evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Major Joint Replacement (Hip and Knee) (A57765)
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) L33618 Major Joint Replacement (Hip and Knee). Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceBilateral knee or hip replacement surgery during the same encounter is subject to bilateral pricing. Generally, there are two surgeons acting as co-surgeons, with each one operating on a distinct knee or hip. Modifier  50 (bilateral procedure) and  62 (co-surgeon) should be appended to the appropriate CPT procedure code.RT and LT modifiers should be used as appropriate.Notice: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.Documentation Requirements
Article - Billing and Coding: Major Joint Replacement (Hip and Knee) (A57765)
All 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.When the procedure is indicated for advanced joint disease, the following should be documented in the medical record:Arthritis of the knee or hip supported by X-ray or MRI. The X-ray or MRI should demonstrate one of the following: a) subchondral cysts, b) subchondral sclerosis, c) periarticular osteophytes, d) joint subluxation, e) joint space narrowing, or f) avascular necrosis.Pain or functional disability at the hip or knee. For example, documented pain that interferes with ADLs (functional disability), or pain that is increased with initiation of activities or pain that increases with weight bearing.Unsuccessful conservative therapy (non-surgical medical management). The documentation should demonstrate a history of a reasonable attempt (usually 3 months or more) at conservative therapy as appropriate for the patient in their current episode of care. For example, documented trial of NSAIDs or contraindication to such therapy and/or documented supervised physical therapy. Documentation should support that ADLs are diminished due to pain and/or disability despite non-surgical medical management.For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as TKA or THA should be appropriately addressed in the medical record.Medical record documentation for other TKA and THA indications outlined in the LCD should include the following, when indicated:
Article - Billing and Coding: Major Joint Replacement (Hip and Knee) (A57765)
Medical record documentation for other TKA and THA indications outlined in the LCD should include the following, when indicated:Supporting evidence (e.g., pathology reports and referral from an Oncologist for a malignancy of the joint or X-ray of a fracture).Pain at the hip or knee when indicated as a reason for the procedure (e.g., for revision/replacement TKA/THA). For example, documented pain that interferes with ADLs functional disability), pain that is increased with initiation of activities or pain that increases with weight bearing.For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as TKA or THA should be appropriately addressed in the medical record.When infection is the reason for revision TKA or THA surgery, laboratory and/or pathology reports must be documented in the medical record and all documentation regarding treatment of the infection and a physician note indicating that it is appropriate to proceed with surgery should be in the medical record as well.In the instance that the patient is undergoing a bilateral knee or hip replacement, all criteria listed above would apply to the bilateral surgery when indicated. The medical record should also support the medical necessity for performing THA or TKA bilaterally.If in certain circumstances the patient does not meet all of the required criteria outlined in the local coverage determination (LCD) for a procedure, but the treating physician feels that the procedure is a covered procedure given the current standards of care, then the documentation must clearly outline the patients episode of care that supports the major procedure and must clearly address the reason(s) for coverage. For example, if clinical findings (or lack of) for an indication are not consistent with the LCD criteria, it should be directly addressed in the pre procedure documentation. For example, if certain conservative measures are not necessary for a given patient, it should be directly noted in the pre procedure documentation. The clinical judgment of the treating physician is always a consideration if clearly addressed in the pre procedure record and if consistent with the episode of care for the patient as documented in patient records and claim history.
Article - Billing and Coding: Mohs Micrographic Surgery (MMS) (A57767)
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) L33689 Mohs Micrographic Surgery (MMS). Please refer to the LCD for reasonable and necessary requirements.Mohs Micrographic Surgery (MMS) is the technique for the removal of complex or ill-defined skin cancer with histopathologic examination of 100% of the surgical margins. MMS is a precise tissue-sparing, microscopically-controlled surgical technique used in the removal and treatment of selected malignant neoplasms of the skin. This surgery requires a single surgeon to act in two distinct roles: surgeon and pathologist performing not only the excision but also the histologic evaluation of the specimen(s). It is an approach that aims to achieve the highest possible cure rates and minimize wound size and consequent distortions at critical sites such as the eyes, ears, nose, and lips. MMS is a two-step process in which: (1) the tumor is removed in stages, followed by immediate histologic evaluation of the margins of the specimen(s), and (2) additional excision and evaluation is performed until all margins are clear.Mohs surgery leaves an open wound, which most often is reconstructed (closed) by the Mohs surgeon. Some wound management is included in the intra and post service work of the Mohs surgery codes, and the Mohs surgeon has the option of repair (closure) codes as appropriate.At this time, all laboratory tests covered under CLIA are edited at the CLIA certificate level. The MMS procedure codes would require either a CLIA certificate of registration (certificate type code 9), a CLIA certificate of compliance (certificate type code 1), or a CLIA certificate of accreditation (certificate type code 3). A facility without a valid current CLIA certificate will not be permitted to bill for these procedures.Coding Guidance
Article - Billing and Coding: Mohs Micrographic Surgery (MMS) (A57767)
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.Per the CPT codebook, if repair (closure) is performed, the Mohs surgeon may report separate repair, adjacent tissue transfer or rearrangement, flap, or graft codes. The guidelines at the beginning of applicable sections of the CPT codebook define items that are necessary to report services and procedures. Also, there are other instructions (such as parenthetical notes with selected codes) that may restrict the use of certain additional procedure codes. Physicians must code to specificity and code correctly. The National Correct Coding Initiative edits applicable to certain procedures must not be circumvented.A biopsy is necessary for the physician to determine the exact nature of the lesion(s) to be removed. Occasionally, that biopsy may need to be done on the same day that the Mohs surgery is performed because there was no prior pathology confirmation of a diagnosis. In order to allow separate payment for a biopsy and pathology on the same day as MMS, the -59 modifier or modifier XU- unusual, non-overlapping service is appropriate when there is no biopsy of the lesion for which Mohs surgery is performed within 60 days of the Mohs surgery or when the biopsy is performed on a lesion that is not associated with the Mohs surgery.If a pathology procedure is performed on the same day as the Mohs surgical procedure, documentation must support a separate excision/biopsy/repair was performed. Report diagnostic skin biopsy (11102 - 11107) and frozen section pathology (88331) with modifier -59 or modifier XS-separate structure to distinguish from the subsequent definitive surgical procedure of Mohs surgery.If additional special pathology procedures, stains, or immunostains are required, use 88311-88314, 88341, 88342, and 88344.
Article - Billing and Coding: Mohs Micrographic Surgery (MMS) (A57767)
If additional special pathology procedures, stains, or immunostains are required, use 88311-88314, 88341, 88342, and 88344.Do not report 88314 in conjunction with 17311-17315 for routine frozen section stain (e.g., hematoxylin and eosin, toluidine blue) performed during Mohs surgery. When a non-routine histochemical stain on frozen tissue is utilized, report 88314 with modifier 59 or modifier XU-unusual, non-overlapping service.Do not report 88302-88309 on the same specimen as part of the Mohs surgery.Diagnosis(es) must be present on any claim submitted and must be coded to the highest level of specificity.If repair is performed, use separate repair, flap, or graft codes. The repair of wounds may be classified as simple, intermediate, or complex.Simple repairis used when the wound is superficial, e.g., involving primarily epidermis or dermis or subcutaneous tissue without significant involvement of deeper structures and requires a simple one layer closure.Intermediate repairincludes the repair of wounds that, in addition to the above, required layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (non-muscle) fascia, in addition to the skin (epidermal and dermal closure).Complex repairincludes the repair of wounds requiring more than layered closure, such as scar revision, debridement, extensive, undermining, stents or retention sutures.Adjacent tissue transfer or rearrangement codes are used for excision (including lesion) and/or repair of adjacent tissue transfer or rearrangement (e.g., Z-plasty, W-plasty, V-Y plasty, rotation flap, random island flap, advancement flap). Undermining alone of adjacent tissues to achieve closure, without additional incisions, does not constitute adjacent tissue transfer.Skin graft necessary to close secondary defect is considered an additional procedure. For purposes of code selection, the term defect includes the primary and secondary defects. The primary defect resulting from the excision and the secondary defect resulting from flap design to perform the reconstruction are measured together to determine the code.Documentation Requirements
Article - Billing and Coding: Mohs Micrographic Surgery (MMS) (A57767)
All 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.The physician must document in the patients medical record that the diagnosis is appropriate for MMS and that MMS is an appropriate choice as the treatment of the particular lesion. Also, the options for care (both the primary procedure options and repair options) must be discussed with the patient and clearly noted in the pre-procedure (or post procedure as appropriate) documentation. In summary, the minimal medical need documentation entails that the beneficiary was informed of their treatment options and explained the risks/benefits of the MMS technique and associated repair.Operative notes and pathology documentation in the patients medical record should clearly show that MMS was performed using accepted MMS technique, in which the physician acts in two integrated and distinct capacities: surgeon and pathologist (therefore confirming that the procedure meets the definition of the CPT code[s]).Operative documentation should note: location, number, and size of the lesion(s); number of stages performed; number of specimens per stage. Histology documentation must include the following: (a) First stage: depth of invasion; pathological pattern of the tumor; cell morphology; if present, note perineural invasion of scar tissue. (b) Subsequent stages: if the tumor characteristics are the same as in the first stage, note this fact only. If the tumor characteristics are different from the first stage, describe the differences.
Article - Billing and Coding: Mohs Micrographic Surgery (MMS) (A57767)
Measurement of the primary lesion necessitating MMS and measurements in support of repair or related procedures (such as but not limited to adjacent tissue transfer/rearrangements, grafts/flaps) completing the MMS procedure and confirming the primary defect measurement or other relevant measurements should be verifiable. Documentation of the clinical tumor border definition may be accomplished by preoperative photography with the skin stretched to delineate the visible clinical borders with or without debulking curettage (using a centimeter ruler or relation of size by another anatomic structure). Postoperative photography to document the defect may also be considered, especially for small lesions that have a significant subepithelial component (i.e., tip of the iceberg phenomenon). It is understood that photographic documentation may not be possible in a small percentage of cases because of technical difficulties.When the surgical defect created by MMS requires reconstruction, it should be clear on the documentation that the reconstructive technique performed was an appropriate choice to preserve functional capabilities and to restore physical appearance.If one of the NCCI associated modifiers (XE-separate encounter, XP-separate practitioner, XS-separate structure, XU-unusual, non-overlapping service) is used with a skin biopsy/pathology code on the same day the MMS was performed, physician documentation must clearly support the use of the modifier(s).If a pathology code is billed on the same day as MMS, documentation must support a separate excision/biopsy/repair was performed.
Article - Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) (A57772)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1 Clinical Laboratory Services.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 Allowance.CMS Internet-Only Manual Pub 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure Codes.Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Diagnostic Tests (MDT) L36807.To report a Molecular Diagnostic Test service, please submit the following claim information:Select appropriate CPT codeEnter 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 formNOTE:When entering the DEX Z-Code on the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: MolDX: Breast Cancer Index® (BCI) Gene Expression Test (A57773)
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. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.0 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests, 80.1.1 Certification ChangesCMS 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 2310 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: Breast Cancer Index (BCI) Gene Expression Test.Effective 1/01/2019, MolDX will provide limited coverage for the BCI gene expression test.The BCI test is covered for postmenopausal women with invasive breast cancer when the following criteria are met:Pathology reveals invasive carcinoma of the breast that is ER+ and/or PR+ and HER2 -; andPatient has early-stage disease (T1-3, pN0-N1, M0); andPatient has no evidence of distant breast cancer metastasis (i.e., non-relapsed); andTest results will be used in determining treatment management of the patient for chemotherapy and/or endocrine therapy.MolDX expects this test will be performed once per patient lifetime on formalin-fixed, paraffin-embedded (FFPE) tissue from the primary tumor specimen obtained prior to adjuvant treatment.To report a BCI service, please submit the following claim information:Select CPTcode 81518Enter unit of service (UOS)Enter the appropriate DEX Z-Code identifier 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 claim
Article - Billing and Coding: MolDX: Breast Cancer Index® (BCI) Gene Expression Test (A57773)
Enter the appropriate DEX Z-Code identifier 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 code
Article - Billing and Coding: MolDX: Breast Cancer Index™ (BCI) Gene Expression Test (A57774)
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. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.0 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests, 80.1.1 Certification ChangesCMS 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 2310 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: Breast Cancer Index (BCI) Gene Expression Test.Effective 1/01/2019, MolDX will provide limited coverage for the BCI gene expression test.The BCI test is covered for postmenopausal women with invasive breast cancer when the following criteria are met:Pathology reveals invasive carcinoma of the breast that is ER+ and/or PR+ and HER2 -; andPatient has early-stage disease (T1-3, pN0-N1, M0); andPatient has no evidence of distant breast cancer metastasis (i.e., non-relapsed); andTest results will be used in determining treatment management of the patient for chemotherapy and/or endocrine therapy.MolDX expects this test will be performed once per patient lifetime on formalin-fixed, paraffin-embedded (FFPE) tissue from the primary tumor specimen obtained prior to adjuvant treatment.To report a BCI service, please submit the following claim information:Select CPTcode 81518Enter unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claim
Article - Billing and Coding: MolDX: Breast Cancer Index™ (BCI) Gene Expression Test (A57774)
Enter the appropriate DEX Z-Code identifier 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 code