evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Hospice Cardiopulmonary Conditions (A56610)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1814(i) Payment for Hospice CareTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 10, 40.2 HH PPS ClaimsCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 11, 30.2 Payment Rates, 30.2.2 Service Intensity Add-on (SIA) Payments, 30.3 Data Required on the Institutional Claim to A/B MAC (HHH)Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Hospice Cardiopulmonary Conditions L34548.
Article - Billing and Coding: Corneal Pachymetry (A56611)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.42 CFR 411.15(b)(2) and (c) addresses particular services excluded from coverage.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forCorneal Pachymetry L34512.
Article - Billing and Coding: CT of the Head (A56612)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) states that no payment shall be made to any provider for any claim which lacks the necessary information to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for CT of the Head L34417.1. The ICD-10 codes R51.9 (Headache, unspecified) and G44.1 (Vascular headache, not elsewhere classified) will only be covered in the following situations:a. The patient is suffering from headaches and a head injury. Head computed tomography (CT) is performed to rule out the possibility of an intracranial bleed.b. The patient is suffering from headaches unusual in duration (greater than 2 weeks) not responding to medical therapy. Head CT is performed to rule out the possibility of a tumor.c. The patient is suffering from new onset headache (less than 2 weeks) suggestive of intracranial bleeding as evidenced by signs (e.g., weakness or paralysis), symptoms (e.g., blurred vision, nausea and vomiting), or clinical history.2. Any claim billed with ICD-10 code R51.9 (Headache, unspecified) or G44.1 (Vascular headache, not elsewhere classified) may be subject to manual review.3. Claims billed with ICD-10 codes S09.19XA (Other specified injury of muscle and tendon of head, initial encounter), S09.19XD (Other specified injury of muscle and tendon of head, subsequent encounter) , S09.19XS (Other specified injury of muscle and tendon of head, sequela), S09.8XXA (Other specified injuries of head, initial encounter), S09.8XXD (Other specified injuries of head, subsequent encounter), S09.8XXS (Other specified injuries of head, sequela), S09.90XA (Unspecified injury of head, initial encounter), S09.90XD (Unspecified injury of head, subsequent encounter), or S09.90XS (Unspecified injury of head, sequela) should have documented associated signs and symptoms to support the need for CT scan of the head and may be subject to manual review.
Article - Billing and Coding: Cataract Surgery (A56613)
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 100-04, Medicare Claims Processing Manual, Chapter 12, 40.6 Claims for Multiple Surgeries and 40.7 Claims for Bilateral SurgeriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Cataract Surgery L34413.When billing ICD-10 codes H26.231, H26.232, H26.233, H26.221, H26.222, H26.211, H26.212, H26.213, H26.221, H26.222, H26.223, E08.36, E09.36, E10.36, E11.36, E13.36 or H28 note that coding guidelines require that the ICD-10 code for the underlying condition must appear and be coded first on the claim. For ICD-10 codes H26.31, H26.32, H26.33 and H26.8, coding guidelines require that the causative agent be identified on the claim.
Article - Billing and Coding: Psychiatric Inpatient Hospitalization (A56614)
CMS National Coverage PolicyTitle XVIII of the Social Security Act 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claimArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forPsychiatric Inpatient Hospitalization L34570.Limitations:Listing an ICD-10-CM code in the mental disorders category (F01.50-F99) does not assure coverage of the specific service.
Article - Billing and Coding: Cataract Extraction (including Complex Cataract Surgery) (A56615)
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 provides billing and coding guidance for Local Coverage Determination (LCD) L35091, Cataract Extraction (including Complex Cataract Surgery). Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice: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.The primary diagnosis submitted by the physician performing the preoperative ophthalmologic evaluation must be cataract (ICD-10-CM codes listed in the "ICD-10 Codes that Support Medical Necessity" section of this article).The diagnoses submitted by the physician performing the evaluation and management component of the preoperative workup, when it is medically necessary, should indicate cataract (ICD-10-CM codes listed in the "ICD-10 Codes that Support Medical Necessity" section of this article) as the primary or secondary diagnosis.Complex cataract extraction should require devices or techniques not generally used in routine cataract surgery.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.When complex cataract procedures are reported the medical record must support that devices or techniques not generally used in routine cataract surgery were used, for example:
Article - Billing and Coding: Cataract Extraction (including Complex Cataract Surgery) (A56615)
Insertion of iris retractors through additional incisionsMechanical expansion of the pupil using iris hooksCreation of a sector iridectomy with subsequent suture repair of iris sphincterUse of intraoperative iris expansion device to maintain pupil dilation (i.e., Malyugin ring) iris sphincterotomies created with scissorsThe need to support the lens implant with permanent intraocular suturesPlacement of a capsular support ring is necessary to allow secure placement of an intraocular lens
Article - Billing and Coding: Chiropractic Services (A56616)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.42 CFR 410.21 describes limitations on services of a chiropractor.CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, 70.6 Chiropractors.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 30.5 Physician Services-Chiropractors Services.Article Text
Article - Billing and Coding: Chiropractic Services (A56616)
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Chiropractic Services L37387.Limitations:Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of the hands. Additionally, manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use of the device nor does Medicare recognize an extra charge for the device itself.No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractors order is covered. This means that if a chiropractor orders, takes or interprets an x-ray or any other diagnostic test, the x-ray or other diagnostic test can be used for claims processing purposes but Medicare coverage and payment are not available for those services. This prohibition does not affect the coverage of x-rays or other diagnostic tests furnished by other practitioners under the program. For example, an x-ray or any diagnostic test taken for the purpose of determining or demonstrating the existence of a subluxation of the spine is a diagnostic x-ray test covered under 1861(s)(3) of the Social Security Act if ordered, taken and interpreted by a physician who is a doctor of medicine or osteopathy.The precise level(s) of the subluxation(s) must be specified by the chiropractor to substantiate a claim for manipulation of each spinal region(s).Medicare does not cover chiropractic treatments to extraspinal regions.
Article - Billing and Coding: Chiropractic Services (A56616)
Medicare does not cover chiropractic treatments to extraspinal regions.For Medicare purposes, a chiropractormustplace an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. However, the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary. As always, contractors may deny if appropriate after medical review. Modifier AT must only be used when the chiropractic manipulation is reasonable and necessary as defined by national policy and the Chiropractic Services L37387 LCD. Modifier AT must not be used when maintenance therapy has been performed. The need for a prolonged course of treatment should be appropriate to the reported procedure code(s).The precise level of subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine.A statement on a claim that there is pain is insufficient.Only 1 chiropractic manipulation service for a beneficiary can be reimbursed per day.
Article - Billing and Coding: Debridement Services (A56617)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Debridement Services.Coding Information: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.Specific Coding Guidelines:CPT codes 11000 and 11001 describe removal of extensive eczematous or infected skin.CPT codes 11042-11047 should be used for debridement of relatively localized areas depending upon the involvement of contiguous underlying structures.CPT codes 97597 and 97598:If a simple dressing change is performed without any active wound procedure as described by these codes, do not bill these codes to describe the service.CPT codes 97597 and 97598 are categorized by CMS as sometimes therapy services. If billed by a hospital subject to OPPS for an outpatient service, these CPT codes will be paid under the OPPS when the service is not performed by a qualified therapist and it is inappropriate to bill the service under a therapy plan of care.
Article - Billing and Coding: Debridement Services (A56617)
Use of CPT codes 11000-11047 is not appropriate for the following services: washing bacterial or fungal debris from feet, incision and drainage of abscess including paronychia, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Report these procedures, when they represent covered, reasonable and necessary services, using the CPT or HCPCS code that most closely describes the service rendered.CPT codes 11000 and 11001 are not appropriate for debridement of a localized amount of tissue normally associated with a circumscribed lesion. Examples of the inappropriate use of these codes are ulcers, furuncles, and localized skin infections.The following procedures are considered part of active wound care management, and are not considered as debridement and are not included in the related LCD: Removal of devitalized tissue from wound(s), non - selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care.For services related to removal of callus (hyperkeratotic tissue) around an ulcer, paring or cutting of corns, trimming or debridement of nails, please refer to NGS LCD Routine Foot Care and Debridement of Nails (L33636).Local infiltration, metacarpal/digital block or topical anesthesia are included in the reimbursement for debridement services and are not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable.The care of minor wounds (post-operative, traumatic, or otherwise) is incidental to other covered services. Many claims for debridement are essentially dressing changes and are not separately payable.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included withinthe related LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.The medical record should include the following information:
Article - Billing and Coding: Debridement Services (A56617)
An operative note or procedure note for the debridement service. This note should describe the anatomical location treated, the instruments used, anesthesia used if required, the type of tissue removed from the wound, the depth and area of the wound and the immediate post procedure care and follow-up instructions.Identification of the wound location, size, depth and stage either by description and/or a drawing or photograph.A description of the type(s) of tissue involvement, the severity of tissue destruction, undermining or tunneling, necrosis, infection or evidence of reduced circulation. If infection has developed, the patient's response to this infection should be described.The patient's comorbid medical and mental condition, and all health factors that may influence the patient's ability to heal tissue, such as, but not limited to the following: mental status, mobility, infection, tissue oxygenation, chronic pressure, arterial insufficiency/small vessel ischemia, venous stasis, edema, type of dressing, chronic illness such as diabetes mellitus, uremia, COPD, malnutrition, CHF, anemia, iron deficiency, and immune deficiency disorders.A determination of the initial treatment plan to include the expected frequency and duration of the skilled treatment and the potential to heal. Continuation of treatment plan with ongoing evidence of the effectiveness of that plan, including diminishing area and depth of the ulceration, resolution of surrounding erythema and /or wound exudates, decreasing symptomatology, and overall assessment of wound status (such as stable, improved, worsening, etc). Appropriate changes in the ongoing treatment plan to reflect the clinical presentation must be present in the record.
Article - Billing and Coding: Debridement Services (A56617)
The documentation must include that if indicated, ongoing pressure relief has been prescribed, for example, shoe inserts, modifications, padding, frequent position changes, etc. and monitoring is occurring.In cases of excessive frequency or prolonged duration of treatment, documentation should include an evaluation for possible infection (e.g. culture and sensitivity), osteomyelitis (e.g. x-ray), and treatment of any infection by antibiotics. Any other conditions that may significantly affect wound healing should also be appropriately addressed in the medical record.Photographic documentation of wounds either immediately before or immediately after debridement is recommended for prolonged or repetitive debridement services (especially those that exceed five extensive debridements per wound (CPT code 11043 and/or 11044)). If the provider is unable to use photographs for documentation purposes, the medical record should contain sufficient detail to determine the extent of the wound and the result of the treatment.Supportive Documentation Requirements (required at least every 10 visits) for 97597 and 97598:Etiology and duration of woundPrior treatment by a physician, non-physician practitioner, nurse and/or therapistStage of woundDescription of wound: length, width, depth, grid drawing and/or photographsAmount, frequency, color, odor, type of exudateEvidence of infection, undermining, or tunnelingNutritional statusComorbidities (e.g., diabetes mellitus, peripheral vascular disease)Pressure support surfaces in usePatients functional levelSkilled plan of treatment, including specific frequency, modalities and proceduresType of debridement performed, including instrument used, to support the debridement code billedChanging plan of treatment based on clinical judgment of the patients response or lack of response to treatmentFrequent skilled observation and assessment of wound healing are recommended daily or weekly to justify the skilled service. At a minimum, the Progress Report must document the continuing skilled assessment of wound healing as it has progressed since the evaluation or last Progress Report.
Article - Billing and Coding: Debridement Services (A56617)
Medical records must be made available to Medicare upon request.Utilization Guidelines:Cornerstones of chronic foot ulcer management include relief of pressure, control of infection and appropriate debridement. While there is some consensus that repeated debridement may promote more rapid healing of diabetic foot ulcers, the appropriate interval and frequency of debridement depends on the individual clinical characteristics of patients and ulcers. Reduction of pressure and/or control of infection will facilitate healing and may reduce the need for repeated debridement services. The treatment plan for a patient who requires frequent repeated debridement should be reevaluated, to ensure that pressure reduction and infection control have been adequately addressed. In the presence of documented significant ischemic disease with necrotic ulceration, extensive and definitive debridement may be required.When the patient has required more debridement services per wound than defined below, the medical record must include documentation reflecting neuropathic, vascular, metabolic, or other comorbid conditions.Debridement of diabetic foot ulcers more frequently than once every seven (7) days, for a period longer than three (3) months may not be reasonable and necessary. Services exceeding this intensity and duration of treatment will be considered not medically necessary.Debridement services are now defined by body surface area of the debrided tissue and not by individual ulcers or wounds. For example, debridement of two ulcers on the foot to the level of subcutaneous tissue, total area of 6 sq cm should be billed as CPT code 11042 with unit of service of 1.For patients with chronic wounds being treated in an outpatient setting, services beyond the fifth surgical debridement, CPT code 11043, 11046 and/or 11044, 11047, per patient, per year, per wound may require a medical review of records demonstrating the medical reasonableness and necessity. Providers are reminded that the CPT code used to report the debridement must represent the level of debridement and not the depth of the ulcer.Initial debridement may be deep and through skin, subcutaneous tissue, muscle fascia, and muscle. Subsequent debridement is often more superficial and best described by CPT codes 97597 or 97598 rather than 11043 or 11044.
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A56619)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Transmittal 2677, Change Request 8169, dated March 26, 2013.Article Text
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A56619)
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Nerve Conduction Studies and Electromyography L35048.Physical Therapists Performing Electromyography (EMGs)Program Memorandum Transmittal B-01-28/Change Request 850 sets forth revised levels of physician supervision required for diagnostic tests payable under the Medicare Physician Fee Schedule.Payment will be based on the Medicare Physician Fee Schedule level of supervision designation.Nerve conduction CPTcode 95905 does not have 1 of the above designations and is therefore not allowed by Physical Therapists (PTs).Nerve conduction CPTcodes 95907-95913 had their Physician Supervision of Diagnostic Procedures Indicators adjusted to 7A effective 01/01/2013 (CR 8169). Therefore, if authorized by state law, PTs are allowed the technical portion and professional component of the test according to the description of 7A.The TC component of the Neuromuscular junction testing CPTcode 95937 had its Physician Supervision of Diagnostic Procedures Indicator changed to 7A. This change is effective January 1, 2013.Needle EMG CPTcodes 95860-95872 and 95885-95887 have the designation of 6A for the technical portion of the test. Therefore, if authorized by state law PTs who are presently certified by the ABPTS as a qualified electrophysiologic clinical specialist are allowed the technical portion and the professional component of the test according to the description of 6A.Nerve Conduction Studies (NCS)CPTcode 95905 - Nerve conduction studies performed using automated devices (for example devices such as NC-statSystem) cannot support testing of other locations and other nerves as needed, depending on the concurrent results of testing, and they should not be billed to Medicare with the current CPTcodes.When the beneficiary has a high pre-test or a prior probability for having the diagnosis of carpal tunnel syndrome, the NC-statSystem (alone) will be allowed, 1 service per arm, using CPTcode 95905. The diagnosis code G56.01 or G56.02 should be used. All other diagnosis codes will be denied as not medically necessary.Limitations:Nerve Conduction Studies