evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: MolDX: PAX6 Gene Sequencing (A55625)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Article TextPAX6 is most frequently associated with PAX6-associated aniridia and WAGR syndrome (predisposition to Wilms tumor, Aniridia, Genitourinary anomalies and mental Retardation). Because FISH probes are reported to detect 100% of the WAGR syndrome cases, FISH probes represent the gold standard for patient diagnosis. Although PAX6 sequencing will identify the underlying genetic mutation leading to the development of aniridia in approximately 50% of individuals with sporadic disease, the remaining 50% will have negative test results. Therefore, Noridian has determined PAX6 gene sequencing does not support the required clinical utility for the established Medicare benefit category and is a statutorily excluded test.To receive a PAX6 gene sequencing service denial, please submit the following claim information:CPT code 81479An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientEnter 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 837PItem 19 for paper claimEnter DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim form
Article - Billing and Coding: MolDX: SMPD1 Genetic Testing (A55627)
CMS National Coverage PolicyN/AArticle TextMutations found in sphingomyelin phosphodiesterase 1, (SMPD1) acid lysomal, are associated with Niemann-Pick Disease, characterized by acid sphingomyelinase (ASM) deficiency. For infants and children, SMPD1 genetic testing is used to confirm the clinical findings from blood tests to diagnose ASM. Genetic testing for adults is used to screen the population for potential carriers of the mutation. Therefore, Noridian has determined that SMPD1 genetic testing is not a Medicare benefit and is a statutorily excluded service. In addition to single disease testing, Noridian will also deny panels of tests that include a SMPD1 gene test as a statutorily excluded service.To receive a SMPD1 test denial, please submit the following claim information:CPT code 81330- SMPD1, common variantsCPT code 81412  Ashkenazi Jewish Associated DisordersFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifier. An Advance Beneficiary Notice(ABN) is not required for statutorily excluded services
Article - Billing and Coding: MolDX: SEPT9 Gene Test (A55628)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Article TextNoridian has determined that a Septin 9 methylation analysis test for colorectal cancer detection is not a Medicare covered service. Screening in the absence of signs and symptoms of an illness or injury is not defined as a Medicare benefit. Therefore, Noridian will deny Septin 9 methylation analysis tests as a statutorily excluded service.To receive a SEPT9 service denial, please submit the following claim information:81327- SEPT9 (Septin9) (e.g., colorectal cancer) methylation analysis.An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierEnter 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 837PItem 19 for paper claimEnter DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim form
Article - Billing and Coding: MolDX: SMPD1 Genetic Testing (A55631)
CMS National Coverage PolicyN/AArticle TextMutations found in sphingomyelin phosphodiesterase 1, (SMPD1) acid lysomal, are associated with Niemann-Pick Disease, characterized by acid sphingomyelinase (ASM) deficiency. For infants and children, SMPD1 genetic testing is used to confirm the clinical findings from blood tests to diagnose ASM. Genetic testing for adults is used to screen the population for potential carriers of the mutation. Therefore, Noridian has determined that SMPD1 genetic testing is not a Medicare benefit and is a statutorily excluded service. In addition to single disease testing, Noridian will also deny panels of tests that include a SMPD1 gene test as a statutorily excluded service.To receive a SMPD1 test denial, please submit the following claim information:CPT code 81330- SMPD1, common variantsCPT code 81412  Ashkenazi Jewish Associated DisordersFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifier.An Advance Beneficiary Notice(ABN) is not required for statutorily excluded services
Article - Billing and Coding: MolDX: PAX6 Gene Sequencing (A55632)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Article TextPAX6 is most frequently associated with PAX6-associated aniridia and WAGR syndrome (predisposition to Wilms tumor, Aniridia, Genitourinary anomalies and mental Retardation). Because FISH probes are reported to detect 100% of the WAGR syndrome cases, FISH probes represent the gold standard for patient diagnosis. Although PAX6 sequencing will identify the underlying genetic mutation leading to the development of aniridia in approximately 50% of individuals with sporadic disease, the remaining 50% will have negative test results. Therefore, Noridian has determined PAX6 gene sequencing does not support the required clinical utility for the established Medicare benefit category and is a statutorily excluded test.To receive a PAX6 gene sequencing service denial, please submit the following claim information:CPT code 81479.An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientEnter DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim form
Article - Billing and Coding: Chemotherapy Agents for Non-Oncologic Conditions (A55639)
CMS National Coverage PolicyN/AArticle TextThe article will address anti-neoplastic agent codes provided for treatment of noncancer diagnoses or to substances such as monoclonal antibody agents, and other biologic response modifiers. The drugs cited are not intended to be a complete list of drugs that may be administered using the chemotherapy administration codes.Coverage for medication is based on the patients condition, the appropriateness of the dose and route of administration, based on the clinical condition, medical necessity and the standard of medical practice regarding the effectiveness of the drug for the diagnosis and condition.The listing of the chemotherapy agent and procedure code do not imply coverage. All the procedure codes are subject to Medicare rules and regulations, applicable Local Coverage Determinations (LCDs), and medical necessity. The chemotherapy agents may be subject to CCI (Corrective Coding Initiative) editing and hospital outpatient prospective payment system rules.
(Medicare & Medicaid)
One-Time Notification   Table of Contents  Transmittals through Transmittal Number 12 549, dated March 1 9, 2024, are included in this update. As new transmittals are issued, they will be identified on this page.
(Medicare & Medicaid)
FILE   COMM.  DATE   SUBJECT/SUMMARY OF CHANGES   IMPL  DATE   CR NUM  R12549OTN  03/19/24  Fiscal Intermediary Shared System (FISS) User Enhancement Change Request (UECR) - Expiration of a Unique Tracking Number (UTN) on the Prior Authorization (PA) Tracking File  04/01/24  13284  R12539OTN  03/12/24  Implementation to Expand Monetary Amount Fields Related to Billing and Payment to  Accommodate 10 -Digits in Length ($99,999,999.99) - Phase 3 04/01/24;07/01/24  13370  R12525OTN  03/01/24  Patient Driven Payment Model (PDPM) Corrections to Interrupted Stay Edits  04/01/24  13360  R12518OTN  02/22/24  Report of Hospice Election for Part D (Response File) 04/01/24  13348  R12513OTN  02/21/24  Change Request (CR) to Implement the Medicare Program Final Action: Treatment of  Medicare Part C Days in the Calculation of a Hospitals Medicare Disproportionate Patient Percentage  03/25/24  13294  R12508OTN  02/15/24  Appropriate Use Criteria for Advanced Diagnostic Imaging Policy Update in the Calendar Year 2024 Physician Fee Schedule Final Rule  01/03/25  13485  R12506OTN  02/08/24  User Enhancement Change Request (UECR): New Multi- Carrier System (MCS) Inquiry Search Screen Using a Procedure Code to Display an Associated Edit or Audit  01/06/25  13344  R12493OTN  02/01/24  International Classification of Diseases, 10th Revision (ICD -10) and Other Coding Revisions to National Coverage Determinations (NCDs) --July 2024 Update  07/01/24  13507  R12490OTN  01/25/24  User Enhancement Change Request (UECR): ViPS Medicare System (VMS)- Update Suppression Adjustment Force Code Processing 07/01/24  12066  R12489OTN  01/25/24  User Enhancement Change Request (UECR): ViPS Medicare System (VMS)  Update Paging on Claim/Pricing Inquiry Split Screen 07/01/24  13354  R12488OTN  01/25/24  User Enhancement Change Request (UECR): ViPS Medicare
(Medicare & Medicaid)
ViPS Medicare System (VMS)  Update Paging on Claim/Pricing Inquiry Split Screen 07/01/24  13354  R12488OTN  01/25/24  User Enhancement Change Request (UECR): ViPS Medicare System (VMS)  Update Electronic Funds Transfer (EFT) Process when a Change of Information (COI) Is Received  7/01/240  13022  R12487OTN  01/25/24  User Enhancement Change Request (UECR): ViPS Medicare System (VMS)  Creation of a New Claim Edit to Stop Creation of a Tenth Adjustment 07/01/24  12783  R12486OTN  01/25/24  User Enhancement Change Request (UECR): ViPS Medicare System (VMS)  FIND  Command for SuperOp Value Set Definition Screen  07/01/24  12319  R12482OTN  01/25/24  User Enhancement Change Request (UECR): ViPS Medicare System (VMS) - Create  Multi-line Add Functionality and View Only Mode to the Message File (MSSG)  07/01/24  11556  R12481OTN  01/25/24  User Enhancement Change Request (UECR): ViPS Medicare System (VMS) - Add  System Auditing Function Expert (SAFE) system to Online 07/01/24  11399  Documentation System (OLDS) for Error  Messages  R12464OTN  01/18/24  Fiscal Intermediary Shared System (FISS) - Delete Obsolete Reason Codes - Part 4  07/01/24  13482  R12463OTN  01/18/24  Fiscal Intermediary Shared System (FISS) - Delete Obsolete Reason Codes - Part 3  07/01/24  13459  R12460OTN  01/18/24  Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with Revenue Code 0905 for Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC)  01/02/24  13264  R12454OTN  01/11/24  System Updates to Lump Sum Utility for Addition of Wage Index Fields  07/01/24  13456  R12450OTN  01/11/24  Updating Fiscal Intermediary Shared System (FISS) Editing for Practice Locations to  Bypass Non- OPPS Provider 07/01/24  13415  R12447OTN
(Medicare & Medicaid)
13456  R12450OTN  01/11/24  Updating Fiscal Intermediary Shared System (FISS) Editing for Practice Locations to  Bypass Non- OPPS Provider 07/01/24  13415  R12447OTN  01/11/24  Modifications to the Automated Duplicate Primary Payer (DPP) Process  07/01/24  13450  R12444OTN  01/04/24  International Classification of Diseases, 10th Revision (ICD -10) and Other Coding Revisions to National Coverage Determinations (NCDs) --January 2024 Update  01/02/24  13278  R12441OTN  01/03/24  International Classification of Diseases, 10th Revision (ICD -10) and Other Coding Revisions to National Coverage Determinations (NCDs) --April 2024 Update --CR 1 of 2  11/21/23;04/01/24  13390  R12440OTN  01/03/24  International Classification of Diseases, 10th Revision (ICD -10) and Other Coding Revisions to National Coverage Determinations (NCDs) --April 2024 Update --CR 2 of 2  11/21/23;01/02/24; 04/01/24 13391  R12428OTN  12/21/23  Provider Education for the Review Choice Demonstration (RCD) for Inpatient Rehabilitation  Facility Services (IRFs)  01/24/24  13428  R12410OTN  12/13/23  Updating Calendar Year (CY) 2024 Medicare Diabetes Prevention Program (MDPP) Payment Rates  01/2/24  13484  R12405OTN  12/13/23  Direct Mailing Notification to Hospice Providers Regarding the Value- Based Insurance  Design (VBID) Model, Hospice Benefit Component, Participating Medicare Advantage Organizations  01/16/24  13462  R12397OTN  12/07/23  Payment of Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions  12/21/23  13468  R12392OTN  12/05/23  Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with Revenue Code 0905 for Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC)  01/02/24  13264  R12355OTN  11/09/23  International Classification of Diseases, 10th Revision (ICD -10) and Other Coding
(Medicare & Medicaid)
Qualified Health Centers (FQHC) and Rural Health Clinics (RHC)  01/02/24  13264  R12355OTN  11/09/23  International Classification of Diseases, 10th Revision (ICD -10) and Other Coding  Revisions to National Coverage Determinations (NCDs) --January 2024 Update  01/02/24  13278  R12351OTN  11/03/23  Requirements for a Provider Direct Mailing and Education & Outreach for Behavioral  Health Initiatives  11/06/23  13389  R12350OTN  11/03/23  International Classification of Diseases, 10th Revision (ICD -10) and Other Coding  Revisions to National Coverage Determinations (NCDs) --April 2024 Update --CR 2 of 2  11/21/23; 01/02/2 4; 04/01/24 13391  R12345OTN  10/31/23  Implementation of a National Fee Schedule for Medicare Part B Vaccine Administration  CMS  04/03/23;01/02/24  12943  R12340OTN  11/02/23  Implementation to Expand Monetary Amount Fields Related to Billing and Payment to  Accommodate 10 -Digits in Length ($99,999,999.99) - Phase 3 04/01/24;07/01/24  13370  R12335OTN  10/27/23  Allowing Audiologists to Furnish Certain Diagnostic Tests Without a Physician Order 01/02/24  13279  R12334OTN  10/27/23  Remittance Advice (RA) Changes due to Durable Medical Equipment Medicare  Administrative Contractors (DME MACs) Transition to Healthcare Integrated General Ledger  Accounting System (HIGLAS)  01/02/24;04/01/24;07/01/24;10/07/24 13265  R12331OTN  10/26/23  Report of Hospice Election for Part D (Response File) 04/01/24  13348  R12330OTN  10/26/23  Implement Edits on Hospice Claims  04/01/24  13342  R12292OTN  10/06/23  Implementation to Expand Monetary Amount Fields Related to Billing and Payment to  Accommodate 10 -Digits in Length ($99,999,999.99) - Phase 2 01/02/24  13223  R12286OTN  10/05/23  Patient Driven Payment Model (PDPM) Corrections to Interrupted Stay
(Medicare & Medicaid)
to  Accommodate 10 -Digits in Length ($99,999,999.99) - Phase 2 01/02/24  13223  R12286OTN  10/05/23  Patient Driven Payment Model (PDPM) Corrections to Interrupted Stay Edits  04/01/24  13360  R12285OTN  10/05/23  Requirements for a Provider Direct Mailing and Education & Outreach for Behavioral  Health Initiatives  11/06/23  13389  R12274OTN  09/27/23  Allow Users to Modify the Provider Demonstration File in the User Acceptance Testing  (UAT) Environment - Full Agile Pilot CR  01/02/24  12934  R12273OTN  09/27/23  Report of Hospice Election for Part D  01/02/24  13202  R12269OTN  09/28/23  Fiscal Intermediary Shared System (FISS) - Delete Obsolete Reason Codes - Part 2  04/01/24  13345  R12251OTN  09/15/23  Revision to Implementation of Consolidated Appropriations Act (CAA) of 2023, Section 4143: Waiver of Cap on Annual Payments for Nursing and Allied 03/19/23  13337  Health Education Payments  R12250OTN  09/15/23  Modernize the Vaccine Process and Roster Billing - Full Agile Pilot CR 04/03/23;07/03/23;  10/02/23;01/21/24; 04/01/24 12935  R12240OTN  09/06/23  Patient Responsibility Reporting with Medicare Secondary Payer (MSP)  10/09/23  13037  R12223OTN  08/28/23  User Enhancement Change Request (UECR): Create New System Control Facility (SCF)  Data Elements for Use in the Multi- Carrier System (MCS) 01/02/24; 04/01/24  10744  R12214OTN  08/18/23  OTC COVID -19 Tests  08/14/23;  08/15/23;  08/28/23 13336  R12213OTN  08/17/23  User Enhancement Change Request (UECR) - Update the Multi-Carrier System (MCS) to  Display Edit/Audit and CWF Error Code Override Information on the MCS Desktop Tool 01/02/24  13137  (MCSDT)  R12212OTN  08/17/23
(Medicare & Medicaid)
Multi-Carrier System (MCS) to  Display Edit/Audit and CWF Error Code Override Information on the MCS Desktop Tool 01/02/24  13137  (MCSDT)  R12212OTN  08/17/23  User Enhancement Change Request (UECR): Fiscal Intermediary Shared System (FISS) - Expand Ability to Search Through the Revenue Lines and Apply User Defined Quantity Limits to One or More Services - Full Agile Pilot  07/03/23;10/02/23;  01/02/24;04/01/24 12592  R12207OTN  08/11/23  International Classification of Diseases, 10th Revision (ICD -10) and Other Coding Revisions to National Coverage Determinations (NCDs) --October 2023 Update  08/07/23;10/02/23  13166  R12205OTN  08/11/23  Remittance Advice (RA) Changes due to Durable Medical Equipment Medicare  Administrative Contractors (DME MACs) Transition to Healthcare Integrated General Ledger  Accounting System (HIGLAS)  01/2/24;04/01/24;  07/01/24;01/07/24 13265  R12196OTN  08/10/23  User Enhancement Change Request (UECR): ViPS Medicare System (VMS) - Cancellation  Process Phase 2  01/02/24;04/01/24  13152  R12188OTN  08/04/23  Prior Authorization (PA) Changes to Implement the Inpatient Rehabilitation Facility  (IRF) Review Choice Demonstration (RCD) 10/02/23  13251  R12184OTN  08/03/23  International Classification of Diseases, 10th Revision (ICD -10) and Other Coding Revisions to National Coverage Determinations (NCDs) --January 2024 Update  01/02/24  13278  R12180OTN  08/03/23  Create Additional Location/Statuses in ViPS Medicare System (VMS) that are Excluded  from Claims Processing Timeliness (CPT)  01/02/24  13268  R12179OTN  08/03/23  User Enhancement Change Request (UECR): ViPS Medicare System (VMS) - Copy Tables and Screens from User Acceptance Testing (UAT) Regions to Production - Phase 1  01/02/24  13171  R12178OTN  08/03/23
(Medicare & Medicaid)
ViPS Medicare System (VMS) - Copy Tables and Screens from User Acceptance Testing (UAT) Regions to Production - Phase 1  01/02/24  13171  R12178OTN  08/03/23  User Enhancement Change Request (UECR): ViPS Medicare System (VMS) - Include Additional Documentation Request (ADR) number on Adjustments  01/02/24  11906  R12163OTN  07/27/23  Fiscal Intermediary Shared System (FISS) - Correct CMS Standard on Reason Code File 01/02/24  13249  R12162OTN  07/27/23  Fiscal Intermediary Shared System (FISS) - Delete Obsolete Reason Codes 01/02/24  13247  R12161OTN  07/27/23  Fiscal Intermediary Shared System (FISS) - Create Utility to Update Reason Code File to  Remove Deleted Codes  01/02/24  13245  R12160OTN  07/27/23  Report of Hospice Election for Part D  01/02/24  13202  R12159OTN  07/27/23  Fiscal Intermediary Shared System (FISS) User Enhancement Change Request (UECR) - Add Inquiry Access for the Holiday Update Screen  01/02/24  13100  R12158OTN  07/27/23  Fiscal Intermediary Shared System (FISS) User Enhancement Change Request (UECR) - Enhancement to the Duplicate Payment Process (DPP)  01/02/24  13097  R12155OTN  07/24/23  Implementation to Expand Monetary Amount Fields Related to Billing and Payment to  Accommodate 10 -Digits in Length ($99,999,999.99) - Phase 1 10/02/23  13138  R12151OTN  07/21/23  Remittance Advice (RA) Changes due to Durable Medical Equipment Medicare  Administrative Contractors (DME MACs) Transition to Healthcare Integrated General Ledger  Accounting System (HIGLAS)  01/02/24;04/01/24;  07/01/24;10/07/24 13265  R12146OTN  07/21/23  Patient Driven Payment Model (PDPM) Corrections to Claims Processing Edits 01/02/24  13240  R12145OTN  07/20/23  Implementation to Expand Monetary Amount Fields Related to Billing and Payment to  Accommodate 10 -Digits in Length
(Medicare & Medicaid)
Patient Driven Payment Model (PDPM) Corrections to Claims Processing Edits 01/02/24  13240  R12145OTN  07/20/23  Implementation to Expand Monetary Amount Fields Related to Billing and Payment to  Accommodate 10 -Digits in Length ($99,999,999.99) - Phase 2 01/02/24  13223  R12144OTN  07/20/23  User Enhancement Change Request (UECR) - Update the Multi-Carrier System (MCS) to  Accept Additional Payee Identification Code Qualifiers for Third Party Payee (TPP) Provider Level  Balancing (PLB) Code L3 01/02/24  13170  R12143OTN  07/20/23  User Enhancement Change Request (UECR) - Update the Multi-Carrier System (MCS) to  Display Edit/Audit and CWF Error Code Override Information on the MCS Desktop Tool (MCSDT)  01/02/24  13137  R12142OTN  07/20/23  User Enhancement Change Request (UECR) - Update the Multi-Carrier System (MCS) to  Allow Punctuation on the Beneficiary Name, Sex, Date of Birth Update (BN Transaction)  01/02/24  12722  R12141OTN  07/20/23  User Enhancement Change Request (UECR): Update the Multi- Carrier System (MCS) to  Display the Internal Control Number (ICN) on the H99RBMSD and H99RBMSI Reports  01/02/24  12660  R12140OTN  07/20/23  User Enhancement Change Request (UECR) - Update the Multi-Carrier System (MCS)  Additional Documentation Request (ADR) - ADS History Screen  01/02/24  11774  R12139OTN  07/20/23  User Enhancement Change Request (UECR) - Update the Multi-Carrier System (MCS)  Checks Issued to Payee Screen  01/02/24  10797  R12138OTN  07/20/23  User Enhancement Change Request (UECR) - Update the Multi-Carrier System (MCS)  Primary Function Keys (PF) for the Provider Enrollment Screens  01/02/24  10752  R12137OTN  07/20/23  User Enhancement Change Request (UECR) - Update the Multi-Carrier System (MCS) to  Accept