evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Violations of 1128B (b) of the Act may subject the physician or supplier to criminal penalties or exclusion from the Medicare and Medicaid programs.  Illegal remuneration for referrals can be found even when the ordering physician performs some service for the remuneration.  30 - Computerized Axial Tomography (CT) Procedures  (Rev. 1, 10- 01-03)  A/B MACs (B) do not reduce or deny payment for medically necessary multiple CT scans of different areas of the body that are performed on the same day.  The TC RVUs for CT procedures that specify with contrast include payment for high osmolar contrast media.  When separate payment is made for low osmolar contrast media under the conditions set forth in 30.1.1, reduce payment for the contrast media as set forth in 30.1.2.  30.1 - Low Osmolar Contrast Media (LOCM) (HCPCS Codes Q9945 -Q9951)  (Rev. 627, Issued: 07- 29-05, Effective: 01 -01-05, Implementation: 10- 31-05)  HCPCS codes A4644- A4646 have been replaced with Q9945- Q0051.   30.1.1 - Payment Criteria  (Rev. 627, Issued: 07- 29-05, Effective: 01 -01-05, Implementation: 10 -31-05)  A/B MACs (B) make separate payments for LOCM (HCPCS codes Q9945 -Q9951) in the case of all medically necessary intrathecal radiologic procedures furnished to nonhospital patients.  Effective January 1, 2005 in the case of intraarterial and intravenous radiologic procedures, the five restrictive criteria (a history of previous adverse reaction to contrast material, with the exception of a sensation of heat, flushing, or a single episode of nausea or vomiting; a history of asthma or allergy; significant cardia c dysfunction including recent or imminent cardiac decompensation, severe arrhythmia, unstable angina pectoris, recent myocardial infarction, and pulmonary hypertension; generalized severe debilitation; or sickle cell disease) for the payment of LOCM are eliminated.
(Medicare Claims Processing Manual)
30.1.2 - Payment Level (Rev. 627, Issued: 07- 29-05, Effective: 01 -01-05, Implementation: 10- 31-05)  Determine payment in the same manner as for a drug furnished incident to a physicians service.   The payment methodology for LOCM for the period of January 1, 2005 through March 31, 2005 is made in accordance with the established payment for calendar year 2004 using codes A4644- A4646.   Effective April 1, 2005, the method of payment for LOCM is the average sales price (ASP) plus six percent in accordance with the standard methodology for drug pricing established by the Medicare Modernization Act (MMA0 for other than hospital outpatient cl aims.  Payments for the new Q codes can be found in the respective quarterly Medicare Part B drug pricing files that are posted on the CMS Web site.  30.1.3 - SNF Billing and A/B MAC (A) Payment for Contrast Material Other Than Low Osmolar Contrast Material (LOCM) (Radiology)  (Rev. 1, 10- 01-03)  When a radiology procedure is provided with contrast material, a SNF should bill using the CPT -4 code that indicates with contrast material.  If the coding does not distinguish between with and without contrast material, the SNF should use the availa ble code.   Contrast material other than LOCM may be billed separately in addition to the radiology procedure, or it may be billed as part of the amount for the radiology procedure.  If the SNF bills separately for the contrast material and the charge for the procedur e includes a charge for contrast material, the SNF must adjust the charge for the procedure to exclude any amount for the contrast material.  Regardless of the billing method used, charges are subject to the fee schedule.   When billing separately for this contrast material, the SNF should use revenue code 0255 (drugs incident to radiology and subject to the payment limit) and report the charge on the same bill as the radiology procedure.  The A/B MAC (A)  will not accept late charge bills for this service.
(Medicare Claims Processing Manual)
30.1.3.1 - A/B MAC (A) Payment for Low Osmolar Contrast Material (LOCM) (Radiology)  (Rev. 3227, Issued: 04- 02-15, Effective; ASC -X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  June 11, 2013, ICD -10: Upon Implementation of ICD -10 Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  May 19, 2014 -  MAC Non -Shared System Edits; July 7, 2014 -  CWF development/testing, FISS requirement development; October 6, 2014 -  CWF, FISS, MCS Shared System Edits), ICD -10: Upon Implementation of ICD -10)  The LOCM is paid on a reasonable cost basis when rendered by a SNF to its Part B patients (in addition to payment for the radiology procedure) when it is used in one of the situations listed below.  The following HCPCS are used when billing for LOCM.  HCPCS Code  Description (January 1. 1994, and later)  A4644  Supply of low osmolar contrast material (100 -199 mgs of iodine);  A4645  Supply of low osmolar contrast material (200 -299 mgs of iodine); or  A4646  Supply of low osmolar contrast material (300 -399 mgs of iodine).   When billing for LOCM, SNFs use revenue code 0636.  If the SNF charge for the radiology procedure includes a charge for contrast material, the SNF must adjust the charge for the radiology procedure to exclude any amount for the contrast material.   NOTE:  LOCM is never billed with revenue code 0255 or as part of the radiology procedure.
(Medicare Claims Processing Manual)
NOTE:  LOCM is never billed with revenue code 0255 or as part of the radiology procedure.   The A/B MAC (A) will edit for the intrathecal procedure codes and the following codes to determine if payment for LOCM is to be made.  If an intrathecal procedure code is not present, or one of the ICD codes is not present to indicate that a required medic al condition is met, the A/B MAC (A) will deny payment for LOCM.  In these instances, LOCM is not covered and should not be billed to Medicare.  When LOCM Is Separately Billable and Related Coding Requirements    In all intrathecal injections.  HCPCS codes that indicate intrathecal injections are:   70010 70015 72240 72255 72265 72270 72285 72295  One of these must be included on the claim; or    In intravenous and intra -arterial injections only when certain medical conditions are present in an outpatient.  The SNF must verify the existence of at least one of the following medical conditions, and report the applicable diagnosis code(s) either as a principal diagnosis code or other diagnosis codes on the claim:   o A history of previous adverse reaction to contrast material.  The applicable ICD -9-CM codes are V14.8 and V14.9.  The applicable ICD -10-CM codes are Z88.8 and Z88.9.  The conditions which should not be considered adverse reactions are a sensation of heat, flushing, or a single episode of nausea or vomiting.  If the adverse reaction occurs on that visit with the induction of contrast material, codes describing hives, urticar ia, etc. should also be present, as well as a code describing the external cause of injury and poisoning, ICD -9-CM code E947.8.  The applicable ICD -10 CM codes are:  T50.8X5A Adverse effect of diagnostic agents, initial encounter, T50.8X5S Adverse effect of diagnostic agents, sequela , T50.995A Adverse effect of other drugs, medicaments and biological substances, initial encounter, or T50.995S Adverse effect of other drugs, medicaments and biological substances, sequela;
(Medicare Claims Processing Manual)
o A history or condition of asthma or allergy.  The applicable ICD -9-CM codes are V07.1, V14.0 through V14.9, V15.0, 493.00, 493.01, 493.10, 493.11, 493.20, 493.21, 493.90, 493.91, 495.0, 495.1, 495.2, 495.3, 495.4, 495.5, 495.6, 495.7, 495.8, 495.9, 995.0, 995.1, 995.2, and 995.3.  The applicable ICD -10-CM codes are in the table below:
(Medicare Claims Processing Manual)
ICD-10-CM Codes  J44.0  J44.9  J45.20  J45.22  J45.30  J45.32  J45.40  J45.42  J45.50  J45.52  J45.902  J45.909  J45.998  J67.0  J67.1  JJ67.2  J67.3  J67.4  J67.5  J67.6  J67.7  J67.8  J67.9  J96.00  J96.01  J96.02  J96.90  J96.91  J96.92  T36.0X5A  T36.1X5A  T36.2X5A  T36.3X5A  T36.4X5A  T36.5X5A  T36. 6X5A  T36.7X5A  T36.8X5A  T36.95XA  T37.0X5A  T37.1X5A  T37.2X5A  T37.3X5A  T37.8X5A  T37.95XA  T38.0X5A  T38.1X5A  T38.2X5A  T38.3X5A  T38.4X5A  T38.6X5A  T38.7X5A  T38.805A  T38.815A  T38.895A  T38.905A  T38.995A  T39.015A  T39.095A  T39.1X5A  T39.2X5A  T39.2X5A  T39.315A  T39.395A  T39.4X5A  T39.8X5A  T39.95XA  T40.0X5A  T40.1X5A  T40.2X5A  T40.3X5A  T40.4X5A  T40.5X5A  T40.605A  T40.695A  T40.7X5A  T40.8X5A  T40.905A  T40.995A  T41.0X5A  T41.1X5A  T41.205A  T41.295A
(Medicare Claims Processing Manual)
T40.7X5A  T40.8X5A  T40.905A  T40.995A  T41.0X5A  T41.1X5A  T41.205A  T41.295A  T41.3X5A  T41.4X5A  T41.X5A  T41.5X5A  T42.0X5A  T42.1X5A  T42.2X5A  T42.3X5A  T42.4X5A  T42.5X5A  T42.6X5A  427.5XA  428.X5A  T43.015A  T43.025A  T43.1X5A  T43.205A  T43.215A  T43.225A  T43.295A  T43.3X5A  T43.4X5A  T43.505A  T43.595A  T43.605A  T43.615A  T43.625A  T43.635A  T43.695A  T43.8X5A  T43.95XA  T44.0X5A  T44.1X5A  T44.2X5A  T44.3X5A  T44.6X5A  T44.7X5A  T44.8X5A  T44.905A  T44.995A  T45.0X5A  T45.1X5A  T45.2X5A  T45.3X5A  T45.4X5A  T45.515A  T45.525A  T45.605A  T45.615A  T45.625A  T45.695A  T45.7X5A  T45.8X5A  T45.95XA  T46.0X5A  T46.1X5A  T46.2X5A  T46.3X5A  T46.4X5A  T46.5X5A  T46.6X5A  T46.7X5A  T46.8X5A  T46.905A  T46.995A  T47.0X5A  T47.1X5A  T47.2X5A  T47.3X5A
(Medicare Claims Processing Manual)
T46.8X5A  T46.905A  T46.995A  T47.0X5A  T47.1X5A  T47.2X5A  T47.3X5A  T47.4X5A  T47.5X5A  T47.6X5A  T47.7X5A  T47.8X5A  T47.95XA  T48.0X5A  T48.1X5A  T48.205A  T48.295A  T48.3X5A  T48.4X5A  T48.5X5A  T48.6X5A  T48.905A  T48.995A  T49.0X5A  T49.1X5A  T49.2X5A  T49.3X5A  T49.4X5A  T49.5X5A  T49.6X5A  T49.6X5A  T47.X5A9  T49.8X5A  T49.95XA  T50.0X5A  T50.1X5A  T50.2X5A  T50.3X5A  T50.4X5A  T50.5X5A  T50.6X5A  T50.7X5A  T50.8X5A  T50.905a  T50.995A  T50.A15A  T50.A25A  T50.A95A  T50.B15A  T50.B95A  T50.Z15A  T50.Z95A  T78.2XXA  T78.3XXA  T78.40XA  T78.41XA  T88.52XA  T88.59XA  T88.6XXA  Z51.89  Z88.0  Z88.1  Z88.2  Z88.3  Z88.4  Z88.5  Z88.6  Z88.7  Z88.8  Z88.9  Z91.010
(Medicare Claims Processing Manual)
o Significant cardiac dysfunction including recent or imminent cardiac decompensation, severe arrhythmia, unstable angina pectoris, recent myocardial infarction, and pulmonary hypertension.  The applicable ICD -9-CM codes are:   ICD-9-CM 402.00  402.01  402.10  402.11  402.90  402.91    404.00  404.01  404.02  404.03      404.10  404.11  404.12  404.13      404.90  404.91  404.92  404.93      410.00  410.01  410.02  410.10  410.11  410.12    410.20  410.21  410.22  410.30  410.31  410.32    ICD-9-CM 410.40  410.41  410.42  410.50  410.51  410.52    410.60  410.61  410.62  410.70  410.71  410.72    410.80  410.81  410.82  410.90  410.91  410.92    411.1  415.0  416.0  416.1  416.8  416.9    420.0  420.90  420.91  420.99  424.90  424.91    424.99  427.0  427.1  427.2  427.31  427.32    427.41  427.42  427.5  427.60  427.61  427.69    427.81  427.89  427.9  428.0  428.1  428.9  429.0   429.1  429.2  429.3  429.4  429.5  429.6  429.71   429.79  429.81  429.82  429.89  429.9  785.50  785.51  785.59   o The applicable ICD -10-CM codes are in the table below:
(Medicare Claims Processing Manual)
o The applicable ICD -10-CM codes are in the table below:   ICD-10-CM Codes  A18.84  I11.0  I11.9  I13.0  I13.10  I13.11  I13.2  I20.0  I21.01  I21.02  I21.09  I21.11  I21.19  I21.21  I21.29  I21.3  I21.4  I22.1  I22.2  I22.8  I23.0  I23.1  I23.2  I23.3  I23.4  I23.5  I23.6  I23.7  I23.8  I25.10  I25.110  I25.700  I25.710  I25.720  I25.730  I25.750  I25.760  I25.790  I26.01  I26.02  I26.09  I27.0  I27.1  I27.2  I27.81  I27.89  I27.9  I30.0  I30.1  I30.8  I30.9  I32 I38 I39 I46.2  I46.8  I46.9  I47.0  I471 I472 I47.9  I48.0  I48.1  I48.1  I48.2  I48.3  I48.4  I48.91  I48.92  I49.01  I49.02  I49.1  I49.2  I49.3  I49.40  I49.49  I49.5  I49.8  I49.9  I50.1  I50.20  I50.21  I50.22  I50.23  I50.30  I50.31  I50.32  I50.33  I50.40  I50.41  I50.42  I50.43  I50.9  I51 I51.0  I51.1  I51.2  I51.3  I51.4  I51.5  I51.7  I51.89  I51.9  I52 I97.0  I97.110  I97.111  I97.120  I97.121  I97.130  I97.131  I97.190  I97.191  M32.11  M32.12  R00.1  R57.0  R57.8  R57.9
(Medicare Claims Processing Manual)
o Generalized severe debilitation.  The applicable ICD -9-CM codes are:  203.00, 203.01, all codes for diabetes mellitus, 518.81, 585, 586, 799.3, 799.4, and V46.1.  The applicable ICD-10-CM codes are:  J96.850, J96.00 through J96.02, J96.90 through J96.91, N18.1 through N19, R53.81, R64, and Z99.11 through Z99.12.  Or   o Sickle Cell disease.  The applicable ICD -9-CM codes are 282.4, 282.60, 282.61, 282.62, 282.63, and 282.69.  The applicable ICD -10-CM codes are D56.0 through D56.3, D56.5 through D56.9, D57.00 through D57.1, D57.20, D57.411 through D57.419, and D57.811 through D57.819.  40 - Magnetic Resonance Imaging (MRI) Procedures  (Rev. 2307, Issued: 09- 22-11, Effective: 07 -07-11/02- 24-11(CR 7296), Implementation: 09- 26-11)  Effective September 28, 2009   The Centers for Medicare & Medicaid Services (CMS) finds that the non -coverage of magnetic resonance imaging (MRI) for blood flow determination is no longer supported by the available evidence.  CMS is removing the phrase blood flow measurement and local Medicare contractors will have the discretion to cover (or not cover).   Consult Publication (Pub.) 100- 03, National Coverage Determinations (NCD) Manual , chapter 1, s ection 220.2, for specific coverage and non- coverage indications associated with MRI and MRA (Magnetic Resonance Angiography).   Prior to January 1, 2007  A/B MACs (B) do not make additional payments for three or more MRI sequences.  The relative value units (RVUs) reflect payment levels for two sequences.
(Medicare Claims Processing Manual)
A/B MACs (B) do not make additional payments for three or more MRI sequences.  The relative value units (RVUs) reflect payment levels for two sequences.   The technical component (TC) RVUs for MRI procedures that specify with contrast include payment for paramagnetic contrast media.  A/B MACs (B) do not make separate payment under code A4647.   A diagnostic technique has been developed under which an MRI of the brain or spine is first performed without contrast material, then another MRI is performed with a standard (0.1mmol/kg) dose of contrast material and, based on the need to achieve a better  image, a third MRI is performed with an additional double dosage (0.2mmol/kg) of contrast material.  When the high- dose contrast technique is utilized, A/B MACs (B):    Do not pay separately for the contrast material used in the second MRI procedure;    Pay for the contrast material given for the third MRI procedure through supply code Q9952, the replacement code for A4643, when billed with Current Procedural Terminology (CPT) codes 70553, 72156, 72157, and 72158;    Do not pay for the third MRI procedure.  For example, in the case of an MRI of the brain, if CPT code 70553 (without contrast material, followed by with contrast material(s) and further sequences) is billed, make no payment for CPT code 70551 (without cont rast material(s)), the additional procedure given for the purpose of administering the double dosage, furnished during the same session.  Medicare does not pay for the third procedure (as distinguished from the contrast material) because the CPT definition  of code 70553 includes all further sequences; and    Do not apply the payment criteria for low osmolar contrast media in 30.1.2 to billings for code Q9952, the replacement code for A4643.
(Medicare Claims Processing Manual)
 Do not apply the payment criteria for low osmolar contrast media in 30.1.2 to billings for code Q9952, the replacement code for A4643.   Effective January 1, 2007  With the implementation for calendar year 2007 of a bottom -up methodology, which utilizes the direct inputs to determine the practice expense (PE) relative value units (RVUs), the cost of the contrast media is not included in the PE RVUs.  Therefore, a separate payment for the contrast media used in various imaging procedures is paid.  In addition to the CPT code representing the imaging procedure, separately bill the appropriate HCPCS Q code (Q9945  Q9954; Q9958- Q9964) for the contrast medium utilized in performing the service.  Effective February 24, 2011  Medicare will allow for coverage of MRI for beneficiaries with implanted PMs or cardioverter defibrillators (ICDs) for use in an MRI environment in a Medicare -approved clinical study as described in section 220.C.1 of the NCD manual.   Effective July 7, 2011  Medicare will allow for coverage of MRI for beneficiaries with implanted pacemakers (PMs) when the PMs are used according to the Food and Drug Administration (FDA) -approved labeling for use in an MRI environment as described in section 220.2.C.1 of the NCD  Manual.   40.1  Magnetic Resonance Angiography (MRA)  (Rev. 2171, Issued: 03- 04-11, Effective: 02 -24-11, Implementation: 04 -04-11)  40.1.1  Magnetic Resonance Angiography (MRA) Coverage Summary  (Rev. 2171, Issued: 03 -04-11, Effective: 02 -24-11, Implementation: 04 -04-11)
(Medicare Claims Processing Manual)
40.1.1  Magnetic Resonance Angiography (MRA) Coverage Summary  (Rev. 2171, Issued: 03 -04-11, Effective: 02 -24-11, Implementation: 04 -04-11)  Section 1861(s)(2)(C) of the Social Security Act provides for coverage of diagnostic testing. Coverage of magnetic resonance angiography (MRA) of the head and neck, and MRA of the peripheral vessels of the lower extremities is limited as described in Publication (Pub.) 100 -03, the Medicare National Coverage Determinations (NCD) Manual. This instruction has been revised as of July 1, 2003, based on a determination that coverage is reasonable and necessary in additional circumstances. Under that instruction, MRA is generally cove red only to the extent that it is used as a substitute for contrast angiography, except to the extent that there are documented circumstances consistent with that instruction that demonstrates the medical necessity of both tests.  Prior to June 3, 2010, there was no coverage of MRA outside of the indications and circumstances described in that instruction.  Effective for claims with dates of service on or after June 3, 2010, contractors have the discretion to cover or not cover all indications of MRA (and magnetic resonance imaging (MRI)) that are not specifically nationally covered or nationally non- covered as stated in section 220.2 of the NCD Manual.
(Medicare Claims Processing Manual)
Because the status codes for HCPCS codes 71555, 71555- TC, 71555- 26, 74185, 74185- TC, and 74185-26 were changed in the Medicare Physician Fee Schedule Database from N to R on April 1, 1998, any MRA claims with those HCPCS codes with dates of service bet ween April 1, 1998, and June 30, 1999, are to be processed according to the contractors discretionary authority to determine payment in the absence of national policy.  Effective for claims with dates of service on or after February 24, 201l, Medicare will provide coverage for MRIs for beneficiaries with implanted cardiac pacemakers or implantable cardioverter defibrillators if the beneficiary is enrolled in an approved c linical study under the Coverage with Study Participation form of Coverage with Evidence Development that meets specific criteria per Pub. 100- 03, the NCD Manual, chapter 1, section 220.2.C.1.  40.1.2 - HCPCS Coding Requirements  (Rev. 1472, Issued: 03- 06-08, Effective: 05 -23-07, Implementation: 04- 07-08)  Providers must report HCPCS codes when submitting claims for MRA of the chest, abdomen, head, neck or peripheral vessels of lower extremities. The following HCPCS codes should be used to report these services:
(Medicare Claims Processing Manual)
Providers must report HCPCS codes when submitting claims for MRA of the chest, abdomen, head, neck or peripheral vessels of lower extremities. The following HCPCS codes should be used to report these services:   MRA  Code  MRA of head  70544, 70544- 26, 70544- TC MRA of head  70545, 70545- 26, 70545- TC MRA of head  70546, 70546- 26, 70546- TC MRA of neck  70547, 70547- 26, 70547- TC MRA of neck  70548, 70548- 26, 70548- TC MRA of neck  70549, 70549- 26, 70549- TC MRA of chest  71555, 71555- 26, 71555- TC MRA of pelvis  72198, 72198- 26, 72198- TC MRA of abdomen (dates of service on or after July 1, 2003)  see below.  74185, 74185- 26, 74185- TC MRA of peripheral vessels of lower extremities  73725, 73725- 26, 73725- TC  Hospitals subject to OPPS should report the following C codes in place of the above HCPCS codes as follows:    MRA of chest 71555: C8909  C8911  MRA of abdomen 74185: C8900  C8902   MRA of peripheral vessels of lower extremities 73725: C8912  C8914   For claims with dates of service on or after July 1, 2003, coverage under this benefit has been expanded for the use of MRA for diagnosing pathology in the renal or aortoiliac arteries. The following HCPCS code should be used to report this expanded coverage of MRA:    MRA, pelvis, with or without contrast material(s) 72198, 72198- 26, 72198- TC  Hospitals subject to OPPS report the following C codes in place of HCPCS code 72198:    MRA, pelvis, with or without contrast material(s) 72198: C8918 -  C8920
(Medicare Claims Processing Manual)
Hospitals subject to OPPS report the following C codes in place of HCPCS code 72198:    MRA, pelvis, with or without contrast material(s) 72198: C8918 -  C8920  NOTE:   Information regarding the claim form locator that corresponds to the HCPCS code and a table to crosswalk its CMS -1450 form locator to the 837 transaction is found in Chapter 25.   40.1.3 - Special Billing Instructions for RHCs and FQHCs  (Rev. 3227, Issued: 04- 02-15, Effective; ASC -X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  June 11, 2013, ICD -10: Upon Implementation of ICD -10 Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  May 19, 2014 -  MAC Non -Shared System Edits; July 7, 2014 -  CWF development/testing, FISS requirement development; October 6, 2014 -  CWF, FISS, MCS Shared System Edits), ICD -10: Upon Implementation of ICD -10)  Independent RHCs and free -standing FQHCs bill under bill type 71X and 73X for the professional component utilizing revenue codes 520 and 521 as appropriate.  HCPCS coding is not required.  The technical component is outside the scope of the RHC/FQHC benefit.  The provider of the technical service bills using the ASC X12 837 professional claim format or on Form CMS -1500.  The technical component for a provider based RHC/FQHC is typically furnished by the provider.  The provider of that service bills under bill type 13X or 85X as appropriate using its outpatient provider number (not the RHC/FQHC provider number since these s ervices are not covered as RHC/FQHC services).  Effective 4/1/06, type of bill 14X is for non- patient laboratory specimens and is no longer applicable for radiology services.