evekhm/cms_iom_500 huggingface dataset:
Draft Article - Billing and Coding: Molecular Pathology Procedures (DA56199)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Molecular Pathology Procedures.Specific Coding of Molecular Testing PanelsThe submission of claims using individual gene CPT codes, when either 5-50 or >50 gene panels are ordered, is considered incorrect coding. Correct coding requires that when a panel code is ordered, it should be billed, rather than the individual gene codes. CPT code 81445, 81449, 81450, or 81451 should be billed when 5 to 50 genes are ordered.CPT code 81455, or 81456, should be billed when 51 or greater genes are ordered for molecular biomarkers.Please refer to Local Coverage Determination L37810 Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms and the associated Article A56867.When a panel with greater than one or less than five genes is ordered, use the corresponding existing panel CPT code or CPT code 81479 if none exists.Coding InformationCoding guidance in this article is categorized into four, distinct CPT/HCPCS sections: CPT/HCPCS section-Group1-Tier 1 Covered Codesfor which limited coverage may be provided for the genetic tests and for which specific ICD-10-CM diagnosis to CPT procedure groupings may be listed CPT/ HCPCS section-Group 2-Tier 1 Codes that require Individual Reviewfor which coverage may be provided for the genetic tests submitted, if documentation supports medical necessity, and for which specific ICD-10-CM diagnosis to CPT procedure groupings may be listed. CPT/HCPCS section-Group 3-Tier 1 Non-covered Codesfor which genetic testing is unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary. CPT/HCPCS section-Group 4-Tier 2/NOC Covered Code/Gene Combinationsfor which limited coverage may be provided for specific genes listed in the Group 4 paragraph;Tier 2/NOC Individual Review Code/Gene Combinations;Tier 2/NOC Non-covered Code/Gene Combinations.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.
Draft Article - Billing and Coding: Molecular Pathology Procedures (DA56199)
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.
Draft Article - Billing and Coding: Molecular Pathology Procedures (DA56199)
The diagnosis code(s) must best describe the patient's condition for which the service was performed.Modifier 91Please use Modifier 91 as appropriate, based on the Medicare Claims Processing Manual Chapter 16, Laboratory Services Section 100.5.1. Modifier 91 may be is used"to indicate that a test was performed more than once on the same day forthe same patient., only when it is necessary to obtain multiple results in the course of treatment."Documentation RequirementsDocumentation must be adequate to verify that coverage guidelines listed above have been met. Thus, the medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed. The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition (ICD-10-CM code) that warrants the test(s).Examples of documentation requirements of the ordering physician/nonphysician practitioner (NPP) include, but are not limited to, history and physical or exam findings that support the decision making, problems/diagnoses, relevant data (e.g., lab testing, imaging results).Documentation requirements of the performing laboratory (when requested) include, but are not limited to, lab accreditation, test requisition, test record/procedures, reports (preliminary and final), and quality control record.Documentation requirements for LDT(s)/protocols (when requested) include diagnostic test/assay, lab/manufacturer, names of comparable assays/services (if relevant), description of assay, analytical validity evidence, clinical validity evidence, and clinical utility.Providers are required to code to specificity however, if CPT 81479 (unlisted molecular pathology procedure) is used the documentation must clearly identify the unique molecular pathology procedure performed. When multiple procedure codes are submitted on a claim (unique and/or unlisted) the documentation supporting each code should be easily identifiable. If on review the contractor cannot link a billed code to the documentation, these services will be denied based on Title XVIII of the Social Security Act, 1833(e). For these tests, the ordering provider must provide to the laboratory copies of the signed informed consent documentation.When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary.Utilization Guidelines
Draft Article - Billing and Coding: Molecular Pathology Procedures (DA56199)
Screening services such as pre-symptomatic genetic tests and services used to detect an undiagnosed disease or disease predisposition are not a Medicare benefit and are not covered. Similarly, Medicare may not reimburse the costs of tests/examinations that assess the risk of a condition unless the risk assessment clearly and directly affects the management of the patient.A specific genetic test may only be performed once in a lifetime per beneficiary for inherited conditions; however, when medically reasonable and necessary, genetic testing may be done on acquired conditions such as malignancies (including separate malignancies developing at different times) as they are treated and are being followed, in order to assess response or other relevant clinical criteria. Likewise, there are situations where medical record and literature documentation are able to demonstrate that serial testing can be reasonably predicted to provide additional clinically useful information. When the record documents that this information, such as confirmed significant response to current therapy, is likely to assist in modifying treatment, serial testing can be considered reasonable and necessary and eligible for coverage.
Article - Billing and Coding: Treatment of Abnormal Uterine Bleeding with Intrauterine Device (Hormone-Eluting) (A59619)
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 contains coding and other guidelines that reflect proper billing for insertion of an Intrauterine Device (IUD) (Hormone-Eluting) for the treatment of abnormal uterine bleeding.Coding GuidanceChronic abnormal uterine bleeding (AUB) describes irregularities in the menstrual cycle involving frequency, regularity, duration, and volume of flow outside of pregnancy for at least six months. The following conditions causing AUB can be treated with levonorgestrel-releasing intrauterine device (Hormone-Eluting IUD) depending on the patient's desire for fertility, medical comorbidities, symptoms, and distortion of the uterine cavity: Leiomyomas (fibroids), malignancy or endometrial hyperplasia, and iatrogenic causes of AUB.First Coast is aware that the insertion of a progestin-containing IUD is an alternative method of managing endometrial hyperplasia for patients who wish to preserve fertility or are not surgical candidates. First Coast has determined that the use of a progestin-containing IUD may be approved for the use in the Medicare beneficiary with endometrial hyperplasia without atypia.Medicare does not allow payment for contraceptive devices or medication. For this reason, the service 58300, insertion of intrauterine device (IUD) has an "N" status in the Medicare Physician Fee Schedule, which means the service cannot be covered when billed to Medicare.
Article - Billing and Coding: Treatment of Abnormal Uterine Bleeding with Intrauterine Device (Hormone-Eluting) (A59619)
The CPT code for IUD insertion (58300) will be auto-denied, therefore, providers should bill this service using CPT code 58999, unlisted procedure, female genital system (non-obstetrical), with an appropriate diagnosis for endometrial hyperplasia. Providers must also include the product description hormone IUD for endometrial hyperplasia in item 19 of the CMS-1500 form or electronic equivalent.The diagnosis code(s) must best describe the patient's condition for which the service was performed.Notice:It is not appropriate to bill Medicare for services that are not covered as if they are covered. When billing for non-covered services, use the appropriate modifier.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.The medical record must clearly document the specific clinical circumstances evidencing this medical necessity.
Article - Billing and Coding: Treatment of Abnormal Uterine Bleeding with Intrauterine Device (Hormone-Eluting) (A59620)
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 contains coding and other guidelines that reflect proper billing for insertion of an Intrauterine Device (IUD) (Hormone-Eluting) for the treatment of abnormal uterine bleeding.Coding GuidanceChronic abnormal uterine bleeding (AUB) describes irregularities in the menstrual cycle involving frequency, regularity, duration, and volume of flow outside of pregnancy for at least six months. The following conditions causing AUB can be treated with levonorgestrel-releasing intrauterine device (Hormone-Eluting IUD) depending on the patient's desire for fertility, medical comorbidities, symptoms, and distortion of the uterine cavity: Leiomyomas (fibroids), malignancy or endometrial hyperplasia, and iatrogenic causes of AUB.Novitas is aware that the insertion of a progestin-containing IUD is an alternative method of managing endometrial hyperplasia for patients who wish to preserve fertility or are not surgical candidates. Novitas has determined that the use of a progestin-containing IUD may be approved for the use in the Medicare beneficiary with endometrial hyperplasia without atypia.Medicare does not allow payment for contraceptive devices or medication. For this reason, the service 58300, insertion of intrauterine device (IUD) has an "N" status in the Medicare Physician Fee Schedule, which means the service cannot be covered when billed to Medicare.
Article - Billing and Coding: Treatment of Abnormal Uterine Bleeding with Intrauterine Device (Hormone-Eluting) (A59620)
The CPT code for IUD insertion (58300) will be auto-denied, therefore, providers should bill this service using CPT code 58999, unlisted procedure, female genital system (non-obstetrical), with an appropriate diagnosis for endometrial hyperplasia. Providers must also include the product description hormone IUD for endometrial hyperplasia in item 19 of the CMS-1500 form or electronic equivalent.The diagnosis code(s) must best describe the patient's condition for which the service was performed.Notice:It is not appropriate to bill Medicare for services that are not covered as if they are covered. When billing for non-covered services, use the appropriate modifier.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.The medical record must clearly document the specific clinical circumstances evidencing this medical necessity.
Draft Article - Billing and Coding: Cervical Fusion (DA59624)
CMS National Coverage PolicyN/AArticle TextRefer to the draft Local Coverage Determination (LCD) DL39758 Cervical Fusion for reasonable and necessary requirements and frequency limitations.The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to theNCCI requirements.Coding GuidanceProviders should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.This policy applies only to cervical fusion and related procedures and does not apply to other joint procedures (such as facet, sacroiliitis, epidural or other spinal procedures).General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.If you want to list out the modifiers for known non-covered service you could bullet that out under the notice section.ModifierWhen to Use ModifierGAWaiver of Liability StatementIssued as Required by PayerPolicy, Individual CaseReport when you issue a mandatory ABN for a service as required and keep it on file. You dont need to submit a copy of the ABN, but you must make it available on request. Usethe GA modifier when both covered and non-covered services appear on an ABN-related claim.GXNotice of Liability Issued,Voluntary Under Payer Policy
Draft Article - Billing and Coding: Cervical Fusion (DA59624)
GXNotice of Liability Issued,Voluntary Under Payer PolicyReport when you issue a voluntary ABN for a service we never cover because its statutorily excluded or isnt a Medicarebenefit. Use this modifier combined with modifier GY.GYNotice of Liability Not Issued,Not Required Under PayerPolicyReport Medicare statutorily excludes the item or service, or the item or service doesnt meet the definition of a Medicarebenefit. Use this modifier combined with modifier GXGZExpect Item or ServiceDenied as Not Reasonableand NecessaryReport when you expect well deny payment of the item or service because its medically unnecessary and you didntissue an ABN.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.The operative note should include the procedure performed and any associated/additional procedures performed at the same time.The patients medical record should include, but is not limited to:The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visitRelevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Documentation to support the medical necessity of the procedure(s).Use of BiologicalsThere are currently no FDA approved biologicals to be injected into the joint at the time of surgery. The inclusion of biological and/or other non-FDA approved substances in the injectant will result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180Medicare Benefit Policy Manual (cms.gov). Amniotic and placenta derived injectants, amino acids, vitamins, and platelet rich plasma fall in this category.
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA58403)
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Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA58403)
Refer to the Local Coverage Determination (LCD) L38801 Facet Joint Interventions for Pain Management, for reasonable and necessary requirements and frequency limitations.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Coding GuidanceProviders should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.This policy applies onlyto cervical/thoracic or lumbar facetprocedures and does not apply to other joint procedures (such as sacral injections, sacroiliitis, epidural or other spinal procedures).Diagnostic and Therapeutic Procedures:Each facet level in the spinal region is composed of bilateral facet joints (i.e., there are two facet joints per level, one on the right side and one on the left). Unilateral or bilateral facet interventions may be performed during the facet joint procedure (a diagnostic nerve block, a therapeutic facet joint (intraarticular) injection, a medial branch block injection, or the medial branch radiofrequency ablation (neurotomy) in one session. A bilateral intervention is still considered a single level intervention.Each unilateral or bilateral intervention at any level should be reported as one unit, with bilateral intervention signified by appending the modifier -50.
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA58403)
Regions:An anatomic spinal region for paravertebral facet joint block (diagnostic or therapeutic), is defined as cervical\thoracic (CPT codes 64490, 64491, 64492) or lumbar\sacral (CPT codes 64493, 64494, 64495) per the AMA CPT Manual.Levels:64490 (cervical or thoracic) or 64493 (lumbar or sacral) reports a single level injection performed with image guidance (fluoroscopy or CT). Procedures performed under ultrasound guidance are not covered.64491 or 64494 describes a second level which should be reported separately in addition to the code for the primary procedure. 64491 should be reported in conjunction with 64490 and 64494 should be reported in conjunction with 64493.64492 or 64495 describes a third and additional levels and should be listed separately in addition to the code for the primary procedure and the second level procedure and cannot be reported more than once per day. 64492 should be reported in conjunction with 64490/64491 and 64495 should be reported in conjunction with 64493/64494.Laterality:Bilateral paravertebral facet injection procedures 64490 through 64495 should be reported with modifier 50.One to two levels, either unilateral or bilateral, are allowed per session per spine region (i.e., two (2) unilateral or two (2) bilateral levels per session).For services performed in the ASC, physicians must continue to use modifier 50. Only the ASC Facility itself must report the applicable procedure code on two separate lines, with one unit each and append the -RT and -LT modifiers to each line.KX modifier requirements:The KX modifier should be appended to the line for all diagnostic injections. In most cases the KX modifier will only be used for the two initial diagnostic injections. If the initial diagnostic injections do not produce a positive response as defined by the policy and are not indicative of identification of the pain generator, and it is necessary to perform additional diagnostic injections at a different level, append the KX modifier to the line. Aberrant use of the KX modifier may trigger focused medical review.Therapeutic injections:
Draft Article - Billing and Coding: Facet Joint Interventions for Pain Management (DA58403)
Therapeutic injections:Documentation of why patient is not a candidate for RFA must be submitted for therapeutic treatment.Chemodenervation of nerve:Codes 64633, 64634, 64635, 64636are reported per joint, not per nerve. Although two nerves innervate each facet joint, only one unit per code may be reported for each joint denervated, regardless of the number of nerves treated (AMA CPT Manual 2020).Each unilateral or bilateral intervention at any level should be reported as one unit, with bilateral intervention signified by appending the modifier -50.