evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
1. Medicare will only consider DBS devices to be reasonable and necessary if they are Food and Drug Administration (FDA) approved devices for DBS or devices used in accordance with FDA approved protocols governing Category B Investigational Device Exemptio n (IDE) DBS clinical trials.   2. For thalamic VIM DBS to be considered reasonable and necessary, patients must meet all of the following criteria:  a. Diagnosis of essential tremor (ET) based on postural or kinetic tremors of hand(s) without other neurologic signs, or diagnosis of idiopathic PD (presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia)) which is of a tremor - dominant  form.   b. Marked disabling tremor of at least level 3 or 4 on the Fahn- Tolosa -Marin Clinical Tremor Rating Scale (or equivalent scale) in the extremity intended for treatment, causing significant limitation in daily activities despite optimal medical therapy.   c. Willingness and ability to cooperate during conscious operative procedure, as well as during post -surgical evaluations, adjustments of medications and stimulator settings.   3. For STN or GPi DBS to be considered reasonable and necessary, patients must meet all of the following criteria:  a. Diagnosis of PD based on the presence of at least 2 cardinal PD features (tremor, rigidity or bradykinesia).   b. Advanced idiopathic PD as determined by the use of Hoehn and Yahr stage or Unified Parkinsons Disease Rating Scale (UPDRS) part III motor subscale.  c. L-dopa responsive with clearly defined on periods.  d. Persistent disabling Parkinsons symptoms or drug side effects (e.g., dyskinesias, motor fluctuations, or disabling off periods) despite optimal medical therapy.   e. Willingness and ability to cooperate during conscious operative procedure, as well as during post -surgical evaluations, adjustments of medications and stimulator settings.   The DBS is not reasonable and necessary and is not covered for ET or PD patients with any of the following:   1. Non-idiopathic Parkinsons disease or Parkinsons Plus syndromes.  2. Cognitive impairment, dementia or depression which would be worsened by or would interfere with the patients ability to benefit from DBS.   3. Current psychosis, alcohol abuse or other drug abuse.
(Medicare Claims Processing Manual)
2. Cognitive impairment, dementia or depression which would be worsened by or would interfere with the patients ability to benefit from DBS.   3. Current psychosis, alcohol abuse or other drug abuse.  4. Structural lesions such as basal ganglionic stroke, tumor or vascular malformation as etiology of the movement disorder.   5. Previous movement disorder surgery within the affected basal ganglion.  6. Significant medical, surgical, neurologic or orthopedic co- morbidities contraindicating DBS surgery or stimulation.  Patients who undergo DBS implantation should not be exposed to diathermy (deep heat treatment including shortwave diathermy, microwave diathermy and ultrasound diathermy) or any type of MRI which may adversely affect the DBS system or adversely affect the brain around the implanted electrodes.   The DBS should be performed with extreme caution in patients with cardiac pacemakers or other electronically controlled implants which may adversely affect or be affected by the DBS system.   For DBS lead implantation to be considered reasonable and necessary, providers and facilities must meet all of the following criteria:    1. Neurosurgeons must: (a) be properly trained in the procedure; (b) have experience with the surgical management of movement disorders, including DBS therapy; and (c) have experience performing stereotactic neurosurgical procedures    2. Operative teams must have training and experience with DBS systems, including knowledge of anatomical and neurophysiological characteristics for localizing the targeted nucleus, surgical and/or implantation techniques for the DBS system, and operationa l and functional characteristics of the device.    3. Physicians specializing in movement disorders must be involved in both patient selection and post -procedure care.    4. Hospital medical centers must have: (a) brain imaging equipment (MRI and/or CT) for pre -operative stereotactic localization and targeting of the surgical site(s); (b) operating rooms with all necessary equipment for stereotactic surgery; and (c) support  services necessary for care of patients undergoing this procedure and any potential complications arising intraoperatively or postoperatively.  50.2  Billing Requirements (Rev. 128, 03- 26-04)  50.2.1  Part A Intermediary Billing Procedures  (Rev. 128, 03- 26-04)
(Medicare Claims Processing Manual)
50.2.1  Part A Intermediary Billing Procedures  (Rev. 128, 03- 26-04)  This procedure can be two fold.  Implantation of the electrodes is performed in a hospital inpatient setting.  Implantation of the pulse generator can be performed in an outpatient department.   50.3 - Payment Requirements  (Rev. 128, 03- 26-04)  50.3.1  Part A Payment Methods  (Rev. 128, 03- 26-04)  Payment for the inpatient procedure is under Diagnostic Related Group (DRG).  The outpatient procedure is outpatient prospective payment system.  For critical access hospitals (CAH), the inpatient stay is on reasonable cost and the outpatient procedures ar e also based on reasonable cost.   50.3.2  Bill Types (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Deep Brain Stimulation may be submitted on institutional claims using the following Types of Bill:   11X, 12X, 13X, and 85X   50.3.3  Revenue Codes (Rev. 128, 03- 26-04)  Revenue codes for implementation can be performed in a number of revenue centers within a hospital such as operating room (360) or clinic (510).  The codes to report the pulse generator and/or electrodes are 270, 278, 279.  For CAHs that choose method II, use revenue code 98X for the professional component only.  50.4  Allowable Codes  (Rev. 128, 03- 26-04)  50.4.1  Allowable Covered Diagnosis Codes (Rev. 12435, Issued:12- 28-23, Effective:01 -29-24, Implementation:01- 29-24) Deep Brain Stimulation is covered for the following diagnosis codes:  If ICD -10-CM is applicable:    ICD-10-CM G20.A1 -  Parkinson's disease without dyskinesia, without mention of fluctuations    ICD-10-CM G20.A2 -  Parkinson's disease without dyskinesia, with fluctuations    ICD-10-CM G20.B1 -  Parkinson's disease with dyskinesia, without mention of fluctuations    ICD-10 CM G20.B2 -  Parkinson's disease with dyskinesia, with fluctuations
(Medicare Claims Processing Manual)
 ICD-10 CM G20.B2 -  Parkinson's disease with dyskinesia, with fluctuations    ICD-10-CM G20.C -  Parkinsonism, unspecified   ICD-10-CM G25.0 - Essential  tremor   ICD-10-CM G25.2 - Other specified form of  tremor   50.4.2  Allowable Covered Procedure Codes  (Rev. 11021; Issued: 10-01- 21; Effective: 10 -29-21; Implementation: 10-29-21)   The following procedure codes may be present:     If ICD -10-PCS is applicable:    ICD-10-PCS Code  Code Description  00H00MZ  Insertion of Neurostimulator Lead into Brain, Open Approach  00H03MZ     Insertion of Neurostimulator Lead into Brain, Percutaneous Approach  00H04MZ  Insertion of Neurostimulator Lead into Brain, Endoscopic Approach  00H60MZ  Insertion of Neurostimulator Lead into Cerebral Ventricle, Open Approach  00H63MZ  Insertion of Neurostimulator Lead into Cerebral Ventricle, Percutaneous Approach  00H64MZ  Insertion of Neurostimulator Lead into Cerebral Ventricle, Percutaneous Endoscopic Approach  00P00MZ  Removal of Neurostimulator Lead from Brain, Open Approach  00P03MZ  Removal of Neurostimulator Lead from Brain, Percutaneous Approach  00P04MZ  Removal of Neurostimulator Lead from Brain, Percutaneous Endoscopic Approach  00P60MZ  Removal of Neurostimulator Lead from Cerebral Ventricle, Open Approach  00P63MZ  Removal of Neurostimulator Lead from Cerebral Ventricle, Percutaneous Approach  00P64MZ  Removal of Neurostimulator Lead from Brain, Open Approach  0H80XZZ  Division of Scalp Skin, External Approach  0HSSXZZ  Reposition Hair, External Approach   Coverage policy may be found in the National Coverage Determinations Manual in Chapter 1, section 160.24: Deep Brain Stimulation, using the following link: (http://www.cms.hhs.gov/manuals/103_cov_determ/ncd103index.asp).
(Medicare Claims Processing Manual)
50.4.3  Healthcare Common Procedure Coding System (HCPCS)  (Rev. 11021; Issued: 10-01- 21; Effective: 10 -29-21; Implementation: 10-29-21)  The following HCPCS codes are available for use when billing for covered deep brain stimulation:    61880   Revision or removal of intracranial neurostimulator electrodes    61885   Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array   61886   Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays   61888   Revision or removal of cranial neurostimulator pulse generator or receiver   95961    Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of physician attendance   95962     Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; each additional hour of physician attendance (List separat ely in addition to code for primary procedure) (Use 95962 in conjunction with code 95961)   95970    Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (i.e., cranial nerve, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming
(Medicare Claims Processing Manual)
95971     Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance m easurements); simple brain, spinal cord, or peripheral (i.e., peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming.  95983     Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group(s), interleaving, amplitude, pulse width, frequency (Hz), on/off cycling, burst, magnet mode, doe lockout, patient selectable parameters, responsive n eurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain neurostimulator pulse generator/ transmitter programming, first 15 minutes face -to-face time with physician or other qualified health care professional.  95984     Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group(s), interleaving, amplitude, pulse width, frequency (Hz), on/off cycling, burst, magnet mode, doe lockout, patient selectable parameters, responsive n eurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain neurostimulator pulse generator/transmitter programming, each additional 15 minutes face -to-face time with physician or other qualified health care professional.   50.5  Ambulatory Surgical Centers  (Rev. 128, 03- 26-04)  The following HCPCS codes are approved for billing in Ambulatory Surgical Centers:   61885 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array - ASC Payment Group 02  61888 Revision or removal of cranial neurostimulator pulse generator or receiver - ASC Payment Group 01   NOTE:   Pulse generator is payable in an ASC; implantation of electrodes are not.  50.6  Claims Editing for Intermediaries  (Rev. 128, 03- 26-04)
(Medicare Claims Processing Manual)
NOTE:   Pulse generator is payable in an ASC; implantation of electrodes are not.  50.6  Claims Editing for Intermediaries  (Rev. 128, 03- 26-04)  We do not require nationwide standard system claims processing edits for pre and post payment review of claim(s) at this time.  However, carriers and intermediaries may create local claims processing edits for the requirements listed above.  50.7  Remittance Advice Notice for Intermediaries  (Rev.  2998, Issued: 07- 25-14, Effective: Upon implementation of ICD -10; 01- 01-12 - ASC X12, Implementation: 08- 25-2014 -  ASC X12; Upon Implementation of ICD -10)  Use appropriate existing remittance advice reason and remark codes at the line level to express the specific reason if you deny payment for DBS.  If denying services as furnished before April 1, 2003, use existing ASC X 12- 835 claim adjustment reason code 26 "Expenses incurred prior to coverage" at the line level.   50.8 - Medicare Summary Notice (MSN) Messages for Intermediaries (Rev. 128, 03- 26-04)  Use the following MSN messages where appropriate:   If a claim for DBS is denied because the service was performed prior to April 1, 2003, use the MSN message:    "This service was not covered by Medicare at the time you received it."  (MSN Message 21.11)   The Spanish version of the MSN message should read:    "Este servicio no estaba cubierto por Medicare cuando usted lo recibi."  (MSN Message 21.11)   50.9  Provider Notification  (Rev. 128, 03- 26-04)  Contractors should notify providers of this new national coverage in their next regularly scheduled bulletin, on their Web site within 2 weeks, and in routinely scheduled training sessions.   60  Coverage and Billing for Home Prothrombin Time (PT/INR) Monitoring for Home Anticoagulation Management  (Rev. 1562, Issued: 07- 25-08, Effective: 03 -19-08, Implementation: 08- 25-08)
(Medicare Claims Processing Manual)
The prothrombin time (PT) test is an in -vitro test to assess coagulation.  PT testing and its normalized correlate, the International Normalized Ratio (INR), are the standard measurements for therapeutic effectiveness of warfarin therapy.  Warfarin, Coumad in, and others, are self -administered, oral anticoagulant, or blood thinner, medications that affect a persons Vitamin K -dependent clotting factors.   Use of the INR allows physicians to determine the level of anticoagulation in a patient independent of the laboratory reagents used.  The INR is the ratio of the patient's prothrombin time compared to the mean prothrombin time for a group of normal individuals.   60.1  Coverage Requirements  (Rev. 1562, Issued: 07- 25-08, Effective: 03 -19-08, Implementation: 08- 25-08)  For services furnished on or after July 1, 2002, Medicare will cover the use of home INR monitoring for anticoagulation management for patients with mechanical heart valves on warfarin.  The monitor and the home testing must be prescribed by a physician and the following patient requirements must be met:   Must have been anticoagulated for at least 3 months prior to use of the home INR device;    Must undergo an educational program on anticoagulation management and the use of the device prior to its use in the home; and   Self testing with the device is limited to a frequency of once per week.   For services furnished on or after March 19, 2008, the Centers for Medicare & Medicaid Services revised its national coverage determination (NCD) on PT/INR Monitoring for Home Anticoagulation Management as follows:   Medicare will cover the use of home PT/INR monitoring for chronic, oral anticoagulation management for patients with mechanical heart valves, chronic atrial fibrillation, or venous thromboembolism (inclusive of deep venous thrombosis and pulmonary embolism ) on warfarin.  The monitor and the home testing must be prescribed by a treating physician as provided at 42 CFR 410.32(a), and all of the following requirements must be met:   1. The patient must have been anticoagulated for at least 3 months prior to use of the home INR device; and,
(Medicare Claims Processing Manual)
1. The patient must have been anticoagulated for at least 3 months prior to use of the home INR device; and,   2. The patient must undergo a face -to-face educational program on anticoagulation management and must have demonstrated the correct use of the device prior to its use in the home; and,  3. The patient continues to correctly use the device in the context of the management of the anticoagulation therapy following the initiation of home monitoring; and,  4. Self-testing with the device should not occur more frequently than once a week.   NOTE:   Porcine valves are not included in this NCD, so Medicare will not make payment on home INR monitoring for patients with porcine valves unless covered by local Medicare contractors.   60.2  Intermediary Payment Requirements  (Rev. 216, 06- 25-04)  60.2.1  Part A Payment Methods  (Rev. 216, 06- 25-04)  Payment is as follows:   Hospital outpatient departments -  Outpatient Prospective Payment System (OPPS)    Critical Access Hospital (CAH) -  Reasonable cost or Medicare Physician Fee Schedule (MPFS)   Deductible and coinsurance apply.   60.3  Intermediary Billing Procedures  (Rev. 216, 06- 25-04)  60.3.1  Bill Types (Rev. 216, 06- 25-04)  The applicable bill types are 13X and 85X.   60.3.2  Revenue Codes (Rev. 216, 06- 25-04)  Hospitals may report these services under revenue code 920 or they may report HCPCS codes G0248 and G0249 under the revenue center where they are performed.   60.4  Intermediary Allowable Codes (Rev. 216, 06- 25-04)  60.4.1  Allowable Covered Diagnosis Codes  (Rev.10881; Issued: 08- 06-2021; Effective: 09- 07-2021; Implementation: 09- 07- 2021)   For services furnished on or after the implementation of ICD -10 the applicable ICD -10-CM diagnosis codes for this benefit are:
(Medicare Claims Processing Manual)
ICD-10-CM Code  Code Description  D68.51  Activated protein C resistance  D68.52  Prothrombin gene mutation  D68.59  Other primary thrombophilia  D68.61  Antiphospholipid syndrome  D68.62  Lupus anticoagulant syndrome  I23.6  Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute myocardial infarction  I26.01  Septic pulmonary embolism with acute cor pulmonale  I26.09  Other pulmonary embolism with acute cor pulmonale  I26.90  Septic pulmonary embolism without acute cor pulmonale  I26.93  Single subsegmental pulmonary embolism without acute cor pulmonale  I26.94  Multiple subsegmental pulmonary emboli without acute cor pulmonale  I26.99  Other pulmonary embolism without acute cor pulmonale  I27.24  Chronic thromboembolic pulmonary hypertension  I27.82  Chronic pulmonary embolism  I48.0  Paroxysmal atrial fibrillation  I48.11  Longstanding persistent atrial fibrillation  I48.19  Other persistent atrial fibrillation  I48.21  Permanent atrial fibrillation  I67.6  Nonpyogenic thrombosis of intracranial venous system  I80.11  Phlebitis and thrombophlebitis of right femoral vein  I80.12  Phlebitis and thrombophlebitis of left femoral vein  I80.13  Phlebitis and thrombophlebitis of femoral vein, bilateral  I80.211  Phlebitis and thrombophlebitis of right iliac vein  I80.212  Phlebitis and thrombophlebitis of left iliac vein  I80.213  Phlebitis and thrombophlebitis of iliac vein, bilateral  I80.221  Phlebitis and thrombophlebitis of right popliteal vein  I80.222  Phlebitis and thrombophlebitis of left popliteal vein  I80.223  Phlebitis and thrombophlebitis of popliteal vein, bilateral  I80.231  Phlebitis and
(Medicare Claims Processing Manual)
Phlebitis and thrombophlebitis of left popliteal vein  I80.223  Phlebitis and thrombophlebitis of popliteal vein, bilateral  I80.231  Phlebitis and thrombophlebitis of right tibial vein  I80.232  Phlebitis and thrombophlebitis of left tibial vein  I80.233  Phlebitis and thrombophlebitis of tibial vein, bilateral  I80.241  Phlebitis and thrombophlebitis of right peroneal vein  I80.242  Phlebitis and thrombophlebitis of left peroneal vein  I80.243  Phlebitis and thrombophlebitis of peroneal vein, bilateral  I80.251  Phlebitis and thrombophlebitis of right calf muscular vein  I80.252  Phlebitis and thrombophlebitis of left calf muscular vein  I80.253  Phlebitis and thrombophlebitis of calf muscular vein, bilateral  I80.291  Phlebitis and thrombophlebitis of other deep vessels of right lower extremity  I80.292  Phlebitis and thrombophlebitis of other deep vessels of left lower extremity  I80.293  Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral  I82.0  Budd -Chiari syndrome  I82.210  Acute embolism and thrombosis of superior vena cava  I82.211  Chronic embolism and thrombosis of superior vena cava  I82.220  Acute embolism and thrombosis of inferior vena cava  I82.221  Chronic embolism and thrombosis of inferior vena cava  I82.290  Acute embolism and thrombosis of other thoracic veins  I82.291  Chronic embolism and thrombosis of other thoracic veins  I82.3  Embolism and thrombosis of renal vein  I82.411  Acute embolism and thrombosis of right femoral vein  I82.412  Acute embolism and thrombosis of left femoral vein
(Medicare Claims Processing Manual)
Embolism and thrombosis of renal vein  I82.411  Acute embolism and thrombosis of right femoral vein  I82.412  Acute embolism and thrombosis of left femoral vein  I82.413  Acute embolism and thrombosis of femoral vein, bilateral  I82.421  Acute embolism and thrombosis of right iliac vein  I82.422  Acute embolism and thrombosis of left iliac vein  I82.423  Acute embolism and thrombosis of iliac vein, bilateral  I82.431  Acute embolism and thrombosis of right popliteal vein  I82.432  Acute embolism and thrombosis of left popliteal vein  I82.433  Acute embolism and thrombosis of popliteal vein, bilateral  I82.441  Acute embolism and thrombosis of right tibial vein  I82.442  Acute embolism and thrombosis of left tibial vein  I82.443  Acute embolism and thrombosis of tibial vein, bilateral  I82.451  Acute embolism and thrombosis of right peroneal vein  I82.452  Acute embolism and thrombosis of left peroneal vein  I82.453  Acute embolism and thrombosis of peroneal vein, bilateral  I82.461  Acute embolism and thrombosis of right calf muscular vein  I82.462  Acute embolism and thrombosis of left calf muscular vein  I82.463  Acute embolism and thrombosis of calf muscular vein, bilateral  I82.491  Acute embolism and thrombosis of other specified deep vein of right lower extremity  I82.492  Acute embolism and thrombosis of other specified deep vein of left lower extremity  I82.493  Acute embolism and thrombosis of other specified deep vein of lower extremity, bilateral  I82.511  Chronic embolism and thrombosis of right femoral vein  I82.512  Chronic embolism and thrombosis of left femoral vein