evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility (A56885)
Article TextMedicare covers the following solid organ transplants: kidney, heart, lung, heart/lung, liver, pancreas, pancreas/kidney, and intestinal/multi-visceral. Medicare also covers stem cell transplants for certain conditions.Claims for CPTcodes used to describe Human Leukocyte Antigen (HLA) testing used for transplant histocompatibility testing will be denied. See below for further explanation on correct billing for these services. This does not refer to HLA testing for non-transplant services.HLA testing for histocompatibility testing as part of transplantation are part of solid organ acquisition services.Services for organ transplants must be billed as described in theCenters for Medicare and Medicaid Services (CMS) Internet-Only Manual, Pub100-04, Medicare Claims Processing Manual, Inpatient Hospital Billing, Chapter 3 Section 90 and as described in the Electronic Code of Federal Regulations, Title 42, Public Health, Part 412 Prospective Payment Systems for Inpatient Hospital Services. The acquisition costs of hearts, kidneys, livers, lungs, pancreas, and intestines (or multivisceral organs) incurred by approved transplantation centers are paid on a reasonable cost basis by approved transplant centers; they are not billed as stand-alone laboratory services.HLA typing is a component of the acquisition services for an allogeneic stem cell transplant as well. Payment for these acquisition services is included in the MS-DRG payment for the allogeneic stem cell transplant when the transplant occurs in the inpatient setting and in the OPPS APC payment for the allogeneic stem cell transplant when the transplant occurs in the outpatient setting. The Medicare contractor does not make separate payment for these acquisition services, because hospitals may bill and receive payment only for services provided to the Medicare beneficiary who is the recipient of the stem cell transplant and whose illness is being treated with the stem cell transplant. Unlike the acquisition costs of solid organs for transplant (e.g., hearts and kidneys), which are paid on a reasonable cost basis, acquisition costs for allogeneic stem cells are included in prospective payment.Acquisition charges do not apply to autologous transplants.HLA CPTcodesunrelated to transplant testinghave coverage as outlined in the following Local Coverage Determinations (LCDs):
Article - Billing and Coding: MolDX: HLA Testing for Transplant Histocompatibility (A56885)
CPT81381 The MolDX: Pharmacogenomics Testing L38394 LCD addresses limited coverage for gene-drug interactions.CPT81383  The MolDX: HLA-DQB1*06:02 Testing for Narcolepsy L36485 LCD addresses non-coverage of HLA-DQB1*06:02 typing for the diagnosis or management of narcolepsy.
Article - Billing and Coding: MolDX: Oncotype DX® Breast Cancer for DCIS (Genomic Health™) (A56887)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e). Prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manuals, Publication 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent LaboratorySpecimen Drawing, 60.2. Travel Allowance.CMS Internet Online Manual Pub. 100-04 (Medicare Claims Processing Manual), Chapter 23 (Section 10) "Reporting ICD Diagnosis and Procedure Codes"Article TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Oncotype DX Breast Cancer for DCIS (Genomic Health)L36951.To report an Oncotype DX Breast Cancer for DCIS service, please submit the following claim information:Select PLA code 0045UEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: Loss-of-Heterozygosity Based Topographic Genotyping with Pathfinder TG&reg; (A56897)
CMS National Coverage PolicyN/AArticle TextRefer to the Novitas Local Coverage Determination (LCD) L34864 Loss-of -Heterozygosity Based Topographic Genotyping with PathfinderTG, for reasonable and necessary requirements.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.
Article - Billing and Coding: MolDX: Envisia™, Veracyte™, Idiopathic Pulmonary Fibrosis Diagnostic Test (A56898)
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. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, 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) forMolDX: Envisia, Veracyte, Idiopathic Pulmonary Fibrosis Diagnostic Test L37857.To report an Envisia Genomic Classifier service, please submit the following claim information:Select CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: MolDX: Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) (A56899)
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. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel Allowance.CMS 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 MolDX: Genetic Testing for Hypercoagulability/Thrombophilia (Factor V Leiden, Factor II Prothrombin, and MTHFR) L36089.To report a Genetic Testing for Hypercoagulability/Thrombophilia service, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim form
Article - Billing and Coding: Immunizations (A56900)
CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L34596 Immunizations.
Article - Billing and Coding: Category III Codes (A56902)
CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L35490 Category III Codes with the exception of the following CPT codes:2021 CPT/HCPCS Annual code update: 0295T, 0296T, 0297T, and 0298T deleted. Effective 01/01/2021. Please refer to LCD L34636 Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) and A57476 Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring). The physician (MD/DO) performing the service must meet all criteria in this LCD and Billing and Coding Article.CPT Codes0446T-Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training,0447T-Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision, and0448T-Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation. Please refer to L38686 Implantable Continuous Glucose Monitors (I-CGM) and A58213 Billing and Coding: Implantable Continuous Glucose Monitors (I-CGM). The physician (MD/DO) performing the service must meet all criteria in this LCD and Billing and Coding Article. Effective 10/11/2020.CPT Code0421T Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed) AND HCPCS CodeC2596 Probe, image guided, robotic, waterjet ablation. Please refer to L38682 Transurethral Waterjet Ablation of the Prostate and A58209 Billing and Coding: Transurethral Waterjet Ablation of the Prostate. The provider performing this service must meet all criteria in that LCD and Billing and Coding Article. Effective 12/27/2020.
Article - Billing and Coding: Category III Codes (A56902)
CPT Codes0501T-0504T:coverage in L35490 no longer applicable. Please refer to L38839 Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease and A58473 Billing and Coding: Non-Invasive Fractional Flow Reserve (FFR) for Stable Ischemic Heart Disease for Coverage Indications, Limitations, and/or Medical Necessity. Effective 04/25/2021.Frequency LimitationMedicare may cover only1 unit per eye, per date of service of CPT code 0449Tfor insertion of glaucoma drainage device(s) into the subconjunctival space (e.g., XEN45), when the medically reasonable and necessary criteria as stated in the LCD are met.Documentation RequirementsAll documentation must be maintained in the patient's medical record and must support the medical necessity of the services as directed in this article and be made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
Article - Billing and Coding: Polysomnography and Other Sleep Studies (A56903)
CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity, and documentation requirements described in the associated LCD L36839 Polysomnography and Other Sleep Studies.Diagnostic testing will be considered for coverage if the patient has the symptoms or complaints of one of the conditions listed in L36839.Patients who undergo the diagnostic testing are not considered inpatients, although they may come to the facility in the evening for testing and then leave after testing is over. The overnight stay is considered an integral part of these tests. Documentation must support indications if the patient is admitted.Ordinarily, a single polysomnogram and electroencephalogram (EEG) can diagnose sleep apnea. If more than one such testing session is claimed, the carrier will require persuasive medical evidence justifying the medical necessity for the additional test (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70).Ordinarily, a diagnosis of narcolepsy can be confirmed by three sleep naps. If more than three sleep naps are claimed; the A/B MAC (B) will require persuasive medical evidence justifying the medical necessity for the additional test(s). (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70.)More than one HST per year interval would not be expected. If more than one HST session is performed for suspected OSA, persuasive medical evidence justifying the medical necessity for the additional tests will be required. Similarly, more than two PSG per year interval would not be expected. If more than two PSG sessions are performed for the diagnosis or adjustment of treatment of sleep, pervasive medical evidence justifying the medical necessity for the additional tests will be required upon request. When services are performed in excess of established parameters, they may be subject to review for medical necessity.The routine use of more than one PSG to titrate CPAP therapy would not be considered reasonable and necessary. If more than one CPAP titration PSG is claimed, persuasive medical evidence justifying the medical necessity for the additional tests may be requested.95805 MSLT- includes all the naps done in a single day. Only one (1) unit of service should be submitted.Coding Guidance
Article - Billing and Coding: Polysomnography and Other Sleep Studies (A56903)
Coding GuidanceWatchPat must be billed as CPT code 95800 or 95801.If a sleep study is performed for less than 6 hours, it should be billed with modifier 52. Providers should report the service provided with the appropriate reduced original charge.
Article - Billing and Coding: Surgical Treatment of Obstructive Sleep Apnea (OSA) (A56905)
CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD L34526.Sleep-Disordered Breathing, often referred to as Obstructive Sleep Apnea (OSA), is characterized by frequent episodes of hypopnea or apnea during sleep. Multiple detrimental physiologic changes may result from these hypopneic and apneic episodes. Non-surgical and surgical approaches to obstructive apnea and hypopnea have been developed.The following procedures are not covered at this time.
Article - Billing and Coding: Surgical Treatment of Obstructive Sleep Apnea (OSA) (A56905)
Laser-assisted uvulopalatoplasty (LAUP) is not covered at this time since it is not considered effective for OSA. LAUPmust notbe billed as 42145, Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty). This code is not appropriate for this procedure. If LAUP is billed for denial purposes, it should be coded as 42299, (unlisted procedure, palate, uvula) with "LAUP" in the electronic narrative 2400/SV101-7 equivalent to line 19 of the CMS 1500 form. The claim will be denied as not proven effective.Somnoplasty is a trade name for palate reduction with the Somnoplasty System of Somnus Medical Systems. This is not a term recognized by this Contractor as a covered procedure under Medicare Part B. Therefore Somnoplasty must not be billed as 42145. This code is not appropriate for this procedure. If Somnoplasty is billed for denial purposes, it should be coded as 42299, (unlisted procedure, palate, uvula) with "Somnoplasty" in the electronic narrative 2400/SV101-7 equivalent to line 19 of the CMS 1500 form. This claim will be denied as not proven effective.The Pillar Procedure is a trade name for palatal implants. Palatal implants have not been shown effective for the treatment of obstructive sleep apnea and are not covered. This procedure should be billed by the physician as 42299 (unlisted procedure, palate, uvula) with Pillar Procedure or palatal implant in the electronic narrative 2400/SV101-7 equivalent to line 19 of the CMS 1500 form. This claim will then be denied as not proven effective. Hospital outpatient departments would use code C9727.Submucosal ablation of the tongue base, radiofrequency, one or more sites, per session. (41530) will be denied as investigational and experimental.
Article - Billing and Coding: MolDX: DecisionDx-UM (Uveal Melanoma) (A56906)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, 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) MolDX: DecisionDx-UM (Uveal Melanoma) L37033.To report a DecisionDx-UM (Uveal Melanoma) service, please submit the following claim information:SelectCPTcode 81552Enter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: Bisphosphonate Drug Therapy (A56907)
CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations, and/or medical necessity described in the related LCD, L34648 Bisphosphonate Drug Therapy.Documentation RequirementsNote:If bone metastasis (C79.51 or C79.52) is the condition being treated, the diagnosis of a primary malignant neoplasm must be present in the patients medical record and available if requested.Information in the medical record including diagnostic information and lab results should support the medical necessity of this service. Based on the indications listed, the specific signs and symptoms must be documented to substantiate the FDA labeled or the FDA off labeled reasons for drug usage. An indication that the patient has been advised to take adequate calcium and vitamin D supplementation should be in the medical record. The medical record must be available on request. Diagnosis codes supporting medical necessity should be submitted on the claim.Evidence in the medical record should clearly support the need for the intravenous administration of bisphosphonates for the treatment of osteoporosis including description of treatment failure of oral or self-administered drugs for osteoporosis and heterotrophic ossification. Lab work should include serum creatinine measured prior to the administration of the drug.Utilization GuidelinesIt is expected that these services would be performed as indicated by current literature and/or standards of practice and should follow the guidelines for administration and safety found in the FDA approved labels for these drugs along with the indications found in the Coverage Indications, Limitations, and/or Medical Necessity section of this policy. When services are performed in excess of established parameters, it may result in medical review to determine if the services were medical necessity.Preventive services other than those payable by statute are excluded from Medicare coverage.Per the Summary and Analysis of Evidence contained in the associated LCD, the breast cancer diagnosis codes included in this Billing and Coding Article will reflect the current NCCN recommendations. It will continue to be required to bill the appropriate breast cancer diagnosis code, along with a bone loss diagnosis code, and a diagnosis code to reflect that the patient is currently receiving adjuvant selective estrogen receptor modulators OR aromatase inhibitor therapy for breast cancer.
Article - Billing and Coding: Blepharoplasty, Blepharoptosis and Brow Lift (A56908)
CMS National Coverage PolicyTitle XVIII of the social Security Act section 1833 (e). This section prohibits Medicare Payment for any claim that lacks the necessary information to process the claim.Title XVIII 0f the Social Security Act section 1862 (a)(10). This section excludes cosmetic surgery, except as required to repair an accidental injury or for the improvement of the function of a malformed body member.CR 10236  October 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS), 5. Upper Eyelid Blepharoplasty and Blepharoptosis Repair.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD.List the appropriate CPT code for the procedure performed; include any appropriate modifiers.Physicians services and diagnostic tests must be submitted with a diagnosis code to support the medical necessity for the service and must be coded to the greatest level of accuracy and highest level of digit completeness. This means the precise diagnosis code that fully explains the narrative description of the diagnosis contained in the medical record or the test interpretation and report including the digit sub-classification for the diagnosis category. The diagnosis code based on the results of the test should be the primary diagnosis. If the diagnostic test results are normal or inconclusive the diagnosis code representing the sign, symptom, illness or injury prompting the ordering of the test should be reported as the primary diagnosis. In the absence of signs, symptoms, illness or injury resulting in a functional anomaly of the upper eyelids a cosmetic diagnosis should be reported, and payment will be denied.The Medicare global surgery and CCI rules apply to these eyelid surgeries.If bilateral reconstruction is done on the same day, report one line of service using the 50 modifier or report two lines of service with the RT and LT modifiers.If a patient wishes to have a blepharoplasty or brow lift for cosmetic purposes:The physician should explain to the patient, in advance, that Medicare will not cover cosmetic eyelid or brow surgery and that the beneficiary will be liable for the cost of the service. Charges should be clearly stated. A claim for cosmetic services does not need to be submitted to the Medicare contractor, unless the patient requests that the claim be submitted on his/her behalf.