evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: MolDX: FDA-Approved EGFR Tests (A54021)
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 TextTwo tests have met the FDA criteria for EGFR genetic testing:1. Effective 6/01/16cobas EGFR Mutation Testis a real-time PCR test for the qualitative detection of defined mutations of the epidermal growth factor receptor (EGFR) gene in non-small cell lung cancer (NSCLC) patients. Defined EGFR mutations are detected using DNA isolated from formalin-fixed paraffin-embedded tumor tissue (FFPET) or circulating-free tumor DNA (cfDNA) from plasma derived from EDTA anti-coagulated peripheral whole blood.The test is indicated as a companion diagnostic to aid in selecting NSCLC patients for treatment with the targeted therapies listed in the Table below in accordance with the approved therapeutic product labeling:DrugFFPETPlasmaTARCEVA(erlotinib)Exon 19 deletions and L858RExon 19 deletions and L858RTAGRISSO (osimertinib)T790MPatients with positive cobas EGFR Mutation Test v2 test results using plasma specimens for the presence of EGFR exon 19 deletions or L858R mutations are eligible for treatment with TARCEVA (erlotinib). Patients who are negative for these mutations by this test should be reflexed to routine biopsy and testing for EGFR mutations with the FFPET sample type.2.Effective7/12/13therascreen EGFR RGQPCR kit for the detection of the epidermal growth factor receptor (EGFR) gene for non-small cell lung cancer (NSCLC) tumor tissue to help select patients with NSCLC for whom GILOTRIF (afatinib), an EGFR tyrosine kinase inhibitor (TKI), is indicated.To report an FDA approved or laboratory developed test (LDT) EGFR test kit service, please submit the following claim information:CPTcode: 81235Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:
Article - Billing and Coding: MolDX: FDA-Approved EGFR Tests (A54021)
CPTcode: 81235Enter the appropriate DEX Z-Code identifier 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 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier 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 formICD-10-CM codesNOTE:MolDX will apply NPI to ID editing on FDA approved EGFR kits. All labs that submit claims for an EGFR kitMUSTregister the test and confirm theUNMODIFIEDuse of the kit.This article reflects the FDA-approved indications on article creation date. MolDX will allow future FDA approved and amended indications for these tests.
Article - Billing and Coding: MolDX: MMACHC Test (A54035)
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 memberArticle TextMethylmalonic aciduria (cobalamin deficiency) cblC type, with homocystinuria (MMACHC) is associated with the most common error of vitamin B12 metabolism. Although considered a disease of infancy or childhood, some individuals develop symptoms in adulthood. However to date, the exact function of the protein encoded by this gene is not known. Therefore, MMACHC testing does not meet the clinical utility requirements for a Medicare Benefit and is considered a statutorily excluded service. MolDX will also deny panels of tests that include the MMACHC gene.To receive a MMACHC service denial, please submit the following claim information:CPT code 81404-MMACHC, fgsAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierEnter the appropriate DEX Z-Codeidentifier 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 837PBox 19 for paper claimEnter the appropriate DEX Z-Codeidentifier 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: Arthroscopic Lavage and Arthroscopic Debridement for Osteoarthritic Knees (A54061)
CMS National Coverage PolicyN/AArticle TextThis article is being published to update the provider community on coverage for Arthroscopic Lavage and Arthroscopic Debridement for Osteoarthritic Knees.National Coverage Determination (NCD) 150.9 issued in 2004 describes Medicare coverage for Arthroscopic Lavage and Arthroscopic Debridement for Osteoarthritic Knees. In this NCD, non-covered indications are:Arthroscopic lavage used alone for the osteoarthritic kneeArthroscopic debridement for osteoarthritic patients presenting with knee pain only; or,Arthroscopic debridement and lavage with or without debridement for patients presenting with severe osteoarthritisCPT 29871  Arthroscopy, knee, surgical; for infection, lavage and drainage is used to describe the service covered by NCD 150.9.All other indications for coverage of arthroscopic lavage remain at Contractor discretion.Resources:NCD 150.9 Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic KneeCMS Change Request 3281
Article - Billing and Coding: Arthroscopic Lavage and Arthroscopic Debridement for Osteoarthritic Knees (A54063)
CMS National Coverage PolicyN/AArticle TextThis article is being published to update the provider community on coverage for Arthroscopic Lavage and Arthroscopic Debridement for Osteoarthritic Knees.National Coverage Determination (NCD) 150.9 issued in 2004 describes Medicare coverage for Arthroscopic Lavage and Arthroscopic Debridement for Osteoarthritic Knees. In this NCD, non-covered indications are:Arthroscopic lavage used alone for the osteoarthritic kneeArthroscopic debridement for osteoarthritic patients presenting with knee pain only; or,Arthroscopic debridement and lavage with or without debridement for patients presenting with severe osteoarthritisCPT 29871  Arthroscopy, knee, surgical; for infection, lavage and drainage is used to describe the service covered by NCD 150.9.All other indications for coverage of arthroscopic lavage remain at Contractor discretion.Resources:NCD 150.9 Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic KneeCMS Change Request 3281
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54095)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Medicare National Correct Coding Initiative (NCCI) Policy Manual:Chapter 11, Section L-Neurology and Neuromuscular ProceduresArticle TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35081 Nerve Conduction Studies and Electromyography. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Consistent with the LCD, nerve conduction studies (NCSs) without needle electromyography (NEMG) will be allowed for:Individuals being evaluated for carpal tunnel syndrome or tarsal tunnel syndrome when one of the following diagnosis codes are reported: G56.01, G56.02, G56.03, G57.51, G57.52 or G57.53.Individuals with significant lymphedema in the affected extremity when the following diagnosis code is reported in addition to the primary diagnosis: I89.0.Individuals treated with anticoagulants when one of the following diagnosis codes are reported in addition to the primary diagnosis: Z79.01 or Z79.02.NCSs and NEMG performed on the same day, for the same patient must be reported on the same claim.Consistent with the LCD, the following services/tests are non-covered. Therefore, when billing these services/tests report the unlisted neurological diagnostic CPT code 95999. When submitting claims, providers must provide a description of the service/test in block 80 (Part A for the UBO4 claim), box 19 (Part B for a paper claim) or electronic equivalent of the claim. Failure to include this information on the claim will result in Part A claims being returned to the provider and Part B claims being rejected.
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54095)
Non-invasive electrodiagnostic (EDX) testing using portable hand-held devices or automated point of care nerve conduction monitoring systems, which are incapable of real-time waveform display and analysisPsychophysical measurements (electrical, vibratory, or thermal perceptions), even though they may involve delivery of a stimulus,are considered part of the physical examination and may not be reported as a separate servicePhysiologic recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor using wearable devices with accelerometers or gyroscopesNEMG for Surface electromyography (SEMG) or Macroelectromyography (macro-EMG)For HCPCS code G0255, refer to the CMS IOM Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 2, Section 160.23 Sensory Nerve Conduction Threshold Tests (sNCTs).Utilization ParametersStudies performed per day beyond the reasonable maximum number of studies recommended in the Current Procedural Terminology (CPT) Codebook, Appendix J, Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves will be denied. Additional studies may be considered on redetermination.Consistent with the LCD, the following number of tests per 12-month period per diagnosis per provider for repeat EDX assessment are suitable: 1) Two studies for carpal tunnel-unilateral, carpal tunnel-bilateral, radiculopathy, mononeuropathy, polyneuropathy, myopathy, and neuromuscular junction (NMJ) disorders. 2) Three studies for motor neuron disease and plexopathy.Documentation Requirements
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54095)
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 patients medical records must clearly document the medical necessity for the test. The indication for ordering the test(s) and a clear diagnostic impression are required in each report. In cases where documentation is requested, a hard copy of waveforms and/or a complete written report with an interpretation of the test, sufficient to support that the test was medically reasonable and necessary must be submitted.Normal findings and abnormalities uncovered during the study should be documented with the nerves and muscles tested, the presence and type of spontaneous activity, as well as the characteristics of the voluntary unit potentials and interpretation. Expected normal value range for the specific EDX device should also be included.If a patient has had analogous testing performed in the past, documentation should also be included that references the date it was performed as well as results and subsequent management based on those findings.
Article - Billing and Coding: Speech Language Pathology (SLP) Services: Communication Disorders (A54111)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35070 Speech-Language Pathology (SLP) Services: Communication Disorders. Please refer to the LCD for reasonable and necessary requirements.Coding Guidance:Notice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.When reporting services for speech generating devices the following Current Procedural Terminology (CPT) codes should be utilized:For selection and prescription report 92607For adaptation and training report 92609CPT does not define a specific re-evaluation code for speech language pathology; the evaluation code should be used.The group therapy CPT code 92508 should be reported when patients are not receiving direct one-on-one contact, but are being supervised by the therapist.Documentation Requirements:All documentation must be maintained in the patients 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.
Article - Billing and Coding: Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (A54117)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35041, Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds.Please refer to the LCD for reasonable and necessary requirements.The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing.The individual products will continue to be identified with a Level II Healthcare Common Procedure Coding System (HCPCS) supply code from the section of the manual entitled Skin Substitutes.The Current Procedural Terminology (CPT) application CPT codes 15271-15278 intended for the use of skin substitutes is entitled Skin Substitute Grafts. The skin replacement surgery Skin Substitute Grafts application guidelines in the current CPT codebook provide an overview of the types of procedures performed, measurement of the wound surface area, and reporting of skin closure, biological dressing, and supply of the skin substitute graft material.These procedures are not to be reported for application of non-graft wound dressings or for a biologic implant for soft tissue reinforcement.Coding Guidance:Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Article - Billing and Coding: Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (A54117)
Coding Guidance:Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Per the Current Procedural Terminology (CPT) definition, skin substitute grafts include non-autologous skin (dermal or epidermal, cellular and acellular) grafts (e.g., homograft, allograft), non-human skin substitute grafts (i.e., xenograft), and biological products that form a sheet scaffolding for skin growth. Skin substitute graft codes are not to be reported for application of non-graft wound dressings (e.g., gel, powder, ointment, foam, liquid) or injected skin substitutes.Non-graft wound dressings or injected skin substitue codes are not used with skin replacement surgery application codes and are considered incorrect coding. Such products are bundled into other standard management procedures if medically necessary and not separately payable.Claims reporting skin substitute grafts must contain the presence of an appropriate application CPT code.If the service for the application code is denied, the service for the skin substitute will also be denied.Effective 01/01/2017, per CR 9603, when billing for Part B drugs and biologicals (except those provided under Competitive Acquisition Program [CAP]for Part B drugs and biologicals), the use of the JW modifier to identify unused drugs or biologicals from single use vials or single use packages that are appropriately discarded is required. The discarded amount shall be billed on a separate claim line using the JW modifier. Providers are required to document the discarded drug or biological in the patients medical record.Novitas expects that where multiple sizes of a specific product are available, the size that best fits the wound with the least amount of wastage will be utilized.When a portion of a drug/biological is discarded, the medical record must clearly document the amount administered and the amount wasted. The documentation must include the date, time, amount of medication wasted, and the reason for the wastage.
Article - Billing and Coding: Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (A54117)
When a portion of a drug/biological is discarded, the medical record must clearly document the amount administered and the amount wasted. The documentation must include the date, time, amount of medication wasted, and the reason for the wastage.In situations where a portion of asingle use packagemust be discarded, payment will be made for the portion discarded along with the amount applied up to the amount of the product on the package label. Medical record documentation must clearly indicate the information noted above.Note: The unused portion must actually be discarded and may not be used for another patient.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.
Article - Billing and Coding: MolDX: Afirma™ Assay by Veracyte Update (A54185)
CMS National Coverage PolicyN/AArticle TextThe MolDX Program contractor has completed the Afirma assessment and determined that the test meets criteria for analytical and clinical validity, and clinical utility as a reasonable and necessary Medicare benefit. Effective 10/01/2015, CGS Administrators and the MolDX Program contractor will reimburse Afirma services for patients with the following conditions(patient must have 1 and 2):1. Patients with one or more thyroid nodules with a history or characteristics suggesting malignancy such as:Nodule growth over timeFamily history of thyroid cancerHoarseness, difficulty swallowing or breathingHistory of exposure to ionizing radiationHard nodule compared with rest of gland consistencyPresence of cervical adenopathy2. Have an indeterminate follicular pathology on fine needle aspirationMolDX expects this test will be performed once per patient lifetime. Should the unlikely situation of a second, unrelated thyroid nodule with indeterminate pathology occur, coverage may be considered upon appeal with support documentation.To report an Afirma service, please submit the following claim information:Select the appropriate CPTcodeSelect the appropriate ICD-10-CM diagnosisEnter 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 837PBox 19 for paper claimEnter 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: MolDX: bioTheranostics Cancer TYPE ID® (A54188)
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.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 AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextEffective November 19, 2012, Cancer TYPE ID, an RT-PCR 92-gene assay, has been assigned a DEX Z-Code identifier. To bill for Cancer TYPE ID, please provide the following claim information:CPT code: 81540- Oncology (tumor of unknown origin) mRNA gene expression of 92 genesEnter 1 in the Days/Unit fieldEnter DEX Z-Code Identifier in the comment/narrative field for the following claim field/types:Loop 2300 NTE01/SV202-7 for Part A or SV101-7 field for Part BSubmit DEX Z-Code Identifier on an attachment to the claim form for paper claim (Form locator 80 for Part A or Box 19 for Part BSelect the appropriate ICD-10-CM code:Note: MolDX expects this test to ONLY be ordered by the treating physician.