evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Venous Angioplasty with or without Stent Placement for the Treatment of Chronic Cerebrospinal Venous Insufficiency (A56845)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Venous Angioplasty with or without Stent Placement for the Treatment of Chronic Cerebrospinal Venous Insufficiency.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must 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.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Article - Billing and Coding: Multiple Imaging in Oncology (A56848)
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) L35391, Multiple Imaging in Oncology. 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.
Article - Billing and Coding: MolDX: Percepta® Bronchial Genomic Classifier (A56849)
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, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual Publication 100-04 Medicare Claims Processing Manual, Chapter 23 Section 10 "Reporting ICD Diagnosis and Procedure Codes"Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: PerceptaBronchial Genomic Classifier L36854.To report a PerceptaBronchial Genomic Classifier service, please submit the following claim information:Select CPTcode 81479.Enter 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 837Box 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: Psychiatric Partial Hospitalization Programs (A56850)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Psychiatric Partial Hospitalization Programs.National Coverage Provisions:Professional Services Related to Psychiatric Partial Hospitalization:Note: The following billing requirements also apply to CMHC providers.(See CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 4, Section 260.1 [B].)The professional services listed below when provided in all hospital outpatient departments are separately covered and paid as the professional services of physicians and other practitioners. These professional services are unbundled and these practitioners bill the Medicare Part B carrier directly for the professional services furnished to hospital outpatient partial hospitalization patients. The hospital can also serve as a billing agent for these professionals by billing the Part B carrier on their behalf under their billing number for their professional services. The following direct professional services are unbundled and not paid as partial hospitalization services: Physician services that meet the criteria of 42 CFR 415.102, for payment on a fee schedule basis; Physician assistant (PA) services as defined in 1861(s)(2)(K)(i) of the Act; Nurse practitioner and clinical nurse specialist services, as defined in 1861(s)(2)(K)(ii) of the Act; and Clinical psychologist services as defined in 1861(ii) of the Act.
Article - Billing and Coding: Psychiatric Partial Hospitalization Programs (A56850)
The services of other practitioners (including clinical social workers and occupational therapists), are bundled when furnished to hospital patients, including partial hospitalization patients. The hospital must bill the contractor for such nonphysician practitioner services as partial hospitalization services. [P] ayment for the services [is made] to the hospital.See CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 4, Section 260.1.1[C] for billing requirements for CMHCs.Patients admitted to a partial hospitalization programmust require a minimum of 20 hours per week of therapeutic services, as evidenced by their plan of care.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must 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.Documentations Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. (See "Indications and Limitations of Coverage." in LCD) This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Upon admission, acertificationby the physician (MD/DO) must be made that the patient admitted to the partial hospitalization program would require inpatient psychiatric hospitalization if the partial hospitalization services were not provided and must include an attestation that the services are furnished while the individual is under the care of a physician, and that the services are furnished under an individualized written plan of care.
Article - Billing and Coding: Psychiatric Partial Hospitalization Programs (A56850)
Recertificationmust be signed by a physician who is treating the patient and has knowledge of the patient's response to treatment. The first recertification is required as of the 18 th day of partial hospitalization services. Subsequent recertifications are required at intervals established by the provider, but no less frequently than every 30 days[i.e., no less frequently than every 30 days following the first recertification which must be made as of the 18 th day of partial hospitalization services].The recertification must specify that the patient would otherwise require inpatient psychiatric care in the absence of continued stay in the partial hospitalization program and describe the following:
Article - Billing and Coding: Psychiatric Partial Hospitalization Programs (A56850)
The patient's response to the therapeutic interventions provided by the partial hospitalization program.The patient's psychiatric symptoms that continue to place the patient at risk of hospitalization.Treatment goals for coordination of services to facilitate discharge from the partial hospitalization program.Theinitial psychiatric evaluationwith medical history and physical examination must be performed and placed in the chart within 48 hours of admission in order to establish medical necessity for partial hospitalization services. If the patient is being discharged from an inpatient psychiatric admission to a partial hospitalization program, the psychiatric evaluation, medical history, and physical examination from that admission with appropriate update is acceptable. In order to support the medical necessity of admission to the partial hospitalization program, the documentation in the initial psychiatric evaluation should include the following items:Patient's chief complaint;Description of acute illness or exacerbation of chronic illness requiring admission;Current medical history, including medications and evidence of failure at or inability to benefit from a less intensive outpatient program;Past psychiatric and medical history;History of substance abuse;Family, vocational and social history, including documentation of an adequate support system to sustain/maintain the patient outside the partial hospitalization program;Mental status examination, including general appearance and behavior, orientation, affect, motor activity, thought content, long and short term memory, estimate of intelligence, capacity for self harm and harm to others, insight, judgment, capacity for activities of daily living (ADLs);Physical examination (if not done within the past 30 days and available for inclusion in the medical record);Formulation of the patient's status, including an assessment of the reasonable expectation that the patient will make timely and significant practical improvement in the presenting acute symptoms as a result of the partial hospitalization program;ICD-10-CM/DSM-IV-TR diagnoses, including all five axes of the multiaxial assessment as described in theDSM-IV-TR;Treatment plan, including long and short term goals related to the active treatment of the reason for admission, and types, amount, duration, and frequency of therapy services, including activity therapy, required to address the goals.
Article - Billing and Coding: Psychiatric Partial Hospitalization Programs (A56850)
A team approach may be used in developing the initial psychiatric evaluation, but the physician (MD/DO) must document the mental status examination, physical examination, formulation, diagnosis, treatment plan, and certification.Partial hospitalization is active treatment that incorporates an individualizedtreatment plan, which describes a coordination of services wrapped around the particular needs of the patient, and includes a multidisciplinary team approach to patient care. The treatment plan is established by the physician, in consultation with appropriate staff members, and should be reviewed according to the changing needs of the patient's acute psychiatric illness, but never less than every 31 days. The treatment plan should be reviewed more frequently if the severity of the clinical condition or changes in the clinical condition of the patient (e.g., change of medication) make it reasonable to do so. The long and short-term treatment goals described in the treatment plan are the basis for evaluating the patient's response to treatment. Treatment goals should be designed to measure the response to treatment, for this relationship will be used in determining whether services are medically necessary. The treatment goals should be measurable, functional, time-framed, and directly related to the reason for admission. The treatment plan must include the specific treatments ordered, including reference to psychotropic medication management, the expected timeframes and outcomes for each treatment, and the discharge plan.Section 1833(e) of the Social Security Act requires services to be documented in order for payment to be made. Therefore, a separate progress note is required for each service rendered (e.g., HCPCS or revenue code billed). The progress note should be written by the team member rendering the service and should include a description of the nature of the treatment service, the patient's status (behavior, verbalizations, mental status) during the course of the service, the patient's response to the therapeutic intervention and its relation to the long or short term goals in the treatment plan. Each progress note should be legible, dated and signed, and include the credentials of the rendering provider. Documentation of group therapy sessions must indicate the name of the group, group type, an indication of the material under discussion, and the patient's response to the treatment encounter.
Article - Billing and Coding: Laparoscopic Sleeve Gastrectomy for Severe Obesity (A56852)
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 32, 150.1 General, 150.2 HCPCS Procedure Codes for Bariatric Surgery, 150.3 ICD Procedure Codes for Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity (A/MACs only), 150.4 ICD Diagnosis Codes for Bariatric Surgery, 150.5 ICD Diagnosis Codes for BMI 35, 150.5.1 ICD Codes for Type II Diabetes Mellitus Complication, 150.6 Claims Guidance for Payment, 150.7 Medicare Summary Notices (MSNs) and Claim Adjustment Reason Codes and 150.8 B/MAC Billing RequirementsCMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity 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 Laparoscopic Sleeve Gastrectomy for Severe Obesity L34576.
Article - Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) (A56853)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual,Chapter 15, 80.1 Clinical Laboratory ServicesCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 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) forMolDX: Molecular Diagnostic Tests (MDT) L35025.To report a Molecular Diagnostic Test 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 formNOTE: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: HLA-DQB1*06:02 Testing for Narcolepsy (A56857)
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 100-02, Medicare Benefit Policy Manual, Chapter 15,80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual Publication 100-04 Medicare Claims Processing Manual, Chapter 23 Section 10 "Reporting ICD Diagnosis and Procedure Codes"Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: HLA-DQB1*06:02 Testing for Narcolepsy L36464.
Article - Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility (A56859)
CMS National Coverage PolicyCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Inpatient Hospital Billing, Chapter 3, Section 90 Billing Transplant ServicesTitle 42 CFR 412 Prospective Payment Systems for Inpatient Hospital ServicesArticle Text
Article - Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility (A56859)
Article TextMedicare covers the following solid organ transplants: kidney, heart, lung, heart/lung, liver, pancreas, pancreas/kidney, and intestinal/multi-visceral. Medicare also covers stem cell transplants for certain conditions.Claims for CPTcodes used to describe Human Leukocyte Antigen (HLA) testing used for transplant histocompatibility testing will be denied. See below for further explanation on correct billing for these services. This does not refer to HLA testing for non-transplant services.HLA testing for histocompatibility testing as part of transplantation are part of solid organ acquisition services.Services for organ transplants must be billed as described in theCenters for Medicare and Medicaid Services (CMS) Internet-Only Manual, Pub100-04, Medicare Claims Processing Manual, Inpatient Hospital Billing, Chapter 3 Section 90 and as described in the Electronic Code of Federal Regulations, Title 42, Public Health, Part 412 Prospective Payment Systems for Inpatient Hospital Services. The acquisition costs of hearts, kidneys, livers, lungs, pancreas, and intestines (or multivisceral organs) incurred by approved transplantation centers are paid on a reasonable cost basis by approved transplant centers; they are not billed as stand-alone laboratory services.HLA typing is a component of the acquisition services for an allogeneic stem cell transplant as well. Payment for these acquisition services is included in the MS-DRG payment for the allogeneic stem cell transplant when the transplant occurs in the inpatient setting and in the OPPS APC payment for the allogeneic stem cell transplant when the transplant occurs in the outpatient setting. The Medicare contractor does not make separate payment for these acquisition services, because hospitals may bill and receive payment only for services provided to the Medicare beneficiary who is the recipient of the stem cell transplant and whose illness is being treated with the stem cell transplant. Unlike the acquisition costs of solid organs for transplant (e.g., hearts and kidneys), which are paid on a reasonable cost basis, acquisition costs for allogeneic stem cells are included in prospective payment.Acquisition charges do not apply to autologous transplants.HLA CPTcodesunrelated to transplant testinghave coverage as outlined in the following Local Coverage Determinations (LCDs):
Article - Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility (A56859)
CPT81381 The MolDX: Pharmacogenomics Testing L38294 LCD addresses limited coverage for gene-drug interactions.CPT81383  The MolDX: HLA-DQB1*06:02 Testing for Narcolepsy L36464 LCD addresses non-coverage of HLA-DQB1*06:02 typing for the diagnosis or management of narcolepsy.
Article - Billing and Coding: Select Minimally Invasive GERD Procedures (A56863)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Select Minimally Invasive GERD Procedures.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included withintheLCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Article - Billing and Coding: Psychiatric Inpatient Hospitalization (A56865)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Psychiatric Inpatient Hospitalization.National Coverage Provisions:For services in an IPF (Inpatient Psychiatric Facility) to be designated as "active treatment," they must be:provided under an individualized treatment or diagnostic plan;reasonably expected to improve the patient's condition or for the purpose of diagnosis; andsupervised and evaluated by a physician.
Article - Billing and Coding: Psychiatric Inpatient Hospitalization (A56865)
Such factors as diagnosis, length of hospitalization, and the degree of functional limitation, while useful as general indicators of the kind of care most likely being furnished in a given situation, are not controlling in deciding whether the care was active treatment. Refer to 42 CFR 482.61 on "Conditions of Participation for Hospitals" for a full description of what constitutes active treatment(CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 2, Section 30.2.2.1).The services must be provided in accordance with an individualized program of treatment or diagnosis developed by a physician in conjunction with staff members of appropriate other disciplines on the basis of a thorough evaluation of the patient's -strengths and disabilities. The plan of treatment must be recorded in the patient's medical record in accordance with 42 CFR 412.27(c)(3) and the Conditions of Participation for Hospitals in 42 CFR 482.61.The services provided must reasonably be expected to improve the patient's condition or must be for the purpose of diagnostic study. It is not necessary that a course of therapy have as its goal the restoration of the patient to a level which would permit discharge from the institution although the treatment must, at a minimum, be designed both to reduce or control the patient's psychotic or neurotic symptoms that necessitated hospitalization and improve the patient's level of functioning(CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 2, Section 30.3.2).