evekhm/cms_iom_500 huggingface dataset:
Article - Knee Orthoses - Policy Article (A52465)
Codes L1834 (KNEE ORTHOSIS, WITHOUT KNEE JOINT, RIGID, MOLDED TO PATIENT MODEL, CUSTOM-FABRICATED) and L1836 (KNEE ORTHOSIS, RIGID, WITHOUT JOINT(S), INCLUDES SOFT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF) describe rigid knee orthoses without a knee joint. Both are designed to prevent knee motion. These orthoses are designed for beneficiaries who can bear weight on the knee, are capable of ambulating, and need additional support provided through immobilization of the knee joint. Code L1834 refers to a custom fabricated knee orthotic while L1836 refers to one that is pre-fabricated.Code L1840 (KNEE ORTHOSIS, DEROTATION, MEDIAL-LATERAL, ANTERIOR CRUCIATE LIGAMENT, CUSTOM-FABRICATED) describes a custom fabricated knee orthosis with knee joints designed to protect the ligaments of the knee through medial-lateral torsion, providing stability and preventing rotation.
Article - Knee Orthoses - Policy Article (A52465)
Codes L1843 (KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE), L1844 (KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, CUSTOM FABRICATED ), and L1851 (KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED, OFF-THE-SHELF) describe prefabricated and custom fabricated knee orthoses which are constructed of rigid thigh and calf cuffs and a single upright with an adjustable flexion and extension knee joint. These orthoses must have condylar pads. Through a series of straps/supports that cross over and around the knee joint, rotational control and varus or valgus force is exerted on the knee joint. These orthoses are designed to open the medial or lateral compartment of the knee to provide pain relief due to osteoarthritis. These orthoses are designed for beneficiaries who are fully ambulatory.
Article - Knee Orthoses - Policy Article (A52465)
Codes L1845 (KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE), L1846 (KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, CUSTOM FABRICATED), and L1852 (KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, PREFABRICATED, OFF-THE-SHELF) describe prefabricated and custom fabricated knee orthoses that have double uprights, condylar pads, and an adjustable flexion and extension joint and provide both medial-lateral and rotation control. Medial-lateral control of the knee is accomplished by the solid metal (or similar material) structure of the double uprights. Rotation control is accomplished by the combination of (1) solid metal (or similar material) in the anterior or posterior portion of the thigh and calf cuffs and (2) the condylar pads. These orthoses are designed for beneficiaries who are fully ambulatory.Code L1850 (KNEE ORTHOSIS, SWEDISH TYPE, PREFABRICATED, OFF-THE-SHELF) describes a prefabricated knee orthosis with double uprights and thigh and calf pads. It may or may not have joints. These orthoses are used to prevent hyperextension of the knee joint in ambulatory beneficiaries.Code L1860 (KNEE ORTHOSIS, MODIFICATION OF SUPRACONDYLAR PROSTHETIC SOCKET, CUSTOM-FABRICATED (SK)) describes a custom fabricated knee orthosis without joints, constructed of plastic or other similar material. These orthoses are used to prevent hyperextension of the knee joint in ambulatory beneficiaries.LOWER EXTREMITY ADDITIONS
Article - Knee Orthoses - Policy Article (A52465)
LOWER EXTREMITY ADDITIONSCustom-fabricated additions are appropriate only for custom-fabricated base orthotics and should not be billed with prefabricated base orthotics unless a product has been previously assigned an addition code per PDAC/CMS prior to 1/1/2023. Correct coding with use of addition codes should not include, or partially include, features or functions described by other codes billed for a specific device.Code L2755 (ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, PER SEGMENT, FOR CUSTOM FABRICATED ORTHOSIS ONLY) describes an addition to a lower extremity orthosis composed of high strength and/or lightweight material such as Kevlar, carbon fiber or other laminated or impregnated composite material.
Article - Knee Orthoses - Policy Article (A52465)
Addition codes are grouped into four (4) categories in relation to knee orthosis base codes.Eligible for separate paymentNot reasonable and necessaryNot separately payableIncompatibleAddition codes in the first two categories are addressed in the related LCD. Addition codes that are not separately payable are addressed in the tables below.The following table lists addition codes which describe components or features that can be physically incorporated in thespecified prefabricated baseorthosisbut are considered to be included in the allowance for the orthosis.Base CodeAddition Codes - Not Separately PayableL1810L2390, L2750, L2780, L4002L1812L2390, L2750, L2780, L4002L1820L2390, L2750, L2780, L2810, L4002L1830K0672, L4002L1831K0672, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002L1832K0672, L2390, L2425, L2430, L2750, L2780, L2820, L2830, L4002L1833K0672, L2390, L2425, L2430, L2750, L2780, L2820, L2830, L4002L1836K0672, L2750, L2780, L2810, L2820, L2830, L4002L1843K0672, L2275, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002L1845K0672, L2275, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002L1847K0672, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002
Article - Knee Orthoses - Policy Article (A52465)
L1847K0672, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002L1848K0672, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002L1850K0672, L2750, L2780, L2810, L2820, L2830, L4002L1851K0672, L2275, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002L1852K0672, L2275, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002The following table lists addition codes which describe components or features that can be physically incorporated in thespecified custom fabricated base orthosisbut are considered to be included in the allowance for the orthosis. The addition codes will be denied as not separately payable if they are billed with the related base code.Base CodeAddition Codes - Not Separately PayableL1834K0672, L2820, L2830, L4002L1840K0672, L2320, L2330, L2750, L2780, L2810, L2820, L2830, L4002L1844K0672, L2275, L2320, L2330, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002L1846K0672, L2275, L2320, L2330, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002L1860K0672, L2820, L2830, L4002
Article - Knee Orthoses - Policy Article (A52465)
All addition codes that are not listed as either separately payable or not reasonable and necessary in the tables in the LCD or as not separately payable in the tables above, describe components or features that either cannot be physically incorporated in the specified base orthosis or whose narrative description is incompatible with base orthosis code (e.g., billing a prefabricated base code with an addition code which specifies that it is only used with custom fabricated orthoses). These incompatible addition codes will be rejected as incorrect coding.L-coded additions to knee orthoses (L2275, L2320, L2330, L2385, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2750, L2755, L2780, L2785, L2795, L2800, L2810, L2820, L2830, K0672) will be denied as noncovered when the base orthosis is noncovered.A replacement removable soft interface for a knee orthosis is billed with code K0672 (ADDITION TO LOWER EXTREMITY ORTHOSIS, REMOVABLE SOFT INTERFACE, ALL COMPONENTS, REPLACEMENT ONLY, EACH). One unit of service includes all the components that are used at the same time on a single orthosis.Either a nonremovable soft interface, L2820 (ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, BELOW KNEE SECTION), L2830 (ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, ABOVE KNEE SECTION), or two (2) removable soft interfaces (K0672) are included in the allowance for a knee orthosis. Soft interfaces billed separately at the time of initial issue will be denied as not separately payable.Codes L2320 (ADDITION TO LOWER EXTREMITY, NON-MOLDED LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY) and L2330 (ADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR CUSTOM FABRICATED ORTHOSIS ONLY), non-molded and molded lacers, respectively, may only be billed as replacement items.CONCENTRIC TORSION JOINTS
Article - Knee Orthoses - Policy Article (A52465)
CONCENTRIC TORSION JOINTSAll claims for devices that contain a concentric adjustable torsion style mechanism in the knee joint for any condition other than an assistive function to joint extension motion must be coded as durable medical equipment using code E1810 (DYNAMIC ADJUSTABLE KNEE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL). If a concentric adjustable torsion style mechanism in the knee joint is used solely to provide an assistive function for joint extension, it must be coded as L2999 (See the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD).Claims for devices that contain a concentric adjustable torsion style mechanism in the knee joint and that are being used to treat any condition other than an assistive function to joint extension motion are not covered under the braces benefit and will be denied as incorrect coding when billed using code L2999 (See the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD).REPAIR/REPLACEMENTCode L4205 (REPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15 MINUTES) may only be billed for time involved with the actual repair of an orthosis or for medically necessary adjustments made more than 90 days after delivery. Code L4205 must not be used to bill for time involved with other professional services including, but not limited to:
Article - Knee Orthoses - Policy Article (A52465)
Evaluating the beneficiaryTaking measurements, making a cast, making a model, use of CAD/CAMMaking modifications to a prefabricated item to fit it to the individual beneficiaryFollow-up visitsMaking adjustments at the time of or within 90 days after deliverySuppliers must distinguish between repair and replacement of an orthosis. When an orthotic is replaced, there is no separate billing for the above services because reimbursement for these services is included in the allowance for the replacement item.Repairs to a covered orthosis due to wear or to accidental damage are covered when they are necessary to make the orthosis functional. The reason for the repair must be documented in the supplier's record. If the expense for repairs exceeds the estimated expense of providing another entire orthosis, no payment will be made for the amount in excess.The allowance for the labor involved in replacing/repairing an orthotic component that is coded with a specific L-code is included in the allowance for that component. The allowance for the labor (L4205) involved in replacing/repairing an orthotic component that is coded with the miscellaneous code L4210 (REPAIR OF ORTHOTIC DEVICE, REPAIR OR REPLACE MINOR PARTS) is separately payable in addition to the allowance for that component. (Code L4210 must not be used for casting supplies or other materials used in the fitting or fabrication of an orthosis.)The following chart reflects the reasonable useful lifetime of prefabricated knee orthoses:L18101 yearL18121 yearL18201 yearL18301 yearL18312 yearsL18322 yearsL18332 yearsL18363 yearsL18433 yearsL18453 yearsL18502 yearsL18513 yearsL18523 years
Article - Knee Orthoses - Policy Article (A52465)
The reasonable useful lifetime of a custom fabricated orthosis is 3 years.Replacement during the reasonable useful lifetime, is covered if the item is lost or irreparably damaged. Replacement for other reasons, including but not limited to irreparable wear, during the period of reasonable useful lifetime is denied as noncovered.Addition codes K0672, L2390, L2750, L2780, L4002 are for billing of replacement component(s) and are not payable at initial issue of a base orthosis. When code L4002 is billed at the time of initial issue of a base orthosis, it will be denied as not separately payable.Should a supplier wish to submit a claim for services/items that are included in the allowance for the orthosis, code L9900 (ORTHOTIC AND PROSTHETIC SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS "L" CODE) must be used. Code L9900 is denied as not separately payable.Some replacement items have unique Healthcare Common Procedure Coding System (HCPCS) codes. Replacement components that do not have a unique HCPCS code must be billed with a "not otherwise specified" code - L2999. Items that have unique codes must not be billed using a NOC code.Suppliers should contact the PDAC contractor for guidance on the correct coding of these items.CODING VERIFICATION REVIEWThe only products which may be billed using the following list of HCPCS codes are those for which a written coding verification review (CVR) has been made by the PDAC contractor and subsequently published on the Product Classification List (PCL). Information concerning the documentation that must be submitted to the PDAC for a CVR can be found on the PDAC web site or by contacting the PDAC. A PCL with products which have received a coding verification can be found on the PDAC web site. The effective date of the CVR is included for each code.Effective for claims with dates of service on or after July 1, 2008:L1845Effective for claims with dates of service on or after January 1, 2017:L1852Effective for claims with dates of service on or after October 10, 2022:L1832, L1833 and L1851
Article - Knee Orthoses - Policy Article (A52465)
L1845Effective for claims with dates of service on or after January 1, 2017:L1852Effective for claims with dates of service on or after October 10, 2022:L1832, L1833 and L1851If a product is billed to Medicare using a HCPCS code that requires written CVR, but the product is not on the PCL for that particular HCPCS code, then the claim line will be denied as incorrect coding.
Article - Nebulizers - Policy Article (A52466)
CMS National Coverage PolicyN/AArticle Text
Article - Nebulizers - Policy Article (A52466)
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Nebulizers are covered under the Durable Medical Equipment (DME) benefit (Social Security Act 1861(s)(6)). In order for a beneficiarys equipment to be eligible for reimbursement, the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.A large volume pneumatic nebulizer (E0580) and water or saline (A4217 or A7018) are not separately payable and should not be separately billed when used for beneficiaries with rented home oxygen equipment.If a large volume nebulizer, related compressor/generator, and water or saline are used predominantly to provide room humidification it will be denied as noncovered.A prefilled disposable large volume nebulizer (A7008) is noncovered under the DME benefit because it is a convenience item. An unfilled nebulizer (A7007, A7017, or E0585) filled with water or saline (A4217 or A7018) by the beneficiary/caregiver is an acceptable alternative.Kits and concentrates for use in cleaning respiratory equipment will be denied as noncovered.
Article - Nebulizers - Policy Article (A52466)
Kits and concentrates for use in cleaning respiratory equipment will be denied as noncovered.Aztreonam lysine is an inhalation solution that is indicated for beneficiaries with cystic fibrosis with chronic Pseudomonas aeruginosa infection. Because it has been determined that the nebulizer that is FDA-approved for administration of aztreonam lysine is not sufficiently durable to meet the statutory requirements for coverage under the DME benefit, claims for that nebulizer, aztreonam lysine inhalation solution and related accessories will be denied as noncovered (no Medicare benefit).Drugs that are not administered through DME (e.g. Foradil Aerolizer and metered-dose inhalers (MDIs)) are not billed to the DME MAC but may be covered under other Medicare benefits (i.e., Medicare Part D). If the supplier chooses to submit a claim for drugs not administered through DME, the drug must be billed using code J3535 (DRUG ADMINISTERED THROUGH A METERED DOSE INHALER) and is non-covered by the DME MACs.Disposable equipment or equipment in which a major component required for their function is disposable do not meet the definition of durable medical equipment and must be billed using code A9270 (noncovered item or service).
Article - Nebulizers - Policy Article (A52466)
DISPENSING FEE:
Article - Nebulizers - Policy Article (A52466)
An initial dispensing fee (G0333) is payable to a pharmacy for the initial 30-day supply of covered inhalation drug(s) regardless of the number of drugs dispensed, the number of shipments, or the number of pharmacies used by the beneficiary during that time. This initial 30-day dispensing fee is a once in a lifetime fee and only applies to beneficiaries who are using inhalation drugs for the first time as a Medicare beneficiary on or after 01/01/2006. If code G0333 is billed for a 30-day supply of covered inhalation drugs and it is not the initial 30-day supply (i.e., G0333 has already been billed to Medicare for that beneficiary), the claim will be denied as incorrect coding. When code G0333 has been billed once in a beneficiarys lifetime, subsequent claims for a 30-day dispensing fee must be billed using code Q0513.Medicare will only pay for one of the following for covered inhalation drugs regardless of the number of drugs dispensed, the number of shipments, or the number of pharmacies used by the beneficiary during that time period - an initial dispensing fee (G0333), a 30-day dispensing fee (Q0513), or a 90-day dispensing fee (Q0514).For a refill prescription, payment of a dispensing fee will be allowed no sooner than 10 days before the end of usage for the current 30-day or 90-day period for which a dispensing fee was previously paid. Medicare will not pay for more than 12 months of dispensing fees per beneficiary per 12-month period.If the dispensing fee is billed sooner than the interval specified above, it will be denied as not separately payable. For example, if a 90-day fee (Q0514) is billed on 1/30/06 and is covered and there is a subsequent claim for a 30-day fee (Q0513) on 4/10/06, the dispensing fee on 4/10/06 will be denied as not separately payable.
Article - Nebulizers - Policy Article (A52466)
Both a Q0513 and a Q0514 dispensing fee are not covered on the same date of service. If a supplier dispenses a 90-day supply of one drug and a 30-day supply of another drug on the same day, code Q0514 (90-day fee) must be billed.The dispensing fee must be billed on the same claim as the inhalation drug(s). If it is not, it will be denied as incorrect billing.A dispensing fee is not separately billable or payable for saline, whether used as a diluent or for humidification therapy.Medicare will not pay for a separate fee for the compounding of inhalation drug(s).
Article - Nebulizers - Policy Article (A52466)
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TOFINAL RULE1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated.The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD prior to delivery, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATION REQUIREMENTSIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.MISCELLANEOUSA diagnosis code describing the condition which necessitates nebulizer therapy must be included on each claim for equipment, accessories, and/or drugs.MODIFIERSJW AND JZ MODIFIERS: