evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Speech-Language Pathology (A52866)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement theLocal Coverage Determination (LCD) for Speech-Language Pathology.National Coverage ProvisionsSpeech-language pathology services are those services provided within the scope of practice of speech-language pathologists and necessary for the diagnosis and treatment of speech and language disorders, which result in communication disabilities and for the diagnosis and treatment of swallowing disorders (dysphagia), regardless of the presence of a communication disability.(See CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual, Part 3, Section 170.3) (CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 230.3(A))A qualified speech-language pathologist for program coverage purposes meets one of the following requirements:The education and experience requirements for a Certificate of Clinical Competence in (speech-language pathology) granted by the American Speech-Language Hearing Association; orMeets the educational requirements for certification and is in the process of accumulating the supervised experience required for certification(CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 230.3(B))An SLP normally has a master's degree and a Certificate of Clinical Competence (CCC-SLP) or all the requirements leading to a Certificate of Clinical Competence, that is, he or she is in their clinical fellowship year (CFY-SLP).Speech-language pathology services may be considered reasonable and necessary when the following criteria are met:The services shall be considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition;The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a qualified therapist;If the contractor determines the services furnished were of a type that could have been safely and effectively performed only by or under the supervision of such a qualified professional, the contractor shall presume that such services were properly supervised when required. However, this presumption is rebuttable, and, if in the course of processing a claim, the contractor finds that services were not being furnished under proper supervision, it shall deny the claim and bring this matter to the attention of the Division of Survey and Certification of the Regional Office;
Article - Billing and Coding: Speech-Language Pathology (A52866)
While a beneficiary's particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiary's diagnosis or prognosis cannot be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a qualified therapist are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel. Medicare coverage does not turn on the presence or absence of a beneficiarys potential improvement from the therapy, but rather on the beneficiarys need for skilled care; andThe amount, frequency, and duration of the services must be reasonable under accepted standards of practice. The contractor shall consult local professionals or the state or national therapy associations in the development of any utilization guidelines and any one or more of the following:In the case of rehabilitative therapy, the patients condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time; orThe services must be necessary for the establishment of a safe and effective maintenance program required in connection with a specific disease state including evaluation, plan of treatment, and staff and family training, when the skills of an SLP are required; orIn the case of a progressive degenerative disease, service may be intermittently necessary to determine the need for assistive equipment and/or establish a program to maximize function; orIn the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patients functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel.
Article - Billing and Coding: Speech-Language Pathology (A52866)
Evaluation of Language Disorders:Re-evaluations are usually focused on the current treatment and might not be as extensive as initial evaluations. Continuous assessment of the patient's progress is a component of ongoing therapy services and is not payable as a re-evaluation. A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services. A formal re-evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation. Indications for a re-evaluation include new clinical findings, a significant change in the patient's condition, or failure to respond to the therapeutic interventions outlined in the plan of care.A re-evaluation may be appropriate prior to planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued.A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment or terminating services. Reevaluation requires the same professional skills as evaluation. The minutes for re-evaluation are documented in the same manner as the minutes for evaluation. Current Procedural Terminology does not define a re-evaluation code for speech-language pathology; use the evaluation code. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.3.C)Aural Rehabilitation:The terms, aural rehabilitation, auditory rehabilitation, auditory processing, lipreading and speech reading are among the terms used to describe covered services related to perception and comprehension of sound through the auditory system. (CMS Publication 100-02, Medicare Benefit Policy Manual,Chapter 15, Section 230.3.D.3)Coding Guidelines: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.
Article - Billing and Coding: Speech-Language Pathology (A52866)
The diagnosis code(s) must best describe the patient's condition for which the service was performed.Under the Medicare Program, an independently practicing speech pathologist may now bill the Medicare program directly. Section 143 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes the Centers for Medicare & Medicaid Services (CMS) to enroll speech-language pathologists (SLP) as suppliers of Medicare services and for SLPs to begin billing Medicare for outpatient speech-language pathology services furnished in private practice beginning July 1, 2009. Enrollment will allow SLPs in private practice to bill Medicare and receive direct payment for their services. Previously, the Medicare program could only pay SLP services if an institution, physician or nonphysician practitioner billed them.However, the services of speech-language pathologists may continue to be billed by providers such as rehabilitation agencies, HHAs, CORFs, hospices, outpatient departments of hospitals, and suppliers such as physicians, non-physician practitioners (NPPs), physical and occupational therapists in private practice. When these services are billed by physicians or NPPs, they are covered when billed under the "incident to" provision. "Incident to" services or supplies are defined as those furnished as an integral, although incidental, part of the physician's or NPPs personal professional services in the course of diagnosis or treatment of an injury or illness. These services must be related directly and specifically to a written treatment regimen established by the physician/NPP, after any needed consultation with a qualified speech pathologist, or by the speech pathologist providing such services.
Article - Billing and Coding: Speech-Language Pathology (A52866)
The Medicare Physician Fee Schedule is the method of payment for outpatient physical therapy (which includes outpatient speech-language pathology). Providers must use modifier -GN to identify service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology Plan of Care. (CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 5, Section 20.1)For treatment of auditory processing disorders or auditory rehabilitation/auditory training (including speech-reading or lip-reading), 92507, and 92508 are used to report a single encounter with "1" as the unit of service, regardless of the duration of the service on a given day. These codes always represent SLP services. (CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 12, Section 30.3.C)CPT codes 92626 and 92627 have been added at the end of the comment period at the request of several commenters and are not restricted by the list of ICD-10-CM codes that support medical necessity.ICD-10-CM code Z01.818 should be reported for pre-laryngectomy examinations.Standardized cognitive performance testing (CPT code 96125) may be billed to assess cognitive status.
Article - Billing and Coding: Speech-Language Pathology (A52866)
Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within 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. Not only should documentation describe the condition of the patient that necessitates the skilled intervention of the speech-language pathologist, but should also report clinical judgment and describe the skilled nature of the treatment. Documenting the skilled components of activities will assist in supporting that the services are medically necessary.Documentation of speech language services, like other therapy services, must be objective, clear and concise. Documentation in the clinical record must be descriptive, clearly related to functionality, and complement and correlate with other disciplines. Medical necessity may not be established if there is conflicting documentation between disciplines or widely fluctuating abilities indicating an unstable condition. Prior level of functioning must be documented and considered in the patient's treatment plan, to establish reasonable goals for the patient's present condition. Statements such as "mildly impaired to moderately impaired" or "fair plus to good minus" do not offer sufficient objective and measurable information to assess response to therapy and may result in denial of services as not medically necessary. Documentation of discharge planning should be indicated early in the treatment plan.Rehabilitative Therapy:When the goals of therapy are rehabilitative and a valid expectation of improvement existed at the time services were initiated, or thereafter, the services may be covered even though the expectation may not be realized. Progress reports must document a continued reasonable expectation that the patient's condition will improve significantly, i.e., a measurable and substantial increase in the patient's level of communication, independence, and functional competence compared to the level when treatment was initiated. Documentation should include whatever is deemed pertinent to justify the need for continued intervention, such as any improvements, setbacks, and intervening medical complications.Maintenance Therapy:
Article - Billing and Coding: Speech-Language Pathology (A52866)
Maintenance Therapy:When the goals of therapy are to assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to a disease or illness (maintenance), and a valid expectation existed at the time services were initiated that skilled therapy intervention would achieve such goals, the services may be covered even though the expectation may not be realized. The record should also make clear why the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel. Progress reports must document a continued reasonable expectation that the maintenance therapy goals are reasonable and achievable and that the skills of a therapist are required to meet those goals. Documentation should include whatever is deemed pertinent to justify the need for continued intervention, such as any improvements, setbacks, and intervening medical complications.For additional information on Medicare documentation requirements for speech-language pathology services see: CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section, 220, including the subsections under Section 220.
Article - Billing and Coding: Transesophageal Echocardiography (TEE) (A52868)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Transesophageal Echocardiography (TEE).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 codingUse procedure code 93312 (C8925 for OPPS billing when contrast is used) or 93315 (C8926 for OPPS billing when contrast is used) for the complete procedure, including probe placement, image acquisition, interpretation and report. Code 93315 (C8926 for OPPS billing when contrast is used) should be used for congenital anomalies only.Use procedure code 93313 or 93316 where the provider is reporting only the insertion of the transesophageal probe. Code 93316 is reserved for congenital anomalies only.Use procedure code 93314 or 93317 where the provider is reporting the actual manipulation of the probe to obtain images and to provide an interpretation and report. Code 93317 is reserved for congenital anomalies only.CPT code 93318 (C8927 for OPPS billing when contrast is used) (intraoperative monitoring) is considered part of an anesthesia service and should not be billed separately by the anesthesiologist.
Article - Billing and Coding: Transesophageal Echocardiography (TEE) (A52868)
CPT code 93318 (C8927 for OPPS billing when contrast is used) (intraoperative monitoring) is considered part of an anesthesia service and should not be billed separately by the anesthesiologist.CPT codes 76376 and 76377 and 93319 (3D echocardiography) should be billed in conjunction with the base code for the imaging procedure. For the purposes of this LCD, the base codes for CPT 76376 and 76377 are 93312, 93314, C8925, 93315, C8926, and 93317 and the base codes for CPT 93319 are 93312, 93314, 93315, C8926, and 93317.Diagnosis codingICD-10-CM code R93.1 or R93.8 should be reported when a TEE (CPT codes 93312, 93313, and 93314) is performed because of inadequate visualization of cardiac anatomy on TTE, for structures normally visualized by TTE and for which TEE is not usually indicated. ICD-10-CM code R93.1 or R93.8 should be reported as the primary diagnosis and the cardiac abnormality should be coded as a secondary diagnosis.ICD-10-CM code Z01.89 should be reported when a TEE is performed during an open chest procedure. ICD-10-CM code Z01.89 should be reported as the primary diagnosis and the reason for the surgical procedure should be coded as the secondary diagnosis.For add-on CPT codes 93319, 93320, 93321 and 93325, the ICD-10-CM codes reported should be the same as those reported for the base codes to which they are attached.Bundled servicesProcedure 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.CPT codes 93312-93318 include conscious sedation. Therefore sedation should not be billed separately, and if it is, will be bundled into the primary procedure code.For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.
Article - Billing and Coding: Transesophageal Echocardiography (TEE) (A52868)
For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.For claims submitted to the Part A MAC:The OPPS does not apply to claims for every type of bill submitted by Medicare-certified providers. The following guidelines pertain to claims for bill types that are subject to the OPPS:Hospitals are required to include HCPCS codes for all services paid under the OPPS.HCPCS codes C8925, C8926, and C8927 should be used to report transesophageal echocardiography services by OPPS hospitals when contrast is used. If the transesophageal echocardiography services are performedwithoutcontrast, OPPS hospitals should report CPT codes from the 9xxxx series, as appropriate.
Article - Billing and Coding: Transesophageal Echocardiography (TEE) (A52868)
Every effort should be made to report all services performed on the same day on the same claim to assure proper payment under the OPPS. Claims submitted for the same date of service will be returned to the provider (except duplicates or those containing condition code 20 or 21) with a notification that an adjustment bill should be submitted (CMS Program Memorandum, Transmittal No. A-00-36, Change Request #1229, June 2000).Documentation Requirements:A covered service must include a complete interpretation/report by the performing physician, and must be available if requested.The patient's medical record must contain documentation that fully supports the medical necessity for services included within the attached 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, as well as reasons for repeat testing.In those instances in which repeat tests were denied, the physician must document a good faith effort was made to identify them and to request copies of them from previous providers, in order for NGS to consider reimbursement for such tests on appeal.Each service requires a formal written report with interpretation. This report should be kept on file with copies of image documentation (paper or tape) for review if requested. All appropriate measurements should be included in the report.A Doppler interrogation should state the modes used and should give both qualitative and quantitative information.Documentation of the qualifications of personnel performing tests, as described in the Indications section of the LCD, should be available on request.All documentation must be submitted upon request.Utilization Guidelines:
Article - Billing and Coding: Transesophageal Echocardiography (TEE) (A52868)
TEE services will be covered twice per year for all conditions except endocarditis (ICD-10 code I39), for which four (4) services per year will be covered.TEE may be repeated in patients with repeat episodes of atrial fibrillation/flutter prior to cardioversion.Services exceeding this parameter will be considered not medically necessary, unless there is documentation that the tests were performed for clinical indications reflecting a change in the patients status or underlying cardiac condition, or documentation of a new unrelated condition, sign or symptom.In those instances in which repeat tests were denied and a physician has documented a good faith effort to identify them and to request copies of them from previous providers, then NGS could reimburse such tests on appeal.These guidelines do not apply to tests performed on hospital inpatients.
Article - Billing and Coding: Treatment of Varicose Veins of the Lower Extremity (A52870)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Treatment of Varicose Veins of the Lower Extremity.National Coverage Provisions:Cosmetic surgery is statutorily excluded from coverage by Medicare. The following interventional treatments are considered to be cosmetic and will be denied as such:Interventional treatment of asymptomatic varicosities.Treatment of telangiectases (CPT code 36468).Sclerotherapy for cosmetic purposes.
Article - Billing and Coding: Treatment of Varicose Veins of the Lower Extremity (A52870)
Coding Guidelines: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 patients condition for which the service was performed.Specific coding guidelines:It is inappropriate to report CPT code 37241 for the treatment of superficial varicose veins of the lower extremity.CPT code 36470 should be used when only one vein is injected on a given date of service.CPT codes 36466, 36471 may be reported once per extremity, regardless of the number of veins treated.CPT codes 36474, 36476, 36479, 36483 for subsequent vein(s) treated in the same extremity may only be reported once per extremity, regardless of the number of additional vein(s) treated.When performed in the office setting, all required supplies and equipment are included in CPT codes 36465, 36466, 36470, 36471 and may not bereported separately.When performed in the office setting, all required supplies and equipment are included in CPT codes 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483 and may not be reported separately.For providers other than Ambulatory Surgical Centers (ASC), the appropriate site modifier (RT, LT or 50) must be appended to indicate if the service was performed unilaterally or bilaterally. Claims without a modifier will be returned as unprocessable.For an ASC, the appropriate site modifier (RT and/or LT) must be appended to indicate if the service was performed unilaterally or bilaterally. Bilateral services must be reported on separate lines using an RT and LT modifier (50 modifier should not be used). Services reported without a modifier will be returned as unprocessable.