evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54992)
CPT Code 95869 - Needle electromyography; thoracic paraspinal muscles1. CPT code 95869 should be used to bill a limited EMG study of specific muscles. Examinations confined to distal muscles only, such as intrinsic foot or hand muscles, will be reimbursed as Code 95869 and not as 95860-95866.2. Use CPT Code 96869 to study thoracic paraspinal muscles between T3 and T11.3. One unit can be billed, despite the number of levels studied or whether unilateral or bilateral.CPT Code 95870 Needle electromyography, other than paraspinal1. CPT code 95870 is used for limited testing of specific muscles during an examination. This code should be used only when the muscles tested do not fit more appropriately under another CPT code.2. CPT code 95870 can be billed at one unit per extremity (one limb, arm or leg), when fewer than five muscles are examined.3. It can also be used for examining non-limb (axial) muscles (e.g., intercostal, abdominal wall, cervical and lumbar paraspinal muscles (unilateral or bilateral) regardless of the number of levels tested. However, it should not be billed when the paraspinal muscles corresponding to an extremity are tested, and when the extremity codes 95860, 95861, 95863, or 95864 are reported.CPT Code 95933 - Blink Reflexes1. Recordings should be made bilaterally with both ipsilateral and contralateral stimulation.2. The report of this study should include the presence or absence of the R1 and R2 components.CPT Code 95937 - Neuromuscular Junction Studies
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54992)
CPT Code 95937 - Neuromuscular Junction Studies1. Repetitive stimulation studies are used to identify and to differentiate disorders of the NMJ. This test consists of recording muscle responses to a series of nerve stimuli (at variable rates), both before, and at various intervals after, exercise or transmission of high-frequency stimuli.2. These codes may be used in association with motor and sensory NCS of the same nerves and are reimbursed separately.3. When this study is performed, the physician's report must document characteristics of the test, including the rate of repetition of stimulations, and any significant incremental or decremental response.II. Reasons for Denial in addition to those stated in LCD1. Narrative reports alluding to "normal" or abnormal" results without supporting numerical data.2. Descriptions of F-wave without reference to corresponding motor conduction data; pattern-setting unilateral H-reflex measurements; separate E/M charges without documentation requested from the referral source.3. Surface and/or macro EMGs will not be paid.4. Failure to submit, upon request or when requesting a review, a clinical history indicating the need for testing.5. Absence of a clinical history, preferably written by the referral source, indicating the need for the test.6. Absence of documentation to support repeated testing on the same beneficiary.7. Testing every beneficiary referred for pain.Needle electromyographic (EMG) codes 95860-95872, and 95885-95887 have the designation of 6A for the technical portion of the test. Therefore, if authorized by state law Physical Therapists are allowed the technical portion of the test according to the description of 6A. Definitions below:6A = Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.66 = May be personally performed by a physician or by a physical therapist with ABPTS certification and certification in this specific procedure.III. Comments
Article - Billing and Coding: Nerve Conduction Studies and Electromyography (A54992)
66 = May be personally performed by a physician or by a physical therapist with ABPTS certification and certification in this specific procedure.III. Comments1. Certain less than optimal practices are discouraged, and may invite review. These include: exclusive testing of intrinsic foot muscles in the diagnosis of proximal lesions; definitive diagnostic conclusions based on paraspinal EMG in regions bearing scar of past surgeries (e.g., previous laminectomies); pattern-setting limited limb muscle examinations, without paraspinal muscle testing for diagnosis of radiculopathies, narrative reports without data, and premature EMG testing after trauma when EMG changes are unlikely to have taken place.2. There are situations in which EMG and nerve conduction studies can be valuable in a relatively acute situation with or without trauma, even though full-blown EMG changes may not yet have taken place. An example is, to assess the presence of pre-existing injury or disease after trauma or in the evaluation of some non-traumatic conditions, such as suspected Guillain-Barre syndrome. The clinical record must distinctly document such a need.3. Frequency of testing is a difficult issue to answer. Documented clinical justification, rather than an algorithm, should be the determinant in these instances. While this removes any recipe-style limits, it also calls for clear responsible and evidence-based documentation for any repeat study. Such a guideline applies to all studies including those for patients (i) under medical, surgical or rehabilitative treatment, (ii) for neuropathy and (iii) for patients with chronic renal failure and/or dialysis.
Article - Billing and Coding: Urine Drug Testing (A55001)
CMS National Coverage PolicyN/AArticle TextThis article contains coding that complements the Local Coverage Determination (LCD) for Urine Drug Testing.Coding Guidelines:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Article - Billing and Coding: Lab: Bladder/Urothelial Tumor Markers (A55028)
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, Pub 100-4, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Bladder/Urothelial Tumor Markers (L36678).Noridian will only cover bladder tumor marker fluorescence in situ hybridization (FISH) testing services when performed using validated assays. To date, UroVysion Bladder Cancer Kit is the only Federal Drug Administration (FDA) approved assay that is designed to detect aneuploidy for chromosomes 3, 7, 17 and loss of the 9p21 locus via FISH. The assay is performed on urine specimens from persons with hematuria suspected of having bladder cancer as an aid for initial diagnosis of bladder carcinoma and subsequent monitoring for tumor recurrence in patient previously diagnosed with bladder cancer. UroVysion Bladder Kit services may only be billed by a CLIA certified lab.To bill UroVysion Bladder Kit services, submit the following claim information:Select CPT code 88120 or 88121 as appropriate.Laboratories reporting only the technical component for a UroVysion service should append the appropriate code 88120 or 88121 with the TC modifier.Select CPTcode 88120 or 88121 as appropriate.
Article - Billing and Coding: Lab: Bladder/Urothelial Tumor Markers (A55028)
Laboratories reporting only the technical component for a UroVysion service should append the appropriate code 88120 or 88121 with the TC modifier.Select CPTcode 88120 or 88121 as appropriate.Note:Physicians may NOT submit claims for a code 88120 and 88121 professional components when the interpretive information is provided by a lab technician or scientist. Per Chapter 10 in the NCCI Policy Manual for Medicare Services, Version 16.3, the physician work component requires a physician to read, quantitate and interpret the tissues/cells stained with the probes(s). Physicians who knowingly report and interpretation based on the documented results of another professional may be subject to additional corrective action including Recovery Audit Contractor (RAC) or fraud referrals.To report a Bladder/Urothelial Tumor Marker service, please submit the following claim information:Select the appropriate CPTcode.Enter 1 unit of service (UOS)Select the appropriate ICD-10 code.
Article - Billing and Coding: Lab: Bladder/Urothelial Tumor Markers (A55029)
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, Pub 100-4, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Bladder/Urothelial Tumor Markers (L36680).Noridian will only cover bladder tumor marker fluorescence in situ hybridization (FISH) testing services when performed using validated assays. To date, UroVysion Bladder Cancer Kit is the only Federal Drug Administration (FDA) approved assay that is designed to detect aneuploidy for chromosomes 3, 7, 17 and loss of the 9p21 locus via FISH. The assay is performed on urine specimens from persons with hematuria suspected of having bladder cancer as an aid for initial diagnosis of bladder carcinoma and subsequent monitoring for tumor recurrence in patient previously diagnosed with bladder cancer. UroVysion Bladder Kit services may only be billed by a CLIA certified lab.To bill UroVysion Bladder Kit services, submit the following claim information:Select CPTcode 88120 or 88121 as appropriate.Laboratories reporting only the technical component for a UroVysion service should append the appropriate code 88120 or 88121 with the TC modifier.All other services that meet the code 88120 or 88121 definition performed by any provider type MUST bill the following claim information.Select CPTcode 88120 or 88121 as appropriate.
Article - Billing and Coding: Lab: Bladder/Urothelial Tumor Markers (A55029)
All other services that meet the code 88120 or 88121 definition performed by any provider type MUST bill the following claim information.Select CPTcode 88120 or 88121 as appropriate.Note:Physicians may NOT submit claims for a code 88120 and 88121 professional components when the interpretive information is provided by a lab technician or scientist. Per Chapter 10 in the NCCI Policy Manual for Medicare Services, Version 16.3, the physician work component requires a physician to read, quantitate and interpret the tissues/cells stained with the probes(s). Physicians who knowingly report and interpretation based on the documented results of another professional may be subject to additional corrective action including Recovery Audit Contractor (RAC) or fraud referrals.To report a Bladder/Urothelial Tumor Marker service, please submit the following claim information:Select the appropriate CPTcode.Enter 1 unit of service (UOS)Select the appropriate ICD-10 code.
Article - Billing and Coding: Urine Drug Testing (A55030)
CMS National Coverage PolicyN/AArticle TextThis article contains coding that complements the Local Coverage Determination (LCD) for Urine Drug Testing.Coding Guidelines: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 results of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Article - Billing and Coding: Patients Supplied Donated or Free-of-Charge Drug (A55044)
CMS National Coverage PolicyN/AArticle TextThe Medicare Program provides limited benefits for outpatient drugs. The program covers drugs that are furnished "incident to" a physician's service, provided that the drugs are not usually self-administered by the patients who take them, and is reasonable and necessary for the diagnosis or treatment of the illness or injury according to accepted standards of medical practice.In order to meet all the general requirements for coverage under the "incident to" provision an FDA approved drug or biological must be furnished by a physician and administered by the physician or by auxiliary personnel employed by the physician and under the physician's personal supervision.The charge, if any, for the drug or biological must be included in the physician's bill and the cost of the drug or biological must represent an expense to the physician.Pharmacies cannot bill Medicare Part B for drugs furnished to a physician for administration to a Medicare beneficiary.Pharmacies, suppliers and providers cannot bill Medicare Part B for drugs dispensed directly to a beneficiary for administration "incident to" a physician service, such as refilling an implanted drug pump.Providers can bill Medicare only when such drugs are purchased by the physician, from the pharmacy, and administered in the physician's office.Donated or Free-of-Charge DrugTo avoid a chemotherapy or other drug administration code denial, a drug code must be present on the same or prior claim. Enter the below information in the appropriate Part A or Part B electronic claim or the equivalent Part A UB04 or Part B CMS-1500 claim form.Part ALoop 2400 Segment SV202-7 or Box 80Enter "Drug Donated"Enter code description, strength and dosage - if billing a Not Otherwise Classified (NOC) HCPCS codeLoop 2400 Segment SV202-2 or Box 44Enter drug (HCPCS) codeLoop 2300 Segment CLM02 or Box 47 and 48Enter $0.01 for the billed amountPart BLoop 2400 Segment SV101-7 for the 5010A1 837P or Item 19Enter "Drug Donated"Enter code description, strength and dosage - if billing a Not Otherwise Classified (NOC) HCPCS codeLoop 2400 Segment SV101-2 or Item 24DEnter drug (HCPCS) code
Article - Billing and Coding: Patients Supplied Donated or Free-of-Charge Drug (A55044)
Loop 2400 Segment SV101-2 or Item 24DEnter drug (HCPCS) codeLoop 2300 CLM02 or Item 28Enter $0.01 for the billed amountThis will allow the claim processing system to register the drug claim as being allowed which should allow the administration.NOTE:Per the "incident to" guidelines explained above and in the CMS Internet-Only Manual (IOM) Publication 100-02, Chapter 15, Sections 50 and 50.3(MBPM). Providers areNOTallowed to instruct their patients to purchase the drug themselves and then bring them to the provider's office for administration. If the drug is not supplied as a donation or free of charge, then the provider must provide the drug under incident to guidelines.
Article - Billing and Coding: Patients Supplied Donated or Free-of-Charge Drug (A55045)
CMS National Coverage PolicyN/AArticle TextThe Medicare Program provides limited benefits for outpatient drugs. The program covers drugs that are furnished "incident to" a physician's service, provided that the drugs are not usually self-administered by the patients who take them, and is reasonable and necessary for the diagnosis or treatment of the illness or injury according to accepted standards of medical practice.In order to meet all the general requirements for coverage under the "incident to" provision an FDA approved drug or biological must be furnished by a physician and administered by the physician or by auxiliary personnel employed by the physician and under the physician's personal supervision.The charge, if any, for the drug or biological must be included in the physician's bill and the cost of the drug or biological must represent an expense to the physician.Pharmacies cannot bill Medicare Part B for drugs furnished to a physician for administration to a Medicare beneficiary.Pharmacies, suppliers and providers cannot bill Medicare Part B for drugs dispensed directly to a beneficiary for administration "incident to" a physician service, such as refilling an implanted drug pump.Providers can bill Medicare only when such drugs are purchased by the physician, from the pharmacy, and administered in the physician's office.Donated or Free-of-Charge DrugTo avoid a chemotherapy or other drug administration code denial, a drug code must be present on the same or prior claim. Enter the below information in the appropriate Part A or Part B electronic claim or the equivalent Part A UB04 or Part B CMS-1500 claim form.Part ALoop 2400 Segment SV202-7 or Box 80Enter "Drug Donated"Enter code description, strength and dosage - if billing a Not Otherwise Classified (NOC) HCPCS codeLoop 2400 Segment SV202-2 or Box 44Enter drug (HCPCS) codeLoop 2300 Segment CLM02 or Box 47 and 48Enter $0.01 for the billed amountPart BLoop 2400 Segment SV101-7 for the 5010A1 837P or Item 19Enter "Drug Donated"Enter code description, strength and dosage - if billing a Not Otherwise Classified (NOC) HCPCS codeLoop 2400 Segment SV101-2 or Item 24DEnter drug (HCPCS) code
Article - Billing and Coding: Patients Supplied Donated or Free-of-Charge Drug (A55045)
Loop 2400 Segment SV101-2 or Item 24DEnter drug (HCPCS) codeLoop 2300 CLM02 or Item 28Enter $0.01 for the billed amountThis will allow the claim processing system to register the drug claim as being allowed which should allow the administration.NOTE:Per the "incident to" guidelines explained above and in the CMS Internet-Only Manual (IOM) Publication 100-02, Chapter 15, Sections 50 and 50.3(MBPM). Providers areNOTallowed to instruct their patients to purchase the drug themselves and then bring them to the provider's office for administration. If the drug is not supplied as a donation or free of charge, then the provider must provide the drug under incident to guidelines.
Article - Billing and Coding: Testopel Coverage (A55056)
CMS National Coverage PolicyN/AArticle TextInjectable testosterone pellets (brand name Testopel) may be covered, by Medicare, for the FDA approved indication, if the service meets all Medicare coverage requirements quoted below verbatim in the Internet Only Manual (IOM)Medicare Benefit Policy Manual(MBPM) Chapter 15, Section 50.4.3.2MBPMInjection Method Not IndicatedMedication given by injection (parenterally) is not covered if standard medical practice indicates that the administration of the medication by mouth (orally) is effective and is an accepted or preferred method of administration. For example, the accepted standard of medical practice for the treatment of certain diseases is to initiate therapy with parenteral penicillin and to complete therapy with oral penicillin. Carriers exclude the entire charge for penicillin injections given after the initiation of therapy if oral penicillin is indicated unless there are special medical circumstances that justify additional injections."The Noridian Contractor Medical Directors (CMDs) believe that the use of this product should be rare since the "accepted method of medical practice" is to administer testosterone transdermally, but there may be reasons that require this injectable medication. Compliance with Medicare requirements is subject to review by the Recovery Auditors.A submitted claim form must contain the below information.In Item 19 of CMS-1500 paper claim form or Loop 2400/SV101-7 for electronic claimsEnter word "Testopel"Enter drug dosage given (include milligrams delivered only)NOTE:Medicare may only cover the number of pellets actually implanted in the patient (maximum of six pellets); wastage is not covered. Use of additional pellets may be paid on appeal if the documentation supports medical necessity as determined by the FDA approved drug label and the service complies with all Medicare requirements as indicated above.Item 24D or electronic equivalentEnter J3490
Article - Billing and Coding: Testopel Coverage (A55057)
CMS National Coverage PolicyN/AArticle TextInjectable testosterone pellets (brand name Testopel) may be covered, by Medicare, for the FDA approved indication, if the service meets all Medicare coverage requirements quoted below verbatim in the Internet Only Manual (IOM)Medicare Benefit Policy Manual(MBPM) Chapter 15, Section 50.4.3.2MBPMInjection Method Not IndicatedMedication given by injection (parenterally) is not covered if standard medical practice indicates that the administration of the medication by mouth (orally) is effective and is an accepted or preferred method of administration. For example, the accepted standard of medical practice for the treatment of certain diseases is to initiate therapy with parenteral penicillin and to complete therapy with oral penicillin. Carriers exclude the entire charge for penicillin injections given after the initiation of therapy if oral penicillin is indicated unless there are special medical circumstances that justify additional injections."The Noridian Contractor Medical Directors (CMDs) believe that the use of this product should be rare since the "accepted method of medical practice" is to administer testosterone transdermally, but there may be reasons that require this injectable medication. Compliance with Medicare requirements is subject to review by the Recovery Auditors.A submitted claim form must contain the below information.In Item 19 of CMS-1500 paper claim form or Loop 2400/SV101-7 for electronic claimsEnter word "Testopel"Enter drug dosage given (include milligrams delivered only)NOTE:Medicare may only cover the number of pellets actually implanted in the patient (maximum of six pellets); wastage is not covered. Use of additional pellets may be paid on appeal if the documentation supports medical necessity as determined by the FDA approved drug label and the service complies with all Medicare requirements as indicated above.Item 24D or electronic equivalentEnter J3490