evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Molecular Pathology Procedures (A57451)
Code selection is typically based on the specific gene(s) that is being analyzed. Codes that describe tests to assess for the presence of gene variants use common gene variant names. Typically, all of the listed variants would be tested. However, these lists are not exclusive. If other variants are also tested in the analysis, they would be included in the procedure and not reported separately. Full gene sequencing should not be reported using codes that assess for the presence of gene variants unless the CPT code specifically states full gene sequence in the code descriptor. In other words, you may only assign the CPT code that is described as full gene sequence if the test assay performed was a full gene sequence.Tier 2 molecular pathology procedures represent medically useful procedures that are generally performed in lower volumes than Tier 1 molecular pathology procedures (e.g., the incidence of the disease being tested is rare). They are arranged by level of technical resources and interpretive work by the physician or other qualified healthcare professional. If the analyte tested is not listed under one of the Tier 2 codes or is not represented by a Tier 1 code in CPT, use of the unlisted CPT code 81479 is required.HCPCS code G0452 with modifier 26 should be used by pathologists when an interpretation of a molecular pathology test is performed. Non physician practitioners (e.g., PhD, scientists etc.) are not eligible to report this code, only physicians may use/bill this code. This code should not be billed without modifier 26 since it is an interpretation code only.Documentation Requirements
Article - Billing and Coding: Molecular Pathology Procedures (A57451)
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.Documentation must be adequate to verify that coverage guidelines have been met. Thus, the medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed. The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition that warrants the test(s).Providers are required to code to specificity however, if CPT 81479 (unlisted molecular pathology procedure) is used the documentation must clearly identify the unique molecular pathology procedure performed. When multiple procedure codes are submitted on a claim (unique and/or unlisted) the documentation supporting each code should be easily identifiable.For molecular pathology tests, the ordering provider must provide to the laboratory copies of the signed informed consent documentation.An Advance Beneficiary Notice of Noncoverage (ABN) is required before furnishing a beneficiary a test which the physician or laboratory believes to be noncovered as not reasonable or necessary. The physician or laboratory must obtain a signed ABN from the beneficiary (or representative) that the physician or laboratory has informed him/her on the non-coverage of the test and that there will be a charge for the test.
Article - Billing and Coding: Peripheral Nerve Blocks (A57452)
CMS National Coverage PolicyLanguage quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). 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 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext 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.CMS Publication 100-04,Medicare Claims Processing Manual,Chapter 12:Section 50 Payment for Anesthesiology ServicesArticle Text
Article - Billing and Coding: Peripheral Nerve Blocks (A57452)
This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Peripheral Nerve Blocks.National CoverageNon-coverage for prolotherapy, joint sclerotherapy and ligamentous injections with sclerosing agents is found in CMS Publication 100-03,Medicare National Coverage Determinations Manual, Section 150.7.Effective January 21, 2020, all types of acupuncture including dry needling for any condition other than chronic low back pain are non-covered by Medicare. Medicare will cover acupuncture for Medicare patients with chronic lower back pain within specific guidelines in accordance with NCD 30.3.3.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 reportedBased on Medicare rules, regulations, and National Correct Coding Initiative (NCCI) edits, CPT codes 64400-64530 (Peripheral nerve blocks-bolus injection or continuous infusion) may be reported on the date of surgery if performed for post-operative pain management only if the operative anesthesia is general anesthesia, subarachnoid injection or epidural injection and the adequacy of the intraoperative anesthesia is not dependent on the peripheral nerve block. Peripheral nerve blocks codes should not be reported separately on the same date of service as a surgical procedure if used as the primary anesthetic technique or as a supplement to the primary anesthetic technique. However 100-04 (Claims Processing Manual) Chapter 12 40  Surgeons and Global Surgery states under A. Components of a Global Surgical PackagePostsurgical Pain Management - By the surgeon.Similarly, CHAPTER II ANESTHESIA SERVICES CPT CODES 00000-09999
Article - Billing and Coding: Peripheral Nerve Blocks (A57452)
FORNATIONAL CORRECT CODING INITIATIVE POLICY MANUAL FOR MEDICARE SERVICESstatesPostoperative pain management services are generally provided by the surgeon who is reimbursed under a global payment policy related to the procedure and shall not be reported by the anesthesia practitioner unless separate, medically necessary services are required that cannot be rendered by the surgeon. The surgeon is responsible to document in the medical record the reason care is being referred to the anesthesia practitioner. Thus any such additional nerve blocks must not only be properly documented for why they cannot be rendered by the surgeon, but also would be quite rare.Use of physical medicine and rehabilitation CPT/HCPCS codes (97032, 97139, G0282, G0283) for treatment of neuropathies or peripheral neuropathies caused by underlying systemic diseases is inappropriate.Injection therapies for tarsal tunnel syndrome (which include any so-called "Baxter's injections") and for Morton's neuroma (CPT code 64455) do not involve the structures described by CPT code 20550 and 20551 or direct injection into other peripheral nerves but rather the focal injection of tissue surrounding a specific focus of inflammation on the foot.Injections for plantar fasciitis are addressed by CPT code 20550, not CPT code 64450. Injections for calcaneal spurs are addressed as are other tendon origin/insertions by CPT code 20551. Injections to include both the plantar fascia and the area around a calcaneal spur, are to be reported using only CPT code 20551 with a unit of service of 1."Dry needling" of ganglion cysts, ligaments, neuromas, peripheral nerves, tendon sheaths and their origins/insertions, or any tissue are non-covered procedures.Documentation Requirements
Article - Billing and Coding: Peripheral Nerve Blocks (A57452)
The medical record documentation maintained by the performing provider must clearly support the medical necessity of the service being billed. The documentation supporting the service must be included in the patients medical record. This information is usually found in the history and physical, office/progress notes, hospital notes, and/or procedure report. Medical records must be available and submitted upon request for review.Documentation must support the criteria for coverage as set forth in the Indications and Limitations of Coverage and/or Medical Necessity section of the LCD.Assessment of the outcome of this procedure depends on the patients responses, therefore documentation should include: Whether the block was a diagnostic or therapeutic injection Pre- and post-procedure evaluation of patient Patient educationUtilization GuidelinesMore than three injections per anatomic site (specific nerve, plexus or branch as defined by the CPT code description) in a six month period will be denied.It is unusual that more than two nerves would need to be blocked at any one session. If more than two nerves are blocked in one session, this may trigger a medical review and the provider must document the medical necessity for more than two blocks in the patient's medical record.It 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. More than one unit of any code may be subject to prepayment review.
Article - Billing and Coding: Posterior Tibial Nerve Stimulation for Voiding Dysfunction (A57453)
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 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 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Publications:CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Part 1:30.3  AcupunctureArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD)for Posterior Tibial Nerve Stimulation for Voiding Dysfunction.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 Requirements:
Article - Billing and Coding: Posterior Tibial Nerve Stimulation for Voiding Dysfunction (A57453)
The medical record must document the patient has OBS and not stress or neurogenic incontinence. The International Continence Society (ICS) defines OAB as the presence of urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology.Compliance and voiding diaries for a minimum of three days must be kept and provided to document the patient has been compliant with first- and second-line therapies without sufficient improvement prior to receiving PTNS.Compliance and voiding diaries for a minimum of three days must be kept and provided during PTNS treatment and to document any symptoms of relapse.Utilization Guidelines:The initial 12-week PTNS treatment should be periodically evaluated to assure beneficiary improvement and record-keeping compliance.Treatments for relapse would not be expected to occur more often than one to two sessions every one to two months.
Article - Billing and Coding: Urodynamics (A57455)
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 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.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.CMS Publications:CMS Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1:230.2 Uroflowmetric EvaluationsArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD)for Urodynamics.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.If a penile pressure cuff is used when providing a voiding pressure study, CPT Code 55899 should be reported with non-invasive urodynamic studies noted in the narrative portion of the claim.Documentation Requirements:
Article - Billing and Coding: Urodynamics (A57455)
Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will be returned.The 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.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Documentation must be available to Medicare upon request.
Article - Billing and Coding: MolDX: HLA-DQB1*06:02 Testing for Narcolepsy (A57465)
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: Allergy Immunotherapy (A57472)
CMS National Coverage PolicyItalicized font represents CMS national NCD language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national NCD language/wording.Title XVIII of the Social Security Act, Section 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, Section 1862 (a) (1) (A) allows coverage and payment of those items or services that are considered to bemedically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, Section 1862 (a) (1) (D) excludes investigational or experimental from Medicare coverage.42 CFR Section 410.68  Antigens: Scope and Conditions. This section describes thatMedicare Part B pays for (a) antigens that are furnished as services incident to a physicians professional services; or (b) a supply of antigen sufficient for not more than 12 months that is.It describes who prepares, administers, and supervises.CMS Pub 100-02Medicare Benefit Policy Manual, Chapter 15  Covered Medical and Other Health Services, Sections20.2  Physician Expense for Allergy Treatment,50.4.4.1  Antigens,60.2  Services of Nonphysician Personnel Furnished Incident to Physicians Services80.1  Clinical Laboratory Services, and80.6  Requirements for Ordering and Following Orders for Diagnostic Tests.Chapter 16  General ExclusionsFrom Coverage, Section90  Routine Services and Appliances, B. Antigens.CMS Pub 100-03Medicare National Coverage Determinations (NCD) Manual, Chapter 1  Coverage Determinations, Part 2, Sections110.9  Antigens Prepared for Sublingual Administration110.11  Food Allergy Testing and TreatmentCMS Pub 100-04Medicare Claims Processing Manual, Chapter 12  Physicians/Nonphysician Practitioners, Section200 - Allergy Testing and Immunotherapy, andChapter 16  Laboratory Services, Section40.7  Billing for Noncovered Clinical Laboratory Tests.Article Text
Article - Billing and Coding: Allergy Immunotherapy (A57472)
Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD Allergy Immunotherapy L36408.Coding InformationBilling GuidelinesSee NCCI edits inNational Correct Coding Initiative Policy Manual for Medicare Services, Chapter 11 - Medicine Evaluation and Management Services for CPT Codes 90000-99999, Section K  Allergy Testing and Immunotherapy, 3.Evaluation and management (E&M) codes reported with allergy immunotherapy are appropriate only if a significant, separately identifiable service is performed.Obtaining informed consent is included in the immunotherapy service and shall not be reported with an E&M code.If E&M services are reported, modifier 25 should be utilized.Non-covered services includes the following: Sublingual Intracutaneous and subcutaneous Provocative and Neutralization Testing:Effective October 31, l988, sublingual intracutaneous and subcutaneous provocative and neutralization testing and neutralization therapy for food allergies are excluded from Medicare coverage because available evidence does not show that these tests and therapies are effective.(CMS Pub 100-03Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 2 Section 110.11  Food Allergy Testing and Treatment (Rev. 1, 10-03-03).For services rendered on or after January 1, 1995, all antigen/allergy immunotherapy services are paid for under the Medicare physician fee schedule.(CMS Pub 100-04Medicare Claim Processing Manual,Chapter 12, Section 200- Allergy Testing and Immunotherapy, Rev. 2997, Issued: 07-25-14)The following policies are effective as of January 1, 1995:CPT codes 95120 through 95134 are not valid for Medicare. Codes 95120 through 95134 represent complete services, i.e., services that include both the injection service as well as the antigen and its preparation.Separate coding for injection only codes (i.e., codes 95115 and 95117) and/or the codes representing antigens and their preparation (i.e., codes 95144 through 95170) must be used.If both services are provided both codes are billed.
Article - Billing and Coding: Allergy Immunotherapy (A57472)
This includes allergists who provide both services through the use of treatment boards.If a physician bills both an injection code plus either codes 95165 or 95144, A/B MACs (B) pay the appropriate injection code (i.e., code 95115 or code 95117) plus the code 95165 rate. When a provider bills for codes 95115 or 95117 plus code 95144, A/B MACs (B) change 95144 to 95165 and pay accordingly. Code 95144 (single dose vials of antigen) should be billed only if the physician providing the antigen is providing it to be injected by some other entity. Single dose vials, which should be used only as a means of insuring proper dosage amounts for injections, are more costly than multiple dose vials (i.e., code 95165) and therefore their payment rate is higher. Allergists who prepare antigens are assumed to be able to administer proper doses from the less costly multiple dose vials. Thus, regardless of whether they use or bill for single or multiple dose vials at the same time that they are billing for an injection service, they are paid at the multiple dose vial rate.The fee schedule amounts for the antigen codes (95144 through 95170) are for a single dose. When billing those codes, physicians are to specify the number of doses provided. When making payment, A/BMACs (B) multiply the fee schedule amount by the number of doses specified in the units field.