evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
When Condition Code 30 is missing, use CARC 16 and   RARC M44  Missing/incomplete/invalid condition code.   When Clinical Trial modifier Q0/Q1 is missing, use CARC 16 and   RARC N822, Missing procedure modifier(s).    When Clinical Trial Number is missing, use CARC 16 and   RARC MA50, Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number.   When Value Code D4 is missing, use CARC 16 and   RARC M49, Missing/incomplete/invalid value code(s) or amount(s).   190.4  Advance Beneficiary Notice and Hospital Issued Notice of Noncoverage Information  (Rev. 1206; Issued:  03- 16-07; Effective:  December 19, 2006; Implementation:  04- 02-07)  If this service is not reasonable and necessary under 1862(a)(1)(A) of the Act (falls outside the scope of the revised NCD found in Pub. 100- 03, chapter 1, section 110.4), contractors shall advise physicians and/or hospital outpatient departments, including critical access hospitals (CAHs), that they will be held liable for charges unless the physician and/or hospital has the beneficiary sign an Advance Beneficiary Notice in advance of providing the service.   If this service is provided to a hospital inpatient, including CAHs, for a reason unrelated to the admission (outside of the bundled payment) contractors shall advise hospitals billing for inpatient services that they will be held liable for charges unless  the hospital has the beneficiary sign a Hospital Issued Notice of Noncoverage letter 11 in advance of providing the service.   200 - Billing Requirements for Vagus Nerve Stimulation (VNS)  (Rev. 1271, Issued:  06- 22-07; Effective:  05- 04-07; Implementation:  07 -23-07) 200.1 - General  (Rev. 1271, Issued:  06- 22-07; Effective:  05 -04-07; Implementation:  07 -23-07)
(Medicare Claims Processing Manual)
VNS is a pulse generator, similar to a pacemaker, that is surgically implanted under the skin of the left chest and an electrical lead (wire) is connected from the generator to the left vagus nerve.  Electrical signals are sent from the battery -powered gen erator to the vagus nerve via the lead.  These signals are in turn sent to the brain.  FDA approved VNS for treatment of refractory epilepsy in 1999.  Further coverage guidelines can be found in the National Coverage Determination Manual (Publication 100- 03), Chapter 1, Section 160.18.  Since the HCPCS codes for VNS can also be used for other indications, contractors must determine if the service being billed are for VNS and make a determination to pay or deny.  CMS guidance on payment is listed below.  200.2 - ICD-10 Diagnosis Codes for Vagus Nerve Stimulation  (Covered  since  DOS  on and after  July 1, 1999)  (Rev. 12435, Issued:12- 28-23, Effective:01 -29-24, Implementation:01- 29-24)  One of the following diagnosis codes must be reported as appropriate, when  billing  for Vagus  Nerve Stimulation:   If ICD- 10-CM is applicable:   G40.011 Localization- related (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset, intractable, with  status  epileptic    G40.019 Localization- related (focal) (partial) idiopathic epilepsy and  epileptic  syndromes  with seizures  of localized  onset, intractable,  without  status  epilepticus    G40.111 Localization- related (focal) (partial) symptomatic epilepsy and  epileptic syndromes with simple partial seizures, intractable, with status  epilepticus    G40.119 Localization- related (focal) (partial) symptomatic epilepsy and  epileptic  syndromes  with simple  partial  seizures,  intractable,  without  status  epilepticus    G40.211 Localization- related (focal) (partial) symptomatic epilepsy and  epileptic  syndromes  with complex partial  seizures,  intractable,  with status  epilepticus
(Medicare Claims Processing Manual)
 G40.211 Localization- related (focal) (partial) symptomatic epilepsy and  epileptic  syndromes  with complex partial  seizures,  intractable,  with status  epilepticus    G40.219 Localization- related (focal) (partial) symptomatic epilepsy and  epileptic syndromes with complex partial seizures, intractable, without status  epilepticus    G40.833 Dravet  syndrome, intractable,  with  status  epilepticus     G40.834 Dravet  syndrome, intractable,  without  status  epilepticus    G40.C11 Lafora progressive myoclonus epilepsy, intractable, with status epilepticus    G40.C19 Lafora progressive myoclonus epilepsy, intractable, without status epilepticus       200.3 - Carrier/MAC Billing Requirements (Rev. 1271, Issued:  06- 22-07; Effective:  05 -04-07; Implementation:  07 -23-07)  Effective for services performed on or after July 1, 1999, contractors are accepting claims submitted for vagus nerve stimulation for epilepsy and recurrent seizures.   Effective for services performed on or after July 1, 1999, CMS determined that vagus nerve stimulation is not reasonable and necessary for all other types of seizures which are refractory and for whom surgery is not recommended or for whom surgery has fail ed.  Effective for services performed on or after May 4, 2007, contractors will deny claims submitted for vagus nerve stimulation for resistant depression.  Contractors need to update their local coverage determination policy to include this new NCD determination.  There is no coverage for vagus nerve stimulation for patient with resistant depression.   200.4 - Fiscal Intermediary Billing Requirements  (Rev. 1271, Issued:  06- 22-07; Effective:  05 -04-07; Implementation:  07 -23-07)  Effective for services performed on or after July 1, 1999, contractors are accepting claims submitted for vagus nerve stimulation for epilepsy and recurrent seizures.   Effective for services performed on or after July 1, 1999, CMS determined that vagus nerve stimulation is not reasonable and necessary for all other types of seizures which are refractory and for whom surgery is not recommended or for whom surgery has fail ed.
(Medicare Claims Processing Manual)
Effective for services performed on or after May 4, 2007, contractors will reject claims submitted for vagus nerve stimulation for resistant depression.   200.5 - Medicare Summary Notice (MSN), Remittance Advice Remark Code (RARC) and Claim Adjustment Reason Code (CARC) Messages (Rev.11035, Issued:10 -13-21, Effective:  11-17-21; Implementation:  11-17-21)   The following messages are used by Medicare contractors when denying non - covered  VNS services:   MSN:  16.10 Medicare  does  not pay for this  item or  service."   CARC: 50 These are non -covered services because this is not deemed a medical  necessity by the payer."   The following  RARC messages  can be used  depending  on liability:   M27 Alert: The patient has been relieved of liability of payment of these  items and services under the limitation of liability provision of the law.  You, the provider, are ultimately liable for the patient's waived charges,  including any charges for coinsurance, since the  items or  services  were not  reasonable and necessary or constituted custodial care, and you knew or  could reasonably have been expected to know, that they were not covered. You may appeal this determination.  You may ask for an appeal regarding both the coverage determination and the issue of whether you exercised due care. The appeal request must be filed within 120 days of the date you receive  this notice. You must make  the request  through this  office.   Or  M38 Alert: The patient is liable for the charges for this service as you  informed  the patient  in writing  before  the service  was furnished that we  would  not pay for it, and the patient agreed to  pay. Contractors  will also  include  group code  CO (contractual  obligation)  or PR (patient  responsibility)  depending on liability.   200.6 - Advance Beneficiary Notice and HINN Information  (Rev. 1271, Issued:  06- 22-07; Effective:  05 -04-07; Implementation:  07 -23-07)  Physicians are liable for non -covered VNS procedures unless they issue an appropriate advance beneficiary notice (ABN).  T he following language should be included in the ABN:   Items or Service Section:  Vagas Nerve Stimulation.
(Medicare Claims Processing Manual)
Physicians are liable for non -covered VNS procedures unless they issue an appropriate advance beneficiary notice (ABN).  T he following language should be included in the ABN:   Items or Service Section:  Vagas Nerve Stimulation.   Because Section:  As specified in section 160.18 of Pub.100- 03, Medicare National Coverage Determination Manual, Medicare will not pay for this procedure as it is not a reasonable and necessary treatment for (select either your type of seizure disorder or resistant depression.)   Note that the ABN is the appropriate notice for Part B services and is valid whether the language above is inserted or not.  210 - Billing Requirements for Continuous Positive Airway Pressure (CPAP) for Obstructive Sleep Apnea (OSA)  (Rev.)   220 - Billing Requirements for Thermal Intradiscal Procedures (TIPs)  (Rev. 1646, Issued: 12- 09-08, Effective: 09 -29-08, Implementation: 01- 05-09)  220.1 - General  (Rev. 1646, Issued: 12- 09-08, Effective: 09 -29-08, Implementation: 01- 05-09)  Effective for services on or after September 29, 2008, the Center for Medicare & Medicaid Services (CMS) made the decision that Thermal Intradiscal Procedures (TIPS) are not reasonable and necessary for the treatment of low back pain. Therefore, TIPs are non-covered.  Refer to Pub.100- 03, Medicare National Coverage Determination (NCD) Manual Chapter 1, Part 2, Section 150.11, for further information on the NCD.  220.2 - Contractors, A/B Medicare Administrative Contractors (MACs)  (Rev. 1646, Issued: 12- 09-08, Effective: 09 -29-08, Implementation: 01- 05-09)  The following Healthcare Common Procedure Coding System (HCPCS) codes will be nationally non- covered by Medicare effective for dates of service on and after September 29, 2008:   22526: Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level   22527:  Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; one or more additional levels
(Medicare Claims Processing Manual)
22527:  Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; one or more additional levels   0062T:  Percutaneous intradiscal annuloplasty, any method except electrothermal, unilateral or bilateral including fluoroscopic guidance; single level  0063T:  Percutaneous intradiscal annuloplasty, any method except electrothermal, unilateral or bilateral including fluoroscopic guidance; one or more additional levels  NOTE:   The change to add the non-covered indicator for the above HCPCS codes will be part of the January 2009 Medicare Physician Fee Schedule Update.  The change to the status indicator to non-cover the above HCPCS will be part of the January Integrated Outpati ent Code Editor (IOCE) update.  Claims submitted with the non -covered HCPCS codes on or after September 29, 2008, will be denied by Medicare contractors. 220.3 - Medicare Summary Notice (MSN), Claim Adjustment Reason Code (CARC), and Remittance Advice Remark Code (RARC)  (Rev. 1646, Issued: 12- 09-08, Effective: 09-29-08, Implementation: 01-05-09)  The following messages are used by Medicare contractors when denying non- covered TIP services:    MSN: 21.11  This service was not covered by Medicare at the time you received it.    CARC:  96  Non-covered charge(s)   N386 This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/med/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.  220.4 - Advance Beneficiary Notice (ABN)  (Rev. 1646, Issued: 12- 09-08, Effective: 09-29-08, Implementation: 01-05-09)  Providers are liable for charges if TIPS is used in surgery, unless the beneficiary was informed that he/she would be financially responsible prior to performance of the procedure. To avoid this liability the provider should have the beneficiary sign an AB N.
(Medicare Claims Processing Manual)
230  Billing Wrong Surgical or Other Invasive Procedures Performed on a Patient, Surgical or Other Invasive Procedures Performed on the Wrong Body Part, and Surgical or Other Invasive Procedures Performed on the Wrong Patient  (Rev.  2998, Issued: 07- 25-14, Effective: Upon implementation of ICD-10; 01-01-12 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD -10)  The Centers for Medicare & Medicaid Services (CMS) internally generated a request for a national coverage analysis (NCA) to establish national coverage determinations (NCDs) addressing Medicare coverage of Wrong Surgical or Other Invasive Procedures Performed on a Patient, Surgical or Other Invasive Procedures Performed on the Wrong Body Part, and Surgical or Other Invasive Procedures Performed on the Wrong Patient.  Information regarding these NCDs can be found in Publication (Pub.) 100-03, Chapter 1, sections 140.6, 140.7, and 140.8, respectively.  Inpatient Claims   Hospitals are required to bill two claims when a surgical error is reported and a covered service is also being reported:    One claim with covered service(s)/procedure(s) unrelated to the erroneous surgery(s) on a Type of Bill (TOB) 11X (with the exception of 110), and  The other claim with the non- covered service(s)/procedure(s) related to the erroneous surgery(s) on a TOB 110 (no- pay claim)   NOTE:   Both the covered and non- covered claim shall have a matching Statement Covers Period.  For discharges prior to October 1, 2009, the non-covered TOB 110 must indicate on the 837 institutional claim format, or in the Remarks field of the Form CMS1450 one of the applicable erroneous surgery(s) two- digit codes (entered exactly as specified below ):   For a wrong surgery on patient, enter the following: MX   For a surgery on a wrong body part, enter the following: MY   For a surgery on wrong patient, enter the following: MZ
(Medicare Claims Processing Manual)
 For a wrong surgery on patient, enter the following: MX   For a surgery on a wrong body part, enter the following: MY   For a surgery on wrong patient, enter the following: MZ   For discharges on or after October 1, 2009, the non-covered TOB 110 must have one of the following diagnosis codes reported in diagnosis position 2-9, instead of billing the aforementioned two-digit codes in Remarks:  If ICD -9-CM Is Applicable   E876.5 - Performance of wrong operation (procedure) on correct patient (existing code)   E876.6 - Performance of operation (procedure) on patient not scheduled for surgery  E876.7- Performance of correct operation (procedure) on wrong side/body part  NOTE : The above codes shall not be reported in the External Cause of Injury (E- code) field.   If ICD -10-CM Is Applicable   Y65.51 Performance of wrong procedure (operation) on correct patient  Y65.52 Performance of procedure (operation) on patient not scheduled for surgery  Y65.53 Performance of correct procedure (operation) on wrong side of body parts Outpatient, Ambulatory Surgical Centers, and Practitioner Claims   Providers are required to append one of the following applicable HCPCS modifiers to all lines related to the erroneous surgery(s):   PA: Surgery Wrong Body Part   PB: Surgery Wrong Patient  PC: Wrong Surgery on Patient  All claims   Claim/Lines submitted with a surgical error will be denied/line -item denied using the following:  Medicare Summary Notice  23.17  Medicare wont cover these services because they are not considered medically necessary.  23.17  Medicare no cubrir estos servicios porque no son considerados necesarios por razones mdicas.   Claim Adjustment Reason Code  CARC 50  These are non -covered services because this is not deemed a medical necessity by the payer.  Group Code CO  Contractual Obligation   Beneficiary Liability
(Medicare Claims Processing Manual)
Group Code CO  Contractual Obligation   Beneficiary Liability   Generally, beneficiary liability notices such an Advance Beneficiary Notice of Non- coverage (ABN) or a Hospital Issued Notice of Non-coverage (HINN) is appropriate when a provider is furnishing an item or service that the provider reasonably believes Medicare will not cover on the basis of 1862(a)(1).  An ABN must include all of the elements described in Pub. 100-04, Claims Processing Manual (CPM), Ch. 30, 50.6.3, in order to be considered valid.  For example, the ABN must specifically describe the item o r service expected to be denied (e.g. a left leg amputation) and must include a cost estimate for the non -covered item or service.  Similarly, HINNs must specifically describe the item or service expected to be denied (e.g. a left leg amputation) and must include all of the elements described in the instructions found in the CPM Ch. 3,0 200. Thus, a provider cannot shift financial liability for the non-covered services to the beneficiary, unless the ABN or the HINN satisfies all of the applicable requirements in the CPM Ch. 30, 50.6.3 and 200, respectively.  Given these requirements, CMS cannot envision a scenario in which HINNs or ABNs could be validly delivered in these NCD cases.  However, an ABN or a HINN could be validly delivered prior to furnishing services related to the follow -up care for the non-covered surgical error that would not be considered a related service to the non -covered surgical error.   240  Special Instructions for Services with a Gender/Procedure Conflict  (Rev. 1877, Issued: 12- 18-09, Effective: 04-01-10, Implementation: 04-05-10)  Claims for some services for beneficiaries with transgender, ambiguous genitalia, and hermaphrodite issues, may inadvertently be denied due to sex related edits unless these services are billed properly.
(Medicare Claims Processing Manual)
Claims for some services for beneficiaries with transgender, ambiguous genitalia, and hermaphrodite issues, may inadvertently be denied due to sex related edits unless these services are billed properly.   The National Uniform Billing Committee (NUBC) has approved condition code 45 (Ambiguous Gender Category) as a result of the increasing number of claims received that are denied due to sex/diagnosis and sex/procedure edits.  This claim level condition code should be used by institutional providers to identify these unique claims and alerts the fiscal intermediary that the gender/procedure or gender/diagnosis conflict is not an error allowing the sex related edits to be by- passed.   The KX modifier ( Requirements specified in the medical policy have been met ) is now a multipurpose informational modifier and will also be used identify services for transgender, ambiguous genitalia, and hermaphrodite beneficiaries in addition to its other existing uses.  Physicians and non-physician practitioners should use modifier KX with procedure codes that are gender specific in the particular cases of transgender, ambiguous genitalia, and hermaphrodite beneficiaries.  Therefore, if a gender/procedure or gender/diagnosis conflict edit occurs, the KX modifier alerts the MAC that it is not an error and will allow the claim to continue with normal processing.  240.1 - Billing Instructions for Institutional Providers  (Rev. 1877, Issued: 12- 18-09, Effective: 04-01-10, Implementation: 04-05-10)  Institutional providers are to report condition code 45 on any inpatient or outpatient claim related to transgender, ambiguous genitalia, or hermaphrodite issues.  240.2  Billing Instructions for Physicians and Non -Physician Practitioners  (Rev. 1877, Issued: 12- 18-09, Effective: 04 -01-10, Implementation: 04- 05-10)  The KX modifier is to be billed on the detail line only with the procedure code(s) that is gender specific for transgender, ambiguous genitalia, and hermaphrodite  beneficiaries.  (NOTE:  The KX modifier is a multipurpose informational modifier, and may also be used in conjunction with other medical policies.)
(Medicare Claims Processing Manual)
250  Pharmacogenomic Testing for Warfarin Response  (Rev. 1889, Issued:  01- 08-10; Effective Date:  08 -03-09; Implementation Date:  04- 05-10)  250.1  Coverage Requirements  (Rev. 1889, Issued:  01- 08-10; Effective Date:  08 -03-09; Implementation Date:  04- 05-10)  Effective August 3, 2009, pharmacogenomic testing to predict warfarin responsiveness is covered only when provided to Medicare beneficiaries who are candidates for anticoagulation therapy with warfarin; i.e., have not been previously tested for CYP2C9 or V KORC1 alleles; and have received fewer than five days of warfarin in the anticoagulation regimen for which the testing is ordered; and only then in the context of a prospective, randomized, controlled clinical study when that study meets certain criteria a s outlined in Pub 100- 03, section 90.1, of the NCD Manual.   NOTE:   A new temporary HCPCS Level II code effective August 3, 2009, G9143, warfarin responsiveness testing by genetic technique using any method, any number of specimen(s), was developed to enable implementation of CED for this purpose.  250.2  Billing Requirements  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Institutional clinical trial claims for pharmacogenomic testing for warfarin response are identified through the presence of all of the following elements:    Value Code D4 and 8- digit clinical trial number (when present on the claim) -  Refer to Transmittal 310, Change Request 5790, dated January 18, 2008;    ICD-10 diagnosis code Z00.6 (secondary) -  Refer to Transmittal 310, Change Request 5790, dated January 18, 2008; and Z79.01 (primary);    Condition Code 30 -  Refer to Transmittal 310, Change Request 5790, dated January 18, 2008;    HCPCS modifier Q0: outpatient claims only -  Refer to Transmittal 1418, Change Request 5805, dated January 18, 2008;  and,
(Medicare Claims Processing Manual)
 HCPCS modifier Q0: outpatient claims only -  Refer to Transmittal 1418, Change Request 5805, dated January 18, 2008;  and,   HCPCS code G9143 (mandatory with the April 2010 Integrated Outpatient Code Editor (IOCE) and the January 2011 Clinical Laboratory Fee Schedule (CLFS) updates. Prior to these times, any trials should bill FIs for this test as they currently do absent these instructions, and the FIs should process and pay those claims  accordingly.)   Practitioner clinical trial claims for pharmacogenomic testing for warfarin response are identified through the presence of all of the following elements:          ICD-10-diagnosis code  Z00.6 (secondary), and ICD -10 diagnosis code Z79.01 (primary) MCS edit 031L70.7;   8-digit clinical trial number(when present on the claim);   HCPCS modifier Q0; and, MCS edit 031L   HCPCS code G9143 (to be carrier priced for claims with dates of service on and after August 3, 2009, that are processed prior to the January 2011 CLFS update.)   NOTE: This NCD does not determine coverage to identify CYP2C9 or VKORC1 alleles for other purposes beside warfarin responsiveness, nor does it determine national coverage to identify other alleles to predict warfarin responsiveness. These decisions are made at the local MAC level.   250.3  Payment Requirements  (Rev. 11021; Issued: 10-01- 21; Effective: 10 -29-21; Implementation: 10-29-21)  Beginning April 5, 2010, for claims with dates of service on and after August 3, 2009, the Medicare Shared System will track the number of times a beneficiary receives pharmacogenomic testing for warfarin response. When a claim is received for pharmacogeno mic testing for warfarin response, and the shared system has determined that the beneficiary has already received the test in his/her lifetime, it will generate a Medicare line-item denial and the Medicare contractor will provide the following messages to enforce the one- time limitation for the test: