evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Fracture Care (A53322)
CMS National Coverage PolicyN/AArticle TextMany times the initial treating physician does not provide all of the follow-up care after surgery.  View examples of acceptable ways to bill for definitive or restorative treatment of a fracture.Coding and Billing OptionsClaim Coding Example #1When the surgeon does not provide any of the follow-up care for the 90 day global payment period, the surgeon bills the closed treatment of radial shaft fracture as follows:DatePlace of ServiceCPT/ModifierChargeUnits2/15/2014Applicable Code25500 54$$1Second physician bills the follow-up care for the closed treatment of radial shaft fracture as follows:DatePlace of ServiceCPT/ModifierChargeUnits2/15/2014Applicable Code25500 55$$1Documentation in item 19 of 1500 claim form:  2/16/2014- 5/16/2014Claim Coding Example #2When post operative care is provided by both physicians (45 days each), the surgeon bills the closed treatment of radial shaft fracture as follows:DatePlace of ServiceCPT/ModifierChargeUnits2/15/2014Applicable Code25500 54$$12/15/2014Applicable Code25500 55$$1Document in item 19 of 1500 claim form 2/16/14-4/1/2014Second physician bills the closed treatment of radial shaft fracture as follows:DatePlace of ServiceCPT/ModifierChargeUnits2/15/2014Applicable Code25500 55$$1Document in item 19 of 1500 claim form 4/2/2014-5/16/2014If the decision to have surgery was made by the surgeon on the day before or the day of surgery, a modifier 57 needs to be appended to the evaluation and management code used.  Without this modifier, your visit will be denied as included in the global package of the surgery.If a patient visit occurs after surgery which is unrelated to the surgical procedure, a modifier 24 must be appended to the evaluation and management code.To assist physicians and practitioners to select the correct code for the casting, splinting and splinting supplies, the following crosswalk provides guidance on which supply code are applicable for the various types of casts listed by Level I CPT codes.
Article - Billing and Coding: Fracture Care (A53322)
To assist physicians and practitioners to select the correct code for the casting, splinting and splinting supplies, the following crosswalk provides guidance on which supply code are applicable for the various types of casts listed by Level I CPT codes.The splints and cast Q codes are considered Level II codes and to be used when supplies are indicated for cast and splint purposes.  The payment is in addition to the payment made under the physician fee schedule for the procedure for applying the splint or cast.Level ILevel IILevel ILevel II29000Q4001 or Q400229126Q4021 through Q402429010Q4001 or Q400229130Q404929015Q4001 or Q400229131Q405129020Q4001 or Q400229305Q4025 through Q402829025Q4001 or Q400229325Q4025 through Q402829035Q4001 or Q400229345Q4029 through Q403229040Q4001 or Q400229355Q4029 through Q403229044Q4001 or Q400229365Q4033 through Q403629046Q4001 or Q400229405Q4037 through Q40402949Q405029425Q4037 through Q404029055Q4003 or Q400429435Q4037 through Q404029058Q400329440Q405029065Q4005 through Q400829445Q4037 through Q404029075Q4009 through Q401229450Q4035, Q4036, Q403929085Q4013 through Q4016Q404029105Q4017 through Q402029505Q4041 through Q404429125Q4021 through Q402429515Q4045 through Q4048The allowance for application of a cast, splint or strapping includes removal or repair by the same physician or other physician in the same group.  Billing for cast removal or repair (29700-29750) should be employed only for casts applied by another physician group.
Article - Billing and Coding: Therapy Students and Aides (A53339)
CMS National Coverage PolicyN/AArticle TextCoverage and documentation requirements for the provision of services by/or in the presence of a therapy student or therapy aide in both inpatient and outpatient therapy settings.Inpatient: Skilled Nursing Facility (SNF)Outpatient: therapist In Private Practice (TPP), Physician, Non-Physician Practitioner (NPP), long-term care facility, Hospital-based outpatient therapy clinic, outpatient rehabilitation facility (ORF), comprehensive outpatient rehabilitation facility (CORF)Medicare coverage requirements state that rehabilitation services must be provided and/or supervised by a qualified clinician i.e., physician, non-physician practitioner (NPP), qualified physical therapist (PT), occupational therapist (OT), speech-language pathologist (SLP), or appropriately supervised/qualified therapy assistant.Inpatient SNF SettingTherapy AidesTherapy aides cannot provide skilled services. However, the time that a therapy aide spends on set-up preceding skilled therapy may be coded on the Minimum Data Set (MDS) (e.g., set up the treatment area for wound therapy) and should be coded under the appropriate mode for the skilled therapy (individual, concurrent, or group) in O0400. The therapy aide must be under direct supervision of the therapist or assistant.Therapy StudentsTherapy students are not required to be in line-of-sight of the supervising therapist/assistant. The determination of whether or not a student is ready to treat patients without line-of-sight supervision is left to the discretion of the supervising therapist/assistant. Time may be coded on the MDS when the therapist provides skilled services and direction to a student who is participating in the provision of therapy. All state and professional practice guidelines for student supervision must be followed.Individual therapy is for treatment of one patient at a time. When a therapy student is involved the minutes may be coded when only one patient is being treated by the therapy student and the supervising therapist/assistant. The supervising therapist/assistant cannot be treating or supervising another individual and he/she must be available to immediately assist the student as needed.Concurrent therapy is for treatment of two residents who are performing different activities at the same time and are both in line-of sight of the treating therapist/assistant. When a therapy student is involved the minutes may be coded when one of the following occurs:
Article - Billing and Coding: Therapy Students and Aides (A53339)
Student is treating one patient and the supervising therapist/assistant is treating another patient and both patients are in line of sight of the therapist/assistant or student; orStudent is treating two patients both of whom are in line-of-sight of the student and the therapist/assistant is not treating any patients and is not supervising other individuals; orStudent is not treating any patients and the supervising therapist/assistant is treating two patients at the same time both of whom are in line-of-sight.Group therapy is for treatment of four patients who are performing the same or similar activities and are supervised by a therapist/assistant who is not supervising any other individuals. When a therapy student is involved with group therapy the minutes may be coded when one of the following occurs:Student is providing group treatment and the supervising therapist/assistant is not treating any patient and is not supervising other individuals (students or patients); orSupervising therapist/assistant is providing group treatment and the student is not treating any patient.Outpatient Therapy SettingsTherapy AidesTherapy aides cannot provide skilled services. Also, unskilled service minutes provided by the therapy aide cannot be counted and are not reimbursable even when provided under direct supervision by the qualified therapist or assistant e.g.The patient arrived at the clinic and worked in the gym with the therapy aide for 15 minutes, then the qualified therapist provided direct patient treatment for 20 minutes, then the patient worked for another 15 minutes in the gym with the therapy aide. Total of 20 individual minutes of service were provided by the qualified clinician and are billable for the session.The patient arrived at the clinic and received direct patient treatment with the qualified therapist for 10 minutes, then the patient worked in the gym with a qualified therapy assistant for 15 minutes, then the patient received direct patient treatment with the qualified therapist for an additional 15 minutes. Total of 40 individual minutes of service were provided by qualified clinicians and are billable for the session.Therapy StudentsServices provided by therapy students are not reimbursable even if provided under direct supervision of the therapist/assistant. However, when a student is in the room, the time that a qualified clinician spends with the patient is reimbursable when the medical record supports:
Article - Billing and Coding: Therapy Students and Aides (A53339)
The qualified clinician is present and in the room for the entire session. The student may participate in the delivery of services only when the qualified clinician is directing the service, making the skilled judgment, and is responsible for the assessment and treatment.The qualified clinician is not engaged in treating another patient or doing other tasks at the same time and is present in the room guiding the student in service delivery when the therapy student is participating in the provision of services.The qualified clinician is responsible for the services and signs all documentation. A student may also sign but payment is for the clinician's service and not for the student's services.When a therapy student is involved the skilled minutes of the qualified clinician may be counted and coded when all requirements listed above are met. For additional information, see the attached article"Medical Necessity of Therapy Services"in the Related Local Coverage Documents link below.SourcesCMS, Resident Assessment Instrument Manual (RAI) Version 3.0, Section OCMS Medicare Learning Network, Medicare Outpatient Therapy BillingInternet Only Manual (IOM), Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Sections 220(A), 230.230.6
Article - Billing and Coding: Outpatient Therapy Biofeedback Training (A53352)
CMS National Coverage PolicyN/AArticle TextThe amount of time the therapist, physician, or non-physician practitioner (NPP)spends working with a patient must be accurately documented in the medical record to support the units billed on a claim (for both untimed and time-based code services). Providers should be aware of the provision and billing requirements for each Current Procedural Terminology (CPT) code billed.CPTcode 90901 or 90912 or 90913 should beas appropriatebilled when biofeedback training is provided. Biofeedback training consists of the amount of time that the biofeedback modality is attached to the patient with the feedback results to be used and/or analyzed by the patient and/or clinician. Separate billing for concurrently applied modalities and/or procedures during biofeedback training is not appropriate. For example, a therapist may provide a combination of biofeedback and therapeutic exercises during the same 15 minutes to treat a patient. In these instances, the therapeutic exercises are considered to be a component of the biofeedback training and should not be separately billed. Providers should only bill the appropriate biofeedback training code for these combined services.Example 1Treatment=60 MinutesTreatmentBiofeedback Training= 60 minutesTherapeutic Exercises while on Biofeedback Modality and Electrical stimulationBillBiofeedback Training one (1) unitExample 2Treatment=60 MinutesTreatmentBiofeedback Training= 45 minutesTherapeutic Exercises without Biofeedback Training-15 minutesBillBiofeedback Training= one (1) unitTherapeutic Exercises=one (1) unit
Article - Billing and Coding: Outpatient Therapy Biofeedback Training (A53352)
Example 2Treatment=60 MinutesTreatmentBiofeedback Training= 45 minutesTherapeutic Exercises without Biofeedback Training-15 minutesBillBiofeedback Training= one (1) unitTherapeutic Exercises=one (1) unitTreatment for Urinary IncontinenceMedicare covers biofeedback for the treatment of stress and/or urge incontinence in cognitively intact patients when documentation supports a previously failed trial of pelvic muscle exercise (PME) training. A failed trial is observed when no significant clinical improvement in urinary incontinence is noted after completing four weeks of a physician prescribed plan of PME. Medical record documentation of the failed PME trial must be present to justify coverage for biofeedback.When biofeedback training is provided, the most appropriate biofeedback code (90901 or 90912 or 90913) should be billed. Similarly, separate billing for concurrently applied modalities and/or procedures during biofeedback training is not appropriate. For example, a therapist may provide a combination of neuromuscular electrical stimulation (NMES), biofeedback, and therapeutic exercisesduring the same15 minutes to treat a patient with urinary incontinence. In these instances, the therapeutic exercises and the NMES are considered to be a component of the biofeedback training and should not be billed separately. Providers should only bill the appropriate biofeedback training code for these combined services.Example 1Treatment=60 MinutesTreatmentBiofeedback Training= 60 minutesElectrical Stimulation= 15 minutesTherapeutic Exercises while on Biofeedback Modality and Electrical stimulationBillBiofeedback Training one (1) unitExample 2Treatment=60 MinutesTreatmentBiofeedback Training= 45 minutesElectrical Stimulation while on Biofeedback Modality= 15minutesTherapeutic Exercises without Biofeedback or Electrical Stimulation = 15 minutesBillBiofeedback Training= one (1) unitTherapeutic Exercises= one (1) unitExample 3Treatment=60 MinutesTreatmentBiofeedback Training= 45 minutesElectrical Stimulation while not on Biofeedback Modality= 15minutesTherapeutic Exercises during same 15 minute intervalBillBiofeedback Training= one (1) unitTherapeutic Exercises (or attended Electrical Stimulation)= one (1) unitSources
Article - Billing and Coding: Outpatient Therapy Biofeedback Training (A53352)
Electrical Stimulation while not on Biofeedback Modality= 15minutesTherapeutic Exercises during same 15 minute intervalBillBiofeedback Training= one (1) unitTherapeutic Exercises (or attended Electrical Stimulation)= one (1) unitSourcesCMS Internet Only Manual (IOM) National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Sections 30.1 and 30.1.1CMS IOM National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Section 160.12CMS IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 5, Section 20(B)
Article - Sterilization (A53356)
CMS National Coverage PolicyN/AArticle TextSterilization means any medical procedure, treatment or operation for the sole purpose of rendering an individual permanently incapable of reproducing and not related to the repair of a damaged/dysfunctional body part.Under the Medicare Program guidelines the coverage of sterilization is limited to necessary treatment of an illness or injury. An example of necessary treatment is the removal of a uterus or removal of diseased ovaries (bilateral oophorectomy) because of a tumor, or bilateral orchiectomy in the case of prostate cancer.Elective hysterectomy, tubal ligation and vasectomy in the absence of a disease for which sterilization is considered an effective treatment is not covered. In addition, no payment would be made for sterilization procedures if it is a preventive measure e.g., a physician believes pregnancy would cause overall endangerment to a woman's health, or as a measure to prevent the possible development of, or effect on a mental condition, should pregnancy occur. (Section 1862(a)(1)(A) of the Social Security Act and 42 CFR 411.15(k).Claims will be denied on postpay review and payment recouped if the pathological evidence of the necessity to perform any of these procedures to treat an illness or injury is absent and/or when the primary objective is to achieve sterilization.
Article - Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence (A53359)
CMS National Coverage PolicyN/AArticle TextBackgroundSacral Nerve Stimulation for urinary incontinence is covered for the treatment of urinary urge incontinence, urge-frequency syndrome, and urinary retention by the CMS National Coverage Determination (NCD) 230.18, http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf. Direct stimulation of the sacral nerve(s) via an electrode array implanted at the level of the sacrum is the only treatment modality covered by the NCD. In addition, Noridian will cover sacral nerve stimulation by the same modality for the treatment of fecal incontinence, effective March 1, 2012.Indications and LimitationsUrinary IncontinenceSacral nerve stimulation is covered for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. Sacral nerve stimulation involves both a temporary test stimulation to determine if an implantable stimulator would be effective and a permanent implantation in appropriate candidates. Both the test and the permanent implantation are covered.The NCD describes the following limitations for coverage to all three conditions: Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur. Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) which are associated with secondary manifestations of the above three indications are excluded. Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement through test stimulation. Improvement is measured through voiding diaries.Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.Fecal IncontinenceNoridian will cover sacral nerve modulation/stimulation for fecal incontinence effective March 1, 2012, when all of the following criteria are met:
Article - Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence (A53359)
Fecal IncontinenceNoridian will cover sacral nerve modulation/stimulation for fecal incontinence effective March 1, 2012, when all of the following criteria are met: Chronic fecal incontinence with greater than two incontinent episodes on average per week and duration of incontinence greater than six months or for more than twelve months after vaginal childbirth; AND Documented failure or intolerance to conventional therapy (e.g., dietary modification, the addition of bulking and pharmacologic treatment); AND A successful percutaneous test stimulation, defined as at least 50% sustained (more than one week) improvement in symptoms; AND Condition is not related to anorectal malformation (e.g., congenital anorectal malformation; defects of the external anal sphincter over 60 degrees; visible sequelae of pelvic radiation; active anal abscesses and fistulae) and/or chronic inflammatory bowel disease; AND Incontinence is not related to another neurologic condition such as peripheral neuropathy or complete spinal cord injury.Sacral nerve modulation/stimulation is consideredexperimental, investigational and unproven for the treatment of chronic constipation or chronic pelvic pain.Sources:
Article - Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence (A53359)
Sacral nerve modulation/stimulation is consideredexperimental, investigational and unproven for the treatment of chronic constipation or chronic pelvic pain.Sources:Internet Only Manual (IOM)Medicare National Coverage Determination Manual, Publication 100-03, Section 230.18Sacral Nerve Stimulation for Urinary Incontinence;Abrams P et al. Fourth International Consultation on Incontinence recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence;Neurourol Urodyn. 2010; 29(1):213-40;Annals of Surgery, March 2010, Vol 251, Number 3.Sacral Nerve Stimulation for Fecal Incontinence, Results of a 120-Patient Prospective Multicenter Study;Michelsen H, Thompson-Fawcett M, Lundy L, Krogh K, Laurberg S, Buntzen S;Six Year Experience with Sacral Nerve Stimulation for Fecal Incontinence;Dis Colon Rectum. 2010; 53(4)414-421; Mowatt G, Glazener CMA, Jarrett M. Sacral nerve stimulation for fecal incontinence and constipation in adults (Review);The Cochrane Library. 2009, Issue 1; National Institute for Health and Clinical Excellence. Fecal incontinence: the management of fecal incontinence in adults. NICE Clinical Guideline 49, June 2007;Trailblazer Health Enterprises, Local Coverage Determination forSacral Nerve Stimulation 4S-154AB-R9, Effective March 01, 2008
Article - Billing and Coding: Aflibercept (EYLEA®) (A53387)
CMS National Coverage PolicyN/AArticle TextEffective November 18, 2011, September 21, 2012, July 29, 2014, October 6, 2014, March 25, 2015, and May 13, 2019respectively, Aflibercept(EYLEA) was approved by the Food and Drug Administration (FDA) for the treatment of patients with:Neovascular (Wet) Aged-related Macular Degeneration (AMD)Macular Edema following Retinal Vein Occlusion (RVO)Diabetic Macular Edema (DME)Diabetic Retinopathy (DR)For AMD the recommended dose is 2 mg (0.05 mL) administered by intravitreal injection every four weeks for the first 12 weeks (3 months), followed by 2 mg (0.05 mL) once every8 weeks (2 months) by intravitreal injection. AlthoughEYLEAmay be dosed as frequently as 2 mg every 4 weeks (monthly), additional efficacy was not demonstrated in most patients whenEYLEAwasdosed every 4 weeks compared to every 8 weeks. Some patients may need every 4 week (monthly) dosing after the first 12 weeks (3 months).For Macular Edema following RVO the recommended dose is 2 mg (0.05 mL) administered by intravitreal injection once every4 weeks (monthly).
Article - Billing and Coding: Aflibercept (EYLEA®) (A53387)
For Macular Edema following RVO the recommended dose is 2 mg (0.05 mL) administered by intravitreal injection once every4 weeks (monthly).For DME the recommended dose is 2 mg (0.05mL) once every 4 weeks (monthly)for the first 5 injections, and then 2 mg (0.05 mL) every 2 months (8 weeks) by intravitreal injection. AlthoughEYLEAmay be dosed as frequently as 2 mg every 4 weeks (monthly), additional efficacy was not demonstrated in most patients whenEYLEAwasdosed every 4 weeks compared to every 8 weeks. Some patients may need every 4 week (monthly) dosing after the first 20 weeks (5months).For Diabetic retinopathy (DR) the recommended dose is 2 mg (0.05 mL) once every 4 weeks (monthly) for the first 5 injections, followed by 2 mg (0.05 mL) once every 8 weeks (every 2 months). Although may be administered every 4 weeks, additional efficacy has not been demonstrated (compared with every 8 week administration); some patients may require every 4 week (monthly) dosing after the first 20 weeks of therapy (5 months).To bill aflibercept services, submit the following claim information on CMS Form 1500: J0177 OR J0178 67028  Intravitreal injection of a pharmacologic agent (separate procedure)Note:It is not reasonable and necessary to inject more than one anti-vascular endothelial growth factor (VEGF) medication (bevacizumab, ranibizumab, aflibercept) in the same eye during the same treatment session. It is not typical to inject one anti-VEGF medication in one eye and another in the other eye. If different medications are injected into each eye during the same DOS, the rationale for this therapy must be documented in the medical record and the billing modifier (RT/LT) must be appended to the correct drug.Intravitreal injection for the treatment of macular edema more frequently than every 4 weeks regardless of which drug is used for any given injection i.e., alternating drugs every 2 weeks will not be covered.