evekhm/cms_iom_500 huggingface dataset:
(Medicare National Coverage Determinations Manual)
of Metastatic Prostate Cancer  Rescinded and replaced by Transmittal 136  08/08/2011  7431  R127NCD  10/08/2010  Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for Myelodysplastic Syndrome (MDS)  11/10/2010  7137  R121NCD  05/28/2010  Collagen Meniscus Implant  07/06/2010  6903  R111NCD  12/18/2009  Pharmacogenomic Testing for Warfarin Response  04/05/2010  6715  R102NCD  07/02/2009  Wrong Surgical or Other Invasive Procedure Performed on a Patient; Surgical or Other Invasive Procedure Performed on the Wrong Body Part; Surgical or Other Invasive Procedure Performed on the Wrong Patient  07/06/2009  6405  R101NCD  06/12/2009  Wrong Surgical or Other Invasive Procedure Performed on a Patient; Surgical or Other Invasive Procedure Performed on the Wrong Body Part; Surgical or Other Invasive Procedure Performed on the Wrong Patient-Rescinded and replaced by Transmittal 102  07/06/2009  6405  R100NCD  04/17/2009  Surgery for Diabetes  05/18/2009  6419  R97NCD  12/09/2008  Thermal Intradiscal Procedures (TIPs)  01/05/2009  6291  R80NCD  01/14/2008  Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions  04/07/2008  5818  R75NCD  09/11/2007  Lumbar Artificial Disc Replacement (LADR)  10/01/2007  5727  R70NCD  06/22/2007  Vagus Nerve Stimulation (VNS) for Resistant Depression  07/23/2007  5612  R69NCD  05/11/2007  Bone Mass Measurements (BMMs)  07/02/2007  5521  R67NCD  04/06/2007  Blood Brain Barrier Osmotic Disruption for Treatment of Brain Tumors  05/07/2007  5530  R66NCD  03/16/2007  Extracorporeal Photopheresis  04/02/2007  5464  R61NCD  11/24/2006  Cavernous Nerves Electrical Stimulation with Penile Plethysmography  01/08/2007  5294  R60NCD  06/23/2006  Lumbar Artificial Disc Replacement (LADR)  06/17/2006  5057
(Medicare National Coverage Determinations Manual)
Cavernous Nerves Electrical Stimulation with Penile Plethysmography  01/08/2007  5294  R60NCD  06/23/2006  Lumbar Artificial Disc Replacement (LADR)  06/17/2006  5057  R55NCD  05/05/2006  Changes Conforming to CR 3648 Instructions for Therapy Services  10/02/2006  4014  R54NCD  04/28/2006  Bariatric Surgery for Treatment of Morbid Obesity  05/30/2006  5013  R48NCD  03/17/2006  Technical Corrections to the NCD Manual  06/19/2006  4278  R45NCD  12/06/2005  Stem Cell Transplantation  01/03/2006  4173  R43NCD  12/02/2005  Stem Cell Transplantation  01/03/2006  4173  R41NCD  06/24/2005  Osteogenic Stimulators  08/01/2005  3836  R40NCD  06/24/2005  Coverage of Aprepitant for Chemotherapy -Induced Emesis  07/05/2005  3831  R38NCD  06/17/2005  Coverage of Colorectal Anti -Cancer Drugs Included in Clinical Trials  04/18/2005  3742  R34NCD  04/25/2005  Abarelix for the Treatment of Abarelix for the Treatment of Prostate Cancer  05/25/2005  3775  R32NCD  04/15/2005  Autologous Stem Cell Transplantation (AuSCT)  05/16/2005  3797  R30NCD  03/29/2005  Coverage of Colorectal Anti -Cancer Drugs Included in Clinical Trials  04/18/2005  3742  R15NCD  06/18/2004  Sensory Nerve Conduction Threshold Tests  04/01/2004  3339  R14NCD  06/10/2004  Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee  07/11/2004  3281  R13NCD  05/28/2004  Removal of Coding from National Coverage Determination on Stem Cell Transplantation  07/06/2004  3265  R10NCD  04/06/2004  Re-release of NCD Manual  N/A N/A R08NCD  03/19/2004  Sensory Nerve Conduction Threshold (sNCT) Tests  04/01/2004  2988  R01NCD  10/01/2003  Initial Release of Manual  N/A N/A Back to top of Chapter
Article - Oral Surgery and Maxillofacial Surgery Specialty Codes (A53446)
CMS National Coverage PolicyN/AArticle TextPhysicians self-designate their Medicare physician specialty on the Medicare enrollment application (CMS-855I) or Internet-based Provider Enrollment, Chain and Ownership System when they enroll in the Medicare program. Dentists who practice general or specialized dentistry should be enrolled in Medicare as specialty 19 (oral surgery - dentists only) or specialty 85 (maxillofacial surgery). Dentists enrolled as specialty 19 might extract teeth, perform simple surgical biopsies or remove suspicious tumors or lesions in the oral cavity. Dentists enrolled as specialty 85 are trained and practice primarily maxillofacial surgery by doing major repairs of facial trauma, oral tumors or jaw reconstruction. Otolaryngologists should be enrolled in Medicare as specialty 04.It is important for physicians to select the most correct specialty code in order to promote the correct coding and processing of Medicare claims.
Article - Billing and Coding: MolDX: 4q25-AF Risk Genotype (A53457)
CMS National Coverage PolicyN/AArticle TextEffective for dates of services on and after 06/14/2012The 4q25-AF Risk Genotype Test was developed to help predict the risk of atrial fibrillation and cardioembolic stroke. To date, there is insufficient evidence to support the required clinical utility for the established Medicare benefit category.As reviewed, the developer described the indication to perform a 4q25-AF Risk Genotype Test as a risk assessment for developing a disease or condition. Risk assessment for developing a disease or condition in the absence of signs and symptoms of an illness or injury is also not defined as a Medicare benefit. Therefore, the 4q25-AF Risk Genotype Test would continue to be a statutory excluded service.To receive a 4q25-AF Risk genotype service denial, please submit the following claim information:CPTcode 81479  Unlisted molecular pathology procedureAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierEnter 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 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 form
Article - Billing and Coding: MolDX: LPA-Aspirin Genotype (A53467)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) statutory exclusion covers diagnostic testing "except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member".Article TextThe MolDX Team has completed a review of the research on the LPA-Aspirin genotype test, developed to predict increased CVD risk and event reduction during aspirin therapy. To date, there is insufficient evidence to support the required clinical utility for the established Medicare benefit category. Therefore, the LPA-Aspirin genotype test is a statutorily excluded test.As reviewed, the developer described the indication to perform a LPA-Aspirin genotype test as a risk assessment for developing a disease or condition. Risk assessment for developing a disease or condition in the absence of signs and symptoms of an illness or injury is also not defined as a Medicare benefit. Therefore, the LPA-Aspirin genotype test would continue to be a statutory excluded test.To receive a LPA-Aspirin service denial, please submit the following claim information:CPTcode 81479 Unlisted molecular pathology procedureAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierEnter 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 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 form
Article - Billing and Coding: MolDX: LPA-Intron 25 Genotype (A53468)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) statutory exclusion covers diagnostic testing "except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member".Article TextThe MolDX Team has completed a review of the research on the LPA-Intron 25 genotype test, developed to predict increased Coronary Heart Disease risk. To date, there is insufficient evidence to support the required clinical utility for the established Medicare benefit category. Therefore, the LPA-Intron 25 genotype test is a statutorily excluded service.As reviewed, the developer described the indication to perform a LPA-Intron 25 genotype test as a risk assessment for developing a disease or condition. Risk assessment for developing a disease or condition in the absence of signs and symptoms of an illness or injury is also not defined as a Medicare benefit. Therefore, the LPA-Intron 25 genotype test would continue to be a statutory excluded test.To receive a LPA-Intron 25 service denial, please submit the following claim information:CPTcode 81479 Unlisted molecular pathology procedureAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierEnter 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 DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/typesLine SV202-7 for 837I electronic claimBlock 80 for the UB04 claim form
Article - Billing and Coding: Pre/Postoperative Care: Date of Service (A53472)
CMS National Coverage PolicyTitle XVIII of the Social Security Act 1862(a)(1)(A)CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 40.2 - 40.4Article TextWhere physicians agree on the transfer of care during the global surgery period, the following modifiersare used:CPT modifier 54 - for surgical care only; orCPT modifier 55 - for postoperative management onlyThe claim for the surgical care and the claim(s) for the postoperative care must containthe same date of service and the same surgical procedure code, with the services distinguished by the use of the appropriate modifier.AppropriateDateCPT Code/ModifierSurgeon/PhysicianMay 866982-54SurgeonMay 866982-55Post-op Care PhysicianInappropriateDateCPT Code/ModifierSurgeon/PhysicianMay 866982-54SurgeonMay 966982-55Post-op Care PhysicianThe surgeon and the physician(s) providing the postoperative care must collaborate to ensure the appropriate date of service and surgical code are submitted (with the appropriate CPT modifier).Claims are being monitored and will be rejected when submitted inappropriately.For more information regarding global surgery and transfer of care during the global surgery period, refer to the CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 40.2 - 40.4.
Article - Billing and Coding: MolDX: HTTLPR Gene Testing (A53480)
CMS National Coverage PolicyN/AArticle TextEffective for dates of service on and after June 26, 2013.Serotonin Transporter genotyping (HTTLPR) has been associated with response to selective serotonin reuptake inhibitors. However since the literature is conflicting and limited by small sample sizes, the MolDX Team has determined there is insufficient evidence to support coverage. Therefore, HTTLPR testing is a statutorily excluded service.To receive a HTTLPR analysis service denial, please submit the following claim information:CPTcode 81479An 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 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 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 form
Article - Billing and Coding: Repeat or Duplicate Services on the Same Day (A53482)
CMS National Coverage PolicyMedicare Claims Processing Manual, Pub. 100-04, Chapter 34Title XVIII of the Social Security Act, 1833(e)Article TextClaims for multiple and/or identical services provided to an individual patient on the same day, may be denied as duplicate claims if Palmetto Government Benefit Administrators (GBA) cannot determine that these services have, in fact, been performed more than one time. Filing claims properly the first time will reduce denials.Many providers and billing departments re-file claims without allowing sufficient time for the original claim to process. Refilling a claim before the original claim has processed can cause further delays in processing and payment. One submission of a claim is all that is required. If you have not received payment after 30 days and are concerned about your payment, please use the Palmetto GBA interactive voice response (IVR) or the online provider services (OPS) for an electronic claims status inquiry function.A denial should be expected if identical duplicate services are submitted for the same date of service. Should a correction of a previously submitted claim be needed, do not submit the correction as a new claim. Palmetto GBA can reopen claims for minor corrections. Claims denied as not medically necessary cannot be reopened at the claims processing level after a denial for that reason has been issued. An appeal (redetermination) may be requested for services denied as not medically necessary or for other issues beyond minor corrections. Additional documentation in support of the service(s) provided should be submitted with the appeal request. Please refer to the Medicare Claims Processing Manual, Pub. 100-04, Chapter 34 for detailed instructions regarding a reopening vs. an appeal.To ensure correct processing of your claim, please consider the following: Submit services on one claim using the Days/Units fields and appropriate modifier. Please be sure the correct modifiers are submitted on the claim when multiple identical services are submitted in order to identify these services as separate services and not duplicate billing of the same service. A denial can be expected if the same service is submitted on more than one claim or more than one claim line for the same date of service.Example:The patient receives two chest x-rays on 10/1/15 which are interpreted by the same physician. The first interpretation is performed at 10 a.m. and the interpretation of the second x-ray is performed at 1:30 p.m.
Article - Billing and Coding: Repeat or Duplicate Services on the Same Day (A53482)
Submit as:CPT Code/Modifier Days/Units10/1/15 71020-26 110/1/15 71020-26-76 1ModifiersFailure to submit appropriate modifiers may result in delay of payment or denial of service(s). When a modifier is used to indicate a repeat service, as in the above example, the first service should be submitted without the -76 modifier and the repeat service(s) should include the -76 modifier(s).Site Modifiers:Use site modifiers (e. g. RT, LT, T1) as appropriate.Example:The patient receives a percutaneous tenotomy on the second digit and the fourth digit of the left foot by the same physician on the same day.Submit as:Date of Service CPT Code/Modifier Days/Units10/1/15 28010-T1 110/1/15 28010-T3 1Identical services being repeated should be submitted using CPT modifier 76, 77, or 91.CPT Modifier 76: 'Repeat procedure by same physician: The physician may need to indicate that a service was repeated the same day subsequent to the original service. This modifier indicates the difference between duplicate services and repeated services.CPT Modifier 77 'Repeat procedure by another physician': A physician may need to indicate that he or she repeated a service performed by another physician on the same day.Example:Patient receives two EKGs on 10/1/15. The first EKG is taken at 10 a.m. and Dr. A performs the interpretation. The second EKG is taken at 1:30 p.m. and Dr. B performs the interpretation.Submit as:Claim #1 Dr. ADate of Service CPT Code Days/Units10/1/15 93010-26 1Claim #2 Dr. BDate of Service CPT Code Days/Units10/1/15 93010-26-77 1
Article - Billing and Coding: Repeat or Duplicate Services on the Same Day (A53482)
Date of Service CPT Code Days/Units10/1/15 93010-26 1Claim #2 Dr. BDate of Service CPT Code Days/Units10/1/15 93010-26-77 1CPT Modifier 91 'Repeat clinical diagnostic laboratory test': It may be necessary to repeat the same laboratory test on the same day to obtain multiple test results. In this case CPT modifier 91 should be used. This modifier may not be used when tests are repeated to confirm initial results due to testing problems with equipment or specimens. Tests that include multiple specimens being collected at different times (e.g., glucose tolerance) should be submitted using the appropriate code for the test and should not be submitted as repeated tests.Example:The patient had two folic acid tests performed on the same day.Submit as:Date of Service CPT Code/Modifier Days/Units10/1/15 82746 110/1/15 82746-91 1
Article - Billing and Coding: MolDX: BluePrint® Test (A53484)
CMS National Coverage PolicyN/AArticle TextThe MolDX team has completed a technical assessment on BluePrint, a molecular subtyping assay. To date, there is insufficient evidence to support the required clinical utility for the established Medicare benefit category. Therefore, the BluePrint test is a statutorily excluded test.To receive a BluePrint service denial, please submit the following claim information:CPTcode 81479- Unlisted molecular pathology procedureAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierEnter 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 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 form
Article - Billing and Coding: Radiology Services: Multiple, Identical Services on Same Day (A53488)
CMS National Coverage PolicyCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, 100.1Article TextMultiple 'Serial' X-RaysMedicare Part B claims for multiple, identical services provided to an individual patient on the same day may be denied as duplicate services. To ensure correct claims processing:Submit multiple, identical services on the same claim,Use the days/units field when possible to identify multiple procedures,Indicate the time each service was performed in the appropriate documentation field for electronic claims or Item 19 of the CMS-1500 claim form,Use CPTmodifier 76 for multiple, identical services performed on the same date of service by the same physician.Example:Date of ServiceCPT Code/ModifierDays/Units1/1/137300011/1/1373000-762Multiple Interpretations, Same X-RayGenerally, Palmetto GBA may reimburse the first interpretation of an X-ray furnished to an emergency room patient. The 'interpretation and report' of an X-ray requires a complete, written report similar to the kind of report a specialist would prepare. Payment for a second interpretation of the same film is made only in unusual circumstances. Claims for the second interpretation of the same film must be submitted with CPTmodifier 77 when performed by a different physician and must provide documentation as to why a second interpretation is medically reasonable and necessary.Examples:A questionable finding for which the physician performing the initial interpretation believes that another physicians expertise is needed,A changed diagnosis resulting from a second interpretation of the results of the procedure.Palmetto GBA will not reimburse2 interpretations of the same X-ray without the additional required documentation. When an emergency room physician and a radiologist both perform interpretations of the same X-ray, both physicians should work together to determine who should submit the claim.Additional information and guidance on multiple interpretations of the same X-ray are available in theCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, 100.1.
Article - Billing and Coding: MolDX: HBB Gene Tests (A53493)
CMS National Coverage PolicyN/AArticle TextEffective for dates of service on and after 05/03/2013HBB gene testing may be performed during the diagnosis of Sickle cell disease (SCD). Since clinical symptoms and diagnosis usually occur prior to Medicare eligibility and carrier testing is not a covered benefit, the MolDX Team has determined HBB gene testing is a statutorily excluded service. MolDX will also deny panels of tests that include the HBB gene.To receive a HBB gene sequencing service denial, please submit the following claim information:Select the appropriate CPTcode based on gene test:81361  HBB, common variants81362 - HBB, known familiar variants81363 - HBB, duplication/deletion81364 - HBB, full gene sequence81443  Genetic testing for severe inherited conditionsAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifierEnter 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 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 form
Article - Glaucoma Screening (A53495)
CMS National Coverage PolicyN/AArticle TextMedicare coverage of glaucoma screenings was implemented with the Benefits Improvement and Protection Act of 2000 (BIPA).A glaucoma screening is defined to include:A dilated eye examination with an intraocular pressure (IOP) measurementA direct ophthalmoscopy examination or a slit-lamp biomicroscopic examinationMedicare covers glaucoma screening for the following persons considered to be at high risk for developing this disease:Individuals with diabetes mellitusIndividuals with a family history of glaucomaAfrican-Americans age 50 or overHispanics-Americans 65 or olderGlaucoma screening frequency limitations and payment information:Medicare pays for this service annually (i.e., at least 11 full months must have passed following the month in which the last Medicare-covered glaucoma screening examination was performed)Services rendered more frequently than allowed under this screening benefit may require that the beneficiary be given an Advance Beneficiary Notice (ABN)The beneficiary will pay 20 percent as the co-payment or coinsurance after meeting the yearly Part B deductibleMedical record documentation requirements:Medical record documentation to support that the beneficiary is a member of one of the high risk groups, as defined aboveDocumentation must support one of the screening defined:A dilated eye examination with IOP measurement and direct ophthalmoscopic examination, or a slit-lamp biomicroscopic examinationProcedure and Diagnosis Code Information:HCPCS CodesHCPCS Code Descriptors/ModifierDiagnosis CodeG0117Glaucoma screening for high risk patient furnished by an optometrist or ophthalmologistZ13.5 (Encounter for Screening for Eye and Ear Disorders)G0118Glaucoma screening for high risk patient furnished under the direct supervision of optometrist or ophthalmologistZ13.5 (Encounter for Screening for Eye and Ear Disorders)