evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Voretigene Neparvovec-rzyl (Luxturna®) (A56419)
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 23, 30 Services Paid Under the Medicare Physician's Fee ScheduleCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 30 Financial Liability ProtectionsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for voretigene neparvovec-rzyl (Luxturna) L37863.CodingGuidelines:General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and national provider identifier(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.Advance Beneficiary Notice of Noncoverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30 Financial Liability Protections, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.
Article - Billing and Coding: Voretigene Neparvovec-rzyl (Luxturna®) (A56419)
The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary, and theydo havean ABN signed by the beneficiary on file. Modifier GA applies only when services are expected to be denied because they do not meet the Medicare program requirements for reasonable and necessary care. Effective April 1, 2010, Part A Medicare Administrative Contractors (MAC) systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisionsotherthan medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, Part A MAC systems will automatically deny the services.The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and theyhave nothad an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.
Article - Billing and Coding: Voretigene Neparvovec-rzyl (Luxturna®) (A56419)
Specific coding guidelines for this policy:Voretigene neparvovec-rzyl (Luxturna) is a gene therapy product approved by the United States (U.S.) Food and Drug Administration (FDA) for treatment of vision loss due to certain heritable retinal dystrophies with confirmed biallelic RPE65 mutation-associated retinal dystrophies. Specifically, this represents approximately 2% of cases of autosomal recessive retinitis pigmentosa (RP) and 8-16% of cases of Leber congenital amaurosis (LCA).A single treatment with 1.5x1011vector genomes of voretigene neparvovec-rzyl (Luxturna) administered by subretinal injection per eye per lifetime has been found to clinically improve functional vision in patients with RP and LCA with biallelic mutations of the RPE65 gene with sufficient viable photoreceptors.Treatment of the contralateral eye must occur no sooner than 6 days and no later than 18 days after treatment of the first eye.The safety and effectiveness of more than1 treatment per eye per lifetime has not been established.For Part A and B Services:For dates of service 07/01/18 through 12/31/18, to report Luxturnaon a claim, use the HCPCS code C9032 and the appropriate modifier (-RT or LT) designating the recipient eye. Effective for dates of service on and after 01/01/19, the HCPCS code J3398 should be used to report Luxturnaon a claim along with the appropriate modifier (-RT or LT) designating the recipient eye.
Article - Billing and Coding: Voretigene Neparvovec-rzyl (Luxturna®) (A56419)
For all dates of service, the number of HCPCS units administered must be reported on the claim (service units (field locator 46) of the UB-04 (CMS 1450 form)); Box 24g of the CMS 1500 form or electronic equivalent). Additionally, the 11-digit National Drug Code (NDC) must be reported in the revenue description field (Form Locator 43) without delimiters, such as commas or hyphens on the UB-04 (CMS 1450 form) or the equivalent 5010 electronic claims field; or in the shaded area of Box 24.A. of the CMS 1500 form or its electronic equivalent.In addition to the HCPCS and NDC codes for Luxturna, the requisite pars plana vitrectomy (PPV) and subretinal injection surgical procedures should be reported as CPTcode 67036 and CPTcode 67299. The appropriate site modifier (-RT or LT) must be appended to each of the surgical CPTcodes.Manufacturer-designated Centers of Excellence certification must be noted in Box 19 of CMS 1500 form or equivalent electronic claim field.Submission of all of the required elements outlined under theDocumentation Requirementssection of the related LCD is also required for payment of claims for Luxturna.
Article - Billing and Coding: Frequency of Laboratory Tests (A56420)
CMS National Coverage PolicyPlease refer to the Local Coverage Determination (LCD) L35099, Frequency of Laboratory Tests.Article TextRefer to the Novitas Local Coverage Determination (LCD) L35099, Frequency of Laboratory Tests, for reasonable and necessary requirements and frequency limitations.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Per CMS Medicare Learning Network (MLN) Medicare Matters number MM8863, the use of NCCI-associated modifiers should NOT be used to bypass a procedure-to-procedure (PTP) edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.Refer to the NCDs for the procedure code list of ICD-10-CM codes that are considered covered by Medicare at:https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/LabNCDsICD10.html
Article - Billing and Coding: CT of the Abdomen and Pelvis (A56421)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) states that no payment shall be made to any provider for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 6, 20.1.2 Other Excluded Services Beyond the Scope of a SNF Part A BenefitCMS Internet-Only Manual, Pub. 100-20, One-Time Notification, Transmittal 477, dated April 24, 2009, Change Request 6338Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for CT of the Abdomen and Pelvis L34415.
Article - Billing and Coding: Bariatric Surgical Management of Morbid Obesity (A56422)
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) L35022 (Bariatric Surgical Management). 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.CPT code 43659 should be used when BOTH the gastric band and subcutaneous port components were removed AND replaced.CPT code 43843 should be used to bill the following test and a note should be added to identify the specific test performed in the Remarks area of the claim for Part A and the Narrative area of the claim for Part B:Open-sleeve gastrectomyNot otherwise classified (NOC) CPT code 43999 should be used to bill the following tests and a note should be added to identify the specific test performed in the Remarks area of the claim for Part A and the Narrative area of the claim for Part B:Laparoscopic vertical-banded gastroplastyOpen adjustable gastric bandingCoverage for selected bariatric surgery procedures on patients who meet national and local coverage criteria set forth in the LCD requires reporting three appropriate diagnoses. Report the primary diagnosis as E66.01 (morbid obesity). Report a secondary diagnosis fromICD-10 Code group 1 and a tertiary diagnosis fromICD-10 Code group 2.
Article - Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing (A56423)
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.Title XVIII of the Social Security Act, Section 1834(e)(1)(B). Claims for the technical component of advanced diagnostic imaging services.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35083 Cardiology Non-Emergent Outpatient Stress Testing. 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.Current Procedural Terminology (CPT) code 78434 should be reported in conjunction with CPT code 78431 or 78492.Evaluation of the individuals left ventricular wall motion and ejection fractions are routinely performed during SPECT MPI and are included in the codes definition.Attenuation correction, when performed, is included in the MPI service.Documentation Requirements
Article - Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing (A56423)
Attenuation correction, when performed, is included in the MPI service.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.If the provider of the service is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physicians order for the studies.The ordering physician must state the clinical indication/medical necessity for the study in the order for the test.Documentation must be maintained by the referring physician in the beneficiarys medical record that the required conditions (as indicated in the Coverage Indications, Limitations and/or Medical Necessity section of the LCD) for the stress test performed have been met.The rationale for selecting pharmacologic stress testing rather than exercise stress testing must be documented in the medical record.In the instance where regional wall motion abnormalities and ejection fraction have been assessed during the same episode of care by other testing modalities (e.g., echocardiography), the medical necessity of repeating this assessment through the use of nuclear imaging modalities must be clearly documented in the medical record.All segments of the service must have a formal interpretation and report.
Article - Billing and Coding: Allergy Immunotherapy (A56424)
CMS National Coverage PolicyN/AArticle TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L32553-Allergy Immunotherapy.DefinitionsFor allergen immunotherapy purposes a dose describes the amount of antigen(s) administered in a single injection from a multi-dose vial.CPT codes 95115-95117 describe the professional allergenic extract administration. (Injection only)CPT code 95144 describes the allergists preparation and provision of single-dose vials for administration by another physician.CPT codes 95145-95170 represent the antigen preparation. (Preparation only)CPT codes 95120-95134 describe complete service codes for the combined supply of antigen AND allergy injection provided during a SINGLE encounter. Medicare does NOT cover complete service codes. See the component-billing sample.CPT code 95165 includes single OR multiple antigens.CPT codes 95115 - 95117Bill one CPT code 95115 or 95117 per date of service (DOS) and 1 unit in Box 24-G, days or units field.Do NOT bill CPT code 95115 and 95117 on the same DOS.Do NOT bill CPT code 95115 and 95117 if the antigen is self-administered by the patient.Code 95144To bill CPT code 95144, designate the number of single-dose vials prepared and provided.CPT code 95144 indicates ONLY single-dose vialsCPT code 95144 may only be used when a physician prepares an extract to be injected by another entity.CPT Code 95165To bill CPT code 95165, designate the number of doses.CPT code 95165 does NOT include antigen administration.To bill for antigen preparation and administration, use component billing.(Samples below)If a multi-dose vial contains less than 10cc, bill the number of 1 cc aliquots that may be removed from the vial up to a maximum of 10 doses per multi-dose vial.If medically necessary, physicians may bill for preparation of more than one multi-dose vial.CPT code 95165 Billing Exceptions
Article - Billing and Coding: Allergy Immunotherapy (A56424)
CPT code 95165 Billing ExceptionsIf the antigens, i.e. mold and pollen, cannot be mixed together, CGS calculates the practice expense (PE) for mixing a multi-dose vial of antigens based on the following observed practice method:Physicians usually prepare a 10 cc vial and remove aliquots with a volume of 1 cc.10, 1 cc aliquot doses equal the entire PE component for the service.Size or number of aliquots removed do NOT alter the PE for the service.CPT code 95165 Billing SamplesTo bill a 10 cc multi-dose vial filled to 6cc with antigen, submit CPT code 95165 with 6 in the days/units field.If a physician removes  cc aliquots from a 10cc multi-dose vial for a total of 2 doses, submit CPT code 96165 with 10 in the days/unit field. (Billing for more than 10 doses represents an overpayment for the practice expense vial preparation).If a physician prepares two 10cc multi-dose vials, submit CPT code 95165 with 20 in the days/unit field. (The number of aliquots removed from the vials does NOT change the number of doses billed.)CPT codes 95144-95170 Component BillingServices for CPT codes 95144-95170 represent a single dose.To bill, specify number of doses in the days/units field.Use a code below the venom treatment number ONLY for catch up purposes.If a physician prepares the allergen and administers the injection on the same date of service, bill the appropriate injection code (CPT codes 95115-95117) AND the appropriate preparation code (CPT codes 95145-95170).Do NOT bill CPT code 95144 AND an injection code (CPT codes 95115-95117).CPT code 95144 Billing SamplesSample 1:Allergist bills CPT code 95144 and 2 in the days/units field to indicate preparation of 2 single-dose vials of extract.Primary care bills CPT code 95117 and 1 in the days/units field to indicate the administration of 2 or more injections.Sample 2 *Component Billing:
Article - Billing and Coding: Allergy Immunotherapy (A56424)
Sample 2 *Component Billing:Allergist prepares a 10-dose vial and develops a schedule to administer one dose per encounter over a predetermined period of time.Bill CPT code 95145 with 10 in the days/units field for the preparation.Bill CPT code 95115 for one injection.Sample 3Allergist prepares a 10-dose vial and develops a schedule for the patient to self-administer the injections.Bill CPT code 95145 with 10 in the days/units field for the preparation.Do NOT bill an injection code.Sample 4Allergist prepares a 10-dose vial for non-stinging insect venom and administers one injection.Bill CPT code 95165 with 10 in the days/units field for the preparation.Bill CPT code 95115 for one injection.Venom Doses and Catch-Up BillingSince physicians prepare most venom doses in separate vials, a respective dose of CPT code 95146-95149 represents a portion of two, three, four or five venoms. Medicare built savings into the reimbursement for the higher venom codes. Therefore, if a patient receives two-venom, three-venom, four-venom or five-venom therapy, physicians should allow the highest possible venom level.In multi-venom therapy the physician provides a portion of each venom amount. Due to patient reaction, venom administration may not remain synchronized and dosage adjustments must be made. If the physician makes an adjustment, he must synchronize the preparation to the highest-level venom as soon as possible.Sample: A physician prepares ten doses of CPT code 95148 in two vials. One contains 10 doses of three-vespid mix and another contains 10 doses of wasp venom. Because of dose adjustment, the three-vespid mix covers 15 doses. The physician must prepare 5 doses of CPT code 95145 for the catch-up.Bill CPT code 95148 with 10 in the days/units field for a patient in four-venom therapy.Bill CPT code 95145 with 5 in the days/units field.Treatment BoardsTo report treatment boards, use the antigen preparation vial CPT codes (95145-95149, 95165 and 95170) AND the component billing method. Use CPT code 95165 in place of 95144 to bill for other than stinging/biting insects.
Article - Billing and Coding: Allergy Immunotherapy (A56424)
Sample: Allergist prepares a 10-dose vial for non-stinging allergen and administers one injection.Bill CPT code 95165 with 10 in the days/units field for the preparation.Bill CPT code 95115 for one injection.CPT Code 95170Applies ONLY to fire ant extractEvaluation and Management (E/M) Services and ImmunotherapyTo identify a significant, separately identifiable visit service above and beyond the allergen immunotherapy service provided, select the appropriate E/M code and append with Modifier 25.General Guidelines for Claims submitted to Part A or Part B MAC: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.
Article - Billing and Coding: Allergy Immunotherapy (A56424)
Advance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.