evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Cosmetic and Reconstructive Surgery (A56587)
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) L35090, Cosmetic and Reconstructive Surgery. Please refer to the LCD for reasonable and necessary requirements.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.Documentation RequirementsFor all procedures: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.Documentation Requirements for Specified ServicesDermabrasionThe medical record must describe the beneficiarys disease process of the rhinophyma that is being treated with dermabrasion.Abdominal Lipectomy/PanniculectomyThe medical record must contain the following information:Description of the pannus and underlying skin.Documentation that the panniculus causes chronic intertrigo (dermatitis occurring on the opposed surfaces of the skin, skin irritation, infection, or chafing).Description of functional impairments (e.g., difficulty walking, exercising, or impairment in activities of daily living).Description of conservative treatment the beneficiary has received and the results of treatment.Preoperative photographs of the pannus and underlying skin are recommended.Reconstructive Breast Surgery: Removal of Breast ImplantsThe medical record must describe the condition which supports the removal of the breast implant(s) as medically reasonable and necessary.
Article - Billing and Coding: Cosmetic and Reconstructive Surgery (A56587)
Reconstructive Breast Surgery: Removal of Breast ImplantsThe medical record must describe the condition which supports the removal of the breast implant(s) as medically reasonable and necessary.Reduction MammaplastyThe beneficiary's medical record must contain the following information:Height and weight.Clinical evaluation of the signs or symptoms ascribed to the macromastia, therapies prior to reduction mammaplasty and the responses to these therapies.Mammogram report for age appropriate population.The operative report with documentation of the weight of tissue removed from each breast, obtained in the operating room.The pathology report of the tissue removed from each breast.Mastectomy for gynecomastiaGlandular breast tissue confirming true gynecomastia is documented on physical exam and/or mammography.Documentation that the gynecomastia persists, despite correction of any underlying causes.Documentation supporting that the gynecomastia is classified as Grade III or IV per the American Society of Plastic Surgeons (ASPS) classification when the procedure is performed in males.Documentation that hormonal causes, including hyperthyroidism, estrogen excess, hyperprolactinemia and hypogonadism have been excluded by appropriate laboratory testing (e.g., with levels of thyroid stimulating hormone [TSH], estradiol, prolactin, testosterone and/or luteinizing hormone [LH])Documentation supporting that gynecomastia persists after 3 to 4 months of unsuccessful medical treatment, the use of potential gynecomastia-inducing drugs and substances has been ruled out and gynecomastia persists for at least one year.RhinoplastyPhotographic documentation of the patients condition is recommended to help support medical necessity if documentation is requested.The medical record must include a description of the condition requiring the rhinoplasty.When rhinoplasty is being performed for chronic obstruction, the medical record must indicate what is causing the obstruction.Septoplasty
Article - Billing and Coding: Cosmetic and Reconstructive Surgery (A56587)
SeptoplastyThe medical record must describe the conservative medical management utilized and the length of time that the treatment was trialed for septal deviation causing nasal airway obstruction.The medical record must contain the medical and antibiotic therapy that was utilized, and the length of the time treatment was trialed for recurrent sinusitis secondary to deviated septum.The medical record must contain the medical management utilized and the length of time that the treatment was trialed for obstructed nasal breathing due to septal deformity or deviation that is interfering with the effective use of Continuous Positive Airway Pressure (CPAP) for the treatment of an obstructive sleep disorder.
Article - Billing and Coding: Micro-Invasive Glaucoma Surgery (MIGS) (A56588)
CMS National Coverage PolicyN/AArticle TextThisarticle contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Micro-Invasive Glaucoma Surgery (MIGS).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.Specific Coding Guideline:Effective for services rendered on or after 1/1/2022, codes 0191T and 0376T are being replaced by CPT codes 66989, 66991.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services. included in the 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. The medical record and/or test results documenting medical necessity should be maintained and made available on request. iStent, iStent inject, and Hydrus must be performed in conjunction with cataract surgery on the same date of service and documented in the medical record.
Article - Billing and Coding: Blood Glucose Monitoring in a Skilled Nursing Facility (SNF) (A56591)
CMS National Coverage PolicyPlease refer to the Local Coverage Determination (LCD), L34834, Blood Glucose Monitoring in a Skilled Nursing Facility (SNF).Article TextRefer to the Novitas Local Coverage Determination (LCD) L34834, Blood Glucose Monitoring in a Skilled Nursing Facility (SNF), for reasonable and necessary requirements.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.Coding InformationThe material for examination may be from any source unless otherwise specified in the code descriptor. When an analyte is measured in multiple specimens from different sources or in specimens that are obtained at different times, the analyte is reported separately for each source and for each specimen.
Article - Billing and Coding: Panretinal (Scatter) Laser Photocoagulation (A56594)
CMS National Coverage PolicyN/AArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policyL34064-Panretinal (Scatter) Laser Photocoagulation.General Guidelines for Claims submitted to Part A or Part B MAC: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.
Article - Billing and Coding: Panretinal (Scatter) Laser Photocoagulation (A56594)
Advance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.
Article - Billing and Coding: Panretinal (Scatter) Laser Photocoagulation (A56594)
The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Medicare allowance generally includes reimbursement for related procedures performed on the same eye during the global surgery period of the first procedure. Therefore, procedure codes 67208, 67210 or 67227 would be covered only if they represented clearly distinct and different procedures with different indications and were not re-operations or treatment of complications. Such services, and other totally unrelated services, should be billed with a modifier -79 (unilateral procedure or service by the same physician during the post-operative period).For claims submitted to the Part B MAC:Claims for panretinal (scatter) laser photocoagulation (PRP) (67228) services are payable under Medicare Part B in the following places of service: office (11), inpatient hospital (21), outpatient hospital (22), emergency room hospital (23), ambulatory surgical center (24) and independent clinic (49).For claims submitted to the Part A MAC:Hospital Inpatient Claims:The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04.The principal diagnosis is the condition established after study to be chiefly responsible for this admission.
Article - Billing and Coding: Panretinal (Scatter) Laser Photocoagulation (A56594)
Hospital Inpatient Claims:The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04.The principal diagnosis is the condition established after study to be chiefly responsible for this admission.The hospital enters ICD-10-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67.For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.)Hospital Outpatient ClaimsThe hospital should report the full ICD-10-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67.If no definitive diagnosis is made during the outpatient evaluation, the patients symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the providershould report an ICD-10-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00-Z13.9).The hospital enters the full ICD-10-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67.Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.For dates of service on or after April 1, 2010, bill type 77x should be used to report FQHC.The CPT code 67228 should only be reported and paid once per 10-day global period per eye no matter how many treatment sessions occur.
Article - Billing and Coding: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs) (A56596)
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, 80.1.2 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, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs) (L37364).This contractor will provide limited coverage for Gastrointestinal Pathogen (GIP) molecular assays identified by multiplex nucleic acid amplification tests (NAATs). In immune competent beneficiaries, coverage is limited to no more than 5 bacterial targets (when not testing for clostridium difficile). Testing for 6-11 pathogens is covered when there is a clinical concern for clostridium difficile colitis, and clostridium difficile is one of the pathogens being tested.Testing for 12 or more organisms will only be covered in critically ill or immunosuppressed patients.This contractor expects that critically ill patients will be tested and managed in the appropriate inpatient facility. As such, for critically ill patients, only Part A claims should be submitted.ICD-10-CM diagnosis codes supporting medical necessity must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.Any diagnosis submitted must have documentation in the patients record to support coverage and medical necessity.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.Billing and Coding Information:To bill for GIP molecular assays identified by multiplex NAATs, please provide the following claim information:
Article - Billing and Coding: Foodborne Gastrointestinal Panels Identified by Multiplex Nucleic Acid Amplification (NAATs) (A56596)
Billing and Coding Information:To bill for GIP molecular assays identified by multiplex NAATs, please provide the following claim information:If the panel being used does not have its own proprietary CPTcode, use CPTcode 87505, 87506 or 87507For dates of service on or after 7/1/2019, laboratories billing for services using the BioFire FilmArray Gastrointestinal (GI) Panel (BioFire Diagnostics) should report 0097UEnter 1 unit of service (UOS)Enter the appropriate 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 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 formICD-10-CM diagnosis code(s) as set forth below.
Article - Billing and Coding: Cardiac Rhythm Device Evaluation (A56602)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states thatno 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) L34833, Cardiac Rhythm Device Evaluation. Please refer to the LCD for reasonable and necessary requirements.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.CPT code 93292 should be reported when billing Medicare Part B for the analysis of a Wearable Defibrillator System.CPT Codes 93260, 93261, 93279-93292 are reported per procedure.Utilization ParametersCPT Codes 93293, 93294, 93295 and 93296 are reported no more than once every 90 days.Do not report CPT codes 93293, 93294, 93295 and 93296, if the monitoring period is less than 30 days.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.
Article - Billing and Coding: B-type Natriuretic Peptide (BNP) Testing (A56605)
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 TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for B-type Natriuretic Peptide (BNP) Testing L34410.
Article - Billing and Coding: Cardiac Event Detection (A56606)
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 claimArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Cardiac Event Detection L34573.
Article - Billing and Coding: Continuous Peripheral Nerve Blocks (CPNB) (A56607)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) states that no payment shall be made to any provider for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 20.9 National Correct Coding Initiative (NCCI)Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forContinuous Peripheral Nerve Blocks (CPNB) L37641.LimitationsReimbursement for the control or management of pain in the immediate postoperative period is bundled into the payment for the procedure, surgical or anesthetic - regardless of the method by which the care provider, including the anesthesiologist, decides to manage pain.
Article - Billing and Coding: Biomarker Testing for Prostate Cancer Diagnosis (A56609)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines related to Biomarker Testing for Prostate Cancer and is designed to aid in correct billing. Use of the CPT codes below in the CPT/HCPCS section do not guarantee coverage.Specific Coding InformationThe CPT codes are considered medically necessary when ordered by a physician or other qualified health care professional.The ordering provider must be familiar with the proper parameters of use of each test that they may be ordering.An LCD is not currently available due to the fluid nature of this area of medicine.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.ReferencesSuggested references include peer reviewed literature, compendiums such as NCCN or guidelines from professional organizations or societies.