evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Proton Beam Therapy (A55315)
Definitions:Q0- Investigational clinical service provided in a clinical research study that is in an approved clinical research study. Investigational clinical services are defined as those items and services that are being investigated as an objective within the study. Investigational clinical services may include items or services that are approved, unapproved, or otherwise covered (or not covered) under Medicare.Q1- Routine clinical service provided in a clinical research study that is in an approved clinical research study. Q1 replaces QV. Routine clinical services are defined as those items and services that are covered for Medicare beneficiaries outside of the clinical research study; are used for the direct patient management within the study; and, do not meet the definition of investigational clinical services. Routine clinical services may include items or services required solely for the provision of the investigational clinical services (e.g.,administration of a chemotherapeutic agent); clinically appropriate monitoring, whether or not required by the investigational clinical service (e.g., blood tests tomeasure tumor markers); and items or services required for the prevention, diagnosis, or treatment of research related adverse events (e.g., blood levels of variousparameters to measure kidney function).GA Item or serviceis expected to be denied as not reasonable and necessary.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.
Article - Billing and Coding: Proton Beam Therapy (A55315)
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.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.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.
Article - Billing and Coding: Proton Beam Therapy (A55315)
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.
Article - Billing and Coding: Implantable Infusion Pumps for Chronic Pain (A55323)
CMS National Coverage PolicyN/AArticle TextAn implanted infusion pump for chronic pain is covered by Medicare when used to 1) administer opioid drugs, singly or in combination with other opioid or non-opioid drugs, 2) intrathecal or epidural route; 3) for treatment of severe chronic intractable pain of malignant or nonmalignant origin in patients who have a life expectancy of at least three (3) months, and 4) the pain has been proven to be unresponsive to less invasive medical therapy.In order to be considered medically reasonable and necessary, all of the following criteria must be met and clearly documented in the beneficiarys medical record:The administration of the medication must require the intrathecal or epidural route and be effective on a long-term basis andOral or subcutaneous medication treatment are ineffective or complicated by unacceptable side effects andThe patient's medical condition must require the use of an infusion pump for pain relief due to failure of other treatment modalities andThe type and dosage of the medication must reasonably be expected to alleviate or reduce the pain effects.In addition, an evaluation by an orthopedic surgeon, neurologist, neurosurgeon, oncologist or other specialist familiar with the underlying disease is required to validate that other treatments have failed to alleviate the pain and no other reasonable options are available at the time of the evaluation. Documentation that the patient is unresponsive to less invasive medical therapy shall be kept in the patient's medical record and made available upon Medical Review request.If the above criteria have been met, a preliminary trial of intraspinal opioid or non-opioid drug administration must be undertaken with a temporary intrathecal/epidural catheter to substantiate acceptable pain relief, degree of side effects including effects on the activities of daily living, and patient acceptance and compliance.Any drug(s) used to fill the implantable pump must be appropriate for the treatment of the individual patient. Drugs compounded for the special needs of a patient may be covered. Drugs filling the pump are often obtained singly or mixed with other drugs from compounding pharmacies. Unless the medications are administered in the exact concentrations available from national pharmaceutical companies, the medications will be considered as compounded.
Article - Billing and Coding: Implantable Infusion Pumps for Chronic Pain (A55323)
FDA approved drugs used for indications other than what is accepted on the official Prescribing Information label may be covered under Medicare if the contractor determines the use to be medically accepted, taking into consideration the major drug compendia, authoritative medical literature, and/or accepted standards of medical practice. The following are examples of medications that are approved for off-label intrathecal use.This list of drugs is not an all-inclusive list.Clonidine (Duraclon) (J0735-KD)Bupivacaine (J3490-KD)Sufentanil (J3490-KD)Methadone (J1230-KD)Contraindications to coverage: Implantation of an infusion pump is contraindicated under the following circumstances:1.The patient has a known allergy or hypersensitivity to the drug being used;2. Patients who have an infection in particular an infection at or near the implantation site; and3. Patients whose body size is insufficient to support the weight and bulk of the device.The patients medical record documentation must support the reasonable and necessary requirements as outlined under the indications and limitations of coverage. The patients history must indicate that he/she has not responded adequately to noninvasive methods of pain control such as:Systemic opioids;orCombination of oral analgesics (including opioids) plus other drugs known to relieve pain such as:muscle relaxants,clonidine,anti-depressants,anti-seizure medicationorothers known to medicate pain; orAttempts to eliminate physical and behavioral abnormalities which may cause an exaggerated reaction to pain.All of the procedure codes that are related to the refilling and the management of the pump must be billed and documented on the same claim form, including the drugs that are being administered through the pump. The drugs are not to be billed on a separate claim form.IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 17 - Drugs and Biologicals atChapter 17 MCPM.Chapter 32 Billing Requirements for Special Services atChapter 32 MCPM.At the time of the pump refill and/or the pump interrogation and/or the pump reprogramming, documentation should include at a minimum:The pump status before and after the refill,The patients response to the current medication dose and rate,
Article - Billing and Coding: Implantable Infusion Pumps for Chronic Pain (A55323)
The pump status before and after the refill,The patients response to the current medication dose and rate,The reasons for any change in dose or the types of medications,A reassessment of the patient's overall condition and treatment goals (this may be reported as an E&M service),Proof that all applicable "incident to" requirements are met, andProof that any medication billed to Medicare represents a cost to the physician or group accepting Medicare payment.A preliminary trial of the intrathecal/epidural opioid drug or non-opioid administration must be undertaken with a temporary intrathecal/epidural catheter to substantiate adequate acceptable pain relief. The degree of side effects (including the effects on the activities of daily living) and the patients acceptance of and compliance with the therapy must be documented in the patient's record.Legible physicians medical documentation must be maintained in the patients medical record and meet the criteria contained in this article. The subsequent determination that the medical record is lacking the justification for the services and/or that the documentation of the services are illegible will result in a denial as not reasonable and necessary.A periodic reassessment of the patient should be performed according to the needs of the patient and the applicable medical standards. The frequency for interrogating and/or reprogramming the pump (62367 and 62368) should be supported by the patient's symptoms. The frequency for refill must take into account the size of the pump and dosage of the medicine. Noridian has seen problems in the past that included unnecessary frequency of interrogation and refills of the pump every month despite having a pump of 2 or 3 month capacity.
Article - Billing and Coding: Implantable Infusion Pumps for Chronic Pain (A55323)
Compounded drugs are contractor priced under Medicare Part B. Noridian will reimburse compounded drugs for use in implanted infusion pumps by multiplying the price per mcg or mg in the table below by the total number of mcg or mg of each drug used to refill the pump. In addition to the combined allowable calculated by the dosage detailed, a pharmacy compounding fee of $60 per refill will be included in the total allowable for the refill. When these drugs are provided in the hospital outpatient department by providers paid under OPPS, no separate payment is made for these drugs. The payment allowance is packaged into the payment for other services provided on the claim.Drug NameDrug FeeMeasureBaclofen$0.0030per mcgBupivacaine$0.0400per mgClonidine$0.0010per mcgDroperidol$0.0013per mcgFentanyl PF$0.0072per mcgHydromorphone$0.1300per mgKetamine$0.0048per mcgLidocaine$0.0400per mgMeperidine$0.0600per mgMethadone$0.0600per mgMidazolam Hcl$1.1500per mgMorphine Sulfate$0.0500per mgRopivacaine$0.068per mgSufentanyl$0.0900per mcgTetracaine$0.0400per mgZiconotide$9.041per mcgCompounding Fee$60.000per cartridgeResources
Article - Billing and Coding: Implantable Infusion Pumps for Chronic Pain (A55323)
Sufentanyl$0.0900per mcgTetracaine$0.0400per mgZiconotide$9.041per mcgCompounding Fee$60.000per cartridgeResourcesAngel IF, Gould HJ, Carey ME. Intrathecal morphine pump as a treatment option in chronic pain of nonmalignantorigin.Surg Neurol.Jan 1998;49(1):92-8.Chang HM. Chronic Pain, Cancer Pain Management.Med. Clinics of North America. May 1999;83(3):712-36.May 1999;83(3):712-36.Dougherty P, Staats PS. Intrathecal Drug Therapy for Chronic Pain: From Basic Science to Clinical Practice.Anesthesiology. Dec 1999;91(6):1891-918.Fanciullo GJ, Rose RJ, Lunt PG, Whalen PK, Ross E. The state of implantable pain therapies in the United States: anationwide survey of academic teaching programs.Anesth Analg.Jun 1999;88(6):1311-6.Gilmer-Hill HS, Boggan JE, Smith KA, Frey CF, Wagner FC, Eein LS. Intrathecal morphine delivered viasubcutaneous pump for intractable pain in pancreatic cancer.Surg Neurol.Jan 1999:51(1):6-11.
Article - Billing and Coding: Zika Virus Testing by PCR and ELISA Methods (A55326)
CMS National Coverage PolicyN/AArticle TextFor calendar year 2018 CMS has adopted the new 2018 AMA CPT codes for Zika virus testing. For dates of service 1/1/2018 and forward providers should bill using these new codes. For dates of service prior to 1/1/2018 the previous instructions will still apply.Testing for the Zika virus must follow the Food and Drug Administration (FDA) and CDCP guidelines. This article does not address medical necessity but rather proper coding for claims submission.Claims submissions should utilize the coding instructions below regardless of the specimen source. In the narrative section of the claim form (Part A Loop 2300/NTE for EMC claims, or Form Locator 80 on the CMS 1450 form or paper claims, Part B Loop 2400/SV101-7 for EMC claims, or Item 19 on the CMS 1500 form for paper claims) please enter the following verbiage (without quotation marks) as it pertains to the respective tests.For Claims submitted prior to 1/1/2018 use the following guidance:Zika rRT-PCR only  Use CPT 87999 and enter Zika PCR in the narrative field regardless of the CDCP approved proprietary test utilized*Trioplex rRT-PCR  Use CPT 87999 and enter Zika Trioplex*anti-Zika immunoglobulin (IgM)  Use CPT 86790Dengue rRT-PCR only  use CPT 87798Chikungunya rRT-PCR only - use CPT 87798If billing for both Dengue and Chikungunya rRT-PCR  use CPT 87801 once.If a plaque reduction neutralization test (PRNT) is indicated, that testing must be conducted by CDC or by a PRNT laboratory designated by CDC to do confirmatory PRNT testing for the Zika response. The claim for PRNT testing is not submitted to Medicare.Items 1, 2 and 3 above require an FDA Emergency Use Authorization to the respective laboratory. Noridian retains the right to be sent a copy of the respective labs EUA upon request.For claims submitted with dates of service on or after 1/1/2018 use the following instructions:
Article - Billing and Coding: Zika Virus Testing by PCR and ELISA Methods (A55326)
Zika rRT-PCR only - Use CPT 87662Zika virus IgM - Use CPT 86794Dengue rRT-PCR only - use CPT 87798Chikungunya rRT-PCR only - use CPT 87798If billing for both Dengue and Chikungunya rRT-PCR - use CPT87801 once.Diagnosis coding should include at least one of the following ICD-10 codes:CodeDescriptionA92.5Zika virus disease [effective for DOS on or after October 1, 2016]B30.9Viral conjunctivitis, unspecifiedM25.50-M25.579Pain in jointO09.00-O09.93Supervision of high risk pregnancyO28.3Abnormal ultrasonic finding antenatal screening of motherO28.4Abnormal radiological finding on antenatal screening of mother (MRI fetus)O35.00X1-O35.09X9Maternal care for (suspected) central nervous system malformation or damage in fetusR21Rash and other nonspecific skin eruptionR50.9Fever, unspecifiedZ03.73Encounter for suspected fetal anomaly ruled outZ03.79Encounter for other suspected maternal and fetal conditions ruled out.Z03.89Encounter for observation for other suspected diseases and conditions ruled out.Z33.1Pregnant state, incidentalZ34.00-Z34.93Encounter for supervision of normal pregnancy.Z36.89Encounter for other specified antenatal screening
Article - Billing and Coding: Zika Virus Testing by PCR and ELISA Methods (A55327)
CMS National Coverage PolicyN/AArticle TextFor calendar year 2018 CMS has adopted the new 2018 AMA CPT codes for Zika virus testing. For dates of service 1/1/2018 and forward providers should bill using these new codes. For dates of service prior to 1/1/2018 the previous instructions will still apply.Testing for the Zika virus must follow the Food and Drug Administration (FDA) and CDCP guidelines. This article does not address medical necessity but rather proper coding for claims submission.Claims submissions should utilize the coding instructions below regardless of the specimen source. In the narrative section of the claim form (Part A Loop 2300/NTE for EMC claims, or Form Locator 80 on the CMS 1450 form or paper claims, Part B Loop 2400/SV101-7 for EMC claims, or Item 19 on the CMS 1500 form for paper claims) please enter the following verbiage (without quotation marks) as it pertains to the respective tests.For Claims submitted prior to 1/1/2018 use the following guidance:Zika rRT-PCR only  Use CPT 87999 and enter Zika PCR in the narrative field regardless of the CDCP approved proprietary test utilized*Trioplex rRT-PCR  Use CPT 87999 and enter Zika Trioplex*anti-Zika immunoglobulin (IgM)  Use CPT 86790Dengue rRT-PCR only  use CPT 87798Chikungunya rRT-PCR only - use CPT 87798If billing for both Dengue and Chikungunya rRT-PCR  use CPT 87801 once.If a plaque reduction neutralization test (PRNT) is indicated, that testing must be conducted by CDC or by a PRNT laboratory designated by CDC to do confirmatory PRNT testing for the Zika response. The claim for PRNT testing is not submitted to Medicare.Items 1, 2 and 3 above require an FDA Emergency Use Authorization to the respective laboratory. Noridian retains the right to be sent a copy of the respective labs EUA upon request.For claims submitted with dates of service on or after 1/1/2018 use the following instructions:
Article - Billing and Coding: Zika Virus Testing by PCR and ELISA Methods (A55327)
Zika rRT-PCR only  Use CPT 87662Zika virus IgM  Use CPT 86794Dengue rRT-PCR only  use CPT 87798Chikungunya rRT-PCR only - use CPT 8779If billing for both Dengue and Chikungunya rRT-PCR  use CPT 87801 once.Diagnosis coding should include at least one of the following ICD-10 codes:CodeDescriptionA92.5Zika virus disease [effective for DOS on or after October 1, 2016]B30.9Viral conjunctivitis, unspecifiedM25.50-M25.579Pain in jointO09.00-O09.93Supervision of high risk pregnancyO28.3Abnormal ultrasonic finding antenatal screening of motherO28.4Abnormal radiological finding on antenatal screening of mother (MRI fetus)O35.00X1-O35.09X9Maternal care for (suspected) central nervous system malformation in fetusR21Rash and other nonspecific skin eruptionR50.9Fever, unspecifiedZ03.73Encounter for suspected fetal anomaly ruled outZ03.79Encounter for other suspected maternal and fetal conditions ruled out.Z03.89Encounter for observation for other suspected diseases and conditions ruled out.Z33.1Pregnant state, incidentalZ34.00-Z34.93Encounter for supervision of normal pregnancy.Z36.89Encounter for other specified antenatal screening.
Article - Billing and Coding: Retroperitoneal Ultrasound (A55336)
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 claimArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Retroperitoneal Ultrasound L34577.A full (complete) or limited abdominal ultrasound (US) (CPT76700, 76705, 76706*), views all structures in the abdomen including those in the retroperitoneal area. Frequently when a retroperitoneal USis performed findings encountered during the exam may warrant that the exam be expanded to become a full abdominal study.It is expected that CPT76770, 76775, 76776 will only be billed when the exam has been limited to retroperitoneal structures. Exams that include structures other than or in addition to, those listed above should be billed as a full (complete) or appropriately limited abdominalUS (CPT76700, 76705, 76706*).It is not appropriate to bill for both a retroperitonealUS study AND a complete (or limited) abdominalUS when a retroperitonealUS study is expanded to include organs and structures outside the retroperitoneum.Utilization GuidelinesIf the physical exam has primary findings for the involvement of non-retroperitoneal structures/organs (gallbladder, liver, spleen, common bile duct, etc.), even though it may be necessary to visualize retroperitoneal structures in the course of the procedure, a full abdominal US would be required in most cases to be diagnostic, and that is the procedure that should be performed and billed.
Article - Billing and Coding: Frequency of Hemodialysis (A55354)
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 100-02, Medicare Benefit Policy Manual, Chapter 11,10 Definitions Relating to ESRD,20 Renal Dialysis Items and Services,20.1 Composite Rate Items and Services,20.2 Laboratory Services,20.3 Drugs and Biologicals,20.3.1 Drug Designation Process,20.4 Equipment and Supplies,30 Home Dialysis,30.1 Home Dialysis Items and Services,30.2 Home Dialysis Training,40 Other Services,50 ESRD Prospective Payment System (PPS) Base Rate,60 ESRD PPS Case-Mix Adjustments,70 ESRD PPS Transition Period,80 Bad Debt,100 Payment for Renal Dialysis Services Furnished to Individuals with Acute Kidney Injury (AKI)CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 8, Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims All sectionsCMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Transmittal 1084, Change Request 5039, dated October 27, 2006CMS Manual System, Pub 100-20, One-Time Notification, Transmittal 1849, Change Request 9989, dated May 12, 2017CMS Final Rule CMS-1651-F published November 4, 2016Article Text