evekhm/cms_iom_500 huggingface dataset:
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 (A59177)
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 OriginL39398.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.
Draft Article - Billing and Coding: MolDX: Molecular Assays for the Diagnosis of Cutaneous Melanoma (DA59179)
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 837PItem 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 (A59179)
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, 60.1.1 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 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 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
Draft Article - Billing and Coding: MolDX: Molecular Assays for the Diagnosis of Cutaneous Melanoma (DA59181)
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 837PItem 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 (A59181)
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 CPTcode 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-Codeidentifier 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
Draft Article - Billing and Coding: MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer (DA58181)
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 LaboratoriesArticle TextThe following coding and billing guidance is to be used with its associated local coverage determination.To report a service, please submit the following claim information:Select the appropriate CPTcodeEnter 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
Draft Article - Billing and Coding: MolDX: Prognostic and Predictive Molecular Classifiers for Bladder Cancer (DA58187)
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 LaboratoriesArticle TextThe following coding and billing guidance is to be used with its associated local coverage determinationSelect the appropriate CPTcodeEnter 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 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 formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: Magnesium (A59186)
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. 100-02,Medicare Benefit Policy Manual,Chapter 15, 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic TestsCMS Internet-Only Manual, Pub. 100-04, Medicare ClaimsProcessing Manual, Chapter 8, 50.1 Lab Service Included in the End Stage Renal Disease Prospective Payment SystemCMS Internet-Only Manual, Pub. 100-04, Medicare ClaimsProcessing Manual, Chapter 16 Laboratory ServicesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Magnesium L39400.
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59192)
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 16, 180Services Related to and Required as a Result of Services Which Are Not Covered Under MedicareArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Sacroiliac Joint Injections and Procedures L39402.The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.Coding GuidanceProviders should refer to the applicable AMA CPTManual 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.The related LCD 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:SIJIs 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 SIJI procedures reported with CPT27096 or 64451 should be reported with modifier 50. If a unilateral joint injection (CPT27096) is performed and a unilateral sacral nerve block (CPT64451) is performed on the contralateral sidedo not reportmodifier 50 with either code. Do not report a SIJI (CPT27096) and a sacral nerve block (CPT64451) for the same side, per the LCD.For services performed in the Hospital Outpatient Department (TOB 13X) or an Ambulatory Surgical Center (ASC):
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59192)
ASC facility claims (specialty 49) report bilateral procedures on 2 separate lines, with 1 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.CPT27096 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 SIJIs. The medical record must contain documentation that fluoroscopic guidance or CT guidance was used with HCPCS code G0260. Image guidance is packaged into G0260, and no separate payment is made to the ASC or OPPS hospital outpatient department for CPTcodes 77002 and 77012.Injections of the nerves innervating the SJ should be reported with CPT64451. CPT64451 includes imaging guidance. Imaging codes should not be reported with CPT64451.Critical Access Hospitals (TOB 85X) should report SIJI with CPT27096 and a sacral nerve block with CPT64451. Bilateral injections should be reported using modifier 50. If a unilateral SIJI (CPT27096) is performed and a unilateral sacral nerve block (CPT64451) is performed on the contralateral side do not report modifier 50 with either code. Do not report a SIJI (CPT27096) and a sacral nerve block (CPT64451) for the same side, per the LCD.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 1 or 2 required to confirm the diagnosis after beginning treatment are not reasonable and necessary.Utilization ParametersNo more than 2 diagnostic joint sessions (CPTcodes 27096 AND/OR 64451), unilateral or bilateral, will be considered reasonable and necessary, regardless of the code billed.
Article - Billing and Coding: Sacroiliac Joint Injections and Procedures (A59192)
No more than 2 diagnostic joint sessions (CPTcodes 27096 AND/OR 64451), unilateral or bilateral, will be considered reasonable and necessary, regardless of the code billed.No more than 4 therapeutic SIJI sessions (CPTcodes 27096 AND/OR 64451), unilateral or bilateral, will be reimbursed per rolling 12 months regardless of the code billed.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the A/B MAC 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 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 Food and Drug Administration (FDA) approved biologicals for use as injectable agents into the SJ. The inclusion of biological and/or other non-FDA approved substances in the injectant may result in denial of the entire claim based on CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, 180 Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare.Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.
Article - Billing and Coding: Thermal Destruction of the Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain (A59205)
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, Publication 100-04, Medicare Claims Processing Manual, Chapter 13 10.1Billing Part B Radiology Services and Other Diagnostic Procedures and 20 Payment Conditions for Radiology Services.CMS Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 23 20.9 National Correct Coding Initiative (NCCI).Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) forThermal Destruction of the Intraosseous Basivertebral Nerve (BVN) for Vertebrogenic Lower Back Pain (L39420).Coding GuidelinesLevels:64628: describes thermal destruction of the intraosseous basivertebral nerve for the first 2 vertebral bodies with imaging guidance, lumbar or sacral.64629: describes a thermal destruction of the intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral and should be listed separately in addition to the code for the primary procedure.
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 (A59215)
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 25, 75 General Instructions for Completion of Form CMS-1450 for BillingArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin DL39434.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.The following evaluation is recommended to determine if the patient is an appropriate candidate for the procedure. A pretransplant assessment should establish the extent of disease and provide information about the individual's comorbidities that are likely to impact outcomes. This assessment varies by institution.It is expected that documentation of the pretransplant evaluation be included in the documentation maintained for the transplants billing and be available on request.The evaluation should include a significant portion of the following elements or documentation of the completion of the institutions pre-established pre-transplant protocol, demonstrating the elements of that protocol.
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 (A59215)
Detailed historyPhysical examinationLaboratory studiesA chest radiograph, an electrocardiogram, and a study of cardiac functionPulmonary function testDisease-specific restaging studiesFunctional status assessmentRisk assessment for allogenic transplant (multiple scoring systems are available the European Group for Blood and Marrow Transplantation (EMBMT) is commonly used.1Co-morbidity assessment (multiple scoring systems are available the Hematopoietic Cell Transplantation-Specific Comorbidity Index (HCT-CI) is commonly used.1Further studies may be required depending on signs and symptoms.PRETRANSPLANT COUNSELING (1)This A/B MAC suggests the following:Fertility preservationEnd-of-life and advance care planningInformed consent guidelines mandate that patients have an accurate understanding of the risks of HCT.Reference:Deeg HJ, Sandmaier BM. Determining eligibility for Allogeneic hematopoietic transplantation. In: Rosmarin AG, ed.UpToDate; 2022.