evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities (A55229)
Utilization ParametersCPT code 36468 should be reported for the treatment of symptomatic spider veins/telangiectasia in the lower extremities by injection of sclerosing agents. According to the CPTProfessional edition code book, it may only be reported once per extremity per session, regardless of the number of injections performed.Per the CPTProfessional edition code book, codes 36474, 36476, 36479, and 36483 for subsequent vein(s) treated in the same extremity may only be reported once per extremity, regardless of the number of additional vein(s) treated.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.Documentation must include a plan of care, for a 90 day episode of care, that supports the evaluation of the patient including a history, physical examination, CEAP clinical classification, VCSS and a formal venous duplex scan.
Article - Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities (A55229)
The timing of an intervention(s) must be outlined versus the timing of routine post-op (post procedure) follow-up (for example, procedure(s) on day 1 and reevaluation in 3 months versus procedure(s) on day 1 and 7 and reevaluation in 3 months). Therefore, any planned thermal ablation, and/or sclerotherapy, and/or cyanoacrylate/chemical adhesive ablation, and/or mechanochemical ablation, and/or surgical treatments must be addressed in the plan of care  and must be supported in a complete operative procedure note.Serial ablation procedures on the same leg within a 90 day episode of care must clearly be supported in the documentation based on patient specific clinical information that the ablation procedures cannot be performed on a single day.Incompetent perforator vein intervention must be clearly supported in the documentation based on patient specific clinical information as outlined in the LCD covered indications.The initial plan of care is expected to address all sites of clinically significant axial or non-axial reflux along with a description of the specific procedure(s) to be used in a 90 day episode of care consistent with the CEAP and VCSS classification and supporting clinical and diagnostic data.The plan of care must include the date(s) of the examination and diagnostic evaluation.For patients with C2 or C3 disease and VCSS <6, the plan of care shall include documentation of a period of conservative therapy (2-4 weeks) including graduated compression 20-30 mmHg or greater, ambulation, elevation, and avoiding prolonged sitting and standing.Duplex scan documentation must confirm the presence of reversed venous flow (reflux) with provocative maneuvers in the saphenous or perforator veins is 500 milliseconds or greater, and absence of deep venous obstruction.
Article - Billing and Coding: MolDX: Oncotype DX® Breast Cancer Assay (A55230)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextNOTE:The Oncotype DX Breast Cancer Assay and the Oncotype DX DCIS Score are different tests and should NOT be submitted with the same Z-Code Identifier. Because this article ONLY addresses Oncotype DX Breast, the diagnosis codes for breast carcinoma in situ have been removed.Oncotype DX Breast was developed for patients with the following findings:estrogen-receptor positive, node-negative carcinoma of the breastestrogen-receptor positive micrometastases of carcinoma of the breast, andestrogen-receptor positive breast carcinoma with 1-3 positive nodesTo bill an Oncotype Breast service, please provide the following claim information:CPT code 81519  Oncology (breast)Enter 1 in the Days/Unit fieldLabs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.Enter assigned DEXZ-Code Identifier in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PSubmit assigned Z-Code Identifier on an attachment to the claim form for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code.
Article - Billing and Coding: MolDX: Oncotype DX® Colon Cancer Assay Update (A55231)
CMS National Coverage PolicyN/AArticle TextThe Oncotype DX Colon Cancer Assay, developed to predict the recurrence risk for patients with Stage II colon cancer, has been assigned a unique identifier. To bill an Oncotype DX Colon service, please provide the following claim information:CPT code 81525-Oncology (colon), mRNA gene expression of 12 genesEnter 1 in the Days/Unit fieldLabs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.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 claim.Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code:
Article - Billing and Coding: MolDX: VEGFR2 Tests (A55232)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) statutory exclusion covers diagnostic testing "except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member".Article TextEffective for dates of service on and after 05/03/2013.Vascular endothelial growth factor, subtype 2, (VEGFR2) receptor has been found to be oncogenic. Current studies have targeted VEGFR2 as a potential therapeutic option. However, at present there is insufficient evidence to establish a clear association between VEGFR2 mutations and treatment response. Therefore, the MolDX Team has determined VEGFR2 testing is a statutorily excluded service. MolDX will also deny panels of tests that include the VEGFR2 receptor.To receive a VEGFR2 service denial, please submit the following claim information:CPT code 81479An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierEnter 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 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 form
Article - Billing and Coding: MolDx: BCR-ABL (A55233)
CMS National Coverage PolicyN/AArticle TextEffective for dates of service on and after 4/15/13.Breakpoint testing for BCR-ABL1 is commonly performed as a combination or panel of tests (major minor and other breakpoints). To report multiple tests assigned a single ID, submit CPT code 81479. This guideline includes the following CPT code combinations:81206 and 8120781206, 81207, and 81208CPT codes 81206, 81207, and 81208 may only be reported when performed as a single test.To submit a claim for BCR-ABL translocation analysis by NGS, use CPT 81479 and one (1) UOS with the assigned DEX Z-code.To report the FDA-approved MRDx BCR-ABL Test use the CPT code 0040U.Refer to Billing and Coding: MolDX: Testing of Multiple Genes A57880 for additional information regarding single-gene and panel testing of genes.Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submitthis required information.Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in thecomment/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 thecomment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim form
Article - Billing and Coding: MolDX: Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C) Testing (A55235)
CMS National Coverage PolicyN/AArticle TextEffective for dates of service on and after February 7, 2013.ARVD/C, characterized by fatty replacement of heart cells predominantly in the right ventricle of the heart, is most often inherited as an autosomal dominant disease that may be associated with testing in at least seven genes (RYR2, TMEM43, DSP, PKP2, DSG2, DSC2 and JUP). Genetic testing may be performed in panels of 5-7 of these genes and disease-causing mutation is expected to be identified in 42-55% of cases. Testing would be performed to confirm an established diagnosis or on individuals already diagnosed with ARVD/C to identify family members at risk. Therefore, MolDX has determined that testing for ARVD/C is a statutorily excluded test.To receive an ARVD/C panel test denial, please submit the following claim information:CPT code 81439An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientLabs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.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 form
Article - Billing and Coding: Implantable Infusion Pumps for Chronic Pain (A55239)
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 (A55239)
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 (A55239)
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 (A55239)
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 (A55239)
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: Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device) (A55240)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)Social 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 TextIt has come to Novitas attention that auricular peripheral nerve stimulation has been billed to Medicare using the CPT code 64555. CPT code 64555 is described as: Percutaneous implantation of Neurostimulator electrode array; peripheral nerve (excludes sacral nerve).Coding GuidanceNotice: It is not appropriate to bill Medicare for services that are not covered as if they are covered. When billing for non-covered services, use the appropriate modifier.Background:The following devices are listed under the Food and Drug Administration (FDA) approval documents as electro-acupuncture devices used for stimulation of auricular acupuncture points and as such are non-covered. Acupuncture for stimulation of auricular points is not a covered Medicare benefit.NeuroStim system/NSSP-StimANSiStimE-PulseThe following device is FDA classified as a percutaneous nerve stimulator for substance use disorders; Class II device:NSS-2 BridgeThis device is an electrical nerve stimulator (percutaneous nerve field stimulator [PNFS] system) that is placed behind the patients ear (auricular). The NSS-2 Bridge is described as nearly identical to the Electronic Auricular Device (EAD) for a different intended use (to aid in the reduction of opioid withdrawal symptoms). This device is non-covered by Medicare when used for acupuncture (stimulation of auricular acupuncture points) for any indication.For additional information, please refer to National Coverage Determination (NCD) 30.3 for Acupuncture.Coding Guidelines:
Article - Billing and Coding: Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device) (A55240)
Coding Guidelines:The CPT code 64555, does not describe the procedure of auricular acupuncture stimulation and it should be coded using the NOC CPT code 64999 - unlisted procedure, nervous system.Reporting:When billing for auricular peripheral nerve stimulation, use the NOC CPT code 64999 - unlisted procedure, nervous system. The term for the device used for this procedure (e.g. NeuroStim/NSS, P-Stim, ANSiStim, E-Pulse, Electro-Acupuncture, NSS-2 Bridge) should be reported in the Remarks area of the claim for Part A and the Narrative area of the claim for Part B.The service for auricular peripheral nerve stimulation (CPT code 64999) will be denied as non-covered. This service is not a covered Medicare benefit because acupuncture for auricular stimulation does not meet the definition of reasonable and necessary under Section 1862(a)(1) of the Act.While the information given in this article is directed to Neurostim system/NSS, P-Stim, ANSiStim,E-Pulse, and NSS-2 Bridge, other current or future devices when used for the procedure auricular peripheral nerve stimulation or electro-acupuncture, would also be considered a non-covered service.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.