evekhm/cms_iom_500 huggingface dataset:
Article - Chiropractic Services – Medical Policy Article (A57889)
An acute exacerbation is a temporary but marked deterioration of the patients condition that is causing significant interference with activities of daily living due to an acute flare-up of the previously treated condition. The patients clinical record must specify the date of occurrence, nature of the onset, or other pertinent factors that would support the medical necessity of treatment. As with an acute injury, treatment should result in improvement or arrest of the deterioration within a reasonable period of time.A. Maintenance TherapyMaintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.(CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3A)B. ContraindicationsDynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement. A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The doctor should discuss this risk with the patient and record this in the chart.(CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3B)The following arerelative contraindicationsto Dynamic thrust:Articular hyper mobility and circumstances where the stability of the joint is uncertain;Severe demineralization of bone;Benign bone tumors (spine);Bleeding disorders and anticoagulant therapy;and Radiculopathy with progressive neurological signs.(CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3B).Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation and proposed manipulation in the following:Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation; including acute rheumatoid arthritis and ankylosing spondylitis;Acute fractures and dislocations or healed fractures and dislocations with signs of instability;An unstable os odontoideum;Malignancies that involve the vertebral column;
Article - Chiropractic Services – Medical Policy Article (A57889)
Acute fractures and dislocations or healed fractures and dislocations with signs of instability;An unstable os odontoideum;Malignancies that involve the vertebral column;Infection of bones or joints of the vertebral column;Signs and symptoms of myelopathy or cauda equina syndrome;For cervical spinal manipulations, vertebrobasilar insufficiency syndrome; and A significant major artery aneurysm near the proposed manipulation.(CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3B).The term physician under Part B includes a chiropractor who meets the specified qualifying requirements set forth in 30.5 but only for treatment by means of manual manipulation of the spine to correct a subluxation.(CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 240)Coverage extends only to treatment by means of manual manipulation of the spine to correct a subluxation provided such treatment is legal in the State where performed. All other services furnished or ordered by chiropractors are not covered.(CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 30.5)No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractors order is covered. This means that if a chiropractor orders, takes, or interprets an x-ray, or any other diagnostic test, the x-ray or other diagnostic test, can be used for claims processing purposes, but Medicare coverage and payment are not available for those services. This prohibition does not affect the coverage of x-rays or other diagnostic tests furnished by other practitioners under the program. For example, an x-ray or any diagnostic test taken for the purpose of determining or demonstrating the existence of a subluxation of the spine is a diagnostic x-ray test covered under 1861(s)(3) of the Act if ordered, taken, and interpreted by a physician who is a doctor of medicine or osteopathy.(CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 240.1.1)
Article - Chiropractic Services – Medical Policy Article (A57889)
The mere statement or diagnosis of "pain" is not sufficient to support medical necessity for the treatments. The precise level(s) of the subluxation(s) must be specified by the chiropractor to substantiate a claim for manipulation of each spinal region(s). There are five spinal regions addressed: cervical region (atlanto-occipital joint), thoracic region (costovertebral/costotransverse joints), lumbar region, pelvic region (sacro-iliac joint) and sacral region (ref. CPT Professional Edition 2017 p. 672).Medicare does not cover chiropractic treatments to extraspinal regions (CPT 98943). The five extraspinal regions are: head (including temporomandibular joint, excluding atlanto-occipital) region; lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints) and abdomen (CPT Assistant Nov 98:38).For Medicare purposes, a chiropractormustplace an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. However the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary. As always, contractors may deny if appropriate after medical review.(CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3). Modifier AT must only be used when the chiropractic manipulation is reasonable and necessary as defined by national policy. Modifier AT must not be used when maintenance therapy has been performed. The need for a prolonged course of treatment should be appropriate to the reported procedure code(s) and medical necessity must be documented clearly in the medical record.
Article - Chiropractic Services – Medical Policy Article (A57889)
Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed.Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines:An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04,Medicare Claims Processing Manual,Chapter 30, for complete instructions.Specific coding guidelines for this policy:
Article - Chiropractic Services – Medical Policy Article (A57889)
The precise level of the subluxation must be listed.The date of the initial treatment or date of exacerbation of the existing condition must be entered in Item 14 of the CMS-1500 form or the electronic equivalent.If using an x-ray as documentation of the subluxation, the date of the x-ray (or existing MRI or CT scan) must be entered in Item 19 of the CMS-1500 form or the electronic equivalent.If an authorized ordering practitioner orders the x-ray, then he/she should enter his/her name in Item 17 of the CMS-1500 form and his/her own NPI number in Item 17a of the CMS-1500 form, or the electronic equivalent, as the ordering physician.The HCPCS modifier AT (acute treatment)mustbe appended to the chiropractic manipulation code to indicate the manipulation was for medically necessary and reasonable treatment of an acute subluxation or chronic subluxation as defined in national policy and the LCD.The AT modifier must not be placed on the claim when maintenance therapy has been provided. Claims without the AT modifier will be considered as maintenance therapy and denied. Chiropractors who give or receive from beneficiaries an ABN shall follow the instructions in Pub. 100-04, Medicare Claims Processing Manual, chapter 23, section 20.9.1.1 and include a GA (or in rare instances a GZ) modifier on the claim.(CMS Publication 100-02,Medicare Benefit Policy Manual,Chapter 15: Section 240.1.3)For claims submitted to the Part B MAC:All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.
Article - Billing and Coding: MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies (A57891)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Next Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies L38123.Relevant Article: Billing and Coding: MolDX: Testing of Multiple Genes A58120:To report a Next Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode 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-Codeidentifier adjacent to the CPTcode 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 formSelect the appropriate ICD-10-CM codeNOTE:When entering the DEX Z-Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: MolDX: Next-Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies (A57892)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Next Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies L38125.Relevant Article: Billing and Coding: MolDX: Testing of Multiple Genes A58121:To report a Next Generation Sequencing Lab-Developed Tests for Myeloid Malignancies and Suspected Myeloid Malignancies service, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier adjacent to the CPTcode 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-Codeidentifier adjacent to the CPTcode 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 formSelect the appropriate ICD-10-CM codeNOTE:When entering the DEX Z-Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: MolDX: Next-Generation Sequencing for Solid Tumors (A57901)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure Codes.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Next Generation Sequencing for Solid Tumors L38119.Relevant Article: Billing and Coding: MolDx: Testing of Multiple Genes A58120:To report a Next Generation Sequencing for Solid Tumors service, please submit with the following claim information:Select the appropriate CPT codeEnter 1 unit of service (UOS)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 Par A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM codeNOTE:Whenentering the DEX Z-Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: MolDX: Next-Generation Sequencing for Solid Tumors (A57905)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Next Generation Sequencing for Solid Tumors L38121.Relevant Article: Billing and Coding: MolDx: Testing of Multiple Genes A58121:To report a Next Generation Sequencing for Solid Tumors service, please submit with the following claim information:Select the appropriate CPT codeEnter 1 unit of service (UOS)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 Par A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM codeNOTE:Whenentering the DEX Z-Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: MolDX: Testing of Multiple Genes (A57910)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title 42 CFR 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: ConditionsArticle Text
Article - Billing and Coding: MolDX: Testing of Multiple Genes (A57910)
The following information will be effective 10/21/2019 for dates of service on or after 10/15/2019.Refer toBilling and Coding: MolDX: Molecular Diagnostic Tests (MDT) A56973for CPT/HCPCS Codes that are applicable to this article.A panel of genes is a distinct procedural service from a series of individual genes. All services billed to Medicare must be reasonable and necessary. As such, if a provider or supplier submits a claim for a panel, then the patients medical record must reflect that the panel was reasonable and necessary. Alternatively, if a provider or supplier bills for a number of individual genes, then the patients medical record must reflect that each individual gene is reasonable and necessary.For ease of reading the term gene when used in this document will be used to indicate a gene, region of a gene, and / or variant(s) of a gene.Genes can be assayed serially or in parallel. Genes assayed on the same date of service are considered to be assayed in parallel if the result of 1 assay does not affect the decision to complete the assay on another gene, and the 2 genes are being tested for the same indication. Genes assayed on the same date of service are considered to be assayed serially when there is a reflexive decision component where the results of the analysis of 1 or more genes determines whether the results of additional analyses are reasonable and necessary.If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so 1 HCPCS codes must be submitted for the panel. If the laboratory assays genes in serial, then the laboratory must submit claims for genes individually. The order by the treating clinician must reflect whether the treating clinician is ordering a panel or single genes, and additionally, the patients medical record must reflect that the service billed was reasonable and necessary.Two examples:Single Service Example:A clinician orders 5 specific genes associated with breast cancer. The laboratory analyzes the 5 genes for common mutations using polymerase chain reaction. All 5 PCR procedures are started prior to the results of any one PCR procedure being known. The results are signed off on simultaneously, and all 5 results are sent to a clinician.
Article - Billing and Coding: MolDX: Testing of Multiple Genes (A57910)
This would be considered a single procedural service, a single 5 gene panel, and it must be billed as such. This single panel must be reasonable and necessary to be billed to Medicare.Multiple Distinct Procedural Services Example:A clinician requests that genes associated with early onset colorectal cancer be analyzed in a patient. The clinician orders stepwise reflex testing where a negative or positive result in 1 gene determines whether additional analysis on other genes will be performed or what that will be.Each gene assayed represents 1 procedural service, so if more than 1 gene is analyzed, then multiple procedural services may be billed in some patients for whom reflex testing goes beyond the first gene. Each gene billed to Medicare must be individually reasonable and necessary. A clinicians order is not by itself sufficient to indicate that a test was reasonable and necessary. The record must reflect that the test is used in the management of the beneficiary's specific medical problem in accordance with CFR 410.32.Labs must register a test with the Diagnostics Exchange as it reflected on the order form and is run in the laboratory. If a gene / variant is tested as part of a panel, then the lab must register the panel and must submit the correct z-code and CPT code for the panel. If a lab has a panel but sometimes also analyzes individual genes from the panel, the lab must register both the panel and the individual genes that are analyzed.In general 2 or more codes describing a genetic test billed on the same beneficiary on the same date may constitute a panel, and if so the service must be billed as a single procedural service. We would generally expect that a provider or supplier would not bill for more than 2 distinct laboratory genetic testing procedural services on a single beneficiary on a single date of service. If providers or suppliers do bill for more than 2 distinct laboratory genetic testing procedural services on a single beneficiary on a single date of service, the provider or supplier must attest that each additional service billed is a distinct procedural service using the 59 modifier.The use of the 59 modifier will be considered an attestation that distinct procedural services are being performed rather than a panel. Providers and suppliers must use the 59 modifier in conjunction with other modifiers where appropriate. When providers and suppliers bill for multiple distinct procedural services, each service must be reasonable and necessary.
Article - Billing and Coding: MolDX: Testing of Multiple Genes (A57910)
Laboratories that are billing for many individual genes using the 59 modifier rather than panels may be subject to medical review as outliers.When 2 or more codes are submitted for the same beneficiary on the same date of service, the claims processing system will reject every code submitted after the first service. However, if a lab runs more than 1 distinct procedural service on a single date of service, then the lab must use the 59 modifier with each additional service billed as an attestation that it is a distinct procedural service.