evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Genetic Testing for Oncology (A59125)
Utilization ParametersGenetic testing for hereditary cancer syndromes is considered germline testing, and therefore only permitted once per beneficiarys lifecycle.The following tests are germline tests:812028121581217812938129681299813088131881322813538143281433814358143681437814380101U0102U0103U0129U0130U0131U0132U0133U0134U0135U0162U0238UDocumentation 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(s) must describe the service performed.The medical record must demonstrate that the treating clinician who is responsible for the management of the patients cancer or substantiated suspicion of cancer is the same person as the ordering clinician.The medical record must include documentation to support an established diagnosis of cancer or a substantiated suspicion of cancer.The medical record must include documentation of how the test results will directly impact the management of the patients specific medical problem.The medical record must clearly document the communication and discussion of pre-test and post-test counseling and the risk associated with genetic testing.The medical record from the ordering clinician must clearly indicate all tests that are to be performed.
Article - Pegfilgrastim (Fulphila; Neulasta; Neulasta Onpro; Nyvepria; Udenyca; Ziextenzo) J2506 (A59126)
CMS National Coverage PolicyN/AArticle Text
Article - Pegfilgrastim (Fulphila; Neulasta; Neulasta Onpro; Nyvepria; Udenyca; Ziextenzo) J2506 (A59126)
1. Same Day AdminstrationPegfilgrastim is a white blood cell growth factorwith labeled use to decrease the incidence of infection (as manifested by febrile neutropenia), in patients with nonmyeloid malignancies receiving myelosuppressive cancer chemotherapy associated with a clinically significant incidence of febrile neutropenia.1The FDA label recommends administration starting 24 hours after the completion of chemotherapy.To improve compliance and convenience for patients by not having to return 24 hours after chemotherapy for administration there is an interest in same day administration. A survey of physicians who administer pegfilgrastim reported that 31.6% were treated on a same day schedule utilizing patient related considerations in the decision such as patient/caregiver travel distance and practice related consideration such as burden on the practice for next day administration as determining factors.2A double blinded phase two non-inferiority study (n=266) concludes non-inferiority of same day administration, but while not statistically significant an increase in neutropenia within the same day administration group as compared to next day administration group was reported. This lead to the authors conclusion to recommendation for administration according to the FDA label.3Multiple retrospective studies support safety and efficacy of same day administration, but also trending to non-statistically significant increase in side effects with same day administration.4-6A systematic review including four randomized or single arm prospective studies and seven retrospective studies support administration at least one day after chemotherapy.7NCCN guidelines state that pegfilgrastim same day administered the day after myelosuppressive chemotherapy is supported by category one evidence, however there is data for and against same day dosing and the FDA approved dosing schedule is still recommended.8Pegfiligrastim is recommended to be given according to FDA approved dosing schedule. CGS will consider same day administration when patient/caregiver circumstances create a significant barrier to compliance, such as lack of transportation to return for dosing within recommended time frame. CGS expects clear documentation for same day administration to be in the medical record and available upon request.2. Billing Instructions for Neulasta and UDENYCA
Article - Pegfilgrastim (Fulphila; Neulasta; Neulasta Onpro; Nyvepria; Udenyca; Ziextenzo) J2506 (A59126)
2. Billing Instructions for Neulasta and UDENYCANeulasta and UDENYCA are currently available in 2 distinct delivery options. When administered to the patient by means of the prefilled syringe, the appropriate coding procedure is to report the HCPCS code for both the drug (J2506 or Q5111) and the administration of the drug (CPT code 96372).Part B ProvidersWhen Neulasta or UDENYCA are administered to the patient by means of a pegfilgrastim injection device such as the Neulasta Delivery Kit (Onpro) or the UDENYCA ONBODY, the provider does not inject the drug, but instead fills the injector device with the drug and applies the injector device to the patient. Identify the injector device using CPT code 96377 in the medical record to distinguish it from the use of the prefilled syringe which should be identified with CPT code 96372.
Article - Pegfilgrastim (Fulphila; Neulasta; Neulasta Onpro; Nyvepria; Udenyca; Ziextenzo) J2506 (A59126)
Use 96377 for the onbody application injector for Neulasta Onpro Kit or UDENYA Onbody.Outpatient Hospital ProvidersCPT code 96377 (Application of on-body injector (includes cannula insertion) for timed subcutaneous injection) is assigned status indicator N (Items and Services Packaged into APC Rates) to indicate that the service is paid under the Outpatient Prospective Payment System (OPPS). However, payment for the administration of Neulasta Onpro/UDENYCA ONBODY is bundled into the payment for other services and not separately payable.References:
Article - Pegfilgrastim (Fulphila; Neulasta; Neulasta Onpro; Nyvepria; Udenyca; Ziextenzo) J2506 (A59126)
Lexi-Drugs. Pegfilgrastim.https://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/7446?cesid=0knhsFEk1hS&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3DPegfilgastrim%26t%3Dname%26va%3DPegfilgastrim. Accessed 5/1//2022.Marion S, Tzivelekis, S., Darden, C. et al. . Same-Day administration of pegfilgrastim following myelosuppressive chemotherapy: clinical practice and provider rationale.Support Care Cancer2016:3886-3896.Burris HA BC, Kaufman PA, et al. . Pegfilgrastim on the same day versus next day of chemotherapy in patients with breast cancer, non-small-cell lung cancer, ovarian cancer, and non-hodgkin's lymphoma: results of four multicenter, double-blind, randomized phase II studies.J Oncol Pract.2010;6(2):133-140.Schuman SI LN, Robson K, et al. . Pegfilgrastim dosing on same day as myelosuppressive chemotherapy for ovarian or primary peritoneal cancer. .J Support Oncol.2009;7(6):225-228.Whitworth JM MK, Shipman KA, Numnum TM, Kendrick JE, Kilgore LC, Straughn JM. . The safety and efficacy of day 1 versus day 2 administration of pegfilgrastim in patients receiving myelosuppressive chemotherapy for gynecologic malignancies.Gynecol Oncol2009;112:601-604.
Article - Pegfilgrastim (Fulphila; Neulasta; Neulasta Onpro; Nyvepria; Udenyca; Ziextenzo) J2506 (A59126)
McBride A, Alrawashdh, N., Bartels, T., Moore, L., Persky, D., & Abraham. Same-day versus next-day pegfilgrastim or pegfilgrastim-cbqv in patients with lymphoma receiving CHOP-like chemotherapy. .Future oncology (London, England).(2021;17(26):34853497.Lyman GH, Allcott, K., Garcia, J. et al. . The effectiveness and safety of same-day versus next-day administration of long-acting granulocyte colony-stimulating factors for the prophylaxis of chemotherapy-induced neutropenia: a systematic review. .Support Care Cancer2017;25:2619-2929.Oncology NCPGi. Hematopoietic Growth Factors Version 1.2022.https://www.nccn.org/professionals/physician_gls/pdf/growthfactors.pdf. Accessed 5/9/2022.
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59154)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59154)
Refer to the draft Local Coverage Determination (LCD) L39383Sacroiliac Joint Injections andProcedures for reasonable and necessary requirements and frequency limitations.The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to theNCCI requirements.Coding GuidanceProviders should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.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.This policy applies only to sacroiliac joint injections (SIJI) and procedures and does not apply to other joint procedures (such as facet, sacroiliitis, epidural or other spinal procedures).Diagnostic and Therapeutic procedures:Sacroiliac joint injections may be performed unilateral or bilateral in the same session.For professional services performed by the physician and billed on a CMS 1500 or electronic equivalent:Bilateral SIJIs procedures reported with CPT 27096 or 64451 should be reported with modifier 50. If a unilateral joint injection (CPT 27096) is performed and a unilateral sacral nerve block (CPT 64451) is performed on the contralateral side do not report modifier 50 with either code. Do not report a sacroiliac joint injection (CPT 27096) and a sacral nerve block (CPT 64451) for the same side, per the policy.For services performed in the Hospital Outpatient Department (TOB 13X) or an Ambulatory Surgical Center:ASC facility claims (specialty 49) report bilateral procedures on two separate lines, with one unit each. Modifiers -LT and -RT are appended to each line. ASC facilities should not report modifier 50. Professional services performed in the ASC should continue to report bilateral procedures with modifier 50.
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59154)
CPT 27096 is not a covered service for ASC facility (specialty 49) claims and is not recognized under OPPS. ASC facilities and OPPS hospital outpatient departments should report HCPCS code G0260 for sacroiliac joint injections. The medical record must contain documentation that fluoroscopic guidance or CT guidance was used with HCSPCS code G0260. Image guidance is packaged into G0260, and no separate payment is made to the ASC or OPPS hospital outpatient department for CPT codes 77002 and 77012.Injections of the nerves innervating the sacroiliac joint should be reported with CPT 64451. CPT 64451 includes imaging guidance. Imaging codes should not be reported with CPT 64451.Critical Access Hospitals (TOB 85X) should report sacroiliac joint injection with CPT 27096 and a sacral nerve block with CPT 64451. Bilateral injections should be reported using modifier 50. If a unilateral sacroiliac joint injection (CPT 27096) is performed and a unilateral sacral nerve block (CPT 64451) is performed on the contralateral side do not report modifier 50 with either code. Do not report a sacroiliac joint injection (CPT 27096) and a sacral nerve block (CPT 64451) for the same side, per the policy.Physician services in an ASC setting should report codes as noted above in the section on Professional services performed by the physician.KX modifier requirements:The KX modifier should be appended to the line for all diagnostic injections. The KX modifier will only be used for the initial diagnostic injections. Repeat diagnostic injections beyond the first one or two required to confirm the diagnosis, after beginning treatment are not reasonable and necessary.Utilization ParametersNo more than two (2) diagnostic joint sessions (CPT codes 27096 AND/OR 64451), unilateral or bilateral, will be considered reasonable and necessary, regardless of the code billed.No more than four (4) therapeutic SIJI sessions (CPT codes 27096 AND/OR 64451), unilateral or bilateral, will be reimbursed per rolling 12 months regardless of the code billed.
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59154)
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.Maximum conservative management must be documented to include medical management and documentation of reason(s) if not optimized.The procedural report should clearly document the indications and medical necessity for the blocks along with the pre and post percent (%) pain relief achieved immediately post-injection.Films that adequately document (minimum of 2 views) final needle position and contrast flow should be retained and made available upon request.The patients medical record should include, but is not limited to:The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visitRelevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Documentation to support the medical necessity of the procedure(s).Use of BiologicalsThere are currently no FDA approved biologicals for use as injectable agents into the sacroiliac joint. The inclusion of biological and/or other non-FDA approved substances in the injectant may result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180Medicare Benefit Policy Manual (cms.gov). Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.
Article - Billing and Coding: Near-Infrared Spectroscopy in Wound and Flap Management (A59158)
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 claimCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 30A Services Paid Under the Medicare Physicians Fee Schedule - Physicians ServicesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 30, 50A Advance Beneficiary Notice of Non-coverage (ABN)  General Statutory Authority  Applicability to Limitation on Liability (LOL)Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Near-Infrared Spectroscopy in Wound and Flap Management L39385.
Article - Billing and Coding: Luteinizing Hormone-Releasing Hormone (LHRH) Analogs (A59160)
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. 100-04, Medicare ClaimsProcessing Manual,Chapter 17, 40 Discarded Drugs and Biologicals.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Luteinizing Hormone-Releasing Hormone (LHRH) Analogs L39387.*Note:The prescribing information for the dose and frequency of administration should be consistent with the United States Food and Drug Administration (FDA) approved labeling.JW Modifier Requirement:Effective January 1, 2017, The Centers for Medicare and Medicaid Services (CMS) issued CR 9603, regarding the use of the JW modifier for discarded Part B drugs and biologicals. Providers are required to use the JW modifier for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded (except those provided under the CAP for Part B drugs and biologicals). Document the discarded drug or biological in the patients medical record when submitting claims with unused Part B drugs or biologicals from single use vials or single use packages that are appropriately discarded.Administration code 96402 should be billed with HCPCS codes J1950, J9217, J9202, J3315, J1952 and J1954.Administration codes 11981, 11982, and 11983 may be billed with HCPCS codes J9219 and J9225.
Draft Article - Billing and Coding: MolDX: Molecular Assays for the Diagnosis of Cutaneous Melanoma (DA59163)
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 claimCMS Internet-Only Manuals, 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 AllowanceCMS 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: Molecular Assays for the Diagnosis of Cutaneous Melanoma.Please submit the following claim information:Regarding the myPathMelanoma assay:Select CPT code 81479 for dates of service prior to 7/1/2019Select proprietary CPT code 0090U for dates of service on or after 7/1/2019Regarding other molecular assays for the diagnosis of cutaneous melanoma:Select CPT code 81479 if there is not an applicable CPT or PLA code listed belowOnly 1 test may be billed per patient per melanocytic lesion.Enter 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 837PBox 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 formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: Molecular Assays for the Diagnosis of Cutaneous Melanoma (A59163)
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 claimCMS Internet-Only Manuals, 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, 60.1.21 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 TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Assays for the Diagnosis of Cutaneous Melanoma.Please submit the following claim information:Regarding the myPathMelanoma assay:Select CPT code 81479 for dates of service prior to 7/1/2019Select proprietary CPT code 0090U for dates of service on or after 7/1/2019Regarding other molecular assays for the diagnosis of cutaneous melanoma:Select CPT code 81479 if there is not an applicable CPT or PLA code listed belowOnly 1 test may be billed per patient per melanocytic lesion.Enter 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 837PBox 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 formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: Vitamin D Assay Testing (A59170)
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 Vitamin D Assay TestingL39391.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (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.Documentation:Documentation must justify the test(s) chosen for a particular disease entity. Various component sources of 25-OH vitamin D, such as stored D or diet-derived D, should not be billed separately.If vitamin D level is above 30 ng/ml and the patient is clinically stable, documentation in the patient's medical record for repeat testing must clearly indicate the necessity of the test. This additional testing should be rare.
Article - Billing and Coding: Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin (A59175)
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. 100-04, Medicare Claims Processing Manual, Chapter 3, 90.3.1 Allogeneic for Stem Cell TransplantationCMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2,110.23 Stem Cell TransplantationCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 3, 90.3.1 Allogeneic for Stem Cell TransplantationCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing, Chapter 32, 90 Stem Cell Transplantation, 90.1 General and 90.2 HCPCS and Diagnosis Coding  ICD-9-CM ApplicableArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forAllogeneic Hematopoietic Cell Transplantationfor Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell OriginL39396.The CMS National Coverage Determination (NCD 110.23) for Stem Cell Transplantation describes nationally covered indications for stem cell transplant, the details of which will not be repeated within this article. This article describes additional locally covered indications for stem cell transplant.