evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
 Medicare pays for a screening Pap smear and/or screening pelvic examination only once every (2, 3) years unless high risk factors are present.  40.8 - Remittance Advice Codes (Rev. 3329, Issued: 08- 14-15, Effective: 01 -01-12, Implementation: 09- 14-15)  If high risk factors are not present, and the screening Pap smear and/or screening pelvic examination is being denied because the procedure/examination is performed more frequently than allowed, use existing ASC X12 835:    Claim adjustment reason code 119 -  Benefit maximum for this time period has been reached  at the line level, and    Remark code M83 - Service is not covered unless the patient is classified as at high risk at the line item level.   50 - Prostate Cancer Screening Tests and Procedures  (Rev. 1, 10- 01-03)  B3-4182, A3- 3616   Sections 1861(s)(2)(P) and 1861(oo)  of the Act (as added by 4103 of the Balanced Budget Act of 1997), provide for Medicare Part B coverage of certain prostate cancer screening tests subject to certain coverage, frequency, and payment limitations.  Effective for services furnished on or aft er January 1, 2000, Medicare Part B covers prostate cancer screening tests/procedures for the early detection of prostate cancer.  Coverage of prostate cancer screening tests includes the following procedures furnished to an individual for the early detect ion of prostate cancer:    Screening digital rectal examination, and   Screening prostate specific antigen (PSA) blood test.  Each test may be paid at a frequency of once every 12 months for men who have attained age 50 (i.e., starting at least one day after they have attained age 50), if at least 11 months have passed following the month in which the last Medicare -covered screening digital rectal examination was performed (for digital rectal exams) or PSA test was performed (for PSA tests).   50.1 - Definitions  (Rev. 1, 10- 01-03) A3-3616.A.1 and 2  A. Screening Digital Rectal Examination
(Medicare Claims Processing Manual)
50.1 - Definitions  (Rev. 1, 10- 01-03) A3-3616.A.1 and 2  A. Screening Digital Rectal Examination   Screening digital rectal examination means a clinical examination of an individuals prostate for nodules or other abnormalities of the prostate.  This screening must be performed by a doctor of medicine or osteopathy (as defined in 186l(r)(1)  of the Act), or by a physician assistant, nurse practitioner, clinical nurse specialist, or by a certified nurse mid -wife (as defined in 1861(aa)  and 1861(gg)  of the Act), who is authorized under State law to perform the examination, fully knowledgeable about the beneficiary, and would be responsible for explaining the results of the examination to the beneficiary.   B. Screening Prostate Specific Antigen (PSA) Tests   Screening prostate specific antigen (PSA) is a test that measures the level of prostate specific antigen in an individuals blood.  This screening must be ordered by the beneficiarys physician or by the beneficiarys physician assistant, nurse practitione r, clinical nurse specialist, or certified nurse midwife (the term physician is defined in 1861(r)(1)  of the Act to mean a doctor of medicine or osteopathy and the terms physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife are defined in 1861(aa) and 1861(gg) of the Act) who is fully knowledgeable about the beneficiary, and who would be responsible for explaining the results of the test to the beneficiary.   50.2 - Deductible and Coinsurance  (Rev. 1, 10- 01-03)  B3-4182.3  The screening PSA test is a lab test to which neither deductible nor coinsurance apply. Both deductible (if unmet) and coinsurance are applicable to screening rectal examinations.   50.3 - Payment Method - A/B MACs (A) and (B)  (Rev. 11902; Issued:03- 16-23; Effective: 04 -17-23; Implementation: 04 -17-23)  Screening PSA tests (G0103) are paid under the clinical diagnostic lab fee schedule.
(Medicare Claims Processing Manual)
Screening PSA tests (G0103) are paid under the clinical diagnostic lab fee schedule.   Screening PSA tests (Effective 01/01/23 (0359U)) new codes are contractor -priced (where applicable) until they are nationally priced and undergo the CLFS annual payment determination process.  Screening rectal examinations (G0102) are paid under the MPFS except for the following bill types identified (A/B MAC (A) only).  Bill types not identified are paid under the MPFS.  12X = Outpatient Prospective Payment System  13X = Outpatient Prospective Payment System  14X-=Outpatient Prospective Payment System  71X = Included in All Inclusive Rate  73X = Included in All Inclusive Rate  85X = Cost (Payment should be consistent with amounts paid for code 84153 or code 86316.)   Effective 4/1/06 the type of bill 14X is for non- patient laboratory specimens.   The RHCs and FQHCs should include the charges on the claims for future inclusion in encounter rate calculations.   50.3.1 - Correct Coding Requirements for A/B MAC (B)  Claims  (Rev. 1, 10- 01-03)  B3-4182.6  Billing and payment for a Digital Rectal Exam (DRE) (G0102) is bundled into the payment for a covered E/M service (CPT codes 99201 -  99456 and 99499) when the two services are furnished to a patient on the same day.  If the DRE is the only service or is pr ovided as part of an otherwise noncovered service, HCPCS code G0102 would be payable separately if all other coverage requirements are met.   50.4 - HCPCS, Revenue, and Type of Service Codes  (Rev. 11902; Issued:03- 16-23; Effective: 04 -17-23; Implementation: 04 -17-23)  The appropriate bill types for billing the A/B MAC (A) on Form CMS -1450 or its electronic equivalent are 12X, 13X, 14X, 22X, 23X, 71X, 73X, 75X, and 85X.  Effective 4/1/06, type of bill 14X is for non- patient laboratory specimens.   The HCPCS code G0102 -  for prostate cancer screening digital rectal examination.
(Medicare Claims Processing Manual)
The HCPCS code G0102 -  for prostate cancer screening digital rectal examination.    A/B MAC (B) TOS is 1    A/B MAC (A) revenue code is 0770  The HCPCS code G0103 -  for prostate cancer screening PSA tests    A/B MAC (B) TOS is 5     A/B MAC (A) revenue code is 030X   The HCPCS code 0359U  (PROSTATE CANCER), ANALYSIS OF ALL PROSTATE -SPECIFIC ANTIGEN (PSA) STRUCTURAL ISOFORMS BY PHASE SEPARATION AND IMMUNOASSAY, PLASMA, ALGORITHM REPORTS RISK OF CANCER. Effective 01/01/23.    A/B MAC (B) TOS is 5     A/B MAC (A) revenue code is 030X   50.5 - Diagnosis Coding   (Rev. 11021; Issued: 10 -01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Prostate cancer screening digital rectal examinations and screening Prostate Specific Antigen (PSA) blood tests must be billed using either screening code if ICD-10-CM is applicable, diagnosis code Z12.5 (Encounter for screening for malignant neoplasm of prostate).   50.6 - Calculating Frequency  (Rev. 1, 10- 01-03)  A3-3616.D and E, B3- 4182.4, B3- 4182.5  Calculating Frequency -  To determine the 11- month period, the count starts beginning with the month after the month in which a previous test/procedure was performed.   EXAMPLE: The beneficiary received a screening prostate specific antigen test in January 2002.  Start counts beginning February 2002.  The beneficiary is eligible to receive another screening prostate specific antigen test in January 2003 (the month after 11 months have passed).   Common Working File (CWF) Edits   Beginning October 1, 2000, the following CWF edits were implemented for dates of service January 1, 2000, and later, for prostate cancer screening tests and procedures for the following:    Age;   Frequency;   Sex; and   Valid HCPCS code.   50.7 - MSN Messages (Rev. 1, 10- 01-03)  B3-4182.8.B, A3- 3616.F
(Medicare Claims Processing Manual)
50.7 - MSN Messages (Rev. 1, 10- 01-03)  B3-4182.8.B, A3- 3616.F   If a claim for screening prostate specific antigen test or a screening digital rectal examination is being denied because of the age of the beneficiary, A/B MACs (A) use MSN message 18.13:   This service is not covered for patients under 50 years of age.   The Spanish version of this MSN message should read:   Este servicio no est cubierto hasta despus de que el beneficiario cumpla 50 aos.  A/B MACs (B) use MSN Message 18.19:   This service is not covered until after the patients 50th birthday.  The Spanish version of this MSN message should read:   Este servicio no est cubierto hasta despus de que el beneficiario cumpla 50 aos.  If the claim for screening prostate specific antigen test or screening digital rectal examination is being denied because the time period between the same test or procedure has not passed, A/B MACs (A) and (B) use MSN message 18.14:   Service is being denied because it has not been 12 months since your last test/procedure) of this kind.   The Spanish version of this MSN message should read:   Este servicio est siendo denegado ya que no han transcurrido (12, 24, 48) meses desde el ltimo (examen/procedimiento) de esta clase.   50.8 - Remittance Advice Notices  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  If the claim for a screening prostate antigen test or screening digital rectal examination is being denied because the patient is less than 50 years of age, use the ASC X12 835 with   Claim adjustment reason code; 6 the procedure/revenue code is inconsistent with the patients age, at the line level;  and    Remark code M82 Service not covered when patient is under age 50.
(Medicare Claims Processing Manual)
 Claim adjustment reason code; 6 the procedure/revenue code is inconsistent with the patients age, at the line level;  and    Remark code M82 Service not covered when patient is under age 50.   If the claim for a screening prostate specific antigen test or screening digital rectal examination is being denied because the time period between the test/procedure has not passed, A/B MACs (A) and (B) use ASC X12 835 claim adjustment reason code 119, Benefit maximum for this time period has been reached at the line level.   If the claim for a screening prostate antigen test or screening digital rectal examination is being denied due to the absence of ICD -10-CM diagnosis code Z12.5 on the claim, use the ASC X12 835 claim adjustment reason code 167  This (these) diagnosis(es) is (are) not covered.    RARC N386  This decision was based on a National Coverage Determination (NCD).  An NCD provides a coverage determination as to whether a particular item or service is covered.  A copy of this policy is available at www.cms.gov/mcd/search.asp.  If you do not have web access, you may contact the contractor to request a copy of the NCD.
(Medicare Claims Processing Manual)
60 - Colorectal Cancer Screening  (Rev. 10818; Issued: 05- 20-21; Effective: 01 -09-21; Implementation: 10 -04-21) See the Medicare Benefit Policy Manual, Chapter 15, and the Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 210.3 for Medicare Part B coverage requirements and effective dates of colorectal cancer screening services.  Effective for services furnished on or after January 1, 1998, payment may be made for colorectal cancer screening for the early detection of cancer.  For screening colonoscopy services (one of the types of services included in this benefit) prior to July 2001, coverage was limited to high- risk individuals.  For services July 1, 2001, and later, screening colonoscopies are covered for individuals not at high risk. The following services are considered colorectal cancer screening services:   Fecal -occult blood test (FOBT),1 -3 simultaneous determinations (guaiac -based);   Flexible sigmoidoscopy;   Colonoscopy; and,  Barium enema
(Medicare Claims Processing Manual)
Effective for services on or after January 1, 2004, payment may be made for the following colorectal cancer screening service as an alternative for the guaiac- based FOBT, 1 -3 simultaneous determinations:  FOBT, immunoassay, 1- 3 simultaneous determinations  Effective for services on or after October 9, 2014, payment may be made for colorectal cancer screening using the Cologuard multi- target sDNA test:  HCPCS G0464 (Colorectal cancer screening; stool -based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3). Note:  HCPCS code G0464 expired on December 31, 2015, and has been replaced in the 2016 CLFS with CPT code 81528, Oncology (colorectal) screening, quantitative real -time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result, e ffective January 2, 2016. Effective for services on or after January 19, 2021, payment may be made for colorectal cancer using Blood- based DNA Testing:   Blood- based Biomarker Test, HCPCS G0327, effective July 1, 2021  60.1 - Payment  (Rev. 10818; Issued: 05- 20-21; Effective: 01 -09-21; Implementation: 10 -04-21)
(Medicare Claims Processing Manual)
60.1 - Payment  (Rev. 10818; Issued: 05- 20-21; Effective: 01 -09-21; Implementation: 10 -04-21)  Payment is under the MPFS except as follows:   FOBTs [CPT 82270* (HCPCS G0107*) and HCPCS G0328] are paid under the CLFS except reasonable cost is paid to all non- outpatient prospective payment system (OPPS) hospitals, including Critical Access Hospitals (CAHs), but not Indian Health Service (IHS) hospitals billing on type of bill (TOB) 83X.  IHS hospitals billing on TOB 83X are paid the Ambulatory Surgery Center (ASC) payment amount.  Other IHS hospitals (bil ling on TOB 13X) are paid the Office of Management and Budget (OMB) -approved all -inclusive rate (AIR), or the facility specific per visit amount as applicable.  Deductible and coinsurance do not apply for these tests.  See section A below for payment to Ma ryland waiver hospitals on TOB 13X.  Payment to all hospitals for non- patient laboratory specimens on TOB 14X will be based on the CLFS, including CAHs and Maryland waiver hospitals.    For claims with dates of service on or after January 1, 2015, through December 31, 2015, the Cologuard multi- target sDNA test (HCPCS G0464) is paid under the CLFS.    Note: For claims with dates of service October 9, 2014, thru December 31, 2014, HCPCS code G0464 is paid under local contractor pricing.  For claims with dates of service on or after January 1, 2016, CPT code 81528 replaces G0464 is paid under the CLFS.    For claims with dates of service on or after January 19, 2021, Blood- based Biomarker test (HCPCS G0327) is paid under the CLFS    Flexible sigmoidoscopy (code G0104) is paid under OPPS for hospital outpatient departments and on a reasonable cost basis for CAHs; or current payment methodologies for hospitals not subject to OPPS.
(Medicare Claims Processing Manual)
 Flexible sigmoidoscopy (code G0104) is paid under OPPS for hospital outpatient departments and on a reasonable cost basis for CAHs; or current payment methodologies for hospitals not subject to OPPS.    Colonoscopies (HCPCS G0105 and G0121) and barium enemas (HCPCS G0106 and G0120) are paid under OPPS for hospital outpatient departments and on a reasonable cost basis for CAHs or current payment methodologies for hospitals not subject to OPPS.  Also colonoscopies may be performed in an ASC and when done in an ASC, the ASC rate applies.  T he ASC rate is the same for diagnostic and screening colonoscopies.  The ASC rate is paid to IHS hospitals when the service is billed on TOB 83X. The following screening codes must be paid at rates consistent with the rates of the diagnostic codes indicated.  Coinsurance and deductible apply to diagnostic codes.   HCPCS Screening Code  HCPCS Diagnostic Code  G0104 45330 HCPCS Screening Code  HCPCS Diagnostic Code  G0105 and G0121  45378 G0106 and G0120  74280
(Medicare Claims Processing Manual)
HCPCS Screening Code  HCPCS Diagnostic Code  G0104 45330 HCPCS Screening Code  HCPCS Diagnostic Code  G0105 and G0121  45378 G0106 and G0120  74280  A.  Special Payment Instructions for TOB 13X Maryland Waiver Hospitals  For hospitals in Maryland under the jurisdiction of the Health Services Cost Review Commission, screening colorectal services HCPCS G0104, G0105, G0106, 82270* (G0107*), G0120, G0121, G0328, G0464, and 81528 are paid according to the terms of the waiver, that is 94% of submitted charges minus any unmet existing deductible, co- insurance and non- covered charges.  Maryland Hospitals bill TOB 13X for outpatient colorectal cancer screenings.  B.  Special Payment Instructions for Non -Patient Laboratory Specimen (TOB 14X) for All Hospitals  Payment for colorectal cancer screenings (CPT 82270* (HCPCS G0107*), HCPCS G0328, and G0464 (Effective January 1, 2016, HCPCS G0464 is discontinued and replaced with CPT 81528) to a hospital for a non- patient laboratory specimen (TOB 14X), is the lesser of  the actual charge, the fee schedule amount, or the National Limitation Amount (NLA), (including CAHs and Maryland Waiver hospitals).  Part B deductible and coinsurance do not apply.  *NOTE:   For claims with dates of service prior to January 1, 2007, physicians, suppliers, and providers report HCPCS G0107.  Effective January 1, 2007, HCPCS G0107 was discontinued and replaced with CPT 82270.   60.1.1  Deductible and Coinsurance  (Rev. 12299; Issued:10- 12-23; Effective:01 -01-23; Implementation:11 -13-23)
(Medicare Claims Processing Manual)
There is no deductible and no coinsurance or copayment for the FOBTs (HCPCS G0107, G0328), flexible  sigmoidoscopies  (G0104), colonoscopies  on individuals  at high risk (HCPCS G0105), or colonoscopies on individuals not meeting criteria of high risk (HCPCS G0121).  Anesthesia services  furnished in conjunction with and in support  of a screening colonoscopy are reported with CPT code 00812 and coinsurance and deductible are waived. When a screening colonoscopy becomes  a diagnostic  colonoscopy, anesthesia services  are reported  with CPT code 00811 and  with  the -PT modifier; and  the deductible  is waived.  Prior to  January 1, 2022, when a screening colonoscopy became a diagnostic, the beneficiary was liable for the full applicable coinsurance. However, Section 122 of Division CC of the Consolidated Appropriations Act  (CAA)  of 2021, Waiving Medicare  Coinsurance  for Certain  Colorectal  Cancer  Screening  Tests, amended section 1833(a) of the Social Security Act to offer a special coinsurance rule for screening flexible sigmoidoscopies and screening colonoscopies, regardless of the code that is billed for the establishment of a diagnosis as a result of the test, or for the removal of tissue or other matter or other procedure, that is furnished in connection with, as a result of, and in the same clinical encounter as the color ectal cancer screening test.  Consequently, the applicable coinsurance in these specific scenarios will be gradually reduced until it is completely waived for dates of service on or after January 1, 2030. Specifically, for dates of service in CY 2023 through CY 2026, when the PT modifier is appended to at least one code on the claim to indicate that a screening colorectal cancer procedure, HCPCS G0104, G0105, or G0121, has become a diagnostic or therapeutic  service, contractors shall continue to waive deductible and shall apply a reduced coinsurance of 15% for all procedure codes that meet the requirements stated above and are performed on t hat date of service and billed on the same claim.  For dates of service in CY 2027 through CY 2029, contractors shall continue to waive deductible
(Medicare Claims Processing Manual)
for all procedure codes that meet the requirements stated above and are performed on t hat date of service and billed on the same claim.  For dates of service in CY 2027 through CY 2029, contractors shall continue to waive deductible and shall apply a reduced coinsurance of 10% for all procedure codes that meet the requirements stated above and are performed on that date of service and bille d on the same claim.  For dates of service on or after January 1, 2030, contractors shall continue to waive deductible and shall waive coinsurance  for all procedure  codes  that meet  the requirements  stated  above and are performed on that date of service and billed on the same claim.
(Medicare Claims Processing Manual)
Coinsurance  and deductible  are waived  for moderate sedation  services  (reported  with G0500 or 99153) when furnished in conjunction with and in support of a screening colonoscopy service and when reported with modifier - 33. When a screening colonoscopy becomes a diagnostic colonoscopy, moderate sedation services (G0500 or 99153) are reported with only the - PT modifier; only the deductible is waived. Prior to January 1, 2007 deductible and coinsurance apply to other colorectal procedures (HCPCS  G0106 and G0120). After  January  1, 2007, the deductible  is waived  for those  tests. Coinsurance applies.   Effective for claims with dates of service on and after October 9, 2014, deductible and coinsurance  do not apply to the Cologuard multi -target  sDNA  screening  test (HCPCS  G0464). (Note: Beginning January 1, 2016, CPT code 81528 replaced G0464).   Effective  for claims  with dates  of service on and  after  January  19, 2021, deductible  and coinsurance do not apply to the Blood- based biomarker test (HCPCS G0327).
(Medicare Claims Processing Manual)
Effective  for claims  with dates  of service on and  after  January  19, 2021, deductible  and coinsurance do not apply to the Blood- based biomarker test (HCPCS G0327).  Effective for claims with dates of service on or after January 1, 2023, colorectal cancer screening tests include a screening colonoscopy (HCPCS codes G0105, G0121) that follows a non-invasive stool - based test (HCPCS codes 82270, G0328 and 81528). This sc enario shall be identified by the furnishing practitioner by including the  KX modifier  on the screening  colonoscopy claim.  Deductible  and coinsurance  do not apply  to the non-invasive stool -based tests nor the screening colonoscopy because both tests are specified preventive screening services. NOTE: A 25% coinsurance applies for all colorectal cancer screening colonoscopies (HCPCS G0105 and G0121)  performed  in ASCs  and non-OPPS hospitals  effective for services  performed on or after January 1, 2007. The 25% coinsurance was implemented in the OPPS PRICER for OPPS hospitals effective for services performed on or after January 1, 1999. A 25% coinsurance also applies for colorectal cancer screening sigmoidoscopies (HCPCS G0104)  performed  in non-OPPS hospitals  effective for services  performed  on or after January  1, 2007. Beginning January  1, 2008, colorectal  cancer  screening  sigmoidoscopies  (HCPCS  G0104) are payable  in ASCs,  and a 25% coinsurance  applies.  The 25% coinsurance for colorectal  cancer screening  sigmoidoscopies  was implemented  in the OPPS PRICER for OPPS hospitals  effective for services performed on or after January 1, 1999. Effective for claims with dates of service on or after January 1, 2011, coinsurance and deductible  do not apply to screening  colonoscopies, screening  sigmoidoscopies, and other specified colorectal cancer screening services.   60.2 - HCPCS Codes, Frequency Requirements, and Age Requirements  (Rev. 12299; Issued:10 -12-23; Effective:01 -01-23; Implementation:11 -13-23)