evekhm/cms_iom_500 huggingface dataset:
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3. If CWF receives a claim with HCPCS administration codes G0008 or G0009 and it already has on record a claim with the same MBI number, same MAC (Part B) number, same date of service, and same procedure code, CWF will reject the second claim submitted.   CWF will return to the MAC (Part B) a specific reject code for these edits. MACs (Part B) must deny the second claim and use the same messages they currently use for the denial of duplicate claims.   In order to prevent duplicate payment by the centralized billing contractor and local MAC (Part B), CWF will edit by line item for MAC (Part B) number, same MBI number, same date of service, the influenza virus procedure codes 90630, 90653, 90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90672, 90673, 90674, 90685, 90686, 90687, 90688, 90694, or 90756; the pneumococcal virus procedure codes 90670, 90671, 90677, or 90732; and the administration code G0008 or G0009.   If CWF receives a claim with either HCPCS codes 90630, 90653, 90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90672, 90673, 90674, 90682, 90685, 90686, 90687, 90688, 90694, or 90756 and it already has on record a claim with a different MAC (Part B) number, but same MBI number, same date of service, and any one of those same HCPCS codes, the second claim submitted to CWF will reject.
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If CWF receives a claim with HCPCS codes 90670, 90671, 90677, or 90732 and it already has on record a claim with the same MBI number, different MAC (Part B) number, same date of service, and the same HCPCS code, the second claim submitted to CWF will reject.   If CWF receives a claim with HCPCS administration codes G0008 or G0009 and it already has on record a claim with a different MAC (Part B) number, but the same  MBI number, same date of service, and same procedure code, CWF will reject the second claim submitted.   CWF will return a specific reject code for these edits. MACs (Part B) must deny the second claim. The reject code should automatically trigger the following Medicare Summary Notice (MSN) and Remittance Advice (RA) messages.   MSN: 7.2  This is a duplicate of a claim processed by another contractor. You should receive a Medicare Summary Notice from them.   Claim Adjustment Reason Code 18  Exact duplicate claim /service   EDITS FOR CLAIMS SUBMITTED TO THE CENTRALIZED BILLING PROCESSING MAC (PART B) AND THE LOCAL MAC (PART B)  In order to prevent duplicate payment by the centralized billing contractor and local MAC (Part B), CWF will edit by line item for MAC (Part B) number, same MBI number, same date of service, the influenza virus procedure codes 90630, 90653, 90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90672, 90673, 90674, 90685, 90686, 90687, 90688, 90694, or 90756; the pneumococcal virus procedure codes 90670, 90671, 90677, or 90732; and the administra tion code G0008 or G0009.
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1) If CWF receives a claim with either HCPCS codes 90630, 90653, 90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90672, 90673, 90674, 90682, 90685, 90686, 90687, 90688, 90694, or 90756 and it already has on record a claim with a different MAC (Part B)  number, but same MBI number, same date of service, and any one of those same HCPCS codes, the second claim submitted to CWF will reject.   2) If CWF receives a claim with HCPCS codes 90670, 90671, 90677, or 90732 and it already has on record a claim with the same MBI number, different MAC (Part B) number, same date of service, and the same HCPCS code, the second claim submitted to CWF will reject.   3) If CWF receives a claim with HCPCS administration codes G0008 or G0009 and it already has on record a claim with a different MAC (Part B) number, but the same   MBI number, same date of service, and same procedure code, CWF will reject the second claim submitted.   CWF will return a specific reject code for these edits. MACs (Part B) must deny the second claim. The reject code should automatically trigger the following Medicare Summary Notice (MSN) and Remittance Advice (RA) messages.   MSN: 7.2  This is a duplicate of a claim processed by another contractor. You should receive a Medicare Summary Notice from them.   Claim Adjustment Reason Code 18  Exact duplicate claim /service    10.4.3 - CWF Crossover Edits for A/B MAC (B) Claims  (Rev. 11355; Issued:04- 14-22; Effective:05 -16-22; Implementation:05 -16-22)  When CWF receives a claim from the MAC (Part B), it will review Part B outpatient claims history to verify that a duplicate claim has not already been posted.
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When CWF receives a claim from the MAC (Part B), it will review Part B outpatient claims history to verify that a duplicate claim has not already been posted.   CWF will edit on the beneficiary MBI number; the date of service; the influenza virus procedure codes 90630, 90653, 90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90672, 90673, 90674, 90682, 90685, 90686, 90687, 90688, 90694, or 90756; the pneumococcal procedure codes 90670,90671, 90677, or 90732; and the administration code G0008 or G0009.   CWF will return a specific reject code for this edit. MACs (B) must deny the second claim and use the same messages they currently use for the denial of duplicate claims.    20 - Mammography Services (Screening and Diagnostic)  (Rev. 1387, Issued: 12- 07-07, Effective: 04 -01-08, Implementation: 04- 07-08)  A. Screening Mammography   Beginning January 1, 1991, Medicare provides Part B coverage of screening mammographies for women.  Screening mammographies are radiologic procedures for early detection of breast cancer and include a physicians interpretation of the results.  A doctors prescription or referral is not necessary for the procedure to be covered.  Whether payment can be made is determined by a womans age and statutory frequency parameter.  See Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15, section 280.3 for additi onal coverage information for a screening mammography.  Section 4101 of the Balanced Budget Act (BBA) of 1997 provides for annual screening mammographies for women over age 39 and waives the Part B deductible.  Coverage applies as follows:   Age Groups  Screening Period  Under age 35  No payment allowed for screening mammography.  35-39  Baseline (pay for only one screening mammography performed on a woman between her 35th and 40th birthday)  Over age 39  Annual (11 full months have elapsed following the month of last screening
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NOTE:  Count months between screening mammographies beginning the month after the date of the examination.  For example, if Mrs. Smith received a screening mammography examination in January 2005, begin counting the next month (February 2005) until 11 months have  elapsed.  Payment can be made for another screening mammography in January 2006.  B. Diagnostic Mammography  A diagnostic mammography is a radiological mammogram and is a covered diagnostic test under the following conditions:    A patient has distinct signs and symptoms for which a mammogram is indicated;    A patient has a history of breast cancer; or    A patient is asymptomatic, but based on the patients history and other factors the physician considers significant, the physicians judgment is that a mammogram is appropriate.    Beginning January 1, 2005, Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, 644, Public Law 108- 173 has changed the way Medicare pays for diagnostic mammography. Medicare will pay based on the MPFS in lieu of OPPS or the lower  of the actual change.   20.1 - Certification of Mammography Facilities (Rev. 1387, Issued: 12- 07-07, Effective: 04 -01-08, Implementation: 04- 07-08)  The Mammography Quality Standards Act (MQSA) provides specific standards regarding those qualified to perform screening and diagnostic mammograms and how they should be certified.  The MQSA requires the Secretary to ensure that all facilities that provide mammography services meet national quality standards.  Effective October 1, 1994, all facilities providing screening and diagnostic mammography services (except VA facilities) must have a certificate issued by the Food and Drug Administration (FDA) to cont inue to operate.  The FDA, Center for Devices and Radiological Health, is responsible for collecting certificate fees and surveying mammography facilities (screening and diagnostic).
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The FDA provides CMS with a listing of all providers that have been issued certificates to perform mammography services and CMS notifies A/B MACs (A) and (B) accordingly.  A/B MACs (A) and (B) are also notified of situations where a providers certificate has expired, or has been suspended or revoked.  The information provided includes the providers name, address, 6- position certification number, effective/expiration dates and the letter T to designate the facility as terminated.   Medicare will reimburse only FDA -certified mammography centers for mammography services.  A/B MACs (B) must inform physicians and suppliers at least annually, through their provider/supplier publications, of those facilities centers, that are certified.  A /B MACs (B) encourage physicians to inform their patients about centers that are certified.   Mammography facilities that perform screening mammographies are not to release screening mammography x- rays for interpretation to physicians who are not approved under the facilitys certification number unless the patient has requested a transfer of the mammography from one facility to another for a second opinion, or unl ess the patient has moved to another part of the country where the next screening mammography will be performed.  Interpretations are to be performed only by physicians who are associated with the certified mammography facility.  A/B MACs (B) are not required to maintain a list of these associations unless there is a specific reason for doing so and only on a case -by-case basis.   When adjudicating a screening mammography claim, MACs refer to the table of certified facilities provided by the FDA through CMS and confirm that the facility listed on the claim is in fact certified to perform the service.  When the MAC determines that th e facility that performed the mammography service has not been issued a certificate by the FDA or the certificate is suspended or revoked, the claim will be denied utilizing the denial language in 20.8.1  of this chapter, related to certified facilities.   20.1.1 - Services Under Arrangements  (Rev. 1387, Issued: 12- 07-07, Effective: 04 -01-08, Implementation: 04- 07-08)
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20.1.1 - Services Under Arrangements  (Rev. 1387, Issued: 12- 07-07, Effective: 04 -01-08, Implementation: 04- 07-08)  When mammography services are obtained for patients under arrangements with another facility, the provider arranging the service must ensure that the facility performing the services has been issued an MQSA certificate by the FDA.   20.1.2 - FDA Certification Data  (Rev. 1387, Issued: 12- 07-07, Effective: 04 -01-08, Implementation: 04- 07-08)  The FDA furnishes data to CMS on a weekly basis, which specify the certification of facilities under the MQSA.  This data are contained in a MQSA file.   Prior to April 1, 2003, the MQSA file showed all facilities that are certified to perform film screening and diagnostic mammograms.  After April 1, 2003, the file shows a new Record Type with two indicators, 1 for film and 2 for digital to determine wh ich mammograms the facility is certified to perform.   Section 104 of the Benefits Improvement and Protection Act (BIPA) of 2000, entitled Modernization of Screening Mammography Benefit, provided new payment methodologies for both diagnostic and screening mammograms that utilize digital technology.  The new digital mammography codes have a higher payment rate.  In order for Medicare to know whether the mammography facility is certified to perform digital mammography and, therefore, due a higher payment rate, CMS relies upon the FDA certification data containe d in the MQSA file.  The FDA sends an updated file via the CMS Mainframe Telecommunications System (CMSTS), formerly Network Data Mover, on a weekly basis.   Effective July 1, 2006, the MQSA file shows:    Name of Facility,    Certification number of the facility,    Film certification obtained (Record -type =1) or digital certification obtained (Record -type = 2),    Effective and Expiration dates of each certification,    Letter T to designate the facility as terminated,
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 Film certification obtained (Record -type =1) or digital certification obtained (Record -type = 2),    Effective and Expiration dates of each certification,    Letter T to designate the facility as terminated,   Some mammography facilities are certified to perform both film and digital mammography.  In this case, the facilitys name and FDA certification number shows up on this file twice.  One line will indicate film certification with effective date/expiration d ate while the other line will indicate digital certification with effective date/expiration date.   NOTE:  The FDA does not issue printed certification which indicates film or/and digital. Refer to the MQSA file for proof of types of mammography the facility is certified to perform.   If the MQSA file appears to be in error, contact your regional office mammography coordinator. The coordinators will contact the FDA to research the apparent error.    20.2 - HCPCS and Diagnosis Codes for Mammography Services                                          (Rev. 12435, Issued:12- 28-23, Effective:01- 29-24, Implementation:01- 29-24)  The following HCPCS codes are used to bill for mammography services.   HCPCS Code  Definition  77065*  (G0206*)   Diagnostic mammography, including computer -aided detection (CAD) when performed; unilateral  77066*  (G0204*)  Diagnostic mammography, including computer -aided detection (CAD) when performed; bilateral  77067*  (G0202*)  Screening mammography, bilateral (2 -view study of each breast), including computer -aided detection (CAD) when performed    77063**  Screening Breast Tomosynthesis; bilateral (list separately in addition to code for primary procedure).   G0279**  Diagnostic digital breast tomosynthesis, unilateral or bilateral (List separately in addition to code for primary procedure)
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*NOTE:   For claims with dates of service January 1, 2017 through December 31, 2017 providers report HCPCS codes G0202, G0204, and G0206.  For claims with dates of service on or after January 1, 2018 providers report CPT codes 77067, 77066, and 77065 respectively.  **NOTE:  HCPCS codes 77063 and G0279 are effective for claims with dates of service on or after January 1, 2015.  New Modifier  -GG:  Performance and payment of a screening mammography and diagnostic mammography on same patient same day -  This is billed with the Diagnostic Mammography code to show the test changed from a screening test to a diagnostic test.  A/B MACs (A) and (B) will pay both the screening and diagnostic mammography tests.  This modifier is for tracking purposes only.  This applies to claims with dates of service on or after January 1, 2002. A. Diagnosis for Services On or After Oct 1, 2015 The BBA of 1997 eliminated payment based on high- risk indicators.  However, to ensure proper coding, one of the following diagnosis codes should be reported on screening mammography claims as appropriate:  ICD- 10-CM Z12.31 -  Encounter for screening mammogram for malignant neoplasm of breast.  Beginning October 1, 2003, A/B MACs (B) are not permitted to plug the code for a screening mammography when the screening mammography claim has no diagnosis code.  Screening mammography claims with no diagnosis code must be returned as unprocessable for as signed claims.  For unassigned claims, deny the claim. In general, providers report diagnosis codes in accordance with the instructions in the appropriate ASC X12 837 claim technical report 3 (institutional or professional) and the paper claim form instructions found in chapters 25 (institutional) and 26 (prof essional).  In addition, for institutional claims, providers report diagnosis code Z12.31 (if ICD -10-CM is applicable) in Principal Diagnosis Code if the screening mammography is the only service reported on the claim.  If the claim contains other services in additi on to the screening mammography, these diagnostic code Z12.31 (ICD -10-CM)  are reported, as appropriate, in Other Diagnostic Codes.  NOTE:
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the claim.  If the claim contains other services in additi on to the screening mammography, these diagnostic code Z12.31 (ICD -10-CM)  are reported, as appropriate, in Other Diagnostic Codes.  NOTE:   Information regarding the form locator number that corresponds to the principal and other diagnosis codes is found in chapter 25.  A/B MACs (B) receive this diagnosis in field 21 and field 24E with the appropriate pointer code of Form CMS -1500 or in Loop 2300 of ASC - X12 837 professional claim format. ICD- 10-CM Codes for a diagnostic mammography:
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ICD-10 CM code   Definitions  C43.52  Malignant melanoma of skin of breast  C43.59  Malignant melanoma of other part of trunk  C44.511  Basal cell carcinoma of skin of breast  C44.519  Basal cell carcinoma of skin of other part of trunk  C44.521  Squamous cell carcinoma of skin of breast  C44.529  Squamous cell carcinoma of skin of other part of trunk  C44.591  Other specified malignant neoplasm of skin of breast  C44.599  Other specified malignant neoplasm of skin of other part of trunk  C45.9  Mesothelioma, unspecified  C50.011  Malignant neoplasm of nipple and areola, right female breast  C50.012  Malignant neoplasm of nipple and areola, left female breast  C50.021  Malignant neoplasm of nipple and areola, right male breast  C50.022  Malignant neoplasm of nipple and areola, left male breast  C50.111  Malignant neoplasm of central portion of right female breast  C50.112  Malignant neoplasm of central portion of left female breast  C50.121  Malignant neoplasm of central portion of right male breast  C50.122  Malignant neoplasm of central portion of left male breast  C50.211  Malignant neoplasm of upper -inner quadrant of right female breast  C50.212  Malignant neoplasm of upper -inner quadrant of left female breast  C50.221  Malignant neoplasm of upper -inner quadrant of right male breast  C50.222  Malignant neoplasm of upper -inner quadrant of left male breast  C50.311  Malignant neoplasm of lower -inner quadrant of right female breast  C50.312  Malignant neoplasm of lower -inner quadrant of left female breast  C50.321  Malignant neoplasm of lower -inner quadrant of right male breast  C50.322  Malignant neoplasm of lower -inner quadrant of left male breast  C50.411  Malignant neoplasm of upper -outer quadrant of right female breast  C50.412  Malignant neoplasm of upper -outer quadrant of left female breast  C50.421  Malignant neoplasm of upper -outer quadrant
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Malignant neoplasm of upper -outer quadrant of right female breast  C50.412  Malignant neoplasm of upper -outer quadrant of left female breast  C50.421  Malignant neoplasm of upper -outer quadrant of right male breast  C50.422  Malignant neoplasm of upper -outer quadrant of left male breast  C50.511  Malignant neoplasm of lower -outer quadrant of right female breast  C50.512  Malignant neoplasm of lower -outer quadrant of left female breast  C50.521  Malignant neoplasm of lower -outer quadrant of right male breast  C50.522  Malignant neoplasm of lower -outer quadrant of left male breast  C50.611  Malignant neoplasm of axillary tail of right female breast  C50.612  Malignant neoplasm of axillary tail of left female breast  C50.621  Malignant neoplasm of axillary tail of right male breast  C50.622  Malignant neoplasm of axillary tail of left male breast  C50.811  Malignant neoplasm of overlapping sites of right female breast  C50.812  Malignant neoplasm of overlapping sites of left female breast  C50.821  Malignant neoplasm of overlapping sites of right male breast  C50.822  Malignant neoplasm of overlapping sites of left male breast  C56.1  Malignant neoplasm of right ovary  C56.2  Malignant neoplasm of left ovary  C77.3  Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes  C78.01  Secondary malignant neoplasm of right lung  C78.02  Secondary malignant neoplasm of left lung  C78.1  Secondary malignant neoplasm of mediastinum  C78.2  Secondary malignant neoplasm of pleura  C78.7  Secondary malignant neoplasm of liver and intrahepatic bile duct  C79.2  Secondary malignant neoplasm of skin  C79.31  Secondary malignant neoplasm of brain  C79.32  Secondary malignant neoplasm of cerebral meninges  C79.40  Secondary malignant neoplasm of unspecified part of nervous system
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skin  C79.31  Secondary malignant neoplasm of brain  C79.32  Secondary malignant neoplasm of cerebral meninges  C79.40  Secondary malignant neoplasm of unspecified part of nervous system  C79.49  Secondary malignant neoplasm of other parts of nervous system  C79.51  Secondary malignant neoplasm of bone  C79.52  Secondary malignant neoplasm of bone marrow  C79.61  Secondary malignant neoplasm of right ovary  C79.62  Secondary malignant neoplasm of left ovary  C79.81  Secondary malignant neoplasm of breast  C80.0  Disseminated malignant neoplasm, unspecified  C80.1  Malignant (primary) neoplasm, unspecified  C84.7A  Anaplastic large cell lymphoma, ALK -negative, breast  D03.52  Melanoma in situ of breast (skin) (soft tissue)  D03.59  Melanoma in situ of other part of trunk  D04.5  Carcinoma in situ of skin of trunk  D05.01  Lobular carcinoma in situ of right breast  D05.02  Lobular carcinoma in situ of left breast  D05.11  Intraductal carcinoma in situ of right breast  D05.12  Intraductal carcinoma in situ of left breast  D05.81  Other specified type of carcinoma in situ of right breast  D05.82  Other specified type of carcinoma in situ of left breast  D22.5  Melanocytic nevi of trunk  D23.5  Other benign neoplasm of skin of trunk  D24.1  Benign neoplasm of right breast  D24.2  Benign neoplasm of left breast  D48.5  Neoplasm of uncertain behavior of skin  D48.61  Neoplasm of uncertain behavior of right breast  D48.62  Neoplasm of uncertain behavior of left breast  D49.1  Neoplasm of unspecified behavior of respiratory system  D49.6  Neoplasm of unspecified behavior of brain  D49.7  Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system  I80.8  Phlebitis and thrombophlebitis of other sites