evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Influenza Diagnostic Tests (A58817)
A patient has had recent close exposure (this does NOT include eating cooked meat) to pigs or birds (including poultry) or other animals, and there is concern for infection with a novel influenza A virus.Targeted Molecular Methods:UsesRT-PCR or other amplification methods to detect viral nucleic acidsResults available in < 24 hours (often in less than 2-4 hours)Detects from 1-2 to up to 20 respiratory pathogens from 1 specimenA positive result (on testing of an upper respiratory tract specimen) in a person who recently received intranasal administration of live attenuated influenza virus vaccine (LAIV) may indicate detection of vaccine virus.Viral Culture:Confirms present active infectionResults available in 3-10 daysMissesopportunity for Oseltamivir (Tamiflu) treatment for positive patientsImmunofluorescence (IF) - Direct (DFA) or Indirect (IFA) Fluorescent Antibody Staining (antigen detection):Moderatesensitivity and high specificityResults available in approximately 2-4 hoursIf a rapid antigen test is performed and then confirmed using PCR, the second test may require the -59 modifier.If a CLIA-waived test is performed, the -QW modifier should be reported for the waived test.Reference:Centers for Disease Control and Prevention.Information for Clinicians on Rapid Diagnostic Testing for Influenza. Accessed 4/27/21.
Article - Billing and Coding: Cardiac Resynchronization Therapy (CRT) (A58821)
CMS National Coverage PolicyAll providers who report services for Medicare payment must fully understand and follow all existing laws, regulations, and rules for Medicare payment for Biventricular Pacing/CRT and must properly submit only valid claims for them.Title 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. 100-04, Medicare Claims Processing Manual, Chapter 1, 60.4 Noncovered Charges on Outpatient BillsCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, 10.2.2 Cardiac Resynchronization TherapyCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 20.9 National Correct Coding Initiative (NCCI)CMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, 6.5.2 Conducting Patient Status Reviews of Claims for Medicare Part A Payment for Inpatient Hospital AdmissionsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Cardiac Resynchronization Therapy (CRT) L39080.
Article - Billing and Coding: Cardiac Resynchronization Therapy (CRT) (A58821)
Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Cardiac Resynchronization Therapy (CRT) L39080.Services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS NCDs, and all Medicare payment rules. Refer to the related LCD for reasonable and necessary requirements and limitations.It is well-established that indications for CRT are based upon left ventricle (LV) ejection fraction (EF), QRS duration, QRS morphology, New York Heart Association (NYHA) functional class, and the need for ventricular pacing, if applicable. Therefore, it is important that all these attributes be documented within the patients medical record. Documentation detailing the risk-benefit equation for any given patient must be clear. Each patient has specific characteristics such as age, heart failure (HF) impact on quality of life, personal preferences, or a left/right predominance to a non-left bundle branch block (LBBB) scenario, etc. that may play a role in choice of treatment. Such unique issues should be documented.Medical record documentation should also reflect a beneficiary who is on a stable pharmacologic regimen for HF before CRT implantation. This regimen may include any of the following, unless contraindicated: angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, beta blocker, digoxin, or diuretics.The implanted CRT device must be United States Food and Drug Administration (FDA) approved for the CRT indication.Necessary documentation elements for a patient in whom CRT implantation is planned:
Article - Billing and Coding: Cardiac Resynchronization Therapy (CRT) (A58821)
The implanted CRT device must be United States Food and Drug Administration (FDA) approved for the CRT indication.Necessary documentation elements for a patient in whom CRT implantation is planned:Most recent EF measured by echocardiography, radionuclide (nuclear medicine) imaging, cardiac Magnetic Resonance Imaging (MRI), or catheter angiographyQRS duration in milliseconds (ms)QRS morphology such as LBBB, non-LBBB (with additional clarifying comments as applicable), right bundle branch block (RBBB)If present, any markedly prolonged first degree atrioventricular (AV) block or second- or third-degree AV blockAny plan for AV nodal ablationNYHA class and any trends up or down within that classificationFrequent hospitalizations or office visits for acute exacerbations of HF - if occurringComplete operative report outlining operative approach used and all the components of the biventricular pacemaker insertionIf applicable, the need for a pacemaker and an expectation that pacing is likely to occur much of the timeAll documentation must be maintained in the patient's medical record and made available to the A/B MAC 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(s) must describe the service performed. The clinical judgment of the treating physician is always a consideration if clearly addressed in the pre-procedure record and if consistent with the episode of care for the patient as documented in patients records and claims history.For an upgrade from standard pacing to CRT, this A/B MAC would expect documentation narrative regarding the risk-benefit balance for that individual patient and his/her degree of HF, QRS duration/morphology, etc. A "stand-alone" upgrade in patients with an existing pacemaker or implanted cardiac defibrillator should be considered carefully and based on the individual patients unique circumstances.The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the related LCD.
Article - Billing and Coding: Treatment of Males with Low Testosterone (A58828)
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 Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 50.4.3 Examples of Not Reasonable and Necessary #2. Injection Method Not Indicated and 80, Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic TestsArticle Text
Article - Billing and Coding: Treatment of Males with Low Testosterone (A58828)
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Treatment of Males with Low Testosterone L39086.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.General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to NCCI edits or Outpatient Prospective Payment System (OPPS) packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and National Provider Identifier (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 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 Guidance:Providers should refer to the applicable American Medical Association (AMA) CPTManual to assist with proper reporting of these services.Injectable testosterone pellets (brand name Testopel) may be covered, by Medicare, for the United States (U.S.) Food and Drug Administration (FDA) approved indication, if the service meets all Medicare coverage requirements quoted in the CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 50.4.3 Examples of Not Reasonable and Necessary #2. Injection Method Not Indicated.Pellet implantation is much less flexible for dosage adjustment and more invasive than oral medication, nasal administration, transdermal administration or intramuscular injection. This A/B MAC believes that the use of this product should be rare since the "accepted method of medical practice" is to administer testosterone transdermally, but there may be reasons that require this injectable medication.
Article - Billing and Coding: Treatment of Males with Low Testosterone (A58828)
The number of pellets to be implanted depends upon the minimal daily requirements of testosterone propionate titrated to a serum testosterone level in the low normal range for a healthy adult male. The usual dosage is 150 mg to 450 mg subcutaneously every 3 to 6 months, which translates to 2 to 6 pellets every 3 to 6 months. Insertion of more than 6 pellets every 3 months will not be considered reasonable and necessary. Medicare may only cover the number of pellets actually implanted in the patient (maximum of 6 pellets); wastage is not covered.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD (seeCoverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Medical record documentation must be available to Medicare upon request.
Article - Enteral Nutrition - Policy Article (A58833)
CMS National Coverage PolicyN/AArticle Text
Article - Enteral Nutrition - Policy Article (A58833)
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Enteral nutrition is covered under the Prosthetic Device benefit (Social Security Act 1861(s)(8)). In order for a beneficiarys nutrition to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.GENERAL:Enteral nutrition for temporary impairments will be denied as non-covered, no benefit.Enteral nutrition for beneficiaries with a functioning gastrointestinal tract whose need for enteral nutrition is not due to reasons related to the non-function or disease of the structures that normally permit food to reach the small bowel will be denied as non-covered, no benefit.Orally administered enteral nutrition products, related supplies and equipment will be denied non-covered, no benefit.Enteral nutrition provided to a beneficiary in a Part A covered stay must be billed by the SNF to the fiscal intermediary. No payment from Part B is available when enteral nutrition services are furnished to a beneficiary in a stay covered by Part A. However, if a beneficiary is in a stay not covered by Part A, enteral nutrition is eligible for coverage under Part B and may be billed to the DME MAC by either the SNF or an outside supplier.NUTRIENTS:Food thickeners (B4100), baby food, and other regular grocery products that can be blenderized and used with the enteral system will be denied as non-covered.Electrolyte-containing fluids (B4102 and B4103) are not indicated for the maintenance of weight and strength and are therefore non-covered, no benefit.Self-blenderized formulas are non-covered by Medicare.
Article - Enteral Nutrition - Policy Article (A58833)
Electrolyte-containing fluids (B4102 and B4103) are not indicated for the maintenance of weight and strength and are therefore non-covered, no benefit.Self-blenderized formulas are non-covered by Medicare.Code B4104 is an enteral formula additive. The enteral formula codes include all nutrient components, including vitamins, mineral, and fiber. Therefore, code B4104 will be denied as not separately payable.SUPPLIES:The unit of service (UOS) for the supply allowance (B4034, B4035, B4036, or B4148) is one (1) UOS per day. Claims that are submitted for more than one UOS per day for HCPCS codes B4034, B4035, B4036, or B4148 will be rejected.TEST OF PERMANENCE:Coverage of enteral nutrition under the prosthetic device benefit, as outlined in the MedicareBenefit Policy Manual(CMS Pub. 100-02), Chapter 15, Section 120, requires that a beneficiary must have a permanent impairment. However, this does not require a determination that there is no possibility that the beneficiarys condition may improve sometime in the future. If the medical record, including the judgment of the treating practitioner, indicates that the impairment will be of long and indefinite duration, the test of permanence is considered met.
Article - Enteral Nutrition - Policy Article (A58833)
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.
Article - Enteral Nutrition - Policy Article (A58833)
POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.The supplier must enter a diagnosis code corresponding to the beneficiary's diagnosis on each claim.The beneficiarys medical record must contain sufficient documentation of the beneficiarys medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the beneficiarys diagnosis and other pertinent information including, but not limited to, duration of the beneficiarys condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc.Information describing the medical necessity for enteral nutrition must be available upon request. In order to satisfy the test of permanence, there must be documentation to reflect that in the treating practitioners judgement, the impairment will be of long and indefinite duration.Documentation in the medical record shall also reflect that the beneficiary has (a) full or partial non-function or disease of the structures that normally permit food to reach the small bowel; or, (b) disease that impairs digestion and/or absorption of an oral diet, directly or indirectly, by the small bowel.
Article - Enteral Nutrition - Policy Article (A58833)
Special nutrient formulas, HCPCS codes B4149, B4153, B4154, B4155, B4157, B4161, and B4162, are produced to meet unique nutrient needs for specific disease conditions. If a special nutrient formula is ordered, the beneficiarys medical records must specify why a standard formula cannot be used to meet the beneficiarys metabolic needs. This documentation may include other formulas tried and failed or considered and ruled out. A diagnosis alone is not sufficient to support the medical need for a specialty formula. For example, an order for a diabetes-specific formula may be supported by documentation in the medical record that the beneficiary has a diagnosis of diabetes mellitus and has experienced severe fluctuations of glucose levels on standard formula.DME INFORMATION FORM (DIF)Providers and suppliers no longer need to submit a DME Information Form (DIF) for services rendered on or after January 1, 2023.
Article - Enteral Nutrition - Policy Article (A58833)
For claims with dates of service on or after January 1, 2023  Providers and suppliers no longer need to submit CMNs or DIFs with claims. Due to electronic filing requirements, claims received with these forms attached will be rejected and returned to the provider or supplier.For claims with dates of service prior to January 1, 2023  If the CMN or DIF is required, it must be submitted with the claim, or be on file with a previous claim.For dates of service for which a DIF is required, the DIF which has been completed, signed, and dated by the supplier, must be kept on file by the supplier and made available upon request. The DIF for Enteral Nutrition is CMS Form 10126. The initial claim must include an electronic copy of the DIF.For claims with dates of service prior to January 1, 2023 the following requirements for new initial and revised DIFs remain in effect:A new Initial DIF for enteral nutrients is required when:A formula billed with a different code, which has not been previously certified, is ordered, orEnteral nutrition services are resumed after they have not been required for two consecutive months.A new Initial DIF for a pump (B9002) is required when:Enteral nutrition services involving use of a pump are resumed after they have not been required for two consecutive months, orA beneficiary receiving enteral nutrition by the syringe or gravity method is changed to administration using a pump.A revised DIF is required when:The number of calories per day is changed, orThe number of days per week administered is changed, orThe method of administration (syringe, gravity, pump) changes, orThe route of administration is changed from tube feedings to oral feedings (if billing for denial), orThe HCPCS code for the current nutrient changes (revised DIF for the pump)A revised DIF must be submitted when the length of need previously entered on the DIF has expired and the treating practitioner is extending the length of need for the item(s).If two enteral nutrition products, which are described by the same HCPCS code, are being provided at the same time, they should be billed on a single claim line with the units of service reflecting the total calories of both nutrients.MODIFIERSBA, BO, GA, GY, GZ, and KX MODIFIERS:
Article - Enteral Nutrition - Policy Article (A58833)
When an IV pole (E0776) is used for enteral nutrition administered by gravity or a pump, the BA modifier should be added to the code. Code E0776 is the only code with which the BA modifier may be used.When enteral nutrients (B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, and B4162) are administered by mouth, the BO modifier must be added to the code.Suppliers must add the KX modifier to claim lines billed for enteral nutrition, enteral pump, and supplies only if all of the coverage criteria in the Coverage Indications, Limitations, and/or Medical Necessity section in the related LCD have been met and evidence of such is retained in the suppliers files and available to the DME MAC upon request.If all of the criteria in the "Coverage Indications, Limitations, and/or Medical Necessity" section of the related LCD have not been met, the GA, GY or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN. When there is an expectation of a non-covered (no benefit) denial, suppliers must enter the GY modifier on the claim line (refer to the non-covered, no benefit scenarios in the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section).As of January 1, 2023, suppliers must calculate the units of service (UOS) for each enteral product billed to Medicare, based on the treating practitioners order. When billing for medically necessary enteral nutrition, units in excess of the treating practitioners order must not be billed with a KX (as these units are not reasonable and necessary). Instead, these excess units must be billed with a GA or GZ modifier.Claim lines billed with codes without a KX, GA, GY or GZ modifier will be rejected as missing information.