evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: MolDX: Abbott RealTime IDH1 and IDH2 testing for Acute Myeloid Leukemia (AML) (A55712)
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 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, 60.1.1 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 following coding and billing guidance is to be used with its associated Local coverage determination.TheAbbott RealTime IDH1by Abbott Molecular is the only test that has received FDA approval to be used as an aid in identifying acute myeloid leukemia (AML) patients with an isocitrate dehydrogenase-1(IDH1) mutation for treatment with TIBSOVO(ivosidenib).TIBSOVO(ivosidenib) is an isocitrate dehydrogenase-1 (IDH1) inhibitor indicated for the treatment of adult patients with relapsed or refractory acute myeloid leukemia (AML) with a susceptible IDH1 mutation as detected by an FDA-approved test.Abbott RealTime IDH1byAbbott Molecular meets the reasonable and necessary criteria for Medicare reimbursement, effective 7/20/2018.TheAbbott RealTimeIDH2by Abbott Molecular is the only test that has received FDA approval to be usedas an aid in identifying acute myeloid leukemia (AML) patients with an isocitrate dehydrogenase-2 mutation for treatment with enasidenib (IDHIFA).IDHIFA isan isocitrate dehydrogenase-2 inhibitor indicated for the treatment of adult patients with relapsed or refractory acute myeloid leukemia (AML) with an isocitrate dehydrogenase-2 (IDH2) mutation as detected by an FDA-approved test.Abbott RealTime IDH2by Abbott Molecular meets the reasonable and necessary criteria for Medicare reimbursement, effective 8/1/2017.
Article - Billing and Coding: MolDX: Abbott RealTime IDH1 and IDH2 testing for Acute Myeloid Leukemia (AML) (A55712)
Select the CPT 81120 for claims on or after 7/20/2018.To report anAbbott RealTime IDH2service, please submit the following claim information:Select the CPT code 81121 for claims on or after 1/1/2018.Enter 1 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 837PItem 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 codeNote:This MolDX coverage determination and coding guideline ONLY applies to the UNMODIFIED, IDH2 testkit by Abbott Molecular for patients with acute myeloid leukemia. If a lab modifies these tests, a MolDX Technical Assessment, outlined in the MolDx section onwww.PalmettoGBA.com/medicare, must be submitted and a determination assessed prior to claims submission.This article reflects the FDA-approved indications on article creation date. MolDX will allow future FDA approved and amended indications for these tests.
Article - Billing and Coding: Coenzyme Q10 (CoQ10) (A55715)
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 15, 80.0, 80.1.1, 80.2. Clinical Laboratory services.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 AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextCoenzyme Q10 (CoQ10 or Q10) supplementation is purported to prolong life and prevent age-related functional declines; inhibit the development and/or progression of atherosclerosis; have value as an adjunct to conventional medical therapy in the treatment of congestive heart failure, conventional angina therapy, and cancer; provide protection against myocardial damage during ischemia-reperfusion during cardiac surgery; provide benefit in the treatment of hypertension, CV disease and diabetes; play a role in neurodegenerative diseases such as Parkinsons disease, Huntingtons disease and Friedreichs ataxia; enhance athletic performance and enhance fertility. As such, serum or other body fluid testing for Q10 levels has been advocated. However, the scientific evidence to support coverage for Q10 testing for any purpose is controversial and/or limited for all diseases. Consequently, Q10 testing is not reasonable and necessary (LCD L37022), and claims for testing will be denied.To receive a Q10 service denial, please submit the following claim information:CPT code 82542For a voluntary issued Advanced Beneficiary Notice (ABN), append with GX modifierSelect the appropriate diagnosis for the patient
Article - Billing and Coding: MolDX: Abbott RealTime IDH1 and IDH2 testing for Acute Myeloid Leukemia (AML) (A55716)
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 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, 60.1.1 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 TextTheAbbott RealTime IDH1by Abbott Molecular is the only test that has received FDA approval to be usedas an aid in identifying acute myeloid leukemia (AML) patients with an isocitrate dehydrogenase-1(IDH1) mutation for treatment with TIBSOVO(ivosidenib).TIBSOVO(ivosidenib) is an isocitrate dehydrogenase-1 (IDH1) inhibitor indicated for the treatment of adult patients with relapsed or refractory acute myeloid leukemia (AML) with a susceptible IDH1 mutation as detected by an FDA-approved test.Abbott RealTime IDH1byAbbott Molecular meets the reasonable and necessary criteria for Medicare reimbursement, effective 7/20/2018.The Abbott RealTime IDH2by Abbott Molecular is the only test that has received FDA approval to be usedas an aid in identifying acute myeloid leukemia (AML) patients with an isocitrate dehydrogenase-2 mutation for treatment with enasidenib (IDHIFA).IDHIFA is an isocitrate dehydrogenase-2 inhibitor indicated for the treatment of adult patients with relapsed or refractory acute myeloid leukemia (AML) with an isocitrate dehydrogenase-2 (IDH2) mutation as detected by an FDA-approved test.Abbott RealTime IDH2by Abbott Molecular meets the reasonable and necessary criteria for Medicare reimbursement, effective 8/1/2017.To report anAbbott RealTime IDH1service, please submit the following claim information:
Article - Billing and Coding: MolDX: Abbott RealTime IDH1 and IDH2 testing for Acute Myeloid Leukemia (AML) (A55716)
Abbott RealTime IDH2by Abbott Molecular meets the reasonable and necessary criteria for Medicare reimbursement, effective 8/1/2017.To report anAbbott RealTime IDH1service, please submit the following claim information:Select the CPT 81120 for claims on or after 7/20/2018.To report anAbbott RealTime IDH2service, please submit the following claim information:Select the CPT code 81121 for claims on or after 01/01/2018Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier 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-Codeidentifier 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 codeNote:This MolDX coverage determination and coding guideline ONLY applies to the UNMODIFIED, IDH2 test kit by Abbott Molecular for patients with acute myeloid leukemia. If a lab modifies these tests, a MolDX Technical Assessment, outlined in the MolDx section onwww.PalmettoGBA.com/medicare, must be submitted and a determination assessed prior to claims submission.This article reflects the FDA-approved indications on article creation date. MolDX will allow future FDA approved and amended indications for these tests.
Article - Billing and Coding: Lab: Flow Cytometry (A55717)
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, 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 CodesCMS 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 Lab: Flow Cytometry L34513.Flow cytometry is a complex laboratory process to examine body fluids, including blood and cerebrospinal fluid (CSF), bone marrow, and components of the lymphoreticular system, such as lymph nodes, tonsil, and spleen. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. LCD L34513 Flow Cytometry outlines the coverage criteria for flow cytometry testing. When covered, testing is limited to no more than 24 markers without additional medical necessity documentation.Flow cytometry for the detection and/or identification or enumeration of bacteria or viruses in patients with chronic rhinosinusitis with or without polyps is investigational/experimental and is not a Medicare benefit.To report a Flow Cytometry service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Select the appropriate ICD-10-CM code
Article - Sipuleucel-T (Provenge®) - Coverage Criteria for Prostate Cancer – Clarification (A55719)
CMS National Coverage PolicyN/AArticle TextSipuleucel-T (Provenge) is an autologous cellular immunotherapy, FDA-approved for the treatment of asymptomatic or minimally symptomatic metastatic castrate resistant (hormone refractory) prostate cancer.The production of Sipuleucel-T involves collection of the patients own cells (leukapheresis), culture with a proprietary antigen complex, and re-infusion of the antigen-activated patient cells back to the donor. Provenge is administered as three intravenous infusions, generally two weeks apart. When infused back into the patient, usually three days after leukapheresis, the patient-specific medication (autologous cellular therapy) stimulates a positive immunogenic response against the prostate cancer.For coverage, patient records must document that the product is being used according to the NCD 110.22.If the documentation does not describe the criteria above, does not meet all the requirements of the NCD on sipuleucel-T,is inconsistent with the FDA label and/or is not received, the services will be denied. Off-label use of this treatment is not covered unless it meets the requirements for off-label use of chemotherapeutic drugs in the Internet Only Manual 100-02 (Benefit Policy), Chapter 15 (Covered Services), Section 50.4.5.Noridian may coversipuleucel-Tfor the above condition when all requirements are met including the following coding instructions. (NOTE: Noridian will not allow payment for any off-label use of this treatment):For dates of service on/after July 1, 2011, use the following HCPCS code: Q2043 Sipuleucel-T auto CD54+.For dates of service prior to July 1, 2011, use one of the following HCPCS code: J3490, J3590 or C9273 (being replaced by Q2043).
Article - Sipuleucel-T (Provenge®) - Coverage Criteria for Prostate Cancer – Clarification (A55719)
For dates of service prior to July 1, 2011, use one of the following HCPCS code: J3490, J3590 or C9273 (being replaced by Q2043).The payment of HCPCS Q2043 includes collection of patients cells, activation with PAP-CM-CSF, including leukapheresis and all other preparatory procedures associated withsipuleucel-T. The code Q2043 does not include theadministrationof the treatments. CPT code 96365, intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to one (1) hour will be allowed for the administration of Q2043.Medicare will allow a maximum of three (3) infusions per lifetime.Sources: Internet Only Manual (IOM) Medicare National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Section 110.22, IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 32, Section 280; Transmittal 133, Change Request (CR)7431 dated July 8, 2011; Transmittal 2254, CR 7431 dated July 8, 2011.
Article - Billing and Coding: Frequency of Hemodialysis (A55723)
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) L35014, Frequency of Hemodialysis. Please refer to the LCD for reasonable and necessary requirements.This article outlines how to line item bill dialysis sessions for End Stage Renal Disease (ESRD) patients. This does not address line item billing for sessions associated with training or other modalities such as peritoneal dialysis. This article does not change any other billing requirements for dialysis claims.Note:This article uses the terms dialysis session and treatment interchangeably.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.CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 8 requires line item billing for all ESRD claims with dates of service (DOS) on or after April 1, 2007. Each dialysis session performed should be reported on a separate line.CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 11 discusses that ESRD facilities furnishing dialysis treatments in facility or in the beneficiarys home are paid for up to three treatments per week. Payment for additional treatments, defined as any treatments in excess of three treatments per week, may be considered in addition to the ESRD PPS per treatment payment amount paid for up to three treatments per week.For monthly claims submitted with Bill Type 72X and Revenue Codes 0821 and 0881, three approaches of billingper lineare available. Based on the Patients Plan of Care (POC), or other available medical documents, the following scheme should be followed when billing sessions.Note:Dialysis sessions in the patients POC that are not furnished should not be billed.
Article - Billing and Coding: Frequency of Hemodialysis (A55723)
For dialysis sessions that have been furnished three times (3X) per week, each line should be 90999 without any modifiers appended. That is, when the hemodialysis-prescription is three times (3X) per week and each session is furnished, all of these sessions should be billed as 90999 (no modifier appended) and they will be paid as routine conventional dialysis up to 13/14 per month.For each dialysis session furnished in addition to the three sessions per week that do not include medical documentation supporting a reasonable and necessary determination for payment, each line for these sessions should be billed as 90999 CG. Examples of when this could occur include short, more frequent treatments furnished for the convenience of the patient or staff, etc. Additional sessions need to be billed as 90999 CG when medical documentation has not been submitted to support the extra sessions as reasonable and necessary. The CG modifier indicates that the facility attests the additional treatment is not reasonable and necessary and should not receive additional payment. Each line billed as 90999 CG will be denied. However, the use of the modifier is used for data analysis. Please refer to CR 9989, Implementation of Modifier CG for Type of Bill 72X, dated May 12, 2017.For each dialysis session furnished in addition to three sessions per week that includes medical documentation supporting a reasonable and necessary determination for payment, each line for these services should be billed as 90999 KX. These include medical conditions for acute and occasionally chronic conditions that have supporting documentation that the extra sessions are reasonable and necessary (e.g., through documents from recent hospital care, office visits, dialysis progress notes or MCP visits). These sessions must be reasonable and necessary for additional payment based on clinical conditions. On these claims, the 90999 lines without a modifier will be paid as 3X per week and those lines with 90999 KX will be considered for additional payments. Omission of the KX modifier will result in no additional payment for the line item. For diagnoses not listed in this article but felt to be reasonable and necessary, the KX modifier should be appended as well. A denial will occur on these lines, but the redetermination process (an appeal) will be available to submit supportive documentation for review.
Article - Billing and Coding: Frequency of Hemodialysis (A55723)
The expectation is that these three scenarios will be seen on monthly claims, i.e., claims with 90999 lines only, or those with lines of 90999 mixed with 90999 CG or KX modifier appended. Ongoing data analysis may trigger provider specific requests for documentation should unusual patterns occur, i.e., claims with only lines of 90999 KX submitted.Please note that the POC and other supporting medical documentation to justify any of the line item sessions will be most important and may be requested.Please see L35014 for instructions when clinical conditions outside those listed in the available diagnoses should occur.Please see L35014 for Documentation Requirements and Utilization Guidelines.
Article - Billing and Coding: MolDX: Abbott RealTime IDH1 and IDH2 testing for Acute Myeloid Leukemia (AML) (A55738)
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 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, 60.1.1 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 TextTheAbbott RealTime IDH1by Abbott Molecular is the only test that has received FDA approval to be used as an aid in identifying acute myeloid leukemia (AML) patients with an isocitrate dehydrogenase-1(IDH1) mutation for treatment with TIBSOVO (ivosidenib).TIBSOVO (ivosidenib) is an isocitrate dehydrogenase-1 (IDH1) inhibitor indicated for the treatment of adult patients with relapsed or refractory acute myeloid leukemia (AML) with a susceptible IDH1 mutation as detected by an FDA-approved test.Abbott RealTime IDH1by Abbott Molecular meets the reasonable and necessary criteria for Medicare reimbursement, effective 7/20/2018.TheAbbott RealTime IDH2by Abbott Molecular is the only test that has received FDA approval to be used as an aid in identifying acute myeloid leukemia (AML) patients with an isocitrate dehydrogenase-2 mutation for treatment with enasidenib (IDHIFA).IDHIFA is an isocitrate dehydrogenase-2 inhibitor indicated for the treatment of adult patients with relapsed or refractory acute myeloid leukemia (AML) with an isocitrate dehydrogenase-2 (IDH2) mutation as detected by an FDA-approved test.Abbott RealTime IDH2by Abbott Molecular meets the reasonable and necessary criteria for Medicare reimbursement, effective 8/1/2017.To report anAbbott RealTimeIDH1service, please submit the following claim information:
Article - Billing and Coding: MolDX: Abbott RealTime IDH1 and IDH2 testing for Acute Myeloid Leukemia (AML) (A55738)
Select the CPT 81120 for claims on or after 07/20/2018.To report anAbbott RealTime IDH2service, please submit the following claim information:Select the CPT code 81121 for claims on or after 01/01/2018.Enter 1 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.Note:This MolDX coverage determination and coding guideline ONLY applies to the UNMODIFIED, IDH2 test kit by Abbott Molecular for patients with acute myeloid leukemia. If a lab modifies these tests, a MolDX Technical Assessment, outlined in the MolDx section onwww.PalmettoGBA.com/medicare, must be submitted and a determination assessed prior to claims submission.This article reflects the FDA-approved indications on article creation date. MolDX will allow future FDA approved and amended indications for these tests.