evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Implantable Automatic Defibrillators (A56343)
For these patients identified in B3, a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1) of the Act or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in 1861(aa)(5) of the Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision making encounter may occur at a separate visit.ICD-10-CM code I25.5 must be billed with one of the following ICD-10-CM codes which describe the above: I50.21, I50.22, I50.23, I50.41, I50.42 or I50.43.4. Patients who have severe, non-ischemic, dilated cardiomyopathy but no personal history of cardiac arrest or sustained VT, NYHA Class II or III heart failure, LVEF  35%, been on optimal medical therapy for at least three (3) months. Additionally, patients must not have:Had a CABG or PCI with angioplasty and/or stenting, within the past three (3) months; or,Had an MI within the pastforty days; or,Clinical symptoms and findings that would make them a candidate for coronary revascularization.
Article - Billing and Coding: Implantable Automatic Defibrillators (A56343)
For these patients identified in B4, a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1) of the Act) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in 1861(aa)(5) of the Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision making encounter may occur at a separate visit.ICD-10-CM codes I42.0, I42.6, I42.7 or I42.8 must be billed with one of the following ICD-10-CM codes which describe the above: I50.21, I50.22, I50.23, I50.41, I50.42 or I50.43.5. Patients with documented, familial or genetic disorders with a high risk of life-threatening tachyarrhythmias (sustained VT or VF, to include, but not limited to, long QT syndrome or hypertrophic cardiomyopathy).For these patients identified in B5, a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1) of the Act) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in 1861(aa)(5) of the Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision making encounter may occur at a separate visit.ICD-10-CM codes which describe the above: I42.1, I42.2, I45.6, I45.81 or I45.89.6. Patients with an existing ICD may receive an ICD replacement if it is required due to the end of battery life, Elective Replacement Indicator (ERI), or device/lead malfunction.For each of the six (6) covered indications above, the following additional criteria must also be met:
Article - Billing and Coding: Implantable Automatic Defibrillators (A56343)
Patients must be clinically stable (e.g., not in shock, from any etiology);LVEF must be measured by echocardiography, radionuclide (nuclear medicine) imaging, cardiac Magnetic Resonance Imaging (MRI), or catheter angiography;Patients must not have:Significant, irreversible brain damage; or,Any disease, other than cardiac disease (e.g., cancer, renal failure, liver failure) associated with a likelihood of survival less than one (1) year; or,Supraventricular tachycardia such as atrial fibrillation with a poorly controlled ventricular rate.
Article - Billing and Coding: Implantable Automatic Defibrillators (A56343)
Exceptions to waiting periods for patients that have had a CABG, or PCI with angioplasty and/or stenting, within the past three (3) months, or had an MI within the past forty days:Cardiac Pacemakers: Patients who meet all CMS coverage requirements for cardiac pacemakers, and who meet the criteria in this national coverage determination for an ICD, may receive the combined devices in one procedure, at the time the pacemaker is clinically indicated;Replacement of ICDs: Patients with an existing ICD may receive an ICD replacement if it is required due to the end of battery life, ERI, or device/lead malfunction.ICD-10-CM codes which describe the above: T82.110A, T82.111A, T82.118A, T82.119A, T82.120A, T82.121A, T82.128A, T82.129A, T82.190A, T82.191A, T82.198A, T82.199A, T82.7XXA or Z45.02.C. Nationally Non-Covered IndicationsN/AD. OtherFor patients that are candidates for heart transplantation on the United Network for Organ Sharing (UNOS) transplant list awaiting a donor heart, coverage of ICDs, as with cardiac resynchronization therapy, as a bridge-to-transplant to prolong survival until a donor becomes available, is determined by the local Medicare Administrative Contractors (MACs).ICD-10-CM code Z76.82 must be billed with ICD-10-CM code I50.84 which describes the above.All other indications for ICDs not currently covered in accordance with this decision may be covered under Category B Investigational Device Exemption (IDE) trials (42 CFR 405.201).ICD-10-CM code which describes the above: Z00.6,with modifier Q0 appended to the HCPCS code billed.
Article - Billing and Coding: Implantable Automatic Defibrillators (A56343)
ICD-10-CM code which describes the above: Z00.6,with modifier Q0 appended to the HCPCS code billed.The coding and billing guidelines apply to the following ICD-10-Procedure codes: insertion codes: 0JH608Z, 0JH609Z, 0JH60FZ, 0JH638Z, 0JH639Z, 0JH63FZ, 0JH808Z, 0JH809Z, 0JH838Z, 0JH839Z, 02H43KZ, 02H60KZ, 02H63KZ, 02H64KZ, 02H70KZ, 02H73KZ, 02H74KZ, 02HK0KZ, 02HK3KZ, 02HK4KZ, 02HL0KZ, 02HL3KZ, 02HL4KZ, 0WHC0GZ, 0WHC3GZ, 0WHC4GZ, removal codes: 0JPT0FZ, 0JPT0PZ, 0JPT3FZ, 0JPT3PZ, 02PA0MZ, 02PA3MZ, 02PA4MZ 0WPC0GZ, 0WPC3GZ, 0WPC4GZ, 0WPCXGZ and revision codes: 0WWC0GZ, 0WWC3GZ, 0WWC4GZ, 0WWCXGZ.The coding and billing guidelines also apply to the following CPTcodes: 33202, 33203, 33223, 33230, 33231, 33240, 33241, 33243, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, G0448, 33215, 33216, 33217, 33218, 33220, 33224, 33225, C7537, C7538, C7539 and C7540.ICD professional services are only covered for inpatient or outpatient facilities: POS 19, 21, 22, 24, and 26.
Article - Billing and Coding: Removal of Benign and Malignant Skin Lesions (A56346)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Removal of Benign and Malignant Skin Lesions L33445.When using diagnosis code L82.0 (inflamed seborrheic keratosis), the legible medical records should reference a patients complaint or a physicians physical findings.Check the Medicare Physician Fee Schedule Database (MPFSDB) for the codes where the global policy would be applied. Use modifier 25 appended to the appropriate visit code to indicate that the patient's condition required a significant, separately identifiable service by the same physician on the same day of the procedure that was performed.
Article - Billing and Coding: MolDX: Oncotype DX® Genomic Prostate Score (A56372)
CMS National Coverage PolicyN/AArticle TextThe Oncotype DX Genomic Prostate Score (Genomic Health) is covered for use in very low risk, low risk, and favorable intermediate risk prostate cancer.To bill for Oncotype DX Genomic Prostate Score services, please provide the following claim information:CPT code 0047U for services on or after 01/01/2019.Enter 1 in the Days/Unit fieldFor CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim form
Article - Billing and Coding: Rituximab (A56380)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessarydocumentation to process the claimCMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Change Request 10530, Transmittal3996 dated March 9, 2018CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, 40 DiscardedDrugs and BiologicalsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Rituximab L35026.
Article - Billing and Coding: Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication (A56384)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process that claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Supervised Exercise Therapy for the Treatment of Peripheral Arterial Disease with Symptomatic Lower Extremity Intermittent Claudication.After the initial 36 treatment sessions or 12 weeks (whichever comes first) beneficiaries may be eligible for another 36 treatment sessions with another referral from a physician. The requirements of this second referral are the same as for the initial referral. All claims submitted for additional sessions after the first 36 sessions or the initial 12 week period must append modifier -KX to the CPT code for this service in order to attest that those requirements have been fulfilled.ICD-10-CM diagnosis codes supporting medical necessity must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.Any diagnosis submitted must have documentation in the patients record to support coverage and medical necessity.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
Article - Billing and Coding: Upper Gastrointestinal Endoscopy and Visualization (A56389)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Upper Gastrointestinal Endoscopy and Visualization L34434.All unlisted procedure codes billed for services are subject to development and medical review.
Article - Billing and Coding: Lumbar Artificial Disc Replacement (A56390)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary information to process that claimArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lumbar Artificial Disc Replacement L37826.
Article - Billing and Coding: Implantable Automatic Defibrillators (A56391)
CMS National Coverage PolicyN/AArticle TextThe National Coverage Determination (NCD) 20.4, Implantable Automatic Defibrillators was revised with an effective date of February 15, 2018. The CMS A/B Medicare Administrative Contractors (MACs) have been instructed to implement the NCD at the local level. The following provides coding and billing instructions for the implementation of NCD 20.4. (CMS policy language is in italics.) The NCD Item/Service Description and Indications and Limitations are repeated here.Note: This article does not alter previous CMS A/B Medicare Administrative Contractors (MACs) instructions for coding and billing of NCD 20.8.3 (National Coverage Determination (NCD) for Cardiac Pacemakers: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers) nor does it alter MAC Local Coverage for Cardiac Resynchronization Therapy.Item/Service DescriptionA. GeneralAn ICD is an electronic device designed to diagnose and treat life-threatening ventricular tachyarrhythmias.Indications and Limitations of CoverageB. Nationally Covered IndicationsEffective for services performed on or after February 15, 2018, CMS has determined that the evidence is sufficient to conclude that the use of ICDs, (also referred to as defibrillators) is reasonable and necessary:Patients with a personal history of sustained Ventricular Tachyarrhythmia (VT) or cardiac arrest due to Ventricular Fibrillation (VF). Patients must have demonstrated:An episode of sustained VT, either spontaneous or induced by an Electrophysiology (EP) study, not associated with an acute Myocardial Infarction (MI) and not due to a transient or reversible cause; orAn episode of cardiac arrest due to VF, not due to a transient or reversible cause.ICD-10-CM codes which describe the above: I46.2, I46.9, I47.20, I47.21, I47.29, I49.01, I49.02, I49.3, I49.9, I5A, Z45.02 or Z86.74.Patients with a prior MI and a measured Left Ventricular Ejection Fraction (LVEF)  0.30. Patients must not have:
Article - Billing and Coding: Implantable Automatic Defibrillators (A56391)
Patients with a prior MI and a measured Left Ventricular Ejection Fraction (LVEF)  0.30. Patients must not have:New York Heart Association (NYHA) classification IV heart failure; or,Had a Coronary Artery Bypass Graft (CABG), or Percutaneous Coronary Intervention (PCI) with angioplasty and/or stenting, within the past three (3) months; or,Had an MI within the past 40 days; or,Clinical symptoms and findings that would make them a candidate for coronary revascularization.For these patients identified in B2, a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1) of the Social Security Act (the Act)) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in 1861(aa)(5) of the Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision making encounter may occur at a separate visit.ICD-10-CM code I25.2 must be billed with one of the following ICD-10-CM codes which describe the above: I50.21, I50.22, I50.23, I50.41, I50.42 or I50.43.Patients who have severe, ischemic, dilated cardiomyopathy but no personal history of sustained VT or cardiac arrest due to VF, and have NYHA Class II or III heart failure, LVEF  35%. Additionally, patients must not have:Had a CABG, or PCI with angioplasty and/or stenting, within the past three (3) months; or,Had an MI within the past 40 days; or,Clinical symptoms and findings that would make them a candidate for coronary revascularization.
Article - Billing and Coding: Implantable Automatic Defibrillators (A56391)
For these patients identified in B3, a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1) of the Act) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in 1861(aa)(5) of the Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision making encounter may occur at a separate visit.ICD-10-CM code I25.5 must be billed with one of the following ICD-10-CM codes which describe the above: I50.21, I50.22, I50.23, I50.41, I50.42 or I50.43.Patients who have severe, non-ischemic, dilated cardiomyopathy but no personal history of sustained VT or cardiac arrest due to VF, and have NYHA Class II or III heart failure, LVEF  35%, been on optimal medical therapy for at least three (3) months. Additionally, patients must not have:Had a CABG or PCI with angioplasty and/or stenting, within the past three (3) months; or,Had an MI within the past 40 days; or,Clinical symptoms and findings that would make them a candidate for coronary revascularization.For these patients identified in B4, a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1) of the Act) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in 1861(aa)(5) of the Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision making encounter may occur at a separate visit.ICD-10-CM codes I42.0, I42.6, I42.7 or I42.8 must be billed with one of the following ICD-10-CM codes which describe the above: I50.21, I50.22, I50.23, I50.41, I50.42 or I50.43.
Article - Billing and Coding: Implantable Automatic Defibrillators (A56391)
Patients with documented, familial or genetic disorders with a high risk of life-threatening tachyarrhythmias (sustained VT or VF, to include, but not limited to, long QT syndrome or hypertrophic cardiomyopathy).For these patients identified in B5, a formal shared decision making encounter must occur between the patient and a physician (as defined in Section 1861(r)(1) of the Act) or qualified non-physician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in 1861(aa)(5) of the Act) using an evidence-based decision tool on ICDs prior to initial ICD implantation. The shared decision making encounter may occur at a separate visit.ICD-10-CM codes which describe the above: Q24.6, I42.1, I42.2, I45.6, I45.81 or I45.89.Patients with an existing ICD may receive an ICD replacement if it is required due to the end of battery life, Elective Replacement Indicator (ERI), or device/lead malfunction.For each of the six (6) covered indications above, the following additional criteria must also be met:Patients must be clinically stable (e.g., not in shock, from any etiology);LVEF must be measured by echocardiography, radionuclide (nuclear medicine) imaging, cardiac Magnetic Resonance Imaging (MRI), or catheter angiography;Patients must not have:Significant, irreversible brain damage; or,Any disease, other than cardiac disease (e.g., cancer, renal failure, liver failure) associated with a likelihood of survival less than one (1) year; or,Supraventricular tachycardia such as atrial fibrillation with a poorly controlled ventricular rate.
Article - Billing and Coding: Implantable Automatic Defibrillators (A56391)
Exceptions to waiting periods for patients that have had a CABG, or PCI with angioplasty and/or stenting, within the past three (3) months, or had an MI within the past 40 days:Cardiac Pacemakers: Patients who meet all CMS coverage requirements for cardiac pacemakers, and who meet the criteria in this national coverage determination for an ICD, may receive the combined devices in one procedure, at the time the pacemaker is clinically indicated;Replacement of ICDs: Patients with an existing ICD may receive an ICD replacement if it is required due to the end of battery life, ERI, or device/lead malfunction.ICD-10-CM codes which describe the above: T82.110A, T82.111A, T82.118A, T82.119A, T82.120A, T82.121A, T82.128A, T82.129A, T82.190A, T82.191A, T82.198A, T82.199A, T82.7XXA or Z45.02.
Article - Billing and Coding: Implantable Automatic Defibrillators (A56391)
C. Nationally Non-Covered IndicationsN/AD. OtherFor patients that are candidates for heart transplantation on the United Network for Organ Sharing (UNOS) transplant list awaiting a donor heart, coverage of ICDs, as with cardiac resynchronization therapy, as a bridge-to-transplant to prolong survival until a donor becomes available, is determined by the local Medicare Administrative Contractors (MACs).ICD-10-CM code Z76.82 must be billed with ICD-10-CM code I50.84 which describes the above.All other indications for ICDs not currently covered in accordance with this decision may be covered under Category B Investigational Device Exemption (IDE) trials (42 CFR 405.201).ICD-10-CM code which describes the above: Z00.6.The coding and billing guidelines apply to the following ICD-10 Procedure codes: insertion codes: 0JH608Z, 0JH609Z, 0JH638Z, 0JH639Z, 0JH808Z, 0JH809Z, 0JH838Z, 0JH839Z, 0JH60FZ, 0JH63FZ, 02H43KZ, 02H60KZ, 02H63KZ, 02H64KZ, 02H70KZ, 02H73KZ, 02H74KZ, 02HK0KZ, 02HK3KZ, 02HK4KZ, 02HL0KZ, 02HL3KZ, and 02HL4KZ. The following ICD-10 Procedure insertion codes are applicable effective 10/01/2023: 0WHC0GZ, 0WHC3GZ, and 0WHC4GZ.The coding and billing guidelines apply to the following ICD Procedure codes revision codes effective 10/01/2023: 0WWC0GZ, 0WWC3GZ, 0WWC4GZ, and 0WWCXGZ.
Article - Billing and Coding: Implantable Automatic Defibrillators (A56391)
The billing and coding guidelines apply to the following ICD-10 Procedure removal codes, which will not have diagnosis code limitations applied at this time: 0JPT0FZ, 0JPT0PZ, 0JPT3FZ. 0JPT3PZ, 02PA0MZ, 02PA3MZ, and 02PA4MZ. The following ICD Procedure removal codes are applicable effective 10/01/2023: 0WPC0GZ, 0WPC3GZ, 0WPC4GZ, and 0WPCXGZ. Procedure code 02PAXMZ is no longer valid after 10/01/2021.The coding and billing guidelines also apply to the following CPT codes: 33202, 33203, 33223, 33230, 33231, 33240, 33241, 33243, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, G0448, 33215, 33216, 33217, 33218, 33220, 33224 and 33225. Effective 01/01/2023 the billing and coding guidelines apply to the following HCPCS codes: C7537, C7538, C7539 and C7540.
Article - Billing and Coding: Colonoscopy and Sigmoidoscopy-Diagnostic (A56394)
CMS National Coverage PolicyN/AArticle TextThis article only applies todiagnosticcolonoscopies and sigmoidoscopies. Sigmoidoscopy and colonoscopy testing allows for the direct visualization of the lower gastrointestinal tract. Inspection is performed with an illuminated tube. These procedures are performed to detect polyps, tumors and other lesions of the intestines. The site of pathology can be identified during a colonoscopy and a biopsy can be obtained. Refer to associated LCD L34614.Refer to the Medicare Internet Only Manuals (IOM) for coverage of colorectal cancer screening procedures.Documentation RequirementsThe medical record should support the medical reasonableness, necessity and frequency of the diagnostic test performed. This documentation should be made available to the Contractor upon request.Documentation must indicate the precise areas scoped and the depth reached during colonoscopy.Utilization GuidelinesIt is expected that these services would be performed as indicated by current medical literature and/or standards of practice.