evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
40.1.4  Payment Requirements (Rev. 3227, Issued: 04- 02-15, Effective; ASC -X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  June 11, 2013, ICD -10: Upon Implementation of ICD -10 Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  May 19, 2014 -  MAC Non -Shared System Edits; July 7, 2014 -  CWF development/testing, FISS requirement development; October 6, 2014 -  CWF, FISS, MCS Shared System Edits), ICD -10: Upon Implementation of ICD -10)  For claims with dates of service on and after February 24, 2011, the following diagnosis code and modifier shall be reported on MRI claims for beneficiaries with implanted PMs, that are outside FDA -approved labeling for use in an MRI environment (in a Medi care- approved clinical study):    Appropriate MRI code   Q0 modifier   Condition code 30 (for institutional claims)   If ICD -9-CM is applicable  o ICD-9 code V70.7-  Examination of participant in clinical trial (for institutional claims)  o ICD-9 code V45.02 (automatic implantable cardiac defibrillator) or  o ICD-9 code V45.01 (cardiac pacemaker)    If ICD -10-CM is applicable   Z00.6 -  Encounter for examination for normal comparison and control in clinical research program   Z95.810 -  Presence of automatic (implantable) cardiac defibrillator or   Z95.0 -  Presence of cardiac pacemaker   For claims with dates of services on and after July 7, 2011, the following codes shall be reported on MRI claims for beneficiaries with implanted PMs that have FDA -approved labeling for use in an MRI environment:    Appropriate MRI code   KX modifier   If ICD -9-CM is applicable  o ICD-9 code V45.01 (cardiac pacemaker)   If ICD- 10-CM is applicable  o ICD-10 code Z95.0 (cardiac pacemaker)   Payment is as follows:
(Medicare Claims Processing Manual)
Payment is as follows:   Professional claims (practitioners and suppliers) -   based on the Medicare Physician Fee Schedule (MPFS)    Inpatient (11x) -  Prospective payment system (PPS), based on the diagnosis -related group    Hospital outpatient departments (13x) -  Outpatient PPS, based on the ambulatory payment classification    Rural Health Clinics/Federally Qualified Health Centers (RHCs/FQHCs) (71x/77x) -  All-inclusive rate, professional component only, based on the visit furnished to the RHC/FQHC beneficiary to receive the MRI.  The technical component is outside the scope of the RHC/FQHC benefit.  Therefore the provider of the technical service bills their A/B MAC (B) on the ASC X12 837 professional claim format or hardcopy Form CMS -1500 and payment is made under the MPFS.    Critical access hospitals (CAHs) (85x)    o For CAHs that elected the optional method of payment for outpatient services, the payment for technical services would be the same as the CAHs that did not elect the optional method -  Reasonable cost.   o The A/B MAC (A) pays the professional component at 115% of the MPFS.  Deductible and coinsurance apply.   40.2  Medicare Summary Notices (MSN), Reason Codes, and Remark Codes (Rev. 3650, Issued: 11- 10-16, Effective: 02 -10-17, Implementation: 02- 10-17)  The A/B MAC denies MRI line items on claims when billed with the appropriate MRI code and a diagnostic code for cardiac pacemaker if modifier KX is not present.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 188  RARC: N/A  MSN: 21.8  The A/B MAC denies MRI line items that do not include all of the following line items:    An appropriate MRI code,   If ICD -9-CM is applicable, ICD -9 code V45.02 (automatic implantable cardiac defibrillator) or ICD-9 code V45.01 (cardiac pacemaker),
(Medicare Claims Processing Manual)
 If ICD -9-CM is applicable, ICD -9 code V45.02 (automatic implantable cardiac defibrillator) or ICD-9 code V45.01 (cardiac pacemaker),    ICD-10-CM is applicable, ICD -10 code Z95.810 (automatic implantable cardiac defibrillator)or ICD-10 code Z95.0 (cardiac pacemaker),    Modifier Q0,    If ICD -9-CM is applicable, ICD -9 code V70.7 Examination of participant in clinical trial (for institutional claims only)or    If ICD -10-CM is applicable, ICD -10 code Z00.6  Examination of participant in clinical trial (for institutional claims only), and    Condition code 30 (for institutional claims only).   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 272  RARC: N386  MSN: 21.21  50 - Nuclear Medicine (CPT 78000 - 79999)  (Rev. 1, 10- 01-03)  50.1 - Payments for Radionuclides  (Rev. 1, 10- 01-03)  The TC RVUs for nuclear medicine procedures (CPT codes 78XXX for diagnostic nuclear medicine, and codes 79XXX for therapeutic nuclear medicine) do not include the radionuclide used in connection with the procedure.  These substances are separately billed under codes A4641 and A4642 for diagnostic procedures, and code 79900 for therapeutic procedures and are paid on a By Report basis depending on the substance used.  In addition, CPT code 79900 is separately payable in connection with certain clinical brachytherapy procedures.  (See 70.4 for brachytherapy procedures).  50.2 - Stressing Agent  (Rev. 1, 10- 01-03)
(Medicare Claims Processing Manual)
A/B MACs (B) must make separate payment under code J1245 for pharmacologic stressing agents used in connection with nuclear medicine and cardiovascular stress testing procedures furnished to beneficiaries in settings in which TCs are payable.  Such an agen t is classified as a supply and covered as an integral part of the diagnostic test.  However, A/B MACs (B) pay for code J1245 under the policy for determining payments for incident to drugs.  See Chapter 17 for payment for drugs.   50.2.1 - A/B MAC (A) Payment for IV Persantine  (Rev. 1, 10- 01-03)  The A/B MACs (A) pay drug IV Persantine based on the drug pricing methodology when used in conjunction with nuclear medicine and cardiovascular stress testing procedures furnished to SNF outpatients.  Separate drug pricing methodology payments for IV Persa ntine is made in addition to payments made for the procedure.  SNFs bill HCPCS code J1245 (injection, dipyridamole, per 10 mg.) with revenue code 0636.   50.2.2 - A/B MAC (A) Payment for Adenosine  (Rev. 1, 10- 01-03) SNF -533.3  The drug adenosine is paid based on the drug payment methodology when used as a pharmacologic stressor for other diagnostic testing.  Separate based payment for adenosine will be made in addition to payments made for the procedure for SNF Part B patients.  When billing for adenosine, HCPCS code J0150 (Injection, adenosine, 6 mg.) should be reported with revenue code 0636.  50.3 - Application of Multiple Procedure Policy (CPT Modifier - 51) (Rev. 1, 10- 01-03)  A/B MACs (B) must apply the multiple procedure reduction to the following nuclear medicine diagnostic procedures: codes 78306, 78320, 78802, 78803, 78806, and 78807.  50.4 - Generation and Interpretation of Automated Data  (Rev. 1, 10- 01-03)  Payment for CPT codes 78890 and 78891 is bundled into payments for the primary procedure.
(Medicare Claims Processing Manual)
Payment for CPT codes 78890 and 78891 is bundled into payments for the primary procedure.   60 - Positron Emission Tomography (PET) Scans   General Information  (Rev. 1833; Issued:  10- 16-09; Effective Date:  04 -03-09; Implementation Date:  10- 30-09)  Positron emission tomography (PET) is a noninvasive imaging procedure that assesses perfusion and the level of metabolic activity in various organ systems of the human body. A positron camera (tomograph) is used to produce cross -sectional tomographic image s which are obtained by detecting radioactivity from a radioactive tracer substance (radiopharmaceutical) that emits a radioactive tracer substance (radiopharmaceutical FDG) such as 2 [F -18] flouro -D-glucose FDG, that is administered intravenously to the patient.   The Medicare National Coverage Determinations (NCD) Manual, chapter 1, 220.6, contains additional coverage instructions to indicate the conditions under which a PET scan is performed.   A.   Definitions   For all uses of PET, excluding Rubidium 82 for perfusion of the heart, myocardial viability and refractory seizures, the following definitions apply:    Diagnosis : PET is covered only in clinical situations in which the PET results may assist in avoiding an invasive diagnostic procedure, or in which the PET results may assist in determining the optimal anatomical location to perform an invasive diagnostic procedure .  In general, for most solid tumors, a tissue diagnosis is made prior to the performance of PET scanning.  PET scans following a tissue diagnosis are generally performed for the purpose of staging, rather than diagnosis.  Therefore, the use of PET in the diagnosis of lymphoma, esophageal and colorectal cancers, as well as in melanoma, should be rare.  PET is not covered for other diagnostic uses, and is not covered for screening (testing of patients without specific signs and symptoms of disease).
(Medicare Claims Processing Manual)
 Staging: PET is covered in clinical situations in which (1) (a) the stage of the cancer remains in doubt after completion of a standard diagnostic workup, including conventional imaging (computed tomography, magnetic resonance imaging, or ultrasound) or, (b) the use of PET would also be considered reasonable and necessary if it could potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patien t and, (2) clinical management of the patient would differ depending on the stage of the cancer identified.   NOTE:  Effective for services on or after April 3, 2009, the terms diagnosis and staging will be replaced with Initial Treatment Strategy.  For further information on this new term, refer to Pub. 100-03, NCD Manual, section 220.6.17.   Restaging:  PET will be covered for restaging: (1) after the completion of treatment for the purpose of detecting residual disease, (2) for detecting suspected recurrence, or metastasis, (3) to determine the extent of a known recurrence, or (4) if it could potentially replace one or more conventional imaging studies when it is expected that conventional study information is to determine the extent of a known recurrence, or i f study information is insufficient for the clinical management of the patient.  R estaging applies to testing after a course of treatment is completed and is covered subject to the conditions above.    Monitoring : Use of PET to monitor tumor response to treatment during the planned course of therapy (i.e., when a change in therapy is anticipated).  NOTE: Effective for services on or after April 3, 2009, the terms restaging and monitoring will be replaced with Subsequent Treatment Strategy.  For further information on this new term, refer to Pub. 100-03, NCD Manual, section 220.6.17.  B.  Limitations   For staging and restaging: PET is covered in either/or both of the following circumstances:    The stage of the cancer remains in doubt after completion of a standard diagnostic workup, including conventional imaging (computed tomography, magnetic resonance imaging, or ultrasound); and/or
(Medicare Claims Processing Manual)
 The stage of the cancer remains in doubt after completion of a standard diagnostic workup, including conventional imaging (computed tomography, magnetic resonance imaging, or ultrasound); and/or    The clinical management of the patient would differ depending on the stage of the cancer identified.  PET will be covered for restaging after the completion of treatment for the purpose of detecting residual disease, for detecting suspected recurrence, or to determine the extent of a known recurrence.  Use of PET would also be considered reasonable and necessary if it could potentially replace one or more conventional imaging studies when it is expected that conventional study information is insufficient for the clinical management of the patient.   The PET is not covered for other diagnostic uses, and is not covered for screening (testing of patients without specific symptoms).  Use of PET to monitor tumor response during the planned course of therapy (i.e., when no change in therapy is being contemplated) is not covered.   60.1 - Billing Instructions  (Rev. 3227, Issued: 04- 02-15, Effective; ASC -X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  June 11, 2013, ICD -10: Upon Implementation of ICD -10 Implementation: ASC X12: November 10, 2014  Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  May 19, 2014 -  MAC Non -Shared System Edits; July 7, 2014 -  CWF development/testing, FISS requirement development; October 6, 2014 -  CWF, FISS, MCS Shared System Edits), ICD -10: Upon Implementation of ICD -10)  A.  Billing and Payment Instructions or Responsibilities for A/B MACs (B)
(Medicare Claims Processing Manual)
A.  Billing and Payment Instructions or Responsibilities for A/B MACs (B)   Claims for PET scan services must be billed using the ASC X12 837 professional claim format or on Form -CMS 1500 with the appropriate HCPCS or CPT code and diagnosis codes to the A/B MAC (B).  Effective for claims received on or after July 1, 2001, PET modifiers were discontinued and are no longer a claims processing requirement for PET scan claims.   Therefore, July 1, 2001, and after the MSN messages regarding the use of PET modifiers can be discontinued.  The type of service (TOS) for the new PET scan procedure codes is TOS 4, Diagnostic Radiology.  Payment is based on the Medicare Physician Fee Schedule.   B.  Billing and Payment Instructions or Responsibilities for A/B MACs (A)   Claims for PET scan procedures must be billed to the A/B MAC (A) on the ASC X12 837 institutional claim format or on Form CMS -1450 with the appropriate diagnosis and HCPCS G code or CPT code to indicate the conditions under which a PET scan was done.  These codes represent the technical component costs associated with these procedures when furnished to hospital and SNF outpatients. They are paid as follows:    under OPPS for hospitals subject to OPPS   under current payment methodologies for hospitals not subject to OPPS   on a reasonable cost basis for critical access hospitals.   on a reasonable cost basis for skilled nursing facilities.  Institutional providers bill these codes under Revenue Code 0404 (PET Scan).  Medicare contractors shall pay claims submitted for services provided by a critical access hospital (CAH) as follows: Method I technical services are paid at 101% of reasonable cost; Method II technical services are paid at 101% of reasonable cost, and pro fessional services are paid at 115% of the Medicare Physician Fee Schedule Data Base.   C.  Frequency   In the absence of national frequency limitations, for all indications covered on and after July 1, 2001, contractors can, if necessary, develop frequency limitations on any or all covered PET scan services.   D.  Post -Payment Review for PET Scans
(Medicare Claims Processing Manual)
C.  Frequency   In the absence of national frequency limitations, for all indications covered on and after July 1, 2001, contractors can, if necessary, develop frequency limitations on any or all covered PET scan services.   D.  Post -Payment Review for PET Scans   As with any claim, but particularly in view of the limitations on this coverage, Medicare may decide to conduct post -payment reviews to determine that the use of PET scans is consistent with coverage instructions.  Pet scanning facilities must keep patient  record information on file for each Medicare patient for whom a PET scan claim is made.  These medical records can be used in any post -payment reviews and must include the information necessary to substantiate the need for the PET scan.  These records mus t include standard information (e.g., age, sex, and height) along with sufficient patient histories to allow determination that the steps required in the coverage instructions were followed.  Such information must include, but is not limited to, the date, place and results of previous diagnostic tests (e.g., cytopathology and surgical pathology reports, CT), as well as the results and reports of the PET scan(s) performed at the center.  If available, such records should include the prognosis derived from the PET scan, together with information regarding the physician or institution to which the patient proceeded following the scan for treatment or evaluation.  The ordering physician is responsible for forwarding appropriate clinical data to the PET scan faci lity.  Effective for claims received on or after July 1, 2001, CMS no longer requires paper documentation to be submitted up front with PET scan claims. Contractors shall be aware and advise providers of the specific documentation requirements for PET scans for dementia and neurodegenerative diseases.  This information is outlined in section 60.12.  Documentation requirements such as physician referral and medical necessity determination are to be maintained by the provider as part of the beneficiarys medical record.  This information must be made available to the A/B MAC (A or B) upon request of additional documentation to determine appropriate payment of an individual claim.  60.2 - Use of Gamma Cameras and Full Ring and Partial Ring PET Scanners for PET Scans  (Rev. 527, Issued: 04- 15-05, Effective: 01 -28-05, Implementation: 04- 18-05)
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60.2 - Use of Gamma Cameras and Full Ring and Partial Ring PET Scanners for PET Scans  (Rev. 527, Issued: 04- 15-05, Effective: 01 -28-05, Implementation: 04- 18-05)  See the Medicare NCD Manual, Section 220.6, concerning 2- [F-18] Fluoro- D-Glucose (FDG) PET scanners and details about coverage.   On July 1, 2001, HCPCS codes G0210 -  G0230 were added to allow billing for all currently covered indications for FDG PET.  Although the codes do not indicate the type of PET scanner, these codes were used until January 1, 2002, by providers to bill for ser vices in a manner consistent with the coverage policy.  Effective January 1, 2002, HCPCS codes G0210  G0230 were updated with new descriptors to properly reflect the type of PET scanner used.  In addition, four new HCPCS codes became effective for dates of service on and after January 1, 2002, (G0231, G0232, G 0233, G0234) for covered conditions that may be billed if a gamma camera is used for the PET scan.  For services performed from January 1, 2002, through January 27, 2005, providers should bill using the revised HCPCS codes G0210 -  G0234.  Beginning January 28, 2005 providers should bill using the appropriate CPT code.   60.2.1 - Coverage for Myocardial Viability  (Rev. 1, 10- 01-03) AB-02-065  The FDG PET is covered for the determination of myocardial viability following an inconclusive single photon computed tomography test (SPECT) from July 1, 2001, through September 30, 2002.  Only full ring scanners are covered as the scanning medium for this service from July 1, 2001, through December 31, 2001.  However, as of January 1, 2002, full a nd partial ring scanners are covered for myocardial viability following an inconclusive SPECT.
(Medicare Claims Processing Manual)
Beginning October 1, 2002, Medicare will cover FDG PET for the determination of myocardial viability as a primary or initial diagnostic study prior to revascularization, and will continue to cover FDG PET when used as a follow -up to an inconclusive SPECT.  However, if a patient received a FDG PET study with inconclusive results, a follow -up SPECT is not covered.  FDA full and partial ring PET scanners are covered.   In the event that a patient receives a SPECT with inconclusive results, a PET scan may be performed and covered by Medicare.  However, a SPECT is not covered following a FDG PET with inconclusive results.  See the Medicare National Coverage Determinations Manual for specific frequency limitations for Myocardial Viability following an inconclusive SPECT.  In the absence of national frequency limitations, contractors can, if necessary develop reasonable frequency limitations for myocardial viability.   Documentation that these conditions are met should be maintained by the referring physician as part of the beneficiarys medical record.   60.3 - PET Scan Qualifying Conditions and HCPCS Code Chart  (Rev. 527, Issued: 04- 15-05, Effective: 01 -28-05, Implementation: 04- 18-05)  Below is a summary of all covered PET scan conditions, with effective dates.  NOTE:   The G codes below except those a # can be used to bill for PET Scan services through January 27, 2005.  Effective for dates of service on or after January 28, 2005, providers must bill for PET Scan services using the appropriate CPT codes.  See section 60.3.1.  The G codes with a # can continue to be used for billing after January 28, 2005 and these remain non- covered by Medicare.  ( NOTE:  PET Scanners must be FDA -approved.)
(Medicare Claims Processing Manual)
Conditions  Coverage Effective Date  ****HCPCS/CPT  *Myocardial perfusion imaging (following previous PET G0030- G0047) single study, rest or stress (exercise and/or pharmacologic)  3/14/95 G0030 *Myocardial perfusion imaging (following previous PET G0030- G0047) multiple studies, rest or stress (exercise and/or pharmacologic)  3/14/95 G0031 *Myocardial perfusion imaging (following rest SPECT, 78464); single study, rest or stress (exercise and/or pharmacologic)  3/14/95 G0032 *Myocardial perfusion imaging (following rest SPECT 78464); multiple studies, rest or stress (exercise and/or pharmacologic)  3/14/95 G0033 *Myocardial perfusion (following stress SPECT 78465); single study, rest or stress (exercise and/or pharmacologic)  3/14/95 G0034 *Myocardial Perfusion Imaging (following stress SPECT 78465); multiple studies, rest or stress (exercise and/or pharmacologic)  3/14/95 G0035 *Myocardial Perfusion Imaging (following coronary angiography 93510- 93529); single study, rest or stress (exercise and/or pharmacologic)  3/14/95 G0036 *Myocardial Perfusion Imaging, (following coronary angiography), 93510- 93529); multiple studies, rest or stress (exercise and/or pharmacologic)  3/14/95 G0037 *Myocardial Perfusion Imaging (following stress planar myocardial perfusion, 78460); single study, rest or stress (exercise and/or pharmacologic)  3/14/95 G0038 Conditions  Coverage Effective Date  ****HCPCS/CPT  *Myocardial Perfusion Imaging (following stress planar myocardial perfusion, 78460); multiple studies, rest or stress (exercise and/or pharmacologic)  3/14/95 G0039 *Myocardial Perfusion Imaging (following stress echocardiogram 93350); single study, rest or stress (exercise and/or