cancer Assay 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
Draft Article - Billing and Coding: MolDX: Pharmacogenomics Testing (DA57175)
CMS National Coverage PolicyN/AArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: Pharmacogenomics Testing(DL38394).To report a Pharmacogenomics 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: Transesophageal Echocardiogram (A57179)
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) L33756, Transesophageal Echocardiogram. 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.If the service of the cardiologist is requested for a specific reason, his professional services would be billed with CPT 93314 or 93317 with the 26 modifier.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 transesophageal echocardiography studies 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 physician's order for the studies. When ordering transesophageal echocardiography studies, the ordering/referring physician must state the reason for the study in his order.An order from the treating physician/nonphysician practitioner as required by CFR, Title 42, Volume 2, Chapter IV, Part 410.32(a) Ordering diagnostic tests.
Article - Billing and Coding: Allergy Testing (A57181)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1862(a)(7) and 42 Code of Federal Regulations, 411.15, exclude routine physical examinations.Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Manual System, Pub. 100-03,Medicare National Coverage Determinations Manual,Chapter 1, Part 2, 110.11; food allergy testing and treatment.CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 12, 200; allergy testing and immunotherapy.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Documentation RequirementsIt is expected that supportive documentation evidencing the condition and treatment will be documented in the medical record and be available to the Contractor upon request.Documentation, such as ICD-10-CM codes, supporting the medical necessity of the service must be submitted with each claim. Claims submitted without such evidence will be denied as not medically reasonable and necessary.Utilization GuidelinesThe evaluation of an inhalant may require up to 90 prick-puncture tests followed by up to 40 intracutaneous tests which are usually performed when prick/puncture tests are negative.Sometimes 60 intracutaneous tests performed via multi test, in lieu of prick puncture, may be appropriate for selected patients (for example young children, older adults and needle phobic individuals.)The number of percutaneous tests performed for the evaluation of food sensitivity may require up to 40 tests.The total number of tests, i.e. prick or intracutaneous, should not exceed generally accepted standards of testing set forth by professional associations. Exceeding these parameters may be justified if preliminary testing failed and immunotherapy failed to control symptoms.
Article - Billing and Coding: Allergy Testing (A57181)
In California, for CPT code 95004, among patients treated by Allergists, over half required fewer than 100 tests. The great majority required less than 120-130 tests, and only 5% required more than 200 tests. Some of the high-test group includes repeat testing necessitated by unsatisfactory response to clinical treatment and a clinical need for further investigation. For CPT code 95024, among patients treated by Allergists, over half required only 12 tests, and only 5% required 70 or more tests. High-utilization testing may be selected for medical review when inconsistent with clinical practice norms.
Article - Billing and Coding: Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography (A57183)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1862(a)(7) and 42 Code of Federal Regulations, Section 411.15, exclude routine physical examinations.Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 13, 50-50.4, and CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 12, 20.4.4, allows for a separate payment for the supply of a radiopharmaceutical diagnostic imaging agent and/or pharmacologic stressing agent with diagnostic nuclear medicine procedures.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 15, 50. This section specifies coverage for drugs and biologicals.CMS Manual System, Pub. 100-03,Medicare National Coverage Determinations Manual,Chapter 1, 20.10; Supplies, regarding pharmaceutic stressing agents. (Repealed 02/22/2010,see Pub. 100-04, Ch. 32, 140.)The Code of Federal Regulations (CFR), 42 CFR 410.32, specifies that all diagnostic tests must be ordered by the physician who is treating the beneficiary.Section 4317(b), of the Balanced Budget Act (BBA) of 1997, specifies that referring physicians are required to provide diagnostic information to the testing entity at the time the test is ordered.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 15, 80.6.1; Requirements for Ordering and Following Orders for Diagnostic Tests and Definitions.CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 12, 30.6.6.B, clarifies coverage for preoperative evaluations.
Article - Billing and Coding: Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography (A57183)
CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 12, 30.6.6.B, clarifies coverage for preoperative evaluations.CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 13, 20, 20.1, 20.2, 20.2.2, 20.2.3, 20.3.1 and 20.3.2; Payment conditions for Radiology Services.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 15, 80, Requirements for Diagnostic X-Ray, Diagnostic Laboratory and other Diagnostic Tests sets forth the various levels of physician supervision required for diagnostic tests.CMS Manual System, Pub.100.04,Medicare Claims Processing Manual,Chapter 32, 140.1, 140.1.1, 140.2, 140.2.2.1, 140.2.2.3, 140.2.2.4, 140.2.2.5, 140.2.2.6, 140.3, 140.3.1., Cardiac Rehabilitation.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Supportive documentation evidencing the condition and treatment is expected to be documented in the medical record and be available upon request.Documentation in the patients medical record must substantiate the medical necessity of the service, including the following: A clinical diagnosis, The specific reason for the study, Reason for performing a stress echocardiogram as opposed to only an electrical stress test, The reason for using any pharmacological stress, and The reason for a stress echocardiogram if a stress nuclear test is also performed for the same patient for the same clinical condition.Document the referral order (written or verbal) in the patients medical record. For example, if a referring physician calls a cardiologist to order a stress echocardiogram, the test report or office record must document the date of the call, name of the referring physician, and reason for referral.Document the interpretation and report of all segments of the service (e.g., the electrical and echo results).Document the necessity for the test frequency, when applicable.Document (preferably on the test report) that any applicable physician supervision requirement is met.