evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Cataract Extraction (A56544)
If cataract extraction is performed due to anisometropia, the medical record must substantiate the presence of significant aniseikonia secondary to anisometropia arising from the first cataract extraction with IOL implant. The medical record must reflect that the aniseikonia is visually significant to the patient by documenting the patient's subjective complaints and must also document that anisometropia is present by determination of the refractive error in both eyes after the first cataract surgery.If cataract extraction is performed in order to visualize the fundus, the disease being treated must appear in the medical record, and the necessity for visualization must be described in the medical record.For CPT code 66982 and 66987,complex cataract extraction, to be reasonable and necessary, the procedure should require devices or techniques not generally used in routine cataract surgery. Please see examples below:The operative note indicates that a permanent intraocular suture or a capsular support ring was employed to place the intraocular lens in a stable position.The operative note indicates a capsular support ring was employed or an endocapsular support ring was used.The operative note indicates the use of micro iris hooks inserted through four (4) or more separate cornea incisions, use of an iris dilator device, synechiolysis utilizing pupillary stretch maneuvers creation of multiple sphincterotomies with scissors, a sector iridotomy with suture repair of iris sphincter was performed, or a permanent intraocular suture, capsular support ring, or endocapsular support ring was used.The operative note indicates dye was used to stain the anterior capsule.The operative note indicates Phacolytic glaucomaThe operative note indicates a primary posterior capsulorhexis was performedThe operative note or postoperative records indicate an extraordinary amount of work was involved in the preoperative or postoperative care.The operative note indicates an artificial prosthetic iris was placed in the eye.
Article - Billing and Coding: Hospice - Renal Care (A56545)
CMS National Coverage PolicyCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, 30.2, 30.2.2, and 30.3Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Hospice Renal Care L34559.
Article - Billing and Coding: Corneal Pachymetry (A56548)
CMS National Coverage PolicyN/AArticle TextThis articlecontains codingand other guidelines that complement the Local Coverage Determination (LCD) for Corneal Pachymetry.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.CPT and Modifier CodingCPT code 92499 (unlisted ophthalmological service or procedure) should be used to report optical pachymetry services. The phrase, "Optical Pachymetry" should be listed in the narrative note in item 19 of the CMS 1500 form or electronic equivalent for claims submitted to Part B, and in FL 80 for claims submitted to Part A. The optical pachymetry service should be billed and is valued equivalently to the ultrasonic service (CPT code 76514). Modifier RT, LT, or 50 (bilateral) should be reported with CPT code 92499, as appropriate.CPT code 76514 is reimbursed as a bilateral service (both eyes are included in a single test). Therefore, it should be billed once (one unit of service) regardless of whether it was performed on one or two eyes. If the service is performed unilaterally, report modifier RT or LT and modifier 52 (reduced services) on the claim.Documentation RequirementsMedical record documentation maintained by the ordering/referring physician must indicate the medical necessity for performing the test and the test results. In addition, if the service exceeds the frequency parameter listed in this policy, documentation of medical necessity must be submitted. This information is usually found in the history and physical, office/progress notes, or test results.
Article - Billing and Coding: Corneal Pachymetry (A56548)
If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician's order for the studies. The physician must state the clinical indication/medical necessity for the study in his order for the test.Documentation should contain a history and physical which supports the diagnosis for which this service is being rendered.Utilization Guidelines:It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.It is expected that services for the measurement of corneal thickness following the diagnosis of increased intraocular pressure will be performed once in a lifetime, unless there has been interval corneal trauma or surgery.
Article - Billing and Coding: Ophthalmic Biometry for Intraocular Lens Power Calculation (A56549)
CMS National Coverage PolicyN/AArticle TextThis article containscoding and other guidelines that complement the Local Coverage Determination (LCD) for Ophthalmic Biometry for Intraocular Lens (IOL) Power Calculation.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 diagnoses 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.Specific coding guidelines:Currently, theMedicare Physician Fee Schedule Database (MPFSDB) bilateral surgery indicator is 2 for the global and technical componentsof each method of ophthalmic biometry for intraocular lens power calculation (CPT codes 76519 and 92136). The definition of 2 is as follows:2 =150% payment adjustment does not apply. RVUs are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with modifier -50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for both sides on the lower of (a) the actual charge by the physician for both sides, or (b) 100% of the fee schedule for a single code.When the MPFSDB bilateral surgery indicator is 2, the relative value units (RVUs) are based on the procedure performed on each eye.
Article - Billing and Coding: Ophthalmic Biometry for Intraocular Lens Power Calculation (A56549)
When the MPFSDB bilateral surgery indicator is 2, the relative value units (RVUs) are based on the procedure performed on each eye.The global service includes the bilateral technical component (76519-TC or 92136-TC) and a unilateral professional service (76519-26 or 92136-26). The anatomic modifier (-RT or -LT) should be used to indicate the eye on which the professional component was performed.The technical component should not be billed with the bilateral modifier -50. Payment is based on the lower of the submitted charge or the fee schedule for a single code.No additional payment is made when CPT code 76519-TC or 92136 is billed with the bilateral modifier -50.If the technical portion of the procedure is only performed on one eye, the -52 modifier for reduced services should be used as well as the appropriate anatomic modifier (-RT or -LT).Currently, theMedicare Physician Fee Schedule Database (MPFSDB) bilateral surgery indicator is 3 for the professional componentsof each method of ophthalmic biometry for intraocular lens power calculation (CPT codes 76519 and 92136). The definition of 3 is as follows:3= The usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier -50 or is reported for both sides on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for each side or organ or site of a paired organ on the lower of (a) the actual charge for each side or (b) 100% of the fee schedule amount for each side.When the MPFSDB bilateral surgery indicator is 3, the RVUs are calculated based on the procedure being performed as a unilateral procedure on each eye. Payment is based on the lower of the submitted charge or 100% of the fee schedule amount for each eye.
Article - Billing and Coding: Ophthalmic Biometry for Intraocular Lens Power Calculation (A56549)
It is not uncommon for an IOL implant to be required for both eyes. When surgery for bilateral cataracts is scheduled several weeks apart, bill the professional component only when the IOL calculation is done within a timeframe that it can be used for the second planned surgery.When the scan is performed and the calculation done on thefirsteye, bill the technical portion on one line (76519-TC or 92136-TC) and the professional component on a second line [76519 26-RT (or 26-LT) or 92136 26-RT (or 26-LT)].Alternatively, bill the global code and use modifier -RT or -LT to indicate on which eye the professional component was performed [76519-RT (or -LT) or 92136-RT (or LT)]. Do not submit modifier -50.If the technical and professional components are performed onboth eyes on the same date, bill the global service on one line and the second professional component on a second line, indicating the anatomic modifier (-LT/-RT) for the second eye.One physician may do the technical component and another physician the professional component. Each will need to use the appropriate modifier, e.g., -TC (technical component) or -26 (professional component). The professional component should also have the anatomic modifier (-LT/-RT) appended.National Coverage Requirements:Cataract surgery with an intraocular lens (IOL) implant is a high volume Medicare procedure. Along with the surgery, a substantial number of preoperative tests are available to the surgeon. In most cases, a comprehensive eye examination (ocular history and ocular examination) and a single scan to determine the appropriate pseudophakic power of the IOL are sufficient. In most cases involving a simple cataract, a diagnostic ultrasound A-scan is used.For patients with a dense cataract, an ultrasound B-scan may be used. (CMS Publication 100-03,Medicare National Coverage Determinations(NCD)Manual, Chapter 1, Part 1, Section 10.1)
Article - Billing and Coding: Ophthalmic Biometry for Intraocular Lens Power Calculation (A56549)
Accordingly, where the only diagnosis is cataract(s), Medicare does not routinely cover testing other than one comprehensive eye examination (or a combination of a brief/intermediate examination not to exceed the charge of a comprehensive examination) and an A-scan or, if medically justified, a B-scan. Claims for additional tests are denied as not reasonable and necessary unless there is an additional diagnosis and the medical need for the additional tests is fully documented.(CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, Section 10.1)Because cataract surgery is an elective procedure, the patient may decide not to have the surgery until later, or to have the surgery performed by a physician other than the diagnosing physician. In these situations, it may be medically appropriate for the operating physician to conduct another examination. To the extent the additional tests are considered reasonable and necessary by the carriers medical staff, they are covered.(CMS Publication 100-03,Medicare National Coverage Determinations(NCD)Manual, Chapter 1, Part 1, Section 10.1)Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (Please 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. This documentation should include at a minimum the patients name and date of service, the indications for testing, an order for testing, the results of testing, and the IOL power calculation. Documentation must be available to Medicare upon request.Utilization Guidelines:Ophthalmic biometry using A-scans (76519) and optical coherence biometry (92136) for the same patient should not be billed by the same provider/physician/group during a 12-month period. Claims for either of these services in excess of these parameters will be considered not medically necessary.The technical portion of either 76519 or 92136 and the respective interpretations for the same patient should not be billed more than once during a 12 month period by the same provider/physician/group unless there is a significant change in vision. Claims in excess of these parameters will be considered not medically necessary.
Article - Billing and Coding: Panretinal (Scatter) Laser Photocoagulation (A56550)
CMS National Coverage PolicyN/AArticle TextThis article contains codingand other guidelines that complement the Local Coverage Determination (LCD) for Panretinal (Scatter) Laser Photocoagulation (PRP).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.Use modifiers LT/RT to indicate operative site. Claims submitted without modifier -RT, -LT, or -50 (in the rare event both eyes are treated on the same day/session) will be returned as unprocessable under 1833[e]).Panretinal laser photocoagulation is usually performed in two or more sessions (staged surgery). Payment may be made only once during the global period of the initial procedure. Reimbursement for subsequent sessions in the postoperative period of the initial procedure is included in the allowance of the initial procedure.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).Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD.This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Article - Billing and Coding: Visual Fields Testing (A56551)
CMS National Coverage PolicyN/AArticle TextThisarticlecontains codingand other guidelines that complement the Local Coverage Determination (LCD) for Visual Fields Testing.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within this 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.
Article - Billing and Coding: Allergy Testing (A56558)
CMS National Coverage PolicyInternet-Only Manuals (IOMs):CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 12, Section 200 Allergy Testing and ImmunotherapySocial 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) L36241, Allergy Testing. 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.Consistent with the related LCD, CPT code 82785 Gammaglobulin [immunoglobulin]; IgE is not appropriate in most general allergy testing. Please refer to the LCD for details on medically reasonable and necessary guidelines.It is not usually necessary to report CPT code 86003 Allergen specific IgE; quantitative or semiquantitative, crude allergen extract (in vitro testing) in addition to skin testing. Please see the related LCD for medically reasonable and necessary guidelines.Documentation Requirements: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 medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.Prior to performance of allergy testing, there must be evidence in the medical record that a history has been obtained, indicating the possible presence of allergy.
Article - Billing and Coding: Allergy Testing (A56558)
This history should support that attempts to narrow the area of investigation were taken so that the minimal number of necessary skin tests might deliver a diagnosis.The history should support that the selection of antigens was based on the patient specific history and physician examination.The medical record must indicate which allergy test(s) were used, the interpretation(s), and measurement (in mm) of reaction size of both wheal and erythema response or a standardized grading system in vivo testing (as applicable).
Article - Billing and Coding: Allergy Skin Testing (A56559)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 20.2 Physician Expense for Allergy TreatmentArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Allergy Skin Testing L33417.
Article - Billing and Coding: Health and Behavior Assessment/Intervention (A56562)
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 Health and Behavior Assessment/Intervention L37638.CPTcode 90901 Biofeedback is also not covered as a health and behavioral intervention.
Article - Billing and Coding: Brain Natriuretic Peptide (BNP) Level (A56565)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1 Clinical Laboratory ServicesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Brain Natriuretic Peptide (BNP) Level L33422.
Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Sections 1861(g), 1861(p), 1861(s)(2) and 1862(a)(14) of Title XVIII of the Social Security Act define the services of non-physician practitioners.Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1862(a)(20) excludes payment for PT or OT services furnished incident to the physician by personnel that do not meet the qualifications that apply to therapists, except licensing.Code of Federal Regulations42 CFR, Sections 410.59 and 410.61 describe outpatient occupational therapy services and the plan of treatment for outpatient rehabilitation services, respectively.42 CFR, Sections 410.60 and 410.61 describe outpatient physical therapy services and the plan of treatment for outpatient rehabilitation services, respectively.42 CFR, Sections 410.74, 410.75, 410.76, and 419.22 define the services of non-physician practitioners.42 CFR, Sections 424.24 and 424.27 describe therapy certification and plan requirements.42 CFR, Sections 424.4, 482.56, 484 and 485.705 define therapy personnel qualification requirements.42 CFR, Section 486 describes coverage for services rendered by physical therapists in independent practice.