evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
ICD-10-PCS  Code  Code Description  3E030U1  Introduction of Nonautologous Pancreatic Islet Cells into Peripheral Vein, Open Approach  3E033U1  Introduction of Nonautologous Pancreatic Islet Cells into Peripheral Vein, Percutaneous Approach  3E0J3U1  Introduction of Nonautologous Pancreatic Islet Cells into Biliary and Pancreatic Tract, Percutaneous Approach  3E0J7U1  Introduction of Nonautologous Pancreatic Islet Cells into Biliary and Pancreatic Tract, Via Natural or Artificial Opening  3E0J8U1  Introduction of Nonautologous Pancreatic Islet Cells into Biliary and Pancreatic Tract, Via Natural or Artificial Opening Endoscopic  E10.9  Type 1 diabetes mellitus without complications  E10.65  Type 1 diabetes mellitus with hyperglycemia  E10.10  Type 1 diabetes mellitus with ketoacidosis without coma  E10.69  Type 1 diabetes mellitus with other specified complication  E10.21  Type 1 diabetes mellitus with diabetic nephropathy  E10.22  Type 1 diabetes mellitus with diabetic chronic kidney disease  E10.29  Type 1 diabetes mellitus with other diabetic kidney complication  E10.311  Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema  E10.319  Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema  E10.3211  Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye E10.3212  Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye  E10.3213  Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral  E10.3291  Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye  E10.3292  Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E10.3293  Type 1 diabetes mellitus with mild nonproliferative
(Medicare Claims Processing Manual)
right eye  E10.3292  Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eye E10.3293  Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral  E10.3311  Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eye  E10.3312  Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eye  E10.3313  Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateral  E10.3391  Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eye  E10.3392  Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eye  E10.3393  Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral  E10.3411  Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eye E10.3412  Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eye E10.3413  Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateral  E10.3491  Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eye  E10.3492  Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eye  E10.3493  Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateral  E10.3511  Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eye  E10.3512  Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye  E10.3513  Type 1 diabetes
(Medicare Claims Processing Manual)
retinopathy with macular edema, right eye  E10.3512  Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eye  E10.3513  Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral  E10.3521  Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eye  E10.3522  Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eye  E10.3523  Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateral  E10.3531  Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eye  E10.3532  Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eye  E10.3533  Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateral  E10.3541  Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eye  E10.3542  Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eye  E10.3543  Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateral  E10.3551  Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eye  E10.3552  Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eye  E10.3553  Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral  E10.3591  Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema,
(Medicare Claims Processing Manual)
Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateral  E10.3591  Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eye  E10.3592  Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye  E10.3593  Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral  E10.37x1  Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eye  E10.37x2  Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eye  E10.37x3  Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateral  E10.36  Type 1 diabetes mellitus with diabetic cataract  E10.39  Type 1 diabetes mellitus with other diabetic ophthalmic complication  E10.40  Type 1 diabetes mellitus with diabetic neuropathy, unspecified  E10.41  Type 1 diabetes mellitus with diabetic mononeuropathy  E10.42  Type 1 diabetes mellitus with diabetic polyneuropathy  E10.43  Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy  E10.44  Type 1 diabetes mellitus with diabetic amyotrophy  E10.49  Type 1 diabetes mellitus with other diabetic neurological complication  E10.610  Type 1 diabetes mellitus with diabetic neuropathic arthropathy  E10.51  Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene  E10.52  Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene  E10.59  Type 1 diabetes mellitus with other circulatory complications  E10.618  Type 1 diabetes mellitus with other diabetic arthropathy  E10.620  Type 1 diabetes mellitus with diabetic dermatitis  E10.621  Type 1 diabetes mellitus with foot ulcer  E10.622  Type 1 diabetes mellitus with other skin ulcer  E10.628  Type 1 diabetes
(Medicare Claims Processing Manual)
diabetes mellitus with diabetic dermatitis  E10.621  Type 1 diabetes mellitus with foot ulcer  E10.622  Type 1 diabetes mellitus with other skin ulcer  E10.628  Type 1 diabetes mellitus with other skin complications  E10.630  Type 1 diabetes mellitus with periodontal disease  E10.638  Type 1 diabetes mellitus with other oral complications
(Medicare Claims Processing Manual)
If ICD -10 is applicable, ICD -10-CM codes for the clinical trial are:   Secondary ICD -10-CM Diagnosis requirement for Clinical Trial:   Z00.6          Encounter for examination for normal comparison and control in clinical research program   The applicable TOB is 11X. A secondary diagnosis (diagnoses positions 2  9) of ICD-10- CM code Z00.6 (examination of participant or control in clinical research) must be present along with condition code 30 (qualifying clinical trial)  Z00.6 and condition code 30 alerts the claims processing system that this is a clinical trial. The procedure is paid under inpatient prospective payment system for hospitals with patients in the trial. Deductible and coinsurance apply for fee -for-service beneficiaries.    Inpatient hospitals participating in this trial are entitled to an add -on payment of $18,848.00 for islet isolation services. This amount is in addition to the final IPPS payment made to the hospital. Should two infusions occur during the same hospital sta y, Medicare will pay for two add- ons for isolation of the islet cells, but never for more than two add- ons for a hospital stay.  Inpatient hospitals shall report charges for organ acquisition in Revenue Code 0810, 0811, 0812, 0813, or 0819. This includes charges for the pre -transplant items and services related to the acquisition and delivery of the pancreatic islet cell transplants . As is Medicares policy with other organ transplants, Medicare contractors deduct acquisition charges prior to processing through the IPPS Pricer. Pancreata procured for islet cell transplant are not included in the prospective payment. They are paid on a reasonable cost basis. This is a pass- through cost for which interim payments may be made.   Effective for services on or after May 1, 2006, contractors shall accept the QR modifier for islet cell transplantation follow up care when performed in an outpatient department of a hospital when the transplant was done in conjunction with an NIH -sponsore d clinical trial, and when billed on type of bill 13X or 85X.  All other normal inpatient billing practices apply.
(Medicare Claims Processing Manual)
All other normal inpatient billing practices apply.  70.5 - Special Billing and Payment Requirements Medicare Advantage (MA) Beneficiaries  (Rev. 261, Issued: 07- 30-04, Effective: 10 -01-04, Implementation: 10- 04-04)  CMS will make payment directly on a fee -for service basis for the routine costs of pancreatic islet cell transplants as well as transplantation and appropriate related items and services, for MA beneficiaries participating in an NIH -sponsored clinical tria l.  MA organizations will not be liable for payment for routine costs of this new clinical trial until MA payments can be appropriately adjusted to take into account the cost of this national coverage decision.  Medicare contractors shall make payment on behalf of MA organizations directly to providers of these islet cell transplants in accordance with Medicare payment rules, except that beneficiaries are not responsible for the Part A and Part B deductibles.  MA enrollees will be liable for any applicable coinsurance amounts MA organizations have in place for clinical trial benefits.   E10.649  Type 1 diabetes mellitus with hypoglycemia without coma  E10.8  Type 1 diabetes mellitus with unspecified complications  80 - Billing of the Diagnosis and Treatment of Peripheral Neuropathy with Loss of Protective Sensation in People with Diabetes  (Rev. 498, Issued: 03- 11-05, Effective/Implementation: N/A)
(Medicare Claims Processing Manual)
Coverage Requirements -  Peripheral neuropathy is the most common factor leading to amputation in people with diabetes.  In diabetes, peripheral neuropathy is an anatomically diffuse process primarily affecting sensory and autonomic fibers; however, distal motor findings may be present in advanced cases.  Long nerves are affected first, with symptoms typically beginning insidiously in the toes and then advancing proximally.  This leads to loss of protective sensation (LOPS), whereby a person is unable to feel minor trauma from mechanical, thermal, or chemical sources.  Wh en foot lesions are present, the reduction in autonomic nerve functions may also inhibit wound healing.  Peripheral neuropathy with LOPS, secondary to diabetes, is a localized illness of the feet and falls within the regulation's exception to the general exclusionary rule (see 42 C.F.R. 411.15(l)(l)(i)).  Foot exams for people with diabetic peripheral neurop athy with LOPS are reasonable and necessary to allow for early intervention in serious complications that typically afflict diabetics with the disease.   Effective for services furnished on or after July 1, 2002, Medicare covers, as a physician service, an evaluation (examination and treatment) of the feet no more often than every 6 months for individuals with a documented diagnosis of diabetic sensory neuropathy and LOPS, as long as the beneficiary has not seen a foot care specialist for some other reason in the interim.  LOPS shall be diagnosed through sensory testing with the 5.07 monofilament using established guidelines, such as those developed by the N ational Institute of Diabetes and Digestive and Kidney Diseases guidelines.  Five sites should be tested on the plantar surface of each foot, according to the National Institute of Diabetes and Digestive and Kidney Diseases guidelines.  The areas must be tested randomly since the loss of protective sensation may be patchy in distribution, and the patient may get clues if the test is done rhythmically.  Heavily callused areas should be avoided.  As suggested by the American Podiatric Medicine Association, an  absence of sensation at two or more sites out of 5 tested on either foot when tested with the 5.07 Semmes -Weinstein monofilament must be present and documented to diagnose peripheral neuropathy with loss of protective sensation.
(Medicare Claims Processing Manual)
80.1 - General Billing Requirements  (Rev. 2783, Issued: 09- 10-13, Effective: 09 -30-13, Implementation: 09- 30-13)  The following providers of service may bill you for these services:   Hospitals; Critical Access Hospitals  Rural Health Clinics; and  Free-Standing Federally Qualified Health Clinics (FQHC).   80.2 - Applicable HCPCS Codes  (Rev. 498, Issued: 03- 11-05, Effective/Implementation: N/A)   G0245 -  Initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) which must include:   1. The diagnosis of LOPS;   2. A patient history;   3. A physical examination that consists of at least the following elements:   (a) visual inspection of the forefoot, hindfoot, and toe web spaces,   (b) evaluation of a protective sensation,  (c) evaluation of foot structure and biomechanics,   (d) evaluation of vascular status and skin integrity,  (e) evaluation and recommendation of footwear, and   4. Patient education.   G0246 -  Follow -up physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to include at least the following:   1. a patient history;   2. a physical examination that includes:   (a) visual inspection of the forefoot, hindfoot, and toe web spaces,   (b) evaluation of protective sensation,  (c) evaluation of foot structure and biomechanics,   (d) evaluation of vascular status and skin integrity,  (e) evaluation and recommendation of footwear, and   3. patient education.   G0247 -  Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a LOPS to include if present, at least the following:   (1) local care of superficial (i.e., superficial to muscle and fascia) wounds;   (2) debridement of corns and calluses; and   (3) trimming and debridement of nails.  NOTE : Code G0247 must be billed on the same date of service with either G0245 or G0246 in order to be considered for payment.
(Medicare Claims Processing Manual)
(3) trimming and debridement of nails.  NOTE : Code G0247 must be billed on the same date of service with either G0245 or G0246 in order to be considered for payment.   The short descriptors for the above HCPCS codes are as follows:   G0245  INITIAL FOOT EXAM PTLOPS   G0246  FOLLOWUP EVAL OF FOOT PT LOP   G0247  ROUTINE FOOTCARE PT W LOPS   80.3 - Diagnosis Codes (Rev. 11021; Issued: 10-01- 21; Effective: 10 -29-21; Implementation: 10-29-21)  If ICD -10-CM is applicable --Providers should report one of the following diagnosis codes in conjunction with this benefit:
(Medicare Claims Processing Manual)
ICD-10-CM ICD-10 DX Description  E08.40  Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified               E08.42  Diabetes mellitus due to underlying condition with diabetic polyneuropathy               E09.40  Drug or chemical induced diabetes mellitus with neurological complications with diabetic n               E09.42  Drug or chemical induced diabetes mellitus with neurological complications with diabetic p                E10.40  Type 1 diabetes mellitus with diabetic neuropathy, unspecified           E10.41  Type 1 diabetes mellitus with diabetic mononeuropathy           E10.42  Type 1 diabetes mellitus with diabetic polyneuropathy           E10.43  Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy           E10.44  Type 1 diabetes mellitus with diabetic amyotrophy           E10.49  Type 1 diabetes mellitus with other diabetic neurological complication           E10.610  Type 1 diabetes mellitus with diabetic neuropathic arthropathy              E11.40  Type 2 diabetes mellitus with diabetic neuropathy, unspecified         E11.41  Type 2 diabetes mellitus with diabetic mononeuropathy       E11.42  Type 2 diabetes mellitus with diabetic polyneuropathy         E11.43  Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy         E11.44  Type 2 diabetes mellitus with diabetic amyotrophy   E11.49  Type 2 diabetes mellitus with other diabetic neurological complication        E11.610  Type 2 diabetes mellitus with diabetic neuropathic arthropathy  E13.40  Other specified diabetes mellitus with diabetic neuropathy, unspecified  E13.41  Other specified diabetes mellitus with diabetic mononeuropathy         E13.42  Other specified diabetes mellitus with diabetic polyneuropathy         E13.43  Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy         E13.44  Other specified diabetes mellitus with diabetic amyotrophy         E13.49  Other specified diabetes mellitus with other diabetic neurological complication         E13.610  Other specified diabetes mellitus with diabetic neuropathic
(Medicare Claims Processing Manual)
Other specified diabetes mellitus with diabetic amyotrophy         E13.49  Other specified diabetes mellitus with other diabetic neurological complication         E13.610  Other specified diabetes mellitus with diabetic neuropathic arthropathy
(Medicare Claims Processing Manual)
Coverage policy can be found in Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, section 70.2.1 Diabetic neuropathy w/ LOPs. (http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp  80.4  Payment  (Rev. 2783, Issued: 09- 10-13, Effective: 09-30-13, Implementation: 09-30-13)    Hospital outpatient departments  OPPS    Critical Access Hospital (CAH) - Method I -- Reasonable cost; Method II --  Technical - reasonable cost, Professional -- 115 percent of the fee schedule   Rural Health Clinics/Federally Qualified Health Centers (RHCs/FQHCs) - All inclusive rate.   Deductible and coinsurance apply.   While these physician services may be appropriately provided to patients of Comprehensive Outpatient Rehabilitation Facilities (CORFs), the CORF does not bill.   The services are billed by the physician on a professional claim.   Examples of Payment calculation:   Part B Deductible Met:  $900 (MPFS allowed amount) x 20 percent (co- insurance) =  $720 (Medicare reimbursement).  Beneficiary is responsible for $180.  Part B Deductible Not met:  $900 (MPFS allowed amount) -  $100 (Part B deductible) = $800 x 20 percent (co-insurance) = $640 (Medicare reimbursement).  Beneficiary is responsible for $260.   Part B Deductible Met:  $800 (actual charged amount) x 20 percent (co- insurance) = $640 (Medicare Reimbursement), beneficiary is responsible for $160 co- insurance.   Part B Deductible Not Met:  $800 (actual charged amount) -  $100 (Part B deductible) = $700 x 20 percent (co -insurance) = $560 (Medicare reimbursement).  Beneficiary is responsible for $240, ($100 Part B deductible and $140 co- insurance).   Services are paid at 80 percent of the lesser of the fee schedule amount or the actual charges.
(Medicare Claims Processing Manual)
Services are paid at 80 percent of the lesser of the fee schedule amount or the actual charges.   This service, when furnished in an RHC/FQHC by a physician or non- physician, is considered an RHC/FQHC service.  RHCs/FQHCs bill you under bill type 71X or 73X with revenue code 940 and HCPCS G0245, G0246, and G0247.   Payment should not be made for this service unless the claim contains a related visit code.  Therefore, install an edit in your system to assure payment is not made for revenue code 940 unless the claim also contains a visit revenue code (520 or 521).   Applicable Revenue Codes   The applicable revenue code is 940, except for hospitals.  This service can be performed in other revenue centers such as a clinic (510) for hospitals.  Therefore, instruct your hospitals to report these procedures under the revenue center where they are performed.   80.5 - Applicable Revenue Codes  (Rev. 498, Issued: 03- 11-05, Effective/Implementation: N/A)   The applicable revenue code is 940, except for hospitals.  This service can be performed in other revenue centers such as a clinic (510) for hospitals.  Therefore, instruct your hospitals to report these procedures under the revenue center where they are performed.   80.6 - Editing Instructions for A/B MACs (A)  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Edit 1  - Implement diagnosis to procedure code edits to allow payment only for the LOPS codes, G0245, G0246, and G0247 when submitted with one of the following ICD-10-CM diagnosis codes   If ICD -10-CM is applicable: