evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
OPT with Verteporfin is a covered service when billed with the below ICD -10-CM codes      Nationally Covered ICD -10-CM codes    H35.3210 Exudative age -related macular degeneration, right eye, stage unspecified  H35.3211 Exudative age -related macular degeneration, right eye, with active choroidal neovascularization  H35.3212 Exudative age -related macular degeneration, right eye, with inactive choroidal neovascularization  H35.3213 Exudative age -related macular degeneration, right eye, with inactive scar  H35.3220 Exudative age -related macular degeneration, left eye, stage unspecified  H35.3221 Exudative age -related macular degeneration, left eye, with active choroidal neovascularization  H35.3222 Exudative age -related macular degeneration, left eye, with inactive choroidal neovascularization  H35.3223 Exudative age -related macular degeneration, left eye, with inactive scar  H35.3230 Exudative age -related macular degeneration, bilateral, stage unspecified  H35.3231 Exudative age -related macular degeneration, bilateral, with active choroidal neovascularization  H35.3232 Exudative age -related macular degeneration, bilateral, with inactive choroidal neovascularization  H35.3233 Exudative age -related macular degeneration, bilateral, with inactive scar    ICD- 10- Codes for OPT with Verteporfin for other ocular indications are eligible for local coverage determinations through individual contractor discretion.    B39.4  Histocapsulati, unspecified   (Translates to combination of both B39.4 & H32)  B39.5  Histoplasmosis duboisii   (Requires H32 coverage)  B39.9  Histoplasmosis, unspecified   (Requires H32 coverage)  H32 Chorioretinal disorders in diseases classified elsewhere
(Medicare Claims Processing Manual)
(Requires H32 coverage)  B39.9  Histoplasmosis, unspecified   (Requires H32 coverage)  H32 Chorioretinal disorders in diseases classified elsewhere   (Requires B39.4 coverage)  H44.2A1  Degenerative myopia with choroidal neovascularization, right eye  H44.2A2  Degenerative myopia with choroidal neovascularization, left eye  H44.2A3  Degenerative myopia with choroidal neovascularization, bilateral eye  H44.2B1  Degenerative myopia with macular hole, right eye  H44.2B2  Degenerative myopia with macular hole, left eye  H44.2B3  Degenerative myopia with macular hole, bilateral eye  H44.2C1  Degenerative myopia with retinal detachment, right eye  H44.2C2  Degenerative myopia with retinal detachment, left eye  H44.2C3  Degenerative myopia with retinal detachment, bilateral eye H44.2D1  Degenerative myopia with foveoschisis, right eye  H44.2D2  Degenerative myopia with foveoschisis, left eye  H44.2D3  Degenerative myopia with foveoschisis, bilateral eye  H44.2E1  Degenerative myopia with other maculopathy, right eye  H44.2E2  Degenerative myopia with other maculopathy, left eye  H44.2E3  Degenerative myopia with other maculopathy, bilateral eye H44.21  Degenerative Myopia, right eye  H44.22  Degenerative Myopia, left eye  H44.23  Degenerative Myopia, bilateral  H35.711  Central serous chorioretinopathy, right eye  H35.712  Central serous chorioretinopathy, left eye  H35.713  Central serous chorioretinopathy, bilateral   Coverage is denied when billed with the below Nationally Non- Covered ICD -10-CM codes   Nationally Non -Covered ICD -10-CM codes:
(Medicare Claims Processing Manual)
Coverage is denied when billed with the below Nationally Non- Covered ICD -10-CM codes   Nationally Non -Covered ICD -10-CM codes:   H35.30  Unspecified macular degeneration  H35.3110 Nonexudative age-related macular degeneration, right eye, stage unspecified  H35.3111 Nonexudative age -related macular degeneration, right eye, early dry stage  H35.3112 Nonexudative age -related macular degeneration, right eye, intermediate dry stage  H35.3113 Nonexudative age -related macular degeneration, right eye, advanced atrophic without subfoveal involvement  H35.3114 Nonexudative age -related macular degeneration, right eye, advanced atrophic with subfoveal involvement  H35.3120 Nonexudative age -related macular degeneration, left eye, stage unspecified  H35.3121 Nonexudative age -related macular degeneration, left eye, early dry stage  H35.3122 Nonexudative age -related macular degeneration, left eye, intermediate dry stage  H35.3123 Nonexudative age-related macular degeneration, left eye, advanced atrophic without subfoveal involvement  H35.3124 Nonexudative age -related macular degeneration, left eye, advanced atrophic with subfoveal involvement  H35.3130 Nonexudative age -related macular degeneration, bilateral, stage unspecified  H35.3131 Nonexudative age -related macular degeneration, bilateral, early dry stage  H35.3132 Nonexudative age -related macular degeneration, bilateral, intermediate dry stage  H35.3133 Nonexudative age -related macular degeneration, bilateral, advanced atrophic without subfoveal involvement  H35.3134 Nonexudative age -related macular degeneration, bilateral, advanced atrophic with subfoveal involvement    Payment for OPT service (CPT code 67221/67225) must be billed on the same claim as the drug (J3396) for the same date of service.
(Medicare Claims Processing Manual)
Payment for OPT service (CPT code 67221/67225) must be billed on the same claim as the drug (J3396) for the same date of service.   Claims for OPT with Verteporfin for dates of service prior to April 3, 2013 are covered at the initial visit as determined by a fluorescein angiogram (FA) CPT code 92235 . Subsequent follow -up visits also require a FA prior to treatment.   For claims with dates of service on or after April 3, 2013, contractors shall accept and process claims for subsequent follow -up visits with either a FA, CPT code 92235, or optical coherence tomography (OCT), CPT codes 92133 or 92134, prior to treatment.   Regardless of the date of service of the claim, the FA or OCT is not required to be submitted on the claim for OPT and can be maintained in the patients file for audit purposes.   300.3 - Claims Processing Requirements for OPT with Verteporfin Services on Inpatient Facility Claims  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Inpatient facilities shall report ICD -10-CM codes H35.3210- H35.3233 (Exudative Age -related Macular Degeneration) and ICD -10-PCS codes 085E3ZZ (Destruction of Right Retina, Percutaneous Approach) and 085F3ZZ (Destruction of Left Retina, Percutaneous Approac h)   300.4 - Medicare Summary Notice (MSN) and Remittance Advice (RA) Messages (Rev. 2728, Issued: 06- 14-13, Effective: 04 -03-13, Implementation: 07- 16-13)  The following message shall be used to notify beneficiaries and providers of denial situations that may occur:   MSN 14.9: Medicare cannot pay for this service for the diagnosis shown on the claim.  (English version) or Medicare no puede pagar por este servicio debido al diagnostic indicado en la reclamacion. (Spanish Version)   Claims Adjustment Reason Code B22:  This payment is adjusted based on the diagnosis.
(Medicare Claims Processing Manual)
310 - Transesophageal Doppler Used for Cardiac Monitoring  (Rev. 2743, Issued: 07- 25-13, Effective: 07 -01-01-13, Implementation, 08- 26-13)  Effective May 17, 2007, Transesophageal Doppler used for cardiac monitoring is covered for ventilated patients in the ICU and operative patients with a need for intra -operative fluid optimization was deemed reasonable and necessary.  See National Coverage Determinations Manual (Pub. 100- 03) 220.5, for complete coverage guidelines.   A new Healthcare Common Procedure Coding System (HCPCS) code, G9157, Transesophageal Doppler used for cardiac monitoring, will be made effective for use for dates of service on or after January 1, 2013.   310.1 - Coding Requirements for T ransesophageal Doppler Cardiac Monitoring  Furnished Before January 1, 2013  (Rev. 2743, Issued: 07- 25-13, Effective: 07 -01-01-13, Implementation, 08- 26-13)  Prior to January 1, 2013, the applicable HCPCS code for Transesophageal Doppler cardiac monitoring is:   HCPCS 76999 (billed with modifier - 26) when performed in a hospital setting for ventilated patients in the ICU or for operative patients with a need for intra -operative fluid optimization.   If globally billed using code 76999, it shall be returned as unprocessable to the provider using a claim adjustment reason code (CARC) such as:    CARC 58:  Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   HCPCS 76999 (billed with modifier - TC) shall be denied when performed in a hospital setting for ventilated patients in the ICU or for operative patients with a need for intra -operative fluid optimization with a message such as:    CARC 58:  Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
(Medicare Claims Processing Manual)
CARC 58:  Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.    RARC M77: Missing/incomplete/invalid place of service.   MSN 17.9: Medicare (Part A/Part B) pays for this service. The provider must bill the correct Medicare contractor. (English version) or Este servicio es pagado por Medicare (Parte A/Parte B). El proveedor debe enviar la facture al contratista de Medicare correcto.(Spanish version).  HCPCS 76999 (billed globally or with - 26 or - TC) when performed in an ASC setting for operative patients with a need for intra -operative fluid optimization, ultrasound diagnostic procedures are covered when performed by an entity  other than the ASC.  310.2 - Coding Requirements for T ransesophageal Doppler Cardiac Monitoring  Furnished On or After January 1, 2013  (Rev. 2743, Issued: 07- 25-13, Effective: 07 -01-01-13, Implementation, 08- 26-13)  After January 1, 2013, the applicable HCPCS code for Transesophageal Doppler cardiac monitoring is:   HCPCS G9157 : Transesophageal Doppler used for cardiac monitoring  Contractors shall allow HCPCS G9157 to be billed when services are provided in POS 21 for ventilated patients in the ICU or for operative patients with a need for intra -operative fluid optimization.   Contractors shall deny HCPCS 76999 when billed for Esophageal Doppler for ventilated patients in the ICU or for operative patients with a need for intra -operative fluid optimization using the following messages:    CARC 189: Not otherwise classified or unlisted procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service.    RARC M20: Missing/incomplete/invalid HCPCS.
(Medicare Claims Processing Manual)
RARC M20: Missing/incomplete/invalid HCPCS.    MSN 16.13: The code(s) your provider used is/are not valid for the date of service billed. (English version) or El/los cdigo(s) que us su proveedor no es/son vlido(s) en la fecha de servicio facturada. (Spanish version).    Group Code: Contractual Obligation (CO)   310.3 - Correct Place of Service (POS) Code for T ransesophageal Doppler Cardiac Monitoring  Services on Professional Claims  (Rev. 2743, Issued: 07- 25-13, Effective: 07 -01-01-13, Implementation, 08- 26-13)  Contractors shall pay for T ransesophageal Doppler cardiac monitoring , G9157, only when services are provided at POS 21.  Contractors shall deny HCPCS G9157 when billed globally in any POS other than 21 for ventilated patients in the ICU or for operative patients with a need for intra -operative fluid optimization using the following messages:   CARC 58:  Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.  Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   MSN 16.2:   This service cannot be paid when provided in this location/facility.  Group Code: CO   320 - Artificial Hearts and Related Devices  (Rev.10837; Issued: 06- 11-21; Effective: 12 -01-20; Implementation: 07 -27-21)  Effective for claims with dates of service on or after December 1, 2020, as a result of a reconsideration of National Coverage Determination (NCD) 20.9 of the Medicare NCD Manual, coverage determinations for artificial hearts and related devices shall be m ade by the Medicare Administrative Contractors.    320.1  Coding Requirements for Artificial Hearts Furnished Before May 1, 2008 (Rev. 3054, Issued: 08- 29-14, Effective: 10 -30- 13, Implementation: 09 -30-14)
(Medicare Claims Processing Manual)
320.1  Coding Requirements for Artificial Hearts Furnished Before May 1, 2008 (Rev. 3054, Issued: 08- 29-14, Effective: 10 -30- 13, Implementation: 09 -30-14)  Effective for discharges before May 1, 2008, Medicare does not cover the use of artificial hearts, either as a permanent replacement for a human heart or as a temporary life-support system until a human heart becomes available for transplant (often referred to a "bridge to transplant").   320.2  Coding Requirements for Artificial Hearts Furnished On or After May 1, 2008 (Rev. 3054, Issued: 08- 29-14, Effective: 10-30- 13, Implementation: 09-30-14)   Effective for discharges on or after May 1, 2008, the use of artificial hearts will be covered by Medicare under Coverage with Evidence Development (CED) when beneficiaries are enrolled in a clinical study that meets all of the criteria listed in IOM Pub. 100- 03, Medicare NCD Manual, section 20.9.  Claims Coding
(Medicare Claims Processing Manual)
For claims with dates of service on or after May 1, 2008, artificial hearts in the context of an approved clinical study for a Category A IDE, refer to section 69 in this manual for more detail on CED billing. Appropriate ICD-10 diagnosis and procedure cod es are included below:  ICD-10 Diagnosis Code  Definition  Discharges Effective  I09.81  Rheumatic heart failure  On or After ICD-10 Implementation  I11.0  Hypertensive heart disease with heart failure  I13.0  Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease  I13.2  Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease  I20.0  Unstable angina  I21.01  ST elevation (STEMI) myocardial infarction involving left main coronary artery  I21.02  ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery  I21.09  ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall  I21.11  ST elevation (STEMI) myocardial infarction involving right coronary artery  I21.19  ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall  I21.21  ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery  I21.29  ST elevation (STEMI) myocardial infarction involving other sites I21.3  ST elevation (STEMI) myocardial infarction of unspecified site I21.4  Non-ST elevation (NSTEMI) myocardial infarction  I22.0  Subsequent ST elevation (STEMI) myocardial infarction of anterior wall  I22.1  Subsequent ST elevation (STEMI) myocardial infarction of inferior wall  I22.2  Subsequent non -ST elevation (NSTEMI) myocardial infarction  I22.8  Subsequent ST elevation (STEMI) myocardial infarction of other sites  I22.9  Subsequent ST elevation (STEMI) myocardial infarction of unspecified site  I24.0  Acute coronary thrombosis not resulting in myocardial infarction  I24.1  Dressler's syndrome  I24.8  Other forms of acute
(Medicare Claims Processing Manual)
(STEMI) myocardial infarction of unspecified site  I24.0  Acute coronary thrombosis not resulting in myocardial infarction  I24.1  Dressler's syndrome  I24.8  Other forms of acute ischemic heart disease  I24.9  Acute ischemic heart disease, unspecified  I25.10  Atherosclerotic heart disease of native coronary artery without angina pectoris  I25.110  Atherosclerotic heart disease of native coronary artery with unstable angina pectoris  I25.111  Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm  I25.118  Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris  I25.119  Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris  I25.5  Ischemic cardiomyopathy  I25.6  Silent myocardial ischemia  I25.700  Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris  I25.701  Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm  I25.708  Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris  I25.709  Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris  I25.710  Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris  I25.711  Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm  I25.718  Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris  I25.719  Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris  I25.720  Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris  I25.721
(Medicare Claims Processing Manual)
artery bypass graft(s) with unspecified angina pectoris  I25.720  Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris  I25.721  Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm  I25.728  Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris  I25.729  Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris  I25.730  Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris  I25.731  Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm  I25.738  Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris  I25.739  Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris  I25.750  Atherosclerosis of native coronary artery of transplanted heart with unstable angina  I25.751  Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm  I25.758  Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris  I25.759  Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris  I25.760  Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina  I25.761  Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm  I25.768  Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris  I25.769  Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris
(Medicare Claims Processing Manual)
of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris  I25.769  Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris  I25.790  Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris  I25.791  Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm  I25.798  Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris  I25.799  Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris  I25.810  Atherosclerosis of coronary artery bypass graft(s) without angina pectoris  I25.811  Atherosclerosis of native coronary artery of transplanted heart without angina pectoris  I25.812  Atherosclerosis of bypass graft of coronary artery of transplanted heart without angina pectoris  I25.89  Other forms of chronic ischemic heart disease  I25.9  Chronic ischemic heart disease, unspecified  I34.0  Nonrheumatic mitral (valve) insufficiency  I34.1  Nonrheumatic mitral (valve) prolapse  I34.2  Nonrheumatic mitral (valve) stenosis  I34.8  Other nonrheumatic mitral valve disorders  I34.9  Nonrheumatic mitral valve disorder, unspecified  I35.0  Nonrheumatic aortic (valve) stenosis  I35.1  Nonrheumatic aortic (valve) insufficiency  I35.2  Nonrheumatic aortic (valve) stenosis with insufficiency  I35.8  Other nonrheumatic aortic valve disorders  I35.9  Nonrheumatic aortic valve disorder, unspecified  I36.0  Nonrheumatic tricuspid (valve) stenosis  I36.1  Nonrheumatic tricuspid (valve) insufficiency  I36.2  Nonrheumatic tricuspid (valve) stenosis with insufficiency  I36.8  Other nonrheumatic tricuspid valve disorders
(Medicare Claims Processing Manual)
Nonrheumatic tricuspid (valve) insufficiency  I36.2  Nonrheumatic tricuspid (valve) stenosis with insufficiency  I36.8  Other nonrheumatic tricuspid valve disorders  I36.9  Nonrheumatic tricuspid valve disorder, unspecified  I37.0  Nonrheumatic pulmonary valve stenosis  I37.1  Nonrheumatic pulmonary valve insufficiency  I37.2  Nonrheumatic pulmonary valve stenosis with insufficiency  I37.8  Other nonrheumatic pulmonary valve disorders  I37.9  Nonrheumatic pulmonary valve disorder, unspecified  I38 Endocarditis, valve unspecified  I39 Endocarditis and heart valve disorders in diseases classified elsewhere  I42.0  Dilated cardiomyopathy  I42.2  Other hypertrophic cardiomyopathy  I42.3  Endomyocardial (eosinophilic) disease  I42.4  Endocardial fibroelastosis  I42.5  Other restrictive cardiomyopathy  I42.6  Alcoholic cardiomyopathy  I42.7  Cardiomyopathy due to drug and external agent  I42.8  Other cardiomyopathies  I42.9  Cardiomyopathy, unspecified  I43 Cardiomyopathy in diseases classified elsewhere  I46.2  Cardiac arrest due to underlying cardiac condition  I46.8  Cardiac arrest due to other underlying condition  I46.9  Cardiac arrest, cause unspecified  I47.0  Re-entry ventricular arrhythmia  I47.1  Supraventricular tachycardia  I47.2  Ventricular tachycardia  I47.9  Paroxysmal tachycardia, unspecified  I48.0  Atrial fibrillation  I48.1  Atrial flutter  I49.01  Ventricular fibrillation  I49.02  Ventricular flutter  I49.1  Atrial premature depolarization  I49.2  Junctional premature depolarization  I49.3  Ventricular premature depolarization  I49.40  Unspecified premature depolarization  I49.49  Other premature depolarization  I49.5  Sick sinus syndrome  I49.8  Other specified cardiac arrhythmias  I49.9  Cardiac arrhythmia, unspecified  I50.1  Left ventricular failure  I50.20  Unspecified systolic (congestive) heart failure