evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Total Joint Arthroplasty (A57428)
subchondral cysts,subchondral sclerosis,periarticular osteophytes,joint subluxation,joint space narrowing,avascular necrosis, orbone on bone articulationsThe extent to which pain or functional disability interferes with ADLs (functional disability), increases with activity or increases with weight bearing. ADLs include, but are not limited to, dressing, feeding, toileting, grooming, physical ambulation (including balance/risk of falls), and bathing.Documentation of unsuccessful non-surgical medical management. Documentation should establish a history of areasonable attemptat conservative therapyas appropriate for the patientin their current episode of care. Clinically appropriate non-surgical medical management typically includesone or moreof the following:anti-inflammatory medications and/or analgesics; and/orflexibility and muscle strengthening exercises; and/orsupervised physical therapy; and/orassistive device use; and/orreasonable activity restrictions; and/orweight reduction as appropriate; and/ortherapeutic injections into the joint as appropriate.Non-surgical medical management may be inappropriate, ineffective or counterproductive whenone or moreof the following is present:bone on bone articulation; and/orsevere deformity; and/orSevere pain (particularly at rest) and significant disabling interference with activities of daily living (ADL).For patients with significant conditions or co-morbidities, such as coronary artery disease or obstructive pulmonary disease, the risk/benefit of the TKA or THA should be appropriately addressed in the medical record.Medical record documentation for other TKA and THA indications outlined in the LCD should include the following, when indicated:
Article - Billing and Coding: Total Joint Arthroplasty (A57428)
Medical record documentation for other TKA and THA indications outlined in the LCD should include the following, when indicated:Supporting evidence (e.g., pathology reports and referral from an Oncologist for a malignancy of the joint or X-ray of a fracture).The extent to which pain or functional disability interferes with ADLs (functional disability), increases with initiation of activities or weight bearing.For patients with significant conditions or co-morbidities, such as coronary artery disease or obstructive pulmonary disease, the risk/benefit of the TKA or THA should be appropriately addressed in the medical record.When infection is the reason for revision TKA or THA surgery, laboratory and/or pathology reports must be in the medical record and all documentation regarding treatment of the infection and a physician note indicating that it is appropriate to proceed with surgery should be in the medical record as well.In order to meet Medicares reasonable and necessary (R&N) threshold for coverage of a procedure, the documentation should clearly support both the diagnostic criteria for the indication (standard test results and/or clinical findings as applicable) and the medical need (the procedure does not exceed the medical need, is at least as beneficial as existing alternatives, and is furnished within accepted standards of medical practice in a setting appropriate for the patients medical needs and condition). Lacking compelling arguments for an exception in the supporting documentation, the hospital (FISS claim) and physician services (MCS claim) may be denied.If the required criteria outlined in the Indications section above are not met, but the treating physician feels that performing the procedure is within the current standards of care, then the documentation must include, in addition to the above, other information which confirms that the services performed clearly were appropriate. This may include, for example, evidenced based clinical practice guidelines or published and peer reviewed literature in support. For example, if certain conservative measures are not necessary or appropriate for a given patient, it should be directly noted in the pre-procedure documentation. The clinical judgment of the treating physician is always a consideration if clearly addressed in the pre-procedure record and if consistent with the episode of care for the patient as documented in patient records and claim history.In addition to the medical necessity of the procedure itself, the medical necessity of the site of service should also be evident from review of the medical record.Utilization Guidelines
Article - Billing and Coding: Total Joint Arthroplasty (A57428)
In addition to the medical necessity of the procedure itself, the medical necessity of the site of service should also be evident from review of the medical record.Utilization GuidelinesIt is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters they may be subject to review for medical necessity.The devices/implants utilized for total knee and total hip replacement surgeries are regulated by the FDA as medical devices. The devices used should be class II or class III devices that meet the requirements outlined in CFR 21, Chapter 1, subchapter H, Part 888.
Article - Billing and Coding: Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint (A57431)
CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy.  NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Minimally-invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Documentation RequirementsThe patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See Indications and Limitations of Coverage section) This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Medical record documentation must be available to Medicare upon request.
Article - Billing and Coding: MolDX: MGMT Promoter Methylation Analysis (A57432)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-04, 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 CodesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, 30 Correct Coding PolicyCMS Internet-Only Manual, Pub. 100-02, Medicare Claims Processing Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts with Independent Clinical LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: MGMT Promoter Methylation AnalysisTo report a MGMT Promoter Methylation Analysis service, please submit the following claim information:Enter 1 unit of service (UOS)Enter 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 837PItem 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 formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: MGMT Promoter Methylation Analysis (A57433)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-04, 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 CodesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, 30 Correct Coding PolicyCMS Internet-Only Manual, Pub. 100-02, Medicare Claims Processing Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts with Independent Clinical LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: MGMT Promoter Methylation Analysis.To report a MGMT Promoter Methylation Analysis service, please submit the following claim information:Select Bill Type Code 022x  Skilled Nursing  Inpatient (Medicare Part B only)Select CPTcode 81287Enter 1 unit of service (UOS)Enter 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 837PBox19 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 formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: Vestibular and Audiologic Function Studies (A57434)
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) L35007 Vestibular and Audiologic Function Studies. 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, CPT codes 92553, 92557 and 92568 may be performed when there is current long-term use of ototoxic antibiotics.The professional component of the services represented by CPT codes 92537, 92538, 92541, 92542, 92544, 92545, 92546, 92587, 92588, 92651, 92652, and 92653 may be reported for services performed in inpatient, outpatient, nursing facilities (when Part A benefits have been exhausted), rehabilitation facilities, hearing and speech centers, independent clinics, and independent diagnostic testing facilities (IDTF).CPT codes 92547, 92552, 92553, 92555, 92556, 92562, 92563, 92565, 92571, 92572, 92575, 92576, 92577, 92582, 92583, and 92584 are considered technical services only codes and may be reported for services performed in the office setting, clinics, hearing and speech centers, and nursing facilities.Note:Payment for technical components of Technical Component (TC)/Professional Component (PC) services (when the PC is performed by an appropriate professional) and for technical-only services are allowed to hospitals.Utilization ParametersConsistent with the utilization outlined in the related LCD:
Article - Billing and Coding: Vestibular and Audiologic Function Studies (A57434)
Utilization ParametersConsistent with the utilization outlined in the related LCD:CPT codes 92553, 92557, 92567 and 92568 may be reported once a month when a beneficiary is receiving ototoxic medicationsThe following may only be reported once during a session (same date of service)CPT codes 92541, 92542, 92544,92545 and 92546CPT code 92542 should not be billed two times for two positions or any multiple increments.Payment may be made for two of the following services per patient per year:CPT codes 92541, 92542, 92544, 92545 and 92546Documentation 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: Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Tremor (A57435)
CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1862(a)(1)(D) refers to limitations on items or devices that are investigational or experimental.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article Text
Article - Billing and Coding: Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) for Tremor (A57435)
Article TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD)for Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) For Tremor.Coding Information:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.CPT 0398T is inclusive of all radiological services performed. Thus billing for radiological services associated with the performance of 0398T is not appropriate and thus not allowed.Per the Medicare Physician Fee Schedule Relative Value File, co-surgery is not allowed.Coverage is limited to a place of service of a hospital or a hospital outpatient department.
Article - Billing and Coding: MolDX: HLA-DQB1*06:02 Testing for Narcolepsy (A57441)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Ch. 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel Allowance.CMS Internet-Only Manual Publication 100-04 Medicare Claims Processing Manual, Chapter 23 Section 10 "Reporting ICD Diagnosis and Procedure Codes"Article TextThe following coding and billing guidance is to be used with its associated Local Coverage Determination.
Article - Billing and Coding: BRCA1 and BRCA2 Genetic Testing (A57449)
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) L36499, BRCA1 and BRCA2 Genetic Testing. Please refer to the LCD for reasonable and necessary requirements.Coding GuidelinesNotice: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.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.Utilization GuidelinesIn accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Article - Billing and Coding: Genetic Testing for Lynch Syndrome (A57450)
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) L34912 Genetic Testing for Lynch Syndrome. 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.It has been recognized that there is some variation in the order of testing based on tissue availability, prevalence, patient history, test availability, testing turn-around time and patient treatment schedule. However, routine MMR germ-line mutation testing is not expected prior to appropriate screening (IHC/MSI). When MSI/IHC testing cannot be performed or is contradictory, claims for MMR germ-line testing exemptions will require the addition of the -KX modifier with the reported Current Procedural Terminology (CPT) code. The -KX modifier specifies that the Requirements specified in the medical policy have been met. Documentation on file." Documentation is expected to be available upon request.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: Molecular Pathology Procedures (A57451)
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) L34519 Molecular Pathology Procedures. 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.The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia) conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes and the array-based evaluation codes molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification, and detection). (Note: molecular pathology procedure techniques, such as microbial identification using molecular pathology techniques and in situ hybridization analyses, may be described in other sections of the Pathology and Laboratory section of CPT.