evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Chest X-Ray Policy (A57498)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made 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."Title XVIII of the Social Security Act, 1862(a)(7) and 42 Code of Federal Regulations (CFR) 411.15(a)(1), exclude routine physical examinations.Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80, Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests, sets forth the levels of physician supervision required for furnishing the technical component of diagnostic tests for a Medicare beneficiary who is not a hospital inpatient or outpatient.CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.4-80.4.4, Coverage of Portable X-Ray Services Not Under the Direct Supervision of a Physician applicability of health and safety standards apply to all suppliers of portable x-ray services and the scope of portable x-ray benefit and exclusions from coverage as portable x-ray services.CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 250, Medical and Other Health Services Furnished to Inpatients of Hospitals and Skilled Nursing Facilities including payments under arrangement.42 CFR 486.100, stipulates that portable X-rays must comply with Federal, State, and local laws and regulations.CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3, Diagnoses Code Requirement.42 Code of Federal Regulations, 410.32, addresses diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
Article - Billing and Coding: Chest X-Ray Policy (A57498)
42 Code of Federal Regulations, 410.32, addresses diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, 100 and 100.1, Interpretation of Diagnostic Tests describes how physicians should handle billing when two providers read a chest X-ray. Medicare will pay for the interpretation and report that directly contributes to the diagnosis and treatment of the individual patient.CMS Manual System, Pub, 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.6.1, Definitions.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.
Article - Billing and Coding: MolDX: Percepta© Bronchial Genomic Classifier (A57502)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim. 42 Code of Federal Regulations (CFR) 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests:Conditions.CMS Internet Only Manuals, Publication 10004, Medicare Claims Processing Manual Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.12 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.To report a PerceptaBronchial Genomic Classifier service, please submit the following claim information:Enter 1 unit of service (UOS).Enter the appropriate 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 837Item19 for paper claimEnter the appropriate 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 formSelect the appropriate ICD-10-CM code.
Article - Billing and Coding: MolDX: Testing of Multiple Genes (A57503)
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.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title 42 CFR 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: ConditionsArticle TextThe following information will be effective 10/21/2019 for dates of service on or after 10/15/2019.Refer toBilling and Coding: MolDX: Molecular Diagnostic Tests (MDT) A56853for CPT/HCPCS Codes that are applicable to this article.
Article - Billing and Coding: MolDX: Testing of Multiple Genes (A57503)
A panel of genes is a distinct procedural service from a series of individual genes. All services billed to Medicare must be reasonable and necessary. As such, if a provider or supplier submits a claim for a panel, then the patients medical record must reflect that the panel was reasonable and necessary. Alternatively, if a provider or supplier bills for a number of individual genes, then the patients medical record must reflect that each individual gene is reasonable and necessary.For ease of reading the term gene when used in this document will be used to indicate a gene, region of a gene, and / or variant(s) of a gene.Genes can be assayed serially or in parallel. Genes assayed on the same date of service are considered to be assayed in parallel if the result of 1 assay does not affect the decision to complete the assay on another gene, and the 2 genes are being tested for the same indication. Genes assayed on the same date of service are considered to be assayed serially when there is a reflexive decision component where the results of the analysis of 1 or more genes determines whether the results of additional analyses are reasonable and necessary.If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so 1 HCPCS codes must be submitted for the panel. If the laboratory assays genes in serial, then the laboratory must submit claims for genes individually. The order by the treating clinician must reflect whether the treating clinician is ordering a panel or single genes, and additionally, the patients medical record must reflect that the service billed was reasonable and necessary.Two examples:Single Service Example:A clinician orders 5 specific genes associated with breast cancer. The laboratory analyzes the 5 genes for common mutations using polymerase chain reaction. All 5 PCR procedures are started prior to the results of any 1 PCR procedure being known. The results are signed off on simultaneously, and all 5 results are sent to a clinician.This would be considered a single procedural service, a single 5 gene panel, and it must be billed as such. This single panel must be reasonable and necessary to be billed to Medicare.
Article - Billing and Coding: MolDX: Testing of Multiple Genes (A57503)
This would be considered a single procedural service, a single 5 gene panel, and it must be billed as such. This single panel must be reasonable and necessary to be billed to Medicare.Multiple Distinct Procedural Services Example:A clinician requests that genes associated with early onset colorectal cancer be analyzed in a patient. The clinician orders stepwise reflex testing where a negative or positive result in 1 gene determines whether additional analysis on other genes will be performed or what that will be.Each gene assayed represents 1 procedural service, so if more than 1 gene is analyzed, then multiple procedural services may be billed in some patients for whom reflex testing goes beyond the first gene. Each gene billed to Medicare must be individually reasonable and necessary. A clinicians order is not by itself sufficient to indicate that a test was reasonable and necessary. The record must reflect that the test is used in the management of the beneficiary's specific medical problem in accordance with CFR 410.32.Labs must register a test with the Diagnostics Exchange as it reflected on the order form and is run in the laboratory. If a gene / variant is tested as part of a panel, then the lab must register the panel and must submit the correct z-code and CPT code for the panel. If a lab has a panel but sometimes also analyzes individual genes from the panel, the lab must register both the panel and the individual genes that are analyzed.In general 2 or more codes describing a genetic test billed on the same beneficiary on the same date may constitute a panel, and if so the service must be billed as a single procedural service. We would generally expect that a provider or supplier would not bill for more than 1 distinct laboratory genetic testing procedural services on a single beneficiary on a single date of service. If providers or suppliers do bill for more than 1 distinct laboratory genetic testing procedural services on a single beneficiary on a single date of service, the provider or supplier must attest that each additional service billed is a distinct procedural service using the 59 modifier.The use of the 59 modifier will be considered an attestation that distinct procedural services are being performed rather than a panel. Providers and suppliers must use the 59 modifier in conjunction with other modifiers where appropriate. When providers and suppliers bill for multiple distinct procedural services, each service must be reasonable and necessary.
Article - Billing and Coding: MolDX: Testing of Multiple Genes (A57503)
Laboratories that are billing for many individual genes using the 59 modifier rather than panels may be subject to medical review as outliers.When 2 or more codes are submitted for the same beneficiary on the same date of service, the claims processing system will reject every code submitted after the first service. However, if a lab runs more than 1 distinct procedural service on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service.
Article - Billing and Coding: MolDX: Percepta© Bronchial Genomic Classifier (A57504)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim. 42 Code of Federal Regulations (CFR) 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests:Conditions.CMS Internet Only Manuals, Publication 10004, Medicare Claims Processing Manual Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.12 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.To report a PerceptaBronchial Genomic Classifier service, please submit the following claim information:Enter 1 unit of service (UOS).Enter the appropriate 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 837Item19 for paper claimEnter the appropriate 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 formSelect the appropriate ICD-10-CM code.
Article - Billing and Coding: Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (A57512)
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 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, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):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)(1)(D) refers to limitations on items or devices that are investigational or experimental.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.
Article - Billing and Coding: Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor and Tremor Dominant Parkinson's Disease (A57513)
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 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, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):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)(1)(D) refers to limitations on items or devices that are investigational or experimental.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.
Article - Billing and Coding: ProMark® Risk Score (A57515)
CMS National Coverage PolicyCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10, Reporting ICD Diagnosis and Procedure CodesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceTitle 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. 100-02, 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).To report a ProMark assay service, please submit the following claim information:Select CPT code 81479Enter 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 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 ICD-10 CM code C61
Article - Billing and Coding: MolDX: Prometheus IBD sgi Diagnostic Policy (A57516)
CMS National Coverage PolicyCMS Internet-Only Manual Pub. 100-04, Medicare Claims Processing Manual, Chapter 23 10 Reporting ICD Diagnosis and Procedure CodesCMS Internet-Only Manual Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceTitle XVIII of the Social Security Act, 1833(e) Prohibits Medicare payment for any claim which lacks the necessary information to process the claimArticle TextThe following coding and billing guidance is to be used with its associated Local coverage determination.To receive a Prometheus IBD sgi Diagnostic denial, please submit the following claim information:Select the applicable CPTcodeEnter 1 unit of service (UOS)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 modifierIf submitting a DEX Z-Code identifier, 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 claimIf submitting a DEX Z-Code identifier, enter 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 UB 04
Article - Billing and Coding: MolDX: Prometheus IBD sgi Diagnostic Policy (A57517)
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 Manuals, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS Internet Online Manual Pub. 100-04 (Medicare Claims Processing Manual), Chapter 23 (Section 10) "Reporting ICD Diagnosis and Procedure Codes"Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.To receive a Prometheus IBD sgi Diagnostic denial, please submit the following claim information:Select the applicable CPTcodeEnter 1 unit of service (UOS)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 modifierIf submitting a DEX Z-Code identifier, 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 claimIf submitting a DEX Z-Code identifier, enter 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 UB 04
Article - Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services (A57520)
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) L33252 Psychiatric Diagnostic Evaluation and Psychotherapy Services. 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.The psychotherapy for crisis CPT codes 90839 and 90840 are time-based codes used to report the total duration of time face-to-face with the patient and/or family spent by the physician or other qualified health care professional providing psychotherapy for crisis, even if the time spent on that date is not continuous. For any given period of time spent providing psychotherapy for crisis state, the physician or other qualified health care professional must devote his or her full attention to the patient and, therefore, cannot provide service to any other patient during the same time period. The patient must be present for all or some of the service. Do not report with CPT codes 90791 or 90792.When a patient is referred with an organic diagnosis and a mental health diagnosis is established, the mental health diagnosis should be billed.If a psychiatric diagnostic evaluation with medical assessment is performed, the physician or non-physician practitioner (NPP) may use CPT code 90792 or an evaluation and management (E/M) code.
Article - Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services (A57520)
If a psychiatric diagnostic evaluation with medical assessment is performed, the physician or non-physician practitioner (NPP) may use CPT code 90792 or an evaluation and management (E/M) code.If a patient is unable to communicate by any means, the interactive complexity CPT code 90785 should not be billed. This service is used in conjunction with codes for diagnostic psychiatric evaluation (CPT codes 90791, 90792), psychotherapy (CPT codes 90832, 90834, 90837), psychotherapy when performed with an E/M service (CPT codes 90833, 90836, 90838, 99202-99255, 99304-99310, 99341-99350), and group psychotherapy (CPT code 90853). When billed in conjunction with time-based codes, the documentation must indicate the amount of time spent in providing interactive complexity services.