evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
In cases where the face -to-face requirement is obviated such as those when a physician/practitioner provides the PC/interpretation of a diagnostic test, from a distant site, the POS code assigned by the physician /practitioner shall be the setting in which the beneficiary received the TC service.  The POS code for a teleradiology interpretation is generally the place where the beneficiary received the TC, or face- to-face encounter.  The POS code representing the setting where the beneficiary received the TC  is entered in the ASC X12 837 professional claim format or in item 24B on the paper claim Form CMS 1500.  In cases where it is unclear which POS code applies, the Medicare contractor can provide guidance.   For example:  A beneficiary receives an MRI on an outpatient hospital campus near his/her home.  The outpatient hospital submits a claim that would correspond to the TC portion of the MRI.  The physician furnishes the PC portion of the beneficiarys MRI from his/her office location -  POS code 22 (On Campus -Outpatient Hospital) shall be used on the physicians claim to indicate that the beneficiary received the face -to-face portion of the MRI, the TC, on the campus of an outpatient hospital.    B.  Interpretation Provided Outside of the United States   Generally, Medicare will not pay for health care or supplies that are performed outside the United States (U.S.).  The term outside the U.S. means anywhere other than the 50 states of the U.S., the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.  See Pub. 100- 02, chapter 16, section 60, for exceptions to the outside the U.S. exclusions.   C.  Interpretation Provided Under Arrangement -  To A Hospital   Separate TC and PC   If a diagnostic test which has a separate TC and PC is provided under arrangement to a hospital, the physician who reads the test can bill and be paid for the professional component.  Both the technical and professional components of the test are also subject to the physician self -referral prohibition.
(Medicare Claims Processing Manual)
The appropriate POS code for the interpretation (or PC) is the setting where the beneficiary received the TC service.  If the interpretation is performed in the physicians office and the patient received the TC service in the provider -based outpatient hos pital setting, the physician assigns POS code 22, for On Campus -Outpatient Hospital, or POS 19, for Off Campus -Outpatient Hospital, on the claim for the interpretation or PC.   Global Service   When a physician performs a diagnostic test under arrangement to a hospital and the test and the interpretation are not separately billable, the interpretation cannot be billed by the physician.  In this scenario, the hospital is the only entity that can bill for the diagnostic test which encompasses the interpretation.  There is no POS code for the interpretation since a physician claim is not generated.   D.  Global Billing   Billing globally for services that are split into PC and TC components is only possible when the TC and the physician who provides the PC of the diagnostic service are furnished by the same physician or supplier entity and the PC and TC components are furnished within the same Medicare physician fee schedule payment locality.  Merely applying the same POS code to the PC as that of the TC (as described in A above) does not permit global billing for any diagnostic procedure.   E.  Determination of Payment Locality  Under the Medicare physician fee schedule (MPFS), payment amounts are based on the relative resources required to provide services and vary among payment localities as resource costs vary geographically as measured by the geographic practice cost indices (GPCIs).   The payment locality is determined based on the location where a specific service code was furnished.  For purposes of determining the appropriate payment locality, CMS requires that the address, including the ZIP code for each service code be included on the claim form in order to determine the appropriate payment locality.  The location in which the service code was furnished is entered on the ASC X12 837 professional claim format or in Item 32 on the paper claim Form CMS 1500.  Global Service Code
(Medicare Claims Processing Manual)
If the global diagnostic service code is billed, the biller (either the entity that took the test, physician who interpreted the test, or separate billing agent) must report the address and ZIP code of where the test was furnished on the bill for the globa l diagnostic service code.  In other words, when the global diagnostic service code is billed, for example, chest x -ray as described by HCPCS code 71010 (no modifier TC and no modifier - 26), the locality is determined by the ZIP code applicable to the testing facility, i.e. where the TC of the chest x -ray was furnished.  The testing facility (or its billing agent) enters the address and ZIP code of the setting/location where the test took place.  This practice location is entered using the ASC X12 837 profe ssional claim format or in Item 32 on the paper claim Form CMS 1500.  As explained in D above, in order to bill for a global diagnostic service code, the same physician or supplier entity must furnish both the TC and the PC of the diagnostic service and the TC and PC must be furnished within the same MPFS payment locality.   Separate Billing of Professional Interpretation   If the same physician or other supplier entity does not furnish both the TC and PC of the diagnostic service, or if the same physician or other supplier entity furnishes both the TC and PC but the professional interpretation was furnished in a different pa yment locality from where the TC was furnished, the professional interpretation of a diagnostic test must be separately billed with modifier - 26 by the interpreting physician.
(Medicare Claims Processing Manual)
When the physicians interpretation of a diagnostic test is billed separately from the technical component, as identified by modifier - 26, the interpreting physician (or his or her billing agent) must report the address and ZIP code of the interpreting physicians location on the claim form.  If the professional interpretation was furnished at an unusual and infrequent location for example, a hotel, the locality of the professional interpretation is determined based on the Medicare enrolled location where t he interpreting physician most commonly practices.  The address and ZIP code of this practice location is entered using the ASC X12 837 professional claim format or in Item 32 on the paper claim Form CMS 1500.  Transmittals Issued for This Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12364CP  11/16/2023 NCD 220.6.20 -  Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease 12/19/2023 13429  R11021CP  10/01/2021 Revisions To Chapters 13, 18 And 32 To Update Coding  10/29/2021 12376  R10881CP  08/06/2021 REVISIONS TO CHAPTERS 13 AND 32 TO UPDATE CODING  09/07/2021 12069  R4267CP  03/27/2019 Evaluation and Management (E/M) when Performed with Superficial Radiation Treatment  03/25/2019 11137  R4246CP  02/22/2019 Evaluation and Management (E/M) when Performed with Superficial Radiation Treatment  Rescinded and replaced by Transmittal 4267  03/25/2019 11137  R4150CP  10/26/2018 Update to Bone Mass Measurements (BMM) Code 77085 Deductible and Coinsurance  04/01/2019 10956  R3911CP  11/09/2017 New Positron Emission Tomography (PET) Radiopharmaceutical/Tracer Unclassified Codes  12/11/2017 10319  R3820CP  07/28/2017 Payment Reduction for X -Rays Taken Using Computed Radiography 01/02/2018 10188  R3650CP  11/10/2016 Updates to Pub. 100- 04, Chapters 8, 13 and 14 to Correct Remittance Advice Messages  02/10/2016 9841 R3387CP  10/30/2015 Billing of the Transportation Fee by Portable X-ray Suppliers  01/01/2016 9354 R3315CP
(Medicare Claims Processing Manual)
13 and 14 to Correct Remittance Advice Messages  02/10/2016 9841 R3387CP  10/30/2015 Billing of the Transportation Fee by Portable X-ray Suppliers  01/01/2016 9354 R3315CP  08/06/2015 New and Revised Place of Service Codes (POS) for Outpatient Hospital 01/04/2016 9231 Rev #  Issue Date  Subject  Impl Date  CR#  R3230CP  04/03/2015 Updates to the Medicare Internet -Only Manual Chapters for Skilled Nursing Facility (SNF) Providers  06/15/2015 8997 R3227CP  04/02/105 Update to Pub. 100- 04 Chapter 13 to Provide Language -Only Changes for Updating ICD -10 and ASC X12 11/04/2014 8614 R3216CP  03/13/2015 Updates to the Medicare Internet -Only Manual Chapters for Skilled Nursing Facility (SNF) Providers   Rescinded and replaced by Transmittal 3230 06/15/2015 8997 R3091CP  10/08/2014 Update to Pub. 100- 04 Chapter 13 to Provide Language -Only Changes for Updating ICD -10 and ASC X12  Rescinded and replaced by Transmittal 3227 11/04/2014 8614 R2932CP  04/18/2014 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors (This CR rescinds and fully replaces CR8468/TR2873 dated February 6, 2014)  05/19/2014 8739 R2898CP  03/07/2014 Update to Pub. 100- 04 Chapter 13 to Provide Language -Only Changes for Updating ICD -10 and ASC X12  Rescinded and replaced by Transmittal 3091 10/01/2014 8614 R2873CP  02/06/2014 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors  Rescinded and replaced by CR 8739, Transmittal 2932 03/07/2014 8468 R2750CP  08/02/2013 Positron Emission Tomography  09/03/2013 8381 R2679CP  03/29/2013 Revised and Clarified Place of Service (POS) Coding Instructions  04/01/2013 7631
(Medicare Claims Processing Manual)
08/02/2013 Positron Emission Tomography  09/03/2013 8381 R2679CP  03/29/2013 Revised and Clarified Place of Service (POS) Coding Instructions  04/01/2013 7631 R2613CP  12/14/2012 Revised and Clarified Place of Service (POS) Coding Instructions  Rescinded and replaced by Transmittal 2679  04/01/2013 7631 Rev #  Issue Date  Subject  Impl Date  CR#  R2563CP  10/11/2012 Revised and Clarified Place of Service (POS) Coding Instructions  Rescinded and replaced by Transmittal 2613 04/01/2013 7631 R2561CP  09/28/2012 Revised and Clarified Place of Service (POS) Coding Instructions  Rescinded and replaced by Transmittal 2563 04/01/2013 7631 R2435CP  03/29/2012 Revised and Clarified Place of Service (POS) Coding Instructions  Rescinded and replaced by Transmittal 2561 10/01/2012 7631 R2407CP  02/03/2012 Revised and Clarified Place of Service (POS) Coding Instructions  Rescinded and replaced by Transmittal 2435 04/02/2012 7631 R2307CP  09/22/2011 Magnetic Resonance Imaging (MRI) in Medicare Beneficiaries with FDA -Approved Implanted Permanent Pacemakers (PMs) for Use in an MRI Environment  09/26/2011 7441 R2293CP  08/26/2011 Magnetic Resonance Imaging (MRI) in Medicare Beneficiaries with FDA -Approved Implanted Permanent Pacemakers (PMs) for Use in an MRI Environment  Rescinded and replaced by Transmittal 2307 09/26/2011 7441 R2171CP  03/04/2011 Magnetic Resonance Imaging (MRI) in Medicare Beneficiaries with Implanted Permanent Pacemakers (PMs) or Implantable Cardioverter Defibrillators (ICDs)  04/04/20111  7296 R2096CP  11/19/2010 Billing Clarification for Positron Emission Tomography (Sodium Flouride -18) (NaF -18) PET for Identify Bone Metastasis of Cancer in Context of a Clinical Trial 02/22/2011 7125 R1998CP  07/09/2010 Magnetic Resonance Angiography (MRA)  08/09/2010 7040
(Medicare Claims Processing Manual)
-18) PET for Identify Bone Metastasis of Cancer in Context of a Clinical Trial 02/22/2011 7125 R1998CP  07/09/2010 Magnetic Resonance Angiography (MRA)  08/09/2010 7040 R1937CP  03/26/2010 Positron Emission Tomography (NaF -18) to Identify Bone Mestastasis of Cancer  07/06/2010 6861 Rev #  Issue Date  Subject  Impl Date  CR#  R1931CP  03/12/2010 Revision of the Internet Only Manual (IOM) to Remove References to Purchased Diagnostic Test and Replace With Language Consistent With the Anti -Markup Rule  06/14/2010 6627 R1888CP  01/06/2010 Positron Emission Tomography (PET) (FDG) for Cervical Cancer  01/04/2010 6753 R1879CP  12/18/2009 Positron Emission Tomography (PET) (FDG) for Cervical Cancer -  Rescinded and replaced by Transmittal 1888 01/04/2010 6753 R1866CP  12/04/2009 Positron Emission Tomography (PET) (FDG) for Cervical Cancer -  Rescinded and replaced by Transmittal 1879 01/04/2010 6753 R1833CP  10/16/2009 FDG PET for Solid Tumors and Myeloma  10/30/2009 6632 R1831CP  10/16/2009 Magnetic Resonance Imaging (MRI)  01/04/2010 6672 R1817CP  09/18/2009 FDG PET for Solid Tumors and Myeloma -  Rescinded and replaced by Transmittal 1833 10/19/2009 6632 R1782CP  07/30/2009 Section 148 of the Medicare Improvements for Patients and Providers Act (MIPPA)  07/06/2009 6395 R1772CP  07/17/2009 FDG PET for Solid Tumors and Myeloma and Additional Manual Updates  Rescinded and replaced by CR 6632, Transmittal 1817 08/17/2009 and 10/05/2009 6464 R1729CP  05/08/2009 Section 148 of the Medicare Improvements for Patients and Providers Act (MIPPA) -  Rescinded and replaced by Transmittal 1782 07/06/2009 6395 R1472CP  03/06/2008 Update of Institutional Claims References  04/07/2008
(Medicare Claims Processing Manual)
the Medicare Improvements for Patients and Providers Act (MIPPA) -  Rescinded and replaced by Transmittal 1782 07/06/2009 6395 R1472CP  03/06/2008 Update of Institutional Claims References  04/07/2008 5893 R1421CP  01/25/2008 Update of Institutional Claims References -  Rescinded and Replaced by Transmittal 1472  04/07/2008 5893 R1416CP  01/18/2008 Clarification of Bone Mass Measurement (BMM) Billing Requirements  02/20/2008 5847 Rev #  Issue Date  Subject  Impl Date  CR#  R1339CP  09/21/2007 Magnetic Resonance Imaging (MRI) Procedures  10/22/2007 5677 R1301CP  07/20/2007 Revised Information on PET Scan Coding 01/07/2008 5665 R1236CP  05/11/2007 Bone Mass Measurements (BMMs)  07/02/2007 5521 R1221CP  04/18/2007 Common Working File (CWF) Duplicate Claim Edit for the Technical Component (TC) of Radiology and Pathology Laboratory Services Provided to Hospital Patients  04/02/2007 5347 R1098CP  11/02/2006 Common Working File (CWF) Duplicate Claim Edit for the Technical Component (TC) of Radiology and Pathology Laboratory Services Provided to Hospital Patients Replace by Transmittal 1221 04/02/2007 5347 R956CP  05/19/2006 Payment for Position Emission Tomography 06/19/2006 5124 R923CP  04/28/2006 Update of Radiopharmaceutical Imaging Agents HCPCS Codes Applicable to PET Scan Services for Carriers  08/01/2006 5054 R822CP  02/01/2006 Update of Radiopharmaceutical Imaging Agents HCPCS Codes Applicable to PET Scan Services  07/03/2006 4270 R795CP  12/30/2005 Redefined Type of Bill 14 X for Non- Patient Laboratory Specimens  04/03/2006 4208 R716CP  10/21/2005 Modifiers for Transportation of Portable X -rays (R0075) When Billed by Skilled Nursing Facilities (SNFs)  04/03/2006 4039 R628CP  07/29/2005 Radiopharmaceutical Diagnostic Imaging Agents Codes Applicable to PET Scan Services Performed on or After January 28, 2005 10/31/2005 3945 Rev #  Issue Date  Subject
(Medicare Claims Processing Manual)
4039 R628CP  07/29/2005 Radiopharmaceutical Diagnostic Imaging Agents Codes Applicable to PET Scan Services Performed on or After January 28, 2005 10/31/2005 3945 Rev #  Issue Date  Subject  Impl Date  CR#  R627CP  07/29/2005 New Low Osmolar Contrast Material (LOCM) HCPCS Codes/Payment Criteria/Payment Level  10/31/2005 3902 R527CP  04/15/2005 New Coding for FDG PET Scans and Billing Requirements for Specific Indications of Cervical Cancer  04/18/2005 3741 R501CP  03/11/2005 Bone Mass Measurements -  Procedure Coding 04/11/2005 3719 R428CP  01/14/2005 Update to Billing Requirements for FDG -PET Scans for Use in the Differential Diagnosis of Alzheimer's Disease (AD) and Fronto- Temporal Dementia (FTD) and Update to the FI Billing Requirements for Special Payment Procedures for ALL PET Scan Claims for Servi ces Performed in a Critical Access Hospital (CAH)  04/04/2005 3640 R343CP  10/29/2004 Clarification: Modifiers for Transportation of Portable X -rays (R0075)  04/04/2005 3280 R310CP  10/01/2004 Billing Requirements for Positron Emission Tomography (PET) Scans for Dementia and Neurodegenerative Diseases  10/04/2004 3426 R223CP  07/02/2004 PET Scans and Related Claims Processing  N/A 3304 R135CP  04/02/2004 Purchased Diagnostic Test -  Carriers  N/A 1658 R001CP  10/01/2003 Initial Publication of Manual  NA NA Back to top of Chapter
Article - Billing and Coding: IUD (Hormone-Eluting) for Endometrial Hyperplasia - CPT 58999 (A58649)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that reflect proper billing for insertion of an IUD (Hormone-Eluting) for Endometrial Hyperplasia.- CPT Code 58999.Coding Information:The diagnosis code(s) must best describe the patient's condition for which the service was performed.Medicare does not allow payment for contraceptive devices or medication. For this reason the service, 58300, insertion of intrauterine device (IUD) has an "N" status in the Medicare Physician Fee Schedule, which means the service cannot be covered when billed to Medicare.National Government Services (NGS) is aware that insertion of a progestin-containing intrauterine device (IUD) is an alternative method of managing endometrial hyperplasia in patients who are not reasonable surgical candidates or who wish to preserve fertility. NGS has determined that the use of a progestin containing IUD may be approved for use in the Medicare beneficiary who presents with endometrial hyperplasia without atypia.Since the CPT code for IUD insertion will be auto-denied, providers should bill this service using CPT 58999 and an appropriate diagnosis for endometrial hyperplasia, including the product description "hormone IUD for endometrial hyperplasia" in Item 19 of the CMS-1500 form or the electronic equivalent.Coding Information:The diagnosis code(s) must best describe the patient's condition for which the service was performed.DocumentationThe medical record must clearly document the specific clinical circumstances evidencing this medical necessity.
Article - MolDX: Algorithm definition as a component of a laboratory test (A58650)
CMS National Coverage PolicyN/AArticle TextThe aim of this article is to promote a shared understanding of the term "algorithm" within the context of a clinical laboratory test. The objective of this article is to communicate the attributes of an algorithm as defined by this contractor within the stated context. The presence or absence of an algorithm as part of a lab service may be relevant to understanding the components of that service for coding or valuation purposes.An algorithm may be considered a meaningful and independent component of a laboratory process when ALL the following conditions are met:It is an unambiguous problem-solving operation that includes deploying a set of rules or calculations requiring computer processing;The test result (or a component of the result) is the calculated output of this process, and not an intermediary process;The same or similar test result could not be obtained without the use of this process;The input for the computation is derived from biological samples using analytical processes, and must include data from the sample submitted for the test;The process must:Either be required for the analytical result, ORIf adjunct to the analytical result as a post-analytical process, the calculation itself must be independently found to be reasonable and necessary apart from the other components of the test.Examples:A gene expression profile test wherein sequencing data must be compared in a calculation to an existing and validated set of profiles to bin it in one of several possible risk stratification groups would require the use of an algorithm as defined above.A next generation sequencing (NGS) test that uses computation to identify variants in a sampleis notconsidered as using an algorithm in this context. The calculation in this scenario is seen as an intermediary process.Calculations using only clinical information not derived from analytical services on biological samplesare notconsidered algorithms in this context. Examples would include using the clinical information from the patient in a calculation to assess their risk stratification or using a similar process to identify relevant clinical annotations derived from literature as associations with sequencing variants.A test that inputs resultant analytical processes that are reasonable and necessary (such as gene variants or protein markers) that are post processed by computation, but wherein that subsequent computation is not independently established as reasonable and necessary above and beyond the other lab components, shall not be considered an algorithm as a valid component of a laboratory test.
Article - Billing and Coding: MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer (A58652)
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 information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Lab-Developed Tests for Inherited Cancer Syndromes in Patients with Cancer L38966.To report a service, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM codeRegarding single-gene and panel testing of genes-Refer to Billing and Coding: MolDX: Testing of Multiple Genes A57503.Tier 1 and/or Tier 2 individual biomarker CPTcodes should not be used for a single gene or any combination of genes when testing is performed as part of a NGS or other multiplexing technology panel.
Article - Billing and Coding: Thyroid Nodule Molecular Testing (A58656)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Thyroid Nodule Molecular Testing.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 attached 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.