evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: MolDX: Blood Product Molecular Antigen Typing (A57124)
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.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Blood Product Molecular Antigen Typing.Blood product antigen typing is a germline test and the use of panels 0001U and 0084U will be limited to once in a beneficiary lifetime.The individual codes 0180U-0201U, 0221U and 0222U and codes 81105-81112 are also germline tests. These will be noncovered as multiple antigens must be utilized as part of a comprehensive antigen evaluation and will be considered only as part of a panel.To report a Blood Product Molecular Antigen Typing service, please submit the following claim information:Select the appropriate CPTorPLA codeEnter unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier 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 837PItem 19 for paper claimEnter 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: Peripheral Venous Ultrasound (A57125)
CMS National Coverage PolicyInternet Only Manuals (IOMs):CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 4, Section 20.6.2 Use of Modifiers -50, -LT and -RTChapter 12, Section 40.7.B Billing Instructions for Bilateral SurgeriesSocial 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.Medicare National Correct Coding Initiative (NCCI) Policy Manual:Chapter XI Medicine Evaluation and Management ServicesCode of Federal Regulations (CFR) References:CFR, Title 42, Volume 2, Chapter IV, Part 410.32(a) Ordering diagnostic testsArticle TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33693 Peripheral Venous Ultrasound. 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.Note:When an uninterpretable study results in performing another type of study, only the successful study should be billed.Note:Multiple duplex scans plus noninvasive physiologic studies of the upper and lower extremities (93970, 93971, 93922 and 93923) and 93924-93931 cannot be billed on the same day.The use of a simple hand-held or other Doppler device that does not produce hard copy data or that produces a record that does not permit analysis of bidirectional vascular flow, is considered to be part of the physical examination of the vascular system and is not separately reported.
Article - Billing and Coding: Peripheral Venous Ultrasound (A57125)
CPT code 93971Consistent with the LCD, doppler ultrasound scanning is the current standard for the preoperative evaluation of reflux in patients with chronic venous insufficiency.Correct coding guidelines indicate that CPT code 93971 should be used to report either a limited bilateral or a complete unilateral study. It would not be appropriate to report -50 modifier with CPT code 93971 for a limited bilateral study.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.Images of all relevant areas, both normal and abnormal, should be recorded and stored in a retrievable format (electronic preferred).A signed final report of the ultrasound findings and impression should be included in the patients medical record and is the definitive documentation of the study. The final report should include but is not limited to the following demographic components:A description of examination findings, using appropriate anatomic and ultrasound terminology. (Use of acronyms and abbreviations should be avoided)The concluding statements or summary of the report should include these components:An impression, conclusion, or summary statementA specific diagnosis or differential diagnosis, if appropriateA recommendation for follow-up studies, if clinically applicableAn accounting of any failure to include standard views or other necessary components (as listed in the appropriate practice parameter)If prior relevant imaging studies were reviewed, a statement of comparison should be includedDetails concerning any provider-to-provider communication in cases in which a delay in communication may have an adverse effect on the patients outcome.An order from the treating physician/nonphysician practitioner as required by CFR, Title 42, Volume 2, Chapter IV, Part 410.32(a) Ordering diagnostic tests.The medical record for patients with known venous thrombosis on therapy should reflect what clinical change occurred and how the change in thrombus burden will alter treatment.
Article - Billing and Coding: Psychiatric Codes (A57130)
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) L35101, Psychiatric Codes. Please refer to the LCD for reasonable and necessary requirements.Coding Guidance: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.Although the diagnostic interview is indicated for the initial evaluation of a beneficiary, a second provider seeing the beneficiary for the first time may report the diagnostic interview codes.CPT code 96105 represents formal evaluation of aphasia with an instrument such as the Boston Diagnostic Aphasia Examination.Psychological/neuropsychological testing codes should not be reported by the treating physician for only reading the results of the testing.Psychotherapy codes should not be used when an Evaluation and Management (E/M) code would be more appropriate.HCPCS codes G0017 and G0018 are for all non-facility places of service (POS) other than Office.Utilization ParametersCPT code 96105 is typically only performed once during treatment. Refer to the related LCD for information regarding the reasonable and necessary guidelines for this service.Consistent with the related LCD, more than three CPT code(s) 90791, 90792 or a combination of both should not be reported per year, per beneficiary by the same provider.
Article - Billing and Coding: Bone Mass Measurement (A57132)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessaryfor the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to processthe claim.Section 1861(r) provides the definition of a physician.Section 1861(s)(2)(V)(15) includes bone mass measurement as a physician service.Section 1861(rr) provides the definition of bone mass measurement.Code of Federal Regulations:Title IV of the Balanced Budget Act of 1997, Section 4106 includes language providing for Medicare coverageof bone mass measurement procedures, and coverage of FDA-approved bone mass measurement techniquesand equipment for "qualified" individuals. These procedures are only covered when medically necessary.CMS Publications:CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15:80.5 Bone Mass Measurements (BMMs)CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations, Chapter 1:150.3 Bone (Mineral) Density Studies (Effective January 1, 2007)CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13:140 Bone Mass Measurements (BMMs).Article TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policyL36460-Bone Mass Measurement.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: Bone Mass Measurement (A57132)
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: Bone Mass Measurement (A57132)
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.)+Earlier technologies, such assingle and dual photon absorptiometry( CPT code 78350 or 78351), are nolonger used.Limitations:1. Tests not ordered by the physician/qualified non-physician practitioner, who is treating the beneficiary, are not reasonable and necessary.2. Medicare reimbursement for an initial bone mass measurement may be allowed only once, regardless ofsites studied (e.g., if the spine and hip are studied, CPT code 77080 should be billed only once).3. It is not medically necessary to perform more than one type of BMM test in any individual, unless aDXA confirmatory test is performed as a baseline for future monitoring (see Indications #7 and #8).4. It is not medically necessary to have both peripheral and axial BMM tests performed on the same day.5. Medicare will not reimburse BMM tests performed by a second provider, when a test has already beenperformed within the defined coverage period, as stated above, unless as confirmatory testing for futuremonitoring. Beneficiaries must authorize providers to obtain prior test results. If unsuccessful efforts toobtain prior test results from another provider are documented, new tests may be considered forreimbursement.6.Single and dual photon absorptiometry,CPT code 78350 and 78351, are non-covered services.
Article - Billing and Coding: Bone Mass Measurement (A57132)
6.Single and dual photon absorptiometry,CPT code 78350 and 78351, are non-covered services.7. Bone mass measurement is not covered under the portable x-ray benefit and will be denied whenperformed by a portable x-ray supplier. Transportation charges for BMM testing are not covered.8. Bone mass measurement tests provided without an accompanying interpretation and report, as part ofthe test, will be denied as not medically necessary. The report must be separate and distinct from an evaluation and management note/record.9. CPT code 77082 is considered by Medicare to represent vertebral fracture assessment only. Becausecode 77082 does not represent a bone density study, it should NOT be billed for screening. This codemay be billed when medically necessary (i.e. when a vertebral fracture assessment is required).Symptoms should be present and documented, and it should be anticipated that the results of the testwill be used in the management of the patient.Other Comments:For Claims submitted to the Part A MAC: This coverage determination also applies within states outside theprimary geographic jurisdiction with facilities that have nominated CGS Administrators to process their claims.Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not applyto physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.Limitation of liability and refund requirements apply when denials are likely, whether based on medicalnecessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior torendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered byMedicare. The limitation of liability and refund requirements do not apply when the test, item or procedure isstatutorily excluded, has no Medicare benefit category or is rendered for screening purposes.
Article - Billing and Coding: Bone Mass Measurement (A57132)
For outpatient settings other than CORFs, references to "physicians" throughout this policy include nonphysicians,such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physicianpractitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by Statelaw. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)
Article - Billing and Coding: MolDX: Repeat Germline Testing (A57141)
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 claimCMS 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, 60.1 Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesCMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: Repeat Germline Testing L38288.
Draft Article - Billing and Coding: MolDX: Decipher® Biopsy Prostate Cancer Classifier Assay for Men with Favorable Intermediate Risk Disease (DA57144)
CMS National Coverage PolicyN/AArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: Decipher Biopsy Prostate Cancer Classifier Assay for Men with Favorable Intermediate Risk Disease(DL38303).To report a Decipher Biopsy Prostate Cancer Classifier for Menwith Favorable Intermediate Risk Disease Testing service, please submit the following claim information:Select appropriate CPTcodeEnter 1 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 claimEnter 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: Surgical Management of Morbid Obesity (A57145)
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) L33411 Surgical Management of Morbid Obesity. 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 codes 43886, 43887 and 43888 are for open port replacement. The open port replacement procedures are associated with the non-covered open gastric restrictive procedures: adjustable gastric banding and vertical banded gastroplasty and per the National Coverage Determination (NCD) 100.1 Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity, open port replacement procedures are also noncovered.For billing covered laparoscopic restrictive procedures that require port replacements report CPT code 43771, 43772, or 43773.CPT code 43842 is for vertical banded gastroplasty and is non-covered per NCD 100.1 Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity.CPT code 43843 for other than vertical-banded gastroplasty is non-covered since it is associated with the NCD 100.1 non-covered open adjustable gastric banding and open sleeve gastrectomy.Documentation Requirements
Article - Billing and Coding: Surgical Management of Morbid Obesity (A57145)
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.Medical record documentation must include the following: history and physical containing evidence of comorbid conditions, operative report containing a detailed procedure note, and office/progress notes documenting unsuccessful medical treatment for obesity.The medical record must substantiate presence and severity of associated organic diseases requiring the treatment of obesity documented through appropriate physiologic testing and/or imaging.The patients medical record must include documentation of all required preoperative and postoperative evaluations and interventions and all other applicable coverage provisions required as outlined in this LCD.Patients who have a history of psychiatric or psychological disorder must undergo preoperative psychological evaluation and clearance and the patients record must include documentation of the evaluation and assessment.Documentation of smoking history, and that the patient has received counseling on the effects of smoking on surgical outcomes and treatment for smoking cessation, if applicable.
Draft Article - Billing and Coding: MolDX: Signatera and Minimal Residual Disease Testing for Colorectal Cancer (DA57147)
CMS National Coverage PolicyN/AArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: Signatera and Minimal Residual Disease Testing for Colorectal Cancer(DL38305).To report a Signatera and Minimal Residual Disease Testing for Colorectal Cancer service, please submit the following claim information:Select appropriate CPTcodeEnter 1 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 claimEnter 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