evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Frequency of Hemodialysis (A55354)
Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Frequency of Hemodialysis L34575.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.This article outlineshow to lineitem bill dialysis sessionsfor End Stage Renal Disease (ESRD) patients. This does not address line item billing forsessions associated with training or other modalities such as peritoneal dialysis. This article does not change any other billing requirements for dialysis claims. Note: This article uses the terms dialysis "session" and "treatment" interchangeably.CMS Internet-Only Manual, Pub 100-04,Medicare Claims Processing Manual, Chapter 8, requires line item billing for all ESRD claims with dates of service (DOS) on or after April 1, 2007. Each dialysis session performed should be reported on a separate line.CMS Internet-Only Manual, Pub100-02,Medicare Benefit Policy Manual, Chapter 11 discusses that ESRD facilities furnishing dialysis treatments in-facility or in the beneficiary's home are paid for up to 3 treatments per week. Payment for additional treatments, defined as any treatments in excess 3 treatments per week, may be considered in addition to the ESRD PPS per treatment payment amount paid for up to 3 treatments per week.For monthly claims submitted with Bill Type 72X and Revenue Codes 0821 and 0881, 3 approaches of billingper lineare available. Based on the Patients Plan of Care (POC), or other available medical documents, the following scheme should be followed when billing sessions. Note: Dialysis sessions in the patient's POC that are not furnished should not be billed.
Article - Billing and Coding: Frequency of Hemodialysis (A55354)
For dialysis sessions that have been furnished 3 times (3X) per week,each line should be 90999 without any modifiers appended. That is, when the hemodialysis prescription is3 times (3X) per week and each session is furnished, all of these sessions should be billed as 90999 (no modifier appended) and they will be paid as routine conventional dialysis up to 13/14 per month.For each dialysis session furnished in addition to 3 sessions per week that do not include medical documentation supporting a reasonable and necessary determination for payment,each line for these sessions should be billed as 90999 CG. Examples of when this couldoccur include short, more frequent treatments furnished for the convenience of the patient or staff, etc. Additional sessions need to be billed as 90999 CG when medical documentation has not been submitted to support the extra sessions as reasonable and necessary. The CG modifier indicates that the facility attests the additional treatment is not reasonable and necessary andshould not receive additional payment. Each line billed as 90999 CG will be denied. However the use of the modifier is used for data analysis.Please refer to Change Request 9989, Implementation of Modifier CG for Type of Bill 72X, dated May 12, 2017.For eachdialysis session furnished in addition to 3 sessions per week that includes medical documentation supporting areasonable and necessary determination for payment,each line for these sessions should be billed as 90999 KX. These include medical conditions for acute and occasionally chronic conditions that have supporting documentation that the extra sessions are reasonable and necessary (e.g., through documents from recent hospital care, office visits, dialysis progress notes or MCP visits). These sessions must be reasonable and necessary for additional payment based on clinical conditions. On these claims, the 90999 lines without a modifier will be paid as 3X per week and those lines with 90999 KX will be considered for additional payments. Omission of the KX modifier will result in no additional payment for the lineitem. For diagnoses not listed in this article but felt to be reasonable and necessary, the KX modifier should be appended as well. A denial will occur on these lines, but the redetermination process (an appeal) will be available to submit supportive documentation for review.
Article - Billing and Coding: Frequency of Hemodialysis (A55354)
The expectation is that these 3 scenarios will be seen on monthly claims, i.e., claims with 90999 lines only, or those with lines of 90999 mixed with 90999 CG or KX modifier appended. Ongoing data analysis may trigger provider specific requests for documentation should unusual patterns occur, i.e., claims with only lines of 90999 KX submitted.Please note that the POC and other supporting medical documentation to justify any of the line item sessions will be most important and may be requested.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.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.The medical record documentation must support the medical necessity of the services as stated in the related policy.Please see L34575 for instructions when clinical conditions outside those listed in the available diagnoses should occur.Please see L34575 for additionalDocumentation RequirementsandUtilization Guidelines.
Article - Billing and Coding: Therapy Evaluation Coding (A55367)
CMS National Coverage PolicyN/AArticle TextNoridian Healthcare Solutions, LLC is posting this article to assist providers in determining appropriate coding for therapy evaluation services.Providers occasionally receive multiple physician orders for multiple conditions for the same patient.  Because of the multiple conditions and specialization of therapists, this often results in the patient being evaluated by multiple therapists of the same discipline. The Centers for Medicare and Medicaid Services (CMS) does not require therapists to complete separate evaluations and plans of care for the treatment of patients with multiple medical conditions. The licensed clinician is expected to complete a thorough initial patient evaluation, which would include an assessment for each of the medical conditions requiring therapy treatment. Multiple evaluations occurring during a single episode of care (within a single therapy discipline) are not separately reimbursable except in the rare circumstance described below. However, CMS does not restrict the number of therapists (within a single therapy discipline) that can treat a patient. Providers may choose to have one or more on-staff therapists that specialize in the treatment of specific medical conditions (specialty therapists) work with the patient to optimize their full rehabilitation potential.Coding ConsiderationsA patient is being treated at the outpatient therapy clinic for condition A. During the course of treatment for condition A, the patient comes to the clinic for treatment of a new diagnosis, condition B:Scenario 1:When condition Bis relatedto condition A, then the appropriate code to bill for the evaluation service provided is a re-evaluation using CPT code 97164 - Re-evaluation of physical therapy established plan of care. Typically,20 minutesare spent face-to-face with the patient and/or family or 97168 - Reevaluation of occupational therapy established plan of care. Typically,30 minutesare spent face-to-face with the patient and/or family for Occupational Therapists.Example: A patient is receiving treatment for a total knee arthroplasty (TKA). During the episode of care, the patient develops shoulder pain. The clinician determines the pain is due to use of a walker, which the patient is using as a result of the TKA. In this scenario, the shoulder pain is a condition related to the TKA. Therefore, it is appropriate for the clinician to provide a re-evaluation of the patient due to this related condition.
Article - Billing and Coding: Therapy Evaluation Coding (A55367)
Scenario 2:When condition Bis not related, directly or indirectly, to condition A, then the evaluation of condition B would warrant billing for a new evaluation using CPT codes 97161 - Physical therapy evaluation: low complexity. Typically,20 minutesare spent face-to-face with the patient and/or family, 97162 - Physical therapy evaluation: moderate complexity. Typically,30 minutesare spent face-to-face with the patient and/or family or 97163 - Physical therapy evaluation: high complexity. Typically,45 minutesare spent face-to-face with the patient and/or family for Physical Therapy or 97165 - Occupational therapy evaluation, low complexity. Typically,30 minutesare spent face-to-face with the patient and/or family, 97166 - Occupational therapy evaluation, moderate complexity. Typically,45 minutesare spent face-to-face with the patient and/or family or 97167 - Occupational therapy evaluation, high complexity. Typically,60 minutesare spent face-to-face with the patient and/or family for Occupational Therapists.Example: A patient is receiving treatment following a TKA. During the episode of care for the TKA, the patient develops an acute rotator cuff injury from an accident at home. The clinician determines the rotator cuff injury is not related to the TKA. Therefore, it is appropriate for the clinician to provide a new evaluation for the rotator cuff injury since it a newly identified diagnosis for an unrelated condition.In either case, it is necessary for the documentation to accurately support the services provided.Source:Medicare Benefit Policy Manual(MBPM)Chapter 15 section 220(A) and 220.3.5(A)
Article - Billing and Coding: Therapy Evaluation Coding (A55371)
CMS National Coverage PolicyN/AArticle TextNoridian Healthcare Solutions, LLC is posting this article to assist providers in determining appropriate coding for therapy evaluation services.Providers occasionally receive multiple physician orders for multiple conditions for the same patient.  Because of the multiple conditions and specialization of therapists, this often results in the patient being evaluated by multiple therapists of the same discipline. The Centers for Medicare and Medicaid Services (CMS) does not require therapists to complete separate evaluations and plans of care for the treatment of patients with multiple medical conditions. The licensed clinician is expected to complete a thorough initial patient evaluation, which would include an assessment for each of the medical conditions requiring therapy treatment. Multiple evaluations occurring during a single episode of care (within a single therapy discipline) are not separately reimbursable except in the rare circumstance described below. However, CMS does not restrict the number of therapists (within a single therapy discipline) that can treat a patient. Providers may choose to have one or more on-staff therapists that specialize in the treatment of specific medical conditions (specialty therapists) work with the patient to optimize their full rehabilitation potential.Coding ConsiderationsA patient is being treated at the outpatient therapy clinic for condition A. During the course of treatment for condition A, the patient comes to the clinic for treatment of a new diagnosis, condition B:Scenario 1:When condition Bis relatedto condition A, then the appropriate code to bill for the evaluation service provided is a re-evaluation using CPT code 97164 - Re-evaluation of physical therapy established plan of care. Typically,20 minutesare spent face-to-face with the patient and/or family or 97168 - Reevaluation of occupational therapy established plan of care. Typically,30 minutesare spent face-to-face with the patient and/or family for Occupational Therapists.Example: A patient is receiving treatment for a total knee arthroplasty (TKA). During the episode of care, the patient develops shoulder pain. The clinician determines the pain is due to use of a walker, which the patient is using as a result of the TKA. In this scenario, the shoulder pain is a condition related to the TKA. Therefore, it is appropriate for the clinician to provide a re-evaluation of the patient due to this related condition.
Article - Billing and Coding: Therapy Evaluation Coding (A55371)
Scenario 2:When condition Bis not related, directly or indirectly, to condition A, then the evaluation of condition B would warrant billing for a new evaluation using CPT codes 97161 - Physical therapy evaluation: low complexity. Typically,20 minutesare spent face-to-face with the patient and/or family, 97162 - Physical therapy evaluation: moderate complexity. Typically,30 minutesare spent face-to-face with the patient and/or family or 97163 - Physical therapy evaluation: high complexity. Typically,45 minutesare spent face-to-face with the patient and/or family for Physical Therapy or 97165 - Occupational therapy evaluation, low complexity. Typically,30 minutesare spent face-to-face with the patient and/or family, 97166 - Occupational therapy evaluation, moderate complexity. Typically,45 minutesare spent face-to-face with the patient and/or family or 97167 - Occupational therapy evaluation, high complexity. Typically,60 minutesare spent face-to-face with the patient and/or family for Occupational Therapists.Example: A patient is receiving treatment following a TKA. During the episode of care for the TKA, the patient develops an acute rotator cuff injury from an accident at home. The clinician determines the rotator cuff injury is not related to the TKA. Therefore, it is appropriate for the clinician to provide a new evaluation for the rotator cuff injury since it a newly identified diagnosis for an unrelated condition.In either case, it is necessary for the documentation to accurately support the services provided.Source:Medicare Benefit Policy Manual(MBPM)Chapter 15 section 220(A) and 220.3.5(A)
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
CMS National Coverage PolicyN/AArticle Text
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
Many errors reported in Medicare audits are due to claims submitted with incomplete or missing requisite documentation. Consequently, the Durable Medical Equipment Medicare Administrative Contracts (DME MACs) have created guidance to assist Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers in understanding the information necessary to justify payment.The documentation requirements are compiled from Statutes, Code of Federal Regulations, Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs), CMS rulings and sub-regulatory guidance (CMS manuals), and DME MAC publications. This article sets out the general requirements that are applicable to all DMEPOS claims submitted to the DME MACs.Documentation must be maintained in the supplier's files for seven (7) years from date of service (DOS).***IMPORTANT***All Policy Specific Documentation Requirements are located in the LCD-related Policy Article, which is linked to the applicable LCD.It is important that suppliers review the actual LCD, the related Policy Article, and the Standard Documentation Requirements (SDR) article to be sure to have all of the relevant information necessary and applicable to the item(s) provided.Note: The information in this document supersedes the material currently contained in all LCDs and related policy articles. Where there are differences between the policies and this article, this document shall take precedence.ORDERSGENERALAll claims for items billed to Medicare require a written order/prescription from the treating practitioner as a condition for payment.This written order/prescription is referred to as the Standard Written Order (SWO) (see below).All claims refers to all claims submitted for payment of purchases or rentals to Medicare Part B.The term treating practitioner is used throughout this document and except where specifically noted, refers to physician, as defined in section 1861(r) of the Social Security Act, or physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS), as those terms are defined in section 1861(aa)(5) of the Social Security Act.The name and National Provider Identifier (NPI) of the treating practitioner on the order/prescription for the item or service shall be used on the claim submitted to the DME MAC. The order/prescription shall be kept on file and made available upon request.
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
Items dispensed and/or billed that do not meet these order/prescription requirements and those below must be submitted with an EY modifier added to each affected HCPCS code.Certain items require an order based on statute (e.g., therapeutic shoes for diabetics, oral anticancer drugs, and oral antiemetic drugs which are a replacement for intravenous antiemetic drugs). In such instances, if statutory requirements related to the order are not met, the claim will be denied as not meeting the benefit category.For DMEPOS items other than PMDs, someone other than the treating practitioner may complete certain required elements of the SWO; however, the SWO must be signed by the treating practitioner.Prescribing of DMEPOS is limited by Medicare regulations and by the treating practitioners respective scope of practice as determined by the state wherein they practice. Chiropractors are not permitted to prescribe DMEPOS items.NEW ORDER REQUIREMENTSA new order/prescription is required:
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
For all claims for purchases or initial rentals;If there is a change in the DMEPOS order/prescription (e.g., quantity);On a regular basis (even if there is no change in the order/prescription) only if it is so specified in the documentation section of a particular medical policy;When an item is replaced;When there is a change in the supplier, and the new supplier is unable to obtain a copy of a valid order/prescription for the DMEPOS item from the transferring supplier.STANDARD WRITTEN ORDER (SWO)A SWO must be communicated to the supplier prior to claim submission. For certain items of DMEPOS, a written order is required prior to delivery (WOPD) of the item(s) to the beneficiary (see below).A SWO must contain all of the following elements:Beneficiary's name or Medicare Beneficiary Identifier (MBI)Order DateGeneral description of the itemThe description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model numberFor equipment - In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (List each separately).For supplies  In addition to the description of the base item, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (List each separately)Quantity to be dispensed, if applicableTreating Practitioner Name or NPITreating practitioner's signature
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
Quantity to be dispensed, if applicableTreating Practitioner Name or NPITreating practitioner's signatureSignatures must comply with the CMS signature requirements outlined in the Medicare Program Integrity Manual (CMS Pub.100-08), Chapter 3, Section 3.3.2.4. Signature and date stamps are not allowed.Upon request by a contractor, DMEPOS suppliers must provide documentation of the completed SWO.In those limited instances in which the treating practitioner is also the supplier and is permitted to furnish specific items of DMEPOS and fulfill the role of the supplier in accordance with any applicable laws and policies, a SWO is not required. However, the medical record must still contain all of the required SWO elements.WRITTEN ORDERS PRIOR TO DELIVERY (WOPD)A WOPD is a completed SWO that is communicated to the DMEPOS supplier before delivery of the item(s).Pursuant to Final Rule 1713 (84 Fed. Reg Vol 217), CMS may select DMEPOS items appearing on the Master List of DMEPOS Items potentially subject to a Face-to-Face Encounter and WOPD requirement and include them on a Required List.The Required List will be comprised of:Statutorily required DMEPOS items such as Power Mobility Devices (PMDs); andAdditional DMEPOS items selected by CMS appearing on the Required List.
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
Items appearing on the Required List are subject to the face-to-face encounter and WOPD requirements.CMS and the DME MACs will post on their websites the Required List of the selected HCPCS codes, once published through the Federal Register Notice, and the Required List will be periodically updated. The current required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Note that the face-to-face encounter and WOPD requirements are statutorily required for PMDs, and in accordance with this statutory obligation, both will continue to be required, and will be included in any future publications of the Required List.The date of the WOPD shall be on or before the date of delivery.A WOPD must be completed within six (6) months after the required face-to-face encounter.For PMDs, following the face-to-face encounter, the treating practitioner must complete the WOPD of the item pursuant to 1834(a)(1)(E)(iv). The term treating practitioner for PMDs is defined as both physicians (defined in section 1861(r)(1) of the Social Security Act) and non-physician practitioners (i.e., PA, NP, and CNS); defined in section 1861(aa)(5) of the Social Security Act.Upon request by a contractor, DMEPOS suppliers must provide documentation of the completed WOPD.DOCUMENTATION REQUIREMENTSGENERALThere are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment.