evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Blepharoplasty, Blepharoptosis and Brow Lift (A56908)
When the patient requests the claim for cosmetic services be submitted on his/her behalf, the services should be reported with modifier GY (items or services statutorily excluded or does not meet the definition of any Medicare benefit)anddiagnosis code Z41.1. The diagnosis code Z41.1 should be placed in the first position in item 21 on the CMS 1500 claim form or the equivalent diagnosis code field for electronic claims. A Notice of Exclusion from Medicare Benefits (NEMB) may be used with services excluded from Medicare benefits.When the signs or symptoms are present (See L34528 Coverage Indications, Limitations and/or Medical Necessity) physicians are encouraged to place the appropriate diagnosis code in the first position with the available symptom diagnosis code in the second position in item 21 of the CMS 1500 claim form or the equivalent diagnosis code field for electronic claims.Visual Field exams are classified as bilateral procedures where the bilateral adjustment does not apply; the Physician Fee Schedule amount represents payment forbotheyes. The procedure should be reported on a single claim linewithoutthe 50 or RT/LT modifiers. In the event that the procedure is performed on only one eye per DOS the procedure may be reported with a 52 modifier  (reduced service) and a reduced charge.Photographs are not separately billable to Medicare.The following situation will result in the denial of initially billed Blepharoplasty, Blepharoptosis or Brow Lift services or in some cases as a result of a post payment review.Physicians services submitted without a diagnosis code or not coded to the highest level of accuracy and digit level completeness will be denied as unprocessable.When blepharoplasty is performed to improve a patient's appearance in the absence of any signs and/or symptoms of functional abnormalities, the procedure is considered cosmetic and not covered by Medicare. (Use the GY modifier and ICD-10 code Z41.1 for a non-covered denial.)
Article - Billing and Coding: Corneal Hysteresis (A56910)
CMS National Coverage PolicyN/AArticle TextCPT code 92145 is considered not medically necessary and will be automatically denied as a non-covered procedure.
Article - Billing and Coding: MDS FISH (A56913)
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.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts with Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) forMDS FISH L37602.Coding for FISH TestingThere are 2 sets of codes that describe in situ hybridization (ISH). Although the laboratory methods are similar, 1 distinguishes between the 2 sets of codes based on whether the ISH test is an adjunct to a surgical or cytopathology case, versus whether it is part of a clinical, chromosomal analysis. Specifically, the CPTcodes 88271-88291 should be used when the laboratory performs ISH as an ancillary analysis to cytogenetic studies for oncologic or inherited disorders.When a pathologist performsISH techniques as an adjunct to a surgical pathology or cytopathology case,CPTcodes 88365-88377 should be used to distinguish qualitative versus quantitative analysis (computer assisted versus manual).These codes must never be used by a pathologist when ISH is performed as an ancillary analysis to cytogenetic studies.To report an MDS FISH service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Select the appropriate ICD-10-CM codeA DEX Z-Code identifier is not required for FISH testing.
Article - Billing and Coding: Treatment of Varicose Veins of the Lower Extremities (A56914)
CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated Local Coverage Determination (LCD) L34536 Treatment of Varicose Veins of the Lower Extremities.Historically, varicose veins have been treated by conservative measures such as exercise, periodic leg elevation, weight loss, compressive therapy, and avoidance of prolonged immobility. When conservative measures are unsuccessful, and symptoms persist, the next step has been sclerotherapy or surgical ligation with or without stripping.GeneralIt is not enough to link the procedure code to a correct, payable diagnosis code. The diagnosis or clinical suspicion must be present for the procedure to be paid.When performing ligation/ablation on the opposite leg during the postoperative (90 day global) period, bill the appropriate CPT code with the 79 modifier.Use unlisted CPT code 37799 when less than 10stab phlebectomiesare done. Provide a description of what was done and the number of stab phlebectomies in Item 19 on the CMS-1500 claim form, or in the equivalent field for electronic submissions.When reportingsurgical ligationprocedures (37700, 37718, 37722, 37780, 37785) performed bilaterally, report the appropriate code with the 50 modifier. When reporting any combination of surgical ligation procedures performed on opposite legs, report the appropriate CPT codes with a RT or LT modifier on separate lines.When reportingsclerotherapyprocedures (36465, 36466, 36470, and 36471) performed on opposite legs, report CPT code 36465, 36470 (one vein) and 36466, 36471(multiple veins) on separate lines using the RT and LT modifiers. For bilateral services, use the 50 modifier. Only one service should be reported for each leg regardless of how many veins are treated. When the procedure is performed for cosmetic purposes, use code Z41.1.
Article - Billing and Coding: Treatment of Varicose Veins of the Lower Extremities (A56914)
When reporting procedures (36482 and 36483) performed on opposite legs, report CPT code 36482 (one vein) and 36483 (multiple veins) on separate lines using the RT and LT modifiers. For bilateral services, use the 50 modifier. Only one service should be reported for each leg regardless of how many veins are treated. When the procedure is performed for cosmetic purposes, use code Z41.1.Please be advised that the practice expense for CPT codes 36465, 36466, 36470, 36471, 36473, and 36474 already contain the reimbursement for the sclerosant. Providers should not bill separately for the sclerosant.Please be advised that the practice expense for CPT codes 36482 and 36483 already contain the reimbursement for the chemical adhesive. Providers should not bill separately for the chemical adhesive. Use CPT code 36483 to report the second and subsequent veins treated in a single extremityonly when treated through separate access sites.When reportingendoluminal radiofrequency ablation (ERFA), use CPT code 36475 forthefirst vein on each extremity. Use CPT code 36476 to report the second and subsequent veins treated in a single extremityonly when treated through separate access sites.
Article - Billing and Coding: Urine Drug Testing (A56915)
CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD DL34645 Urine Drug Testing.A qualitative/presumptive drug screen is used to detect the presence of a drug in the body. A blood, urine, or oral fluid sample may be used. However, urine is the best specimen for broad screening, as blood is relatively insensitive for many common drugs, including psychotropic agents, opioids, and stimulants.Common methods of drug analysis include chromatography, immunoassay, chemical ("spot") tests, and spectrometry.Coding GuidelinesOne presumptive drug testing code may be billed once per patient per day as indicated by the code description and should only be billed at one unit regardless of the provider.One definitive drug testing code may be billed once per patient per day as indicated by the code description and should only be billed at one unit regardless of the provider.The documentation should support the medical necessity of the drug testing ordered and should support the clinical indicators that led to ordering the test.Documentation RequirementsAll documentation must be maintained in the patients medical record and 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 record must include the identity of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record should support the use of the selected diagnosis code(s). The submitted CPT/HCPCS code should describe the service performed.Medical record documentation (e.g., history and physical, progress notes) maintained by the ordering physician/treating physician must indicate the medical necessity for performing a drug test. All tests must be ordered in writing by the treating provider and all drugs/drug classes to be tested must be indicated in the order.If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of the lab results, along with copies of the ordering/referring physicians order for the drug test. The physician must include the clinical indication/medical necessity in the order for the drug test.
Article - Billing and Coding: Urine Drug Testing (A56915)
This LCD does not apply to acute inpatient claims.Claims for drug screening services are payable under Medicare Part B in the following places of service: office (11), urgent care (20), independent clinic (49), federally qualified health center (freestanding) (50), rural health clinic (freestanding) (72), and independent laboratory (81).All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.All coverage criteria must be met before Medicare can reimburse this service.Billing for these services in a non-covered situation (e.g., does not meet indications of the LCD) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered.Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item, or procedure may not be covered by Medicare.The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category, or is rendered for screening purposes.
Article - Billing and Coding: Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (A56916)
CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L34760 Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI).Medicare will consider SCODI medically reasonable and necessary in evaluating retinal disorders, glaucoma, and anterior segment disorders as documented in L34760.Coding Guidelines: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.Claims for SCODI services (CPT codes 92133 and 92134) are payable under Medicare Part B in the following places of service:The global service is payable in the office (11), nursing facility (32- for Medicare patient not in a Part A stay) and independent clinic (49).The technical component (modifier TC) is payable in the office (11), nursing facility (32- for Medicare patient not in a Part A stay), independent clinic (49), federally qualified health center (50), and rural health clinic (72).The professional component (modifier 26) is payable in the office (11), inpatient hospital (21), Off campus-outpatient hospital (19), On campus- outpatient hospital (22), skilled nursing facility (31), nursing facility (32- for Medicare patient not in a Part A stay), and independent clinic (49).Please review 100-04Medicare Claims Processing Manual, Chapter 32 - Billing Requirements for Special Services, Section 300.2 for Claims Processing Requirements for OPT with Verteporfin Services on Professional Claims and Outpatient Facility Claims.
Article - Billing and Coding: Outpatient Sleep Studies (A56923)
CMS National Coverage PolicyPlease refer to the related LCD, L35050.Article TextRefer to the Novitas Local Coverage Determination (LCD) L35050, Outpatient Sleep Studies, for reasonable and necessary requirements.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.Coding GuidanceWatchPAT must be billed as CPT code 95800 or 95801.While actigraphy coverage is not included in the related LCD, this service may be reported with CPT code 95803 for documentation of coverage of CPAP by NCD but consistent with the related LCD the coverage of interpretation will not be paid separately. CPT code 95803 may also be reported for follow-up CPAP administration if allowed through the DME contractors as an acceptable test.
Article - Billing and Coding: MolDX: Inivata™, InVisionFirst®, Liquid Biopsy for Patients with Lung Cancer (A56924)
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.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts with Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2 Travel Allowance.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Inivata,InVisionFirst, Liquid Biopsy for Patients with Lung Cancer L37870.To report an InvisionFirst Lung service, please submit the following claim information:Select CPTcode 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 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: MDS FISH (A56926)
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.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS 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 AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MDS FISH L37608.Coding for FISH TestingThere are 2 sets of codes that describe in situ hybridization (ISH). Although the laboratory methods are similar, one distinguishes between the 2 sets of codes based on whether the ISH test is an adjunct to a surgical or cytopathology case, versus whether it is part of a clinical, chromosomal analysis. Specifically, the CPTcodes 88271-88291 should be used when the laboratory performs ISH as an ancillary analysis to cytogenetic studies for oncologic or inherited disorders.When a pathologist performsISH techniques as an adjunct to a surgical pathology or cytopathology case,CPTcodes 88365-88377 should be used to distinguish qualitative versus quantitative analysis (computer assisted versus manual).These codes must never be used by a pathologist when ISH is performed as an ancillary analysis to cytogenetic studies.To report an MDS FISH service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Select the appropriate ICD-10-CM codeA DEX Z-Code identifier is not required for FISH testing. If submitting a DEX Z-Code identifier, please submit following the below instructions:Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:
Article - Billing and Coding: MDS FISH (A56926)
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 form
Article - Billing and Coding: BDX-XL2 (A56929)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims,60.1.1 Independent Laboratory Specimen Drawing, and60.2 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) for BDX-XL2 L37031.
Article - Billing and Coding: 4Kscore® Assay (A56932)
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.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for4Kscore Assay L36763.
Article - Billing and Coding: MolDX: Prometheus® IBD sgi Diagnostic® Policy (A56933)
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 information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forMolDX: PrometheusIBD sgi DiagnosticPolicyL37260.To receive a PrometheusIBD sgi Diagnosticdenial, 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 UB04 claim form
Article - Billing and Coding: Psychiatry and Psychology Services (A56937)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Psychiatry and Psychology Services (A56937)
This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) forPsychiatry and Psychology Services.Unless otherwise indicated, these procedures may be used by providers of mental health services licensed or otherwise authorized as designated by Medicare and the state in which they practice.National Coverage Provisions:It is not necessary that a course of therapy have as its goal restoration of the patient to the level of functioning exhibited prior to the onset of the illness, although this may be appropriate for some patients. For many other psychiatric patients, particularly those with long-term, chronic conditions, control of symptoms and maintenance of a functional level to avoid further deterioration or hospitalization is an acceptable expectation of improvement. "Improvement" in this context is measured by comparing the effect of continuing treatment versus discontinuing it. Where there is a reasonable expectation that if treatment services were withdrawn the patient's condition would deteriorate, relapse further, or require hospitalization, this criterion would be met(CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 6, Section 70.1).Some patients may undergo a course of treatment which increases their level of functioning, but then reach a point where further significant increase is not expected(CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 6, Section 70.1).Social and psychological services include the assessment and treatment of a CORF patients mental health and emotional functioning and the response to, and rate of progress of the patients rehabilitation plan of treatment including physical therapy services, occupational therapy services, speech-language pathology services and respiratory therapy services.CORF social and/or psychological covered services are the same, regardless of whether they are provided by a qualified social worker, as defined at 42CFR485.70(l), or a psychologist, as defined at 42CFR485.70(g). Therefore, a CORF may elect to provide these services when they are indicated. Qualifications for individuals providing CORF social and psychological services are, at a minimum, a Bachelors of Science Degree for a social worker and a Masters-level degree for a psychologist. (CMS Publication 100-02, Medicare Benefit Policy Manual,Chapter 12, Section 40.7).