evekhm/cms_iom_500 huggingface dataset:
Article - External Infusion Pumps - Policy Article (A52507)
Claims for Xembify for dates of service on or after July 3, 2019 through June 30, 2020 must be submitted using the HCPCS code J7799 (NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME). One UOS equals one hundred (100) mg. Claims for Xembify for dates of service on or after July 1, 2020 must be submitted using the HCPCS code J1558 (INJECTION, IMMUNE GLOBULIN (XEMBIFY), 100 MG).Claims for Cutaquig for dates of service on or after December 12, 2018 through June 30, 2022 must be submitted using the HCPCS code J7799 (NOC DRUGS, OTHER THAN INHALATION DRUGS, ADMINISTERED THROUGH DME). One UOS equals one hundred (100) mg. Claims for Cutaquig for dates of service on or after July 1, 2022 must be submitted using HCPCS code J1551(INJECTION, IMMUNE GLOBULIN (CUTAQUIG), 100 MG).Claims for Hizentra for beneficiaries with CIDP for dates of service on or after July 18, 2021 must be submitted using the HCPCS code J1559 (INJECTION, IMMUNE GLOBULIN (HIZENTRA), 100 MG). One UOS equals one hundred (100) mg.Specific infusion pump HCPCS codes are used with specific SCIg preparations according to the table below.
Article - External Infusion Pumps - Policy Article (A52507)
Infusion PumpSCIg PreparationE0779J1555, J1559, J1561, J1562, J1569E0781J1575E0779 or E0781J1551, J1558Professional ServicesProfessional services include nursing services, training and education (not otherwise paid for as durable medical equipment), remote monitoring, and monitoring services for the provision of home infusion therapy furnished by a qualified home infusion supplier with administration of certain transitional home infusion drugs administered through an item of DME.For claims with dates of service on or after January 01, 2019 through December 31, 2020, codes G0068, G0069, and G0070 are used to bill for the professional services rendered on the applicable infusion drug administration calendar day for each payment category. Providers should report visit length in 15-minute increments (15 minutes = 1unit). Suppliers must ensure that the appropriate drug associated with the visit is billed with the visit or no more than 30 days prior to the visit.In the event that multiple visits occur on the same date of service, suppliers must only bill for one visit and should report the highest paying visit with the applicable drug. Claims reporting multiple visits on the same line item date of service will be returned as unprocessable.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Article - Hospital Beds And Accessories - Policy Article (A52508)
CMS National Coverage PolicyN/AArticle TextNON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Hospital Beds are covered under the Durable Medical Equipment benefit (Social Security Act 1861(s)(6)). In order for a beneficiarys equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.A bed board (E0273, E0315) is noncovered since it is not primarily medical in nature.An over bed table (E0274, E0315) is noncovered because it is not primarily medical in nature.Trapeze bars attached to a bed (E0910, E0911) are noncovered when used on an ordinary bed.
Article - Hospital Beds And Accessories - Policy Article (A52508)
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.
Article - Hospital Beds And Accessories - Policy Article (A52508)
MODIFIERSKX, GA, AND GZ MODIFIERS:Suppliers must add a KX modifier to a hospital bed code only if all of the criteria in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD have been met.The KX modifier should also be added for an accessory when the applicable accessory criteria are met. If the requirements for the KX modifier are not met, the KX modifier must not be used.If all of the coverage criteria have not been met, the GA or GZ modifier must be added to a claim line for a hospital bed and accessories. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.Claim lines billed without a KX, GA or GZ modifier will be rejected as missing information.UPGRADE MODIFIERS:When a hospital bed upgrade is provided, the GA, GK, GL and/or GZ modifiers must be used to indicate the upgrade. Fully electric hospital beds must always be billed with these modifiers.
Article - Hospital Beds And Accessories - Policy Article (A52508)
CODING GUIDELINESA fixed height hospital bed is one with manual head and leg elevation adjustments but no height adjustment.A variable height hospital bed is one with manual height adjustment and with manual head and leg elevation adjustments.A semi-electric bed is one with manual height adjustment and with electric head and leg elevation adjustments.A total electric bed is one with electric height adjustment and with electric head and leg elevation adjustments.An ordinary bed is one that is typically sold as furniture. It may consist of a frame, box spring and mattress. It is a fixed height and may or may not have head or leg elevation adjustments.E0301 and E0303 are hospital beds that are capable of supporting a beneficiary who weighs more than 350 pounds, but no more than 600 pounds.E0302 and E0304 are hospital beds that are capable of supporting a beneficiary who weighs more than 600 pounds.E0316 is a safety enclosure used to prevent a beneficiary from leaving the bed.E1399 should be used for products not described by the specific HCPCS codes above.A Column II code is included in the allowance for the corresponding Column I code when provided at the same time and must not be billed separately at the time of billing the Column I code.Column IColumn IIE0250E0271, E0272, E0305, E0310E0251E0305, E0310E0255E0271, E0272, E0305, E0310E0256E0305, E0310E0260E0271, E0272, E0305, E0310E0261E0305, E0310E0265E0271, E0272, E0305, E0310E0266E0305, E0310E0290E0271, E0272E0292E0271, E0272E0294E0271, E0272E0296E0271, E0272E0301E0305, E0310E0302E0305, E0310
Article - Hospital Beds And Accessories - Policy Article (A52508)
E0296E0271, E0272E0301E0305, E0310E0302E0305, E0310E0303E0271, E0272, E0305, E0310E0304E0271, E0272, E0305, E0310E0328E0271, E0272, E0305, E0310E0329E0271, E0272, E0305, E0310When mattress or bedside rails are provided at the same time as a hospital bed, use the single code that combines these items.E0271, E0272: Mattress, innerspring/foam rubberWhen combined with E0251, bill as E0250When combined with E0291, bill as E0290When combined with E0293, bill as E0292When combined with E0295, bill as E0294When combined with E0266, bill as E0265When combined with E0297, bill as E0296When combined with E0301, bill as E0303When combined with E0302, bill as E0304E0305, E0310: Bedside rails, half-length/full-lengthWhen combined with E0290, bill as E0250When combined with E0291, bill as E0251When combined with E0292, bill as E0255When combined with E0293, bill as E0256When combined with E0294, bill as E0260When combined with E0295, bill as E0261When combined with E0296, bill as E0265When combined with E0297, bill as E0266E0271, E0272: Mattress, innerspring/foam rubber plusE0305, E0310: Bedside rails, half-length/full-lengthWhen combined with E0291, bill as E0250When combined with E0293, bill as E0255When combined with E0295, bill as E0260
Article - Hospital Beds And Accessories - Policy Article (A52508)
When combined with E0291, bill as E0250When combined with E0293, bill as E0255When combined with E0295, bill as E0260When combined with E0297, bill as E0265Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Article - Intravenous Immune Globulin - Policy Article (A52509)
CMS National Coverage PolicyN/AArticle TextNON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Intravenous immune globulin used for the treatment of primary immunodeficiency is covered under the Intravenous Immune Globulin benefit. (IOM 100-2, Ch. 15, 50.6) In order for a beneficiarys equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.Intravenous immune globulin (IVIG) is covered if all of the following criteria are met:It is an approved pooled plasma derivative for the treatment of primary immune deficiency disease; andThe patient has a diagnosis of primary immune deficiency disease (See Diagnosis Codes that Support Medical Necessity section below); andThe IVIG is administered in the home; andThe treatingpractitioner has determined that administration of the IVIG in the patients home is medically appropriate.
Article - Intravenous Immune Globulin - Policy Article (A52509)
If all of the criteria are not met the IVIG and the related services, supplies and accessorieswill be denied as noncovered - no benefit category.Services, supplies and accessories used in the home for the administration of IVIG are billed to the DME MAC using HCPCS code Q2052. Only one unit of service of Q2052 shall be paid per infusion date of service.Codes J1573 and J2791 are non-covered. They are not indicated for the treatment of primary immune deficiency disease (#2 above).Refer to the External Infusion Pumps LCD for information concerning coverage of subcutaneous immune globulin.REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.The supplier must enter a diagnosis code corresponding to the patient's diagnosis on each claim.
Article - Intravenous Immune Globulin - Policy Article (A52509)
MODIFIERSJW AND JZ MODIFIERSEffective for claims with dates of service on or after January 1, 2017, the JW modifier is required when billing for unused and discarded amounts of drugs and biologicals from single-dose containers that are administered by the supplier.Effective for claims with dates of service on or after July 1, 2023, the JZ modifier is required when billing for drugs and biologicals from single-dose containers that are administered by the supplier but have no unused and discarded amounts. Effective January 1, 2024, the JZ modifier is also required when billing for drugs and biologicals from single-dose containers that are dispensed by the supplier but self-administered by the beneficiary or the beneficiarys caregiver.The JW modifier is not required for drugs dispensed by the supplier and self-administered by the beneficiary or caregiver in the beneficiary's home, as it is not expected that the beneficiary or their caregiver provide discarded drug information to the supplier. The JZ modifier is required in this scenario (effective for claims with dates of service on or after January 1, 2024).Multi-use vials are not subject to payment for discarded amounts of drug or biologicals.The DME MACs expect rare use of the JW modifier on claims due to HCPCS code descriptors and their associated Units of Service (UOS) for DMEPOS in addition to the limited instructions for use.Below are two scenarios in regard to the JW modifier.Scenario 1When the HCPCS code UOS is less than the drug quantity contained in the single use vial or single dose package, the following applies:The quantity administered is billed on one claim line without the JW modifier; and,The quantity discarded is billed on a separate claim line with the JW modifier.In this scenario, the JW modifier must be billed on a separate line to provide payment for the amount of discarded drug or biological. For example:
Article - Intravenous Immune Globulin - Policy Article (A52509)
In this scenario, the JW modifier must be billed on a separate line to provide payment for the amount of discarded drug or biological. For example:A single use vial is labeled to contain 100 mg of a drug.The drug's HCPCS code UOS is 1 UOS = 1 mg.95 mg of the 100 mg in the vial are administered to the beneficiary by the supplier.5 mg remaining in the vial are discarded.The 95 mg dose is billed on one claim line as 95 UOS.The discarded 5 mg is billed as 5 UOS on a separate claim line with the JW modifier.Both claim line items would be processed for payment.Scenario 2When the HCPCS code UOS is equal to or greater than the total of the actual dose and the amount discarded, use of the JW modifier is not permitted. As of July 1, 2023, the JZ modifier is required in this situation.If the quantity of drug administered is less than a full UOS, the billed UOS is rounded to the appropriate UOS. For example:A single use vial is labeled to contain 100 mg of a drug.The drug's HCPCS code UOS is 1 UOS = 100 mg.70 mg of the 100 mg in the vial are administered to the beneficiary by the supplier.30 mg remaining in the vial are discarded.The 70 mg dose is billed correctly by rounding up to one UOS (representing the entire 100 mg vial) on a single line item with the JZ modifier.The single line item of 1 UOS would be processed for payment of the combined total 100 mg of administered and discarded drug.The discarded 30 mg must not be billed as another 1 UOS on a separate line item with the JW modifier. Billing an additional 1 UOS for the discarded drug with the JW modifier is incorrect billing and will result in an overpayment.
Article - Intravenous Immune Globulin - Policy Article (A52509)
CODING GUIDELINESHCPCS code Q2052is billed for services, supplies, and accessories used in the home for the administration of IVIG. HCPCS code Q2052 may be billed separately from, or on the same claim as, the IVIG. Q2052 should be billed as a separate claim line on the same claim and for the same place of service asthe related IVIG HCPCS. In cases where the IVIG product is mailed or delivered to the patient prior to administration, the date of service (DOS) for the administration of the IVIG may be no more than 30 calendar days after the DOS on the IVIG product claim line. Claims for Q2052 will cycle for a total of 15 business days to identify an eligible IVIG drug billed in the previous 30 days. After 15 business days, if no eligible IVIG HCPCS is found in history, the claim line for the Q2052 will be denied.Q2052 must be billed on a separate claim line for each date of service when billed on a single claim. Claims that contain more than one claim line of Q2052 on the same date of service will be returned as unprocessable.Suppliers should report the infusion visit length in 15-minute increments (15 minutes=1 unit) when billing for Q2052 in accordance with rounding rules below. The units are for informational purposes only and a maximum of one unit of service of Q2052 per infusion date will be paid regardless of the units of service billed.UnitTime1<23 minutes2= 23 minutes to <38 minutes3= 38 minutes to <53 minutes4= 53 minutes to <68 minutes5= 68 minutes to <83 minutes6= 83 minutes to <98 minutes7= 98 minutes to <113 minutes8= 113 minutes to <128 minutes9= 128 minutes to <143 minutes10= 143 minutes to <158 minutes
Article - Intravenous Immune Globulin - Policy Article (A52509)
5= 68 minutes to <83 minutes6= 83 minutes to <98 minutes7= 98 minutes to <113 minutes8= 113 minutes to <128 minutes9= 128 minutes to <143 minutes10= 143 minutes to <158 minutesClaims for Panzyga for dates of service from August 2, 2018 to June 30, 2023 must be submitted using the HCPCS code J1599 (INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG). One UOS equals five hundred (500) milligrams (mg).Claims for Panzyga for dates of service on or after July 1, 2023 must be submitted using HCPCS code J1576 (INJECTION, IMMUNE GLOBULIN (PANZYGA), INTRAVENOUS, INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID, 500 MG). One UOS equals five hundred (500) mg.Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) contractor for guidance on the correct coding of these items.
Article - Mechanical In-exsufflation Devices - Policy Article (A52510)
CMS National Coverage PolicyN/AArticle TextNON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Mechanical in-exsufflation equipment is covered under the Durable Medical Equipment benefit (Social Security Act 1861(s)(6)). In order for a beneficiarys equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.