evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Deny these services when submitted without one of the appropriate diagnoses. Use the same messages you currently use for procedure to diagnosis code denials. Edit 2   Deny G0247 if it is not submitted on the same claim as G0245 or G0246. Use MSN 21.21 - This service was denied because Medicare only covers this service under certain circumstances.  Use RA claim adjustment reason code 107 - The related or qualifying claim/service was not identified on this claim. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.  80.7 - CWF General Information  (Rev. 4203, Issued: 01- 18-19, Effective: 02-19-19, Implementation: 02-19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   Though G0245 and G0246 have no technical or professional components, for these codes, CWF will post institutional claims with type of bill 13X as technical, and professional claims as professional.  For bill type 85X with revenue code 940, CWF will post as technical.  For 85X bill type with revenue code 98X, (Method II), CWF will post as technical and professional.  This will allow both the facility and professional service payments to be approved by CWF for payment when the code and date of service match.  Therefore, should a claim be received with the same code and same date of service for the same beneficiary, the second claim submitted will not be rejected as a duplicate.   Due to the billing and payment methodology of Rural Health Clinics - bill type 71X and Federally Qualified Health Centers - bill type 73X, CWF will post these claims as usual, which will correctly allow claims from these entities that are billed on institu tional claims to reject as duplicates when the HCPCS code, date of service, and Medicare beneficiary identifier are an exact match with a claim billed on a professional claim.
(Medicare Claims Processing Manual)
Medicare contractors must react to these duplicate claims as they currently do for any other duplicates.  80.8 - CWF Utilization Edits  (Rev. 1742, Issued: 05- 22-09, Effective: 06-08-09, Implementation: 06-08-09)  Edit 1  - Should CWF receive a claim from an FI for G0245 or G0246 and a second claim from a contractor for either G0245 or G0246 (or vice versa) and they are different dates of service and less than 6 months apart, the second claim will reject.  CWF will edit to  allow G0245 or G0246 to be paid no more than every 6 months for a particular beneficiary, regardless of who furnished the service.  If G0245 has been paid, regardless of whether it was posted as a facility or professional claim, it must be 6 months before  G0245 can be paid again or G0246 can be paid.  If G0246 has been paid, regardless of whether it was posted as a facility or professional claim, it must be 6 months before G0246 can be paid again or G0245 can be paid.  CWF will not impose limits on how man y times each code can be paid for a beneficiary as long as there has been 6 months between each service.   The CWF will return a specific reject code for this edit to the contractors and FIs that will be identified in the CWF documentation.  Based on the CWF reject code, the contractors and FIs must deny the claims and return the following messages:  MSN 18.4 -- This service is being denied because it has not been __ months since your last examination of this kind (NOTE :  Insert 6 as the appropriate number of months.)  RA claim adjustment reason code 96  Non -covered charges, along with remark code M86  Service denied because payment already made for same/similar procedure within set time frame.   Edit 2
(Medicare Claims Processing Manual)
RA claim adjustment reason code 96  Non -covered charges, along with remark code M86  Service denied because payment already made for same/similar procedure within set time frame.   Edit 2   The CWF will edit to allow G0247 to pay only if either G0245 or G0246 has been submitted and accepted as payable on the same date of service.  CWF will return a specific reject code for this edit to the contractors and FIs that will be identified in the CWF documentation.  Based on this reject code, contractors and FIs will deny the claims and return the following m essages:   MSN 21.21 - This service was denied because Medicare only covers this service under certain circumstances.   RA claim adjustment reason code 107  The related or qualifying claim/service was not identified on this claim.   Edit 3   Once a beneficiarys condition has progressed to the point where routine foot care becomes a covered service, payment will no longer be made for LOPS evaluation and management services.  Those services would be considered to be included in the regular exams and treatments afforded to the beneficiary on a routine basis.  The physician or provider must then just bill the routine foot care codes, per Pub 100-02, Chapter 15, 290.  The CWF will edit to reject LOPS codes G0245, G0246, and/or G0247 when on the beneficiarys record it shows that one of the following routine foot care codes were billed and paid within the prior 6 months: 11055, 11056, 11057, 11719, 11720, and/or 11721.  The CWF will return a specific reject code for this edit to the contractors and FIs that will be identified in the CWF documentation.  Based on the CWF reject code, the contractors and FIs must deny the claims and return the following messages:  MSN 21.21 - This service was denied because Medicare only covers this service under certain circumstances.   The RA claim adjustment reason code 96  Non -covered charges, along with remark code M86  Service denied because payment already made for same/similar procedure within set time frame.   90 - Stem Cell Transplantation  (Rev.12533; Issued: 03 -07-24 Effective: 04 -08-24; Implementation:04 -08-24)   A. General
(Medicare Claims Processing Manual)
90 - Stem Cell Transplantation  (Rev.12533; Issued: 03 -07-24 Effective: 04 -08-24; Implementation:04 -08-24)   A. General   Stem cell transplantation is a process in which stem cells are harvested  from  either  a patients  (autologous) or donors (allogeneic)  bone marrow  or peripheral blood for intravenous infusion.  Allogeneic and autologous stem cell transplants are covered under Medicare for specific diagnoses. See Pub. 100-03, National Coverage Determinations Manual, section 110.23, for a complete description of covered and noncovered conditions. For Part A hospital inpatient claims processing instructions, refer to Pub. 100-04, chapter 3, section 90. The following sections contain claims processing instructions for all other claims.   B. Nationally Covered  Indications  C. Allogeneic  Hematopoietic Stem  Cell Transplantation (HSCT)   ICD- 10-PCS  Procedure  Codes
(Medicare Claims Processing Manual)
ICD- 10-PCS  Procedure  Codes   30230G2  Transfusion  of Allogeneic  Related  Bone  Marrow  into Peripheral  Vein,  Open  Approach  30230G3  Transfusion of Allogeneic Unrelated Bone Marrow into Peripheral  Vein,  Open Approach  30233U2  Transfusion of Allogeneic Related T -cell Depleted Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach  30233U3  Transfusion of Allogeneic Unrelated T -cell Depleted Hematopoietic Stem Cells into Peripheral Vein, Percutaneous Approach  30230Y2  Transfusion of Allogeneic Related Hematopoietic Stem Cells into  Peripheral  Vein, Open Approach  30230Y3  Transfusion of Allogeneic Unrelated Hematopoietic Stem Cells into  Peripheral  Vein, Open Approach  30233G2  Transfusion  of Allogeneic  Related  Bone  Marrow  into Peripheral  Vein,  Percutaneous  Approach  30233G3  Transfusion of Allogeneic Unrelated Bone Marrow into Peripheral  Vein,  Percutaneous Approach  30243U2  Transfusion of Allogeneic Related T -cell Depleted Hematopoietic Stem Cells into Central Vein, Percutaneous Approach  30243U3  Percutaneous Approach  30233Y2  Transfusion of Allogeneic Related Hematopoietic Stem Cells into  Peripheral  Vein, Percutaneous Approach  30233Y3  Transfusion of Allogeneic Unrelated Hematopoietic Stem Cells into  Peripheral  Vein, Percutaneous Approach  30240G2  Transfusion of Allogeneic Related Bone Marrow into Central Vein,  Open  Approach  30240G3  Transfusion of Allogeneic Unrelated Bone Marrow into Central Vein,  Open  Approach  30240Y2  Transfusion of Allogeneic Related Hematopoietic Stem Cells into  Central  Vein, Open Approach  30240Y3  Transfusion of Allogeneic Unrelated Hematopoietic Stem Cells into  Central  Vein, Open Approach  30243G2  Transfusion of Allogeneic Related Bone Marrow into Central Vein,  Percutaneous  Approach  30243G3  Transfusion of Allogeneic Unrelated Bone Marrow into Central Vein,  Percutaneous  Approach  30243Y2  Transfusion of Allogeneic Related Hematopoietic Stem Cells into  Central  Vein, Percutaneous Approach  30243Y3  Transfusion of Allogeneic Unrelated Hematopoietic Stem Cells into  Central  Vein, Percutaneous Approach   HCPCS  Code  38240
(Medicare Claims Processing Manual)
HCPCS  Code  38240   See below  table  for ICD-10-DX Codes:   a. Effective  for services  performed on  or after August  1, 1978:   a. For the treatment of leukemia, leukemia in remission; see table below for ICD - 10-CM codes:
(Medicare Claims Processing Manual)
C91.00  Acute  lymphoblastic  leukemia  not having  achieved  remission  C91.01  Acute  lymphoblastic  leukemia,  in remission  C91.02  Acute  lymphoblastic  leukemia,  in relapse  C91.10  Chronic  lymphocytic  leukemia  of B-cell type not having  achieved  remission  C91.11  Chronic  lymphocytic  leukemia  of B-cell type in remission  C91.12  Chronic  lymphocytic  leukemia  of B-cell type in relapse  C91.30  Prolymphocytic  leukemia  of B-cell type not having  achieved  remission  C91.31  Prolymphocytic  leukemia  of B-cell type,  in remission  C91.32  Prolymphocytic  leukemia  of B-cell type,  in relapse  C91.50  Adult  T-cell lymphoma/leukemia (HTLV -1-associated)  not having  achieved remission  C91.51  Adult  T-cell lymphoma/leukemia  (HTLV -1-associated),  in remission  C91.52  Adult  T-cell lymphoma/leukemia (HTLV -1-associated),  in relapse  C91.60  Prolymphocytic  leukemia  of T-cell type not having achieved  remission  C91.61  Prolymphocytic  leukemia  of T-cell type,  in remission  C91.62  Prolymphocytic  leukemia  of T-cell type,  in relapse  C91.90  Lymphoid  leukemia,  unspecified  not having  achieved  remission  C91.91  Lymphoid  leukemia,  unspecified,  in remission  C91.92  Lymphoid  leukemia,  unspecified,  in relapse  C91.A0  Mature  B-cell leukemia  Burkitt -type not having  achieved  remission  C91.A1  Mature  B-cell leukemia Burkitt -type,  in remission  C91.A2  Mature  B-cell leukemia Burkitt -type,  in relapse  C91.Z0  Other  lymphoid  leukemia  not having  achieved  remission  C91.Z1  Other  lymphoid  leukemia,  in remission  C91.Z2  Other  lymphoid  leukemia,  in relapse  C92.00  Acute  myeloblastic
(Medicare Claims Processing Manual)
leukemia  not having  achieved  remission  C91.Z1  Other  lymphoid  leukemia,  in remission  C91.Z2  Other  lymphoid  leukemia,  in relapse  C92.00  Acute  myeloblastic  leukemia,  not having  achieved remission  C92.01  Acute  myeloblastic  leukemia,  in remission  C92.02  Acute  myeloblastic  leukemia,  in relapse  C92.10  Chronic  myeloid  leukemia,  BCR/ABL -positive,  not having  achieved  remission  C92.11  Chronic  myeloid  leukemia,  BCR/ABL -positive,  in remission  C92.12  Chronic  myeloid  leukemia,  BCR/ABL -positive,  in relapse  C92.20  Atypical  chronic  myeloid  leukemia,  BCR/ABL -negative,  not having  achieved  remission  C92.21  Atypical  chronic  myeloid leukemia,  BCR/ABL -negative,  in remission  C92.22  Atypical  chronic  myeloid  leukemia,  BCR/ABL -negative,  in relapse  C92.30  Myeloid  sarcoma,  not having  achieved  remission  C92.31  Myeloid  sarcoma,  in remission  C92.32  Myeloid  sarcoma,  in relapse  C92.40  Acute  promyelocytic  leukemia,  not having  achieved  remission  C92.41  Acute  promyelocytic  leukemia,  in remission  C92.42  Acute  promyelocytic  leukemia,  in relapse  C92.50  Acute  myelomonocytic  leukemia,  not having  achieved  remission  C92.51  Acute  myelomonocytic  leukemia,  in remission  C92.52  Acute  myelomonocytic  leukemia,  in relapse  C92.60  Acute  myeloid  leukemia with  11q23 -abnormality  not having  achieved  remission  C92.61  Acute  myeloid  leukemia with  11q23 -abnormality  in remission  C92.62  Acute  myeloid  leukemia  with 11q23 -abnormality  in relapse  C92.90  Myeloid  leukemia,  unspecified,  not having  achieved  remission  C92.91  Myeloid  leukemia,  unspecified  in remission  C92.92  Myeloid  leukemia,  unspecified  in relapse  C92.A0  Acute
(Medicare Claims Processing Manual)
Myeloid  leukemia,  unspecified,  not having  achieved  remission  C92.91  Myeloid  leukemia,  unspecified  in remission  C92.92  Myeloid  leukemia,  unspecified  in relapse  C92.A0  Acute  myeloid  leukemia with  multilineage  dysplasia,  not having  achieved  remission  C92.A1  Acute  myeloid  leukemia with  multilineage  dysplasia,  in remission  C92.A2  Acute  myeloid  leukemia  with multilineage  dysplasia,  in relapse  C92.Z0  Other  myeloid  leukemia not  having  achieved  remission  C92.Z1  Other  myeloid  leukemia,  in remission  C92.Z2  Other  myeloid  leukemia, in  relapse  C93.00  Acute  monoblastic/monocytic  leukemia,  not having  achieved  remission  C93.01  Acute  monoblastic/monocytic  leukemia,  in remission  C93.02  Acute  monoblastic/monocytic  leukemia,  in relapse  C93.10  Chronic  myelomonocytic leukemia  not having  achieved  remission  C93.11  Chronic  myelomonocytic leukemia,  in remission  C93.12  Chronic  myelomonocytic leukemia,  in relapse  C93.30  Juvenile  myelomonocytic leukemia,  not having  achieved  remission  C93.31  Juvenile  myelomonocytic  leukemia,  in remission  C93.32  Juvenile  myelomonocytic leukemia,  in relapse  C93.90  Monocytic  leukemia,  unspecified,  not having  achieved  remission  C93.91  Monocytic  leukemia,  unspecified  in remission  C93.92  Monocytic  leukemia,  unspecified  in relapse  C93.Z0  Other  monocytic  leukemia,  not having achieved  remission  C93.Z1  Other  monocytic  leukemia,  in remission  C93.Z2  Other  monocytic  leukemia,  in relapse  C94.00  Acute  erythroid  leukemia,  not having  achieved  remission  C94.01  Acute  erythroid  leukemia,  in remission  C94.02  Acute  erythroid  leukemia, in  relapse  C94.20  Acute  megakaryoblastic  leukemia  not having  achieved  remission  C94.21  Acute  megakaryoblastic  leukemia,  in remission  C94.22  Acute
(Medicare Claims Processing Manual)
Acute  erythroid  leukemia, in  relapse  C94.20  Acute  megakaryoblastic  leukemia  not having  achieved  remission  C94.21  Acute  megakaryoblastic  leukemia,  in remission  C94.22  Acute  megakaryoblastic  leukemia,  in relapse  C94.30  Mast  cell leukemia  not having  achieved  remission  C94.31  Mast  cell leukemia,  in remission  C94.32  Mast  cell leukemia,  in relapse  C94.80  Other  specified  leukemias  not having achieved  remission  C94.81  Other  specified  leukemias,  in remission  C94.82  Other  specified  leukemias,  in relapse  C95.00  Acute  leukemia  of unspecified  cell type not having  achieved  remission  C95.01  Acute  leukemia  of unspecified  cell type, in  remission  C95.02  Acute  leukemia  of unspecified  cell type,  in relapse  C95.10  Chronic  leukemia  of unspecified  cell type not having  achieved  remission  C95.11  Chronic  leukemia  of unspecified  cell type, in  remission  C95.12  Chronic  leukemia  of unspecified  cell type,  in relapse  C95.90  Leukemia,  unspecified  not having  achieved  remission  C95.91  Leukemia,  unspecified,  in remission  C95.92  Leukemia,  unspecified,  in relapse  D45 Polycythemia vera
(Medicare Claims Processing Manual)
ii. For the treatment of aplastic anemia; see table below for ICD -10- CM codes)   ICD-10 Description  D60.0  Chronic  acquired  pure red cell aplasia  D60.1  Transient  acquired  pure red cell aplasia  D60.8  Other  acquired  pure red cell aplasias  D60.9  Acquired  pure red cell  aplasia,  unspecified  D61.01  Constitutional  (pure)  red blood  cell aplasia  D61.09  Other  constitutional  aplastic  anemia  D61.1  Drug -induced aplastic  anemia  D61.2  Aplastic  anemia  due to other  external agents  D61.3  Idiopathic  aplastic  anemia  D61.810  Antineoplastic  chemotherapy  induced pancytopenia  D61.811  Other  drug-induced  pancytopenia  D61.818  Other  pancytopenia  D61.82  Myelophthisis  D61.89  Other  specified  aplastic anemias  and other  bone  marrow failure  syndromes  D61.9  Aplastic  anemia,  unspecified  b. Effective  for services performed  on or after  June  3, 1985:    c. For the treatment of severe combined immunodeficiency disease (SCID) (ICD -10-CM codes D81.0, D81.1, D81.2, D81.6, D81.7, D81.89, and D81.9)  d. For the treatment of Wiskott -Aldrich syndrome ( ICD -10- CM code  D82.0)     c.    Effective  for services  performed on or after August 4, 2010:   For the treatment  of Myelodysplastic  Syndromes  (MDS) (ICD -10- CM codes  D46.A, D46.B, D46.C, D46.Z, D46.0, D46.1, D46.4, D46.9, D46.20, D46.21, D46.22, and Z00.6) pursuant to Coverage  with Evidence Development (CED) in the context of a Medicare - approved, prospective clinical study. Refer to Pub. 100- 03, NCD  Manual, chapter 1, section 110.23, for further information about this  policy. See section F  below  for billing  instructions.
(Medicare Claims Processing Manual)
d.   Effective  for services  performed  on or after  January 27, 2016:    b. Allogeneic HSCT for multiple myeloma (ICD -10-CM codes  C90.00, C90.01, C90.02, and Z00.6) is covered by Medicare  only for beneficiaries with Durie -Salmon Stage II or III multiple myeloma,  or International  Staging  System (ISS) Stage II or Stage III multiple myeloma, and  participating in an approved prospective clinical study. Refer to Pub. 100- 03, NCD Manual,  chapter  1, section  110.23, for further information about this policy. See section F below for billing instructions.  e. Allogeneic HSCT for myelofibrosis (MF) (ICD -10-CM codes  C94.40, C94.41, C94.42, D47.1, D47.4, D75.81, and Z00.6) is covered by Medicare only for beneficiaries with Dynamic  International Prognostic Scoring System (DIPSSplus)  intermediate -2 or High primary or secondary MF and participating in an approved prospective clinical study. Refer to Pub. 100-  03, NCD Manual, chapter 1, section 110.23, for  further information about this policy. See section F below for  billing instructions.
(Medicare Claims Processing Manual)
f. Allogeneic HSCT for sickle cell disease (SCD) (ICD -10-CM  codes D57.00, D57.01, D57.02, D57.03, D57.09, D57.1,  D57.20, D57.211, D57.212, D57.213, D57.218, D57.219, D57.40,  D57.411, D57.412, D57.413, D57.418, D57.419, D57.42, D57.431, D57.432, D57.433, D57.438, D57.439, D57.44, D57.451, D57.452, D57.453, D57.458, D57.459, D57.80, D57.811,D57.812, D57.813, D57.818, D57.819, and Z00.6)                    is covered by Medicare only for beneficiaries  with                    severe, symptomatic SCD who participate in an                      approved prospective clinical study. Refer to Pub.100- 03,                         NCD Manual, chapter 1, section 110.23, for further                     i nformation about this policy. See section F below for billing                                                                                                                                       instructions. II. Autologous  Stem  Cell Transplantation  (AuSCT)   HCPCS  Code  38241   ICD-10-PCS Procedure  Codes:
(Medicare Claims Processing Manual)
i nformation about this policy. See section F below for billing                                                                                                                                       instructions. II. Autologous  Stem  Cell Transplantation  (AuSCT)   HCPCS  Code  38241   ICD-10-PCS Procedure  Codes:    30230C0  Transfusion of Autologous Hematopoietic Stem/Progenitor Cells,  Genetically  Modified  into Peripheral  Vein,  Open  Approach  30230G0  Transfusion  of Autologous  Bone  Marrow  into Peripheral  Vein,  Open  Approach  30230Y0  Transfusion of Autologous Hematopoietic Stem Cells into  Peripheral  Vein, Open Approach  30233G0  Transfusion  of Autologous  Bone  Marrow  into Peripheral  Vein,  Percutaneous  Approach  30233C0  Transfusion of Autologous Hematopoietic Stem/Progenitor Cells,  Genetically  Modified  into Peripheral  Vein,  Percutaneous  Approach  30233Y0  Transfusion of Autologous Hematopoietic Stem Cells into  Peripheral  Vein, Percutaneous Approach  30240C0  Transfusion of Autologous Hematopoietic Stem/Progenitor Cells,  Genetically  Modified into Central Vein,  Open Approach  30240G0  Transfusion  of Autologous  Bone  Marrow  into Central  Vein,  Open  Approach  30240Y0  Transfusion of Autologous Hematopoietic Stem Cells into Central  Vein,  Open Approach  30243C0  Transfusion of Autologous Hematopoietic Stem/Progenitor Cells,  Genetically  Modified into Central  Vein,  Percutaneous  Approach  30243G0  Transfusion of Autologous Bone Marrow into Central Vein,  Percutaneous  Approach  30243Y0  Transfusion of Autologous Hematopoietic Stem Cells into Central  Vein,  Percutaneous Approach  Below ICD -10 CM codes Cover autologous SCT (38241) no trial for acute  leukemia in remission, resistant non- Hodgkins lymphomas, recurrent/refractory  neuroblastoma, advanced Hodgkins Disease on or after 4/28/89, and Cover  autologous SCT (38241) no trial for Durie -Salmon stage II/III responsive multiple  myeloma and responsive relapse on or after 10/1/00 over autologous SCT  (38241) together with high dose melphalan (HDMI) no trial for primary amyloid  light  chain (AL)  amyloidosis on or after 3/15/05
(Medicare Claims Processing Manual)
C81.01  Nodular lymphocyte predominant Hodgkin lymphoma, lymph  nodes  of head, face, and  neck  C81.02  Nodular lymphocyte predominant Hodgkin lymphoma,  intrathoracic  lymph nodes  C81.03  Nodular lymphocyte predominant Hodgkin lymphoma, intra - abdominal  lymph nodes  C81.04  Nodular lymphocyte predominant Hodgkin lymphoma, lymph  nodes  of axilla and upper limb  C81.05  Nodular lymphocyte predominant Hodgkin lymphoma, lymph  nodes  of inguinal region and lower limb  C81.06  Nodular lymphocyte predominant Hodgkin lymphoma,  intrapelvic  lymph nodes  C81.07  Nodular  lymphocyte  predominant  Hodgkin  lymphoma,  spleen  C81.08  Nodular lymphocyte predominant Hodgkin lymphoma, lymph  nodes  of multiple  sites C81.09  Nodular lymphocyte predominant Hodgkin lymphoma,  extranodal  and solid organ sites  C81.11  Nodular  sclerosis  Hodgkin  lymphoma,  lymph  nodes  of head,  face,  and neck  C81.12  Nodular  sclerosis  Hodgkin  lymphoma,  intrathoracic  lymph  nodes  C81.13  Nodular  sclerosis  Hodgkin  lymphoma,  intra-abdominal  lymph  nodes  C81.14  Nodular sclerosis Hodgkin lymphoma, lymph nodes of axilla and  upper  limb C81.15  Nodular sclerosis Hodgkin lymphoma, lymph nodes of inguinal  region  and lower limb  C81.16  Nodular  sclerosis  Hodgkin  lymphoma,  intrapelvic lymph  nodes  C81.17  Nodular  sclerosis  Hodgkin  lymphoma,  spleen  C81.18  Nodular sclerosis Hodgkin lymphoma, lymph nodes of multiple  sites C81.19  Nodular sclerosis Hodgkin