evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
I50.40  Unspecified combined systolic (congestive) and diastolic  (congestive) heart failure   I50.41  Acute combined systolic (congestive) and diastolic  (congestive) heart failure   I50.42  Chronic combined systolic (congestive) and diastolic  (congestive) heart failure   I50.43  Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure  I50.84  End-stage heart failure  I50.9  Heart failure, unspecified  I51.4  Myocarditis, unspecified  I51.9  Heart disease, unspecified  I52 Other heart disorders in diseases classified elsewhere  I97.0  Postcardiotomy syndrome   I97.110  Postprocedural cardiac insufficiency following cardiac  surgery   I97.111  Postprocedural cardiac insufficiency following other  surgery  I97.120  Postprocedural cardiac arrest following cardiac surgery  I97.121  Postprocedural cardiac arrest following other surgery  I97.130  Postprocedural heart failure following cardiac surgery  I97.131  Postprocedural heart failure following other surgery   I97.190  Other postprocedural cardiac functional disturbances  following cardiac surgery   I97.191  Other postprocedural cardiac functional disturbances  following other surgery  I97.710  Intraoperative cardiac arrest during cardiac surgery  I97.711  Intraoperative cardiac arrest during other surgery   I97.790  Other intraoperative cardiac functional disturbances  during cardiac surgery   I97.791  Other intraoperative cardiac functional disturbances  during other surgery   I97.88  Other intraoperative complications of the circulatory  system, not elsewhere classified   I97.89  Other postprocedural complications and disorders of the circulatory system, not elsewhere classified  M32.11  Endocarditis in systemic lupus erythematosus  R00.1  Bradycardia, unspecified  R57.0  Cardiogenic shock   T82.221A  Breakdown (mechanical) of biological heart valve graft,  initial encounter   T82.222A  Displacement of biological heart valve graft, initial  encounter  T82.223A  Leakage of biological heart valve graft, initial encounter   T82.228A  Other mechanical complication of biological heart valve  graft, initial encounter
(Medicare Claims Processing Manual)
T82.512A  Breakdown (mechanical) of artificial heart, initial  encounter   T82.514A  Breakdown (mechanical) of infusion catheter, initial  encounter   T82.518A  Breakdown (mechanical) of other cardiac and vascular devices and implants, initial encounter  T82.522A  Displacement of artificial heart, initial encounter   T82.528A  Displacement of other cardiac and vascular devices and  implants, initial encounter   T82.529A  Displacement of unspecified cardiac and vascular devices  and implants, initial encounter  T82.532A  Leakage of artificial heart, initial encounter   T82.538A  Leakage of other cardiac and vascular devices and  implants, initial encounter   T82.592A  Other mechanical complication of artificial heart, initial  encounter   T82.598A  Other mechanical complication of other cardiac and  vascular devices and implants, initial encounter  T86.20  Unspecified complication of heart transplant  T86.21  Heart transplant rejection  T86.22  Heart transplant failure  T86.23  Heart transplant infection  T86.290  Cardiac allograft vasculopathy  T86.298  Other complications of heart transplant  T86.30  Unspecified complication of heart -lung transplant  T86.31  Heart -lung transplant rejection  T86.32  Heart -lung transplant failure  T86.33  Heart -lung transplant infection  T86.39  Other complications of heart -lung transplant  Z48.21  Encounter for aftercare following heart transplant  Z48.280  Encounter for aftercare following heart -lung transplant  Z94.1  Heart transplant status  Z94.3  Heart and lungs transplant status   This policy does not address coverage of VADs for right ventricular support, biventricular support, use in beneficiaries under the age of 18, use in beneficiaries with complex congenital heart disease, or use in beneficiaries with acute heart failure without a history of chronic heart failure. Coverage under section 1862(a) (1) (A) of the Social Security Act for VADs in these situations will be made by  local Medicare Administrative Contractors (MACs) within their respective jurisdictions.  320.3.4  Replacement Accessories and Supplies for External VADs or Any VAD (Rev.10837; Issued: 06- 11-21; Effective: 12 -01-20; Implementation: 07 -27-21)
(Medicare Claims Processing Manual)
Effective April 1, 2013, claims for replacement of accessories and supplies for VADs implanted in patients who were not eligible for coverage under Medicare Part A or had other insurance that paid for the device and hospital stay at the time that the devic e was implanted, but are now eligible for coverage of the replacement supplies and accessories under Part B, should be submitted using HCPCS code Q0509. Those claims will be manually reviewed.  In rare instances it may be appropriate to pay for replacement of supplies and accessories for external VADs used by patient who are discharged from the hospital. In addition, in some rare instances, it may be necessary for a patient to have an emergency b ack-up controller for an external VAD. Coverage of these items is at the discretion of the contractor. Claims for replacement of supplies and accessories used with an external VAD that are furnished by suppliers should be billed to the Part B MACs. Claims for replacement of supplies and accessories used with an external VAD that are furnished by hospitals and other providers should be billed to the Part AMACs. Effective April 1, 2013, these items should be billed using code Q0507 so that the claims can be m anually reviewed.  Claims for replacement supplies or accessories used with VADs that do not have specific HCPCS codes and do not meet the criteria of codes Q0507 and Q0509 should be billed using code Q0508.   Claims Coding   HCPCS  Definition  Effective Date  Q0507 Miscellaneous Supply Or Accessory For Use With An External Ventricular Assist Device  April 1,  2013 Q0508 Miscellaneous Supply or Accessory For Use With An Implanted Ventricular Assist Device  April 1,  2013 Q0509 Miscellaneous Supply Or Accessory For Use With Any Implanted Ventricular Assist Device For Which Payment Was Not Made Under Medicare Part A  April 1,  2013
(Medicare Claims Processing Manual)
Q0480:Driver for use with pneumatic ventricular assist device, replacement only Q0481:Microprocessor control unit for use with electric ventricular assist device, replacement only  Q0482:Microprocessor control unit for use with electric/pneumatic combination ventricular assist device, replacement only Q0483:Monitor/display module for use with electric ventricular assist device, replacement only Q0484:Monitor/display module for use with electric or electric/pneumatic ventricular assist device, replacement only Q0485:Monitor control cable for use with electric ventricular assist device, replacement only Q0486:Monitor control cable for use with electric/pneumatic ventricular assist device, replacement only Q0487:Leads (pneumatic/electrical) for use with any type electric/pneumatic ventricular assist device, replacement only  Q0488:Power pack base for use with electric ventricular assist device, replacement only  Q0489:Power pack base for use with electric/pneumatic ventricular assist device, replacement only  Q0490:Emergency power source for use with electric ventricular assist device, replacement only  Q0491:Emergency power source for use with electric/pneumatic ventricular assist device, replacement only Q0492:Emergency power supply cable for use with electric ventricular assist device, replacement only  Q0493:Emergency power supply cable for use with electric/pneumatic ventricular assist device, replacement only  Q0494:Emergency hand pump for use with electric or electric/pneumatic ventricular assist device, replacement only Q0495:Battery/power pack charger for use with electric or electric/pneumatic ventricular assist device, replacement only  Q0496:Battery, other than lithium -ion, for use with electric or electric/pneumatic ventricular assist device, replacement only Q0497:Battery clips for use with electric or electric/pneumatic ventricular assist device, replacement only  Q0498:Holster for use with electric or electric/pneumatic ventricular assist device, replacement only  Q0499:Belt/vest/bag for use to carry external peripheral components of any type ventricular assist device, replacement only Q0500:Filters for use with electric
(Medicare Claims Processing Manual)
electric/pneumatic ventricular assist device, replacement only  Q0499:Belt/vest/bag for use to carry external peripheral components of any type ventricular assist device, replacement only Q0500:Filters for use with electric or electric/pneumatic ventricular assist device, replacement only  Q0501:Shower cover for use with electric or electric/pneumatic ventricular assist device, replacement only  Q0502:Mobility cart for pneumatic ventricular assist device, replacement only Q0503:Battery for pneumatic ventricular assist device, replacement only, each  Q0504:Power adapter for pneumatic ventricular assist device, replacement only, vehicle type  Q0506:Battery, lithium -ion, for use with electric or electric/pneumatic ventricular assist device, replacement only  NOTE: When determined to be medically necessary, dressings used with VADs are covered under the prosthetic device benefit as a supply necessary for the effective use of the VAD/prosthetic device. Claims for dressings necessary for the effective use of a VAD should be billed using the appropriate miscellaneous VAD supply code, depending upon whether the patient was eligible for coverage under Medicare Part A at the time that the VAD was implanted. The claims processing jurisdiction for dressings used with VADs is identical to that of other VAD replacement supplies and accessories and does not fall under Durable Medical Equipment MAC jurisdiction.
(Medicare Claims Processing Manual)
330  Percutaneous Image -guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS)  (Rev.  2959, Issued: 05- 16-14, Effective: 01 -09-14, Implementation: 10- 06-14)  PILD is a posterior decompression of the lumbar spine performed under indirect image guidance without any direct visualization of the surgical area.  This is a procedure proposed as a treatment for symptomatic LSS unresponsive to conservative therapy.  Thi s procedure is generally described as a non -invasive procedure using specially designed instruments to percutaneously remove a portion of the lamina and debulk the ligamentum flavum.  The procedure is performed under x -ray guidance (e.g., fluoroscopic, CT)  with the assistance of contrast media to identify and monitor the compressed area via epiduragram. For complete Medical coverage guidelines, see National Coverage Determinations (NCD) Manual (Pub 100- 03) 150.13.   330.1  Claims Processing Requirements for Percutaneous Image -guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS) on Professional Claims  (Rev. 3811, Issued: 07- 25-17, Effective: 12 -07-16, Implementation: 06- 27-17)   For claims with dates of service on or after January 9, 2014, PILD (procedure code 0275T) is a covered service when billed as part of a clinical trial approved by CMS.  The description for CPT 0275T is Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy, any method, under indirect image guidance (e.g., fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar.
(Medicare Claims Processing Manual)
For claims with dates of service on or after January 1, 2015, PILD (procedure code G0276) is a covered service when billed as part of a clinical trial approved by CMS.  HCPCS G0276 is Blinded procedure for lumbar stenosis, percutaneous image- guided lumbar  decompression (PILD), or placebo control, performed in an approved coverage with evidence development (CED) clinical trial.   Effective for dates of service on or after December 7, 2016, Medicare will cover PILD under CED for beneficiaries with LSS who are enrolled in a CMS -approved prospective longitudinal study for PILD procedures using a FDA -approved/cleared device that comple ted a CMS -approved randomized, controlled clinical trial (RCT) that met the criteria listed in the January 2014 NCD (see CR 8757, transmittal # 2959, dated May 16, 2014).    The claim may only contain one of these procedure codes, not both.  To use G0276, the procedure must be performed in an approved CED clinical trial that is randomized, blinded, and contains a placebo control arm of the trial.  CMS will cover procedure code 0275T for PILD only when the procedure is performed within any other CED approved clinical trial.  Regardless of the type of CED approved clinical trial (e.g. G0276 vs 0275T), PILD is only covered when billed for the ICD -9 diagnosis of 724.01- 724.03 or the ICD -10 diagnosis of M48.05- M48.07, when billed in places of service 22 (Outpatient) or 24 (Ambulatory Surgical Center), when billed along with V70.7 (ICD -9) or Z00.6 (ICD -10) in either the primary/secondary positions, and when billed with modifier Q0.   Additionally, per Transmittal 2805 (Change Request 8401), issued October 30, 2013, all claims for clinical trials must contain the 8 digit clinical trial identifier number.   The following message(s) shall be used to notify providers of return situations that may occur:   Professional Claims 8-digit Clinical Trial Number
(Medicare Claims Processing Manual)
The following message(s) shall be used to notify providers of return situations that may occur:   Professional Claims 8-digit Clinical Trial Number   For PILD claims with procedure code 0275T with dates of service on or after January 9, 2014 , or for claims with procedure code G0276 with dates of service on or after January 1, 2015, contractors shall pay for PILD only when billed with the numeric, 8-digit clinical trial identifier number preceded by the two alpha characters CT when placed in  Field 19 of paper Form CMS -1500, or when entered without the CT prefix in the electronic 837P in Loop 2300 REF02 (REF01=P4).  Claims for PILD which are billed wit hout an 8-digit clinical trial identifier number shall be returned as unprocessable.   The following messages shall be used when Medicare contractors return PILD claims billed without an 8 -digit clinical trial identifier number as unprocessable:   Claims Adjustment Reason Code 16:  Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.   Remittance Advice Remark Code N721: This service is only covered when performed as part of a clinical trial.   Remittance Advice Remark Code MA50: Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number .  Remittance Advice Remark Code N704: "Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted."   Professional Claims Place of Service  22 or 24   For PILD claims with procedure code 0275T with dates of service on or after January 9, 2014 , or for claims with procedure code G0276 with dates of service on or after January 1, 2015, contractors shall pay for PILD for LSS claims only when billed in place of service 22 or 24.  Claims for PILD which are billed in any other place of service shall be returned a s unprocessable.   The following messages shall be used when Medicare contractors return PILD claims not billed in place of service 22 or 24:   Claims Adjustment Reason Code 58:  Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.
(Medicare Claims Processing Manual)
Claims Adjustment Reason Code 58:  Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.   Remittance Advice Remark Code N704: "Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted."   Professional Claims Modifier  Q0   For PILD claims with procedure code 0275T with dates of service on or after January 9, 2014 , or for claims with procedure code G0276 with dates of service on or after January 1, 2015, contractors shall pay for PILD for LSS claims only when billed with modifier Q0.  Claims for PILD which are billed without modifier Q0 shall be returned as unproce ssable.   The following messages shall be used when Medicare contractors return PILD claims billed without modifier Q0 as unprocessable:   Claims Adjustment Reason Code 4:  The procedure code is inconsistent with the modifier used or a required modifier is missing.   Remittance Advice Remark Code N657: This should be billed with the appropriate code for these services."   Remittance Advice Remark Code N704: "Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted."   Non-covered Diagnosis   For PILD claims with procedure code 0275T with dates of service on or after January 9, 2014, or for claims with procedure code G0276 with dates of service on or after January 1, 2015, contractors shall pay for PILD for LSS claims only when billed with the ICD -9 diagnosis of 724.01- 724.03 or the ICD -10 diagnosis of M48.05- M48.07.  The following messages shall be used when Medicare contractors return PILD claims, billed without the covered diagnosis, as unprocessable:   Claims Adjustment Reason Code B22:  This payment is adjusted based on the diagnosis.   Remittance Advice Remark Code N704: "Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted."   Clinical Trial Diagnosis
(Medicare Claims Processing Manual)
Remittance Advice Remark Code N704: "Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted."   Clinical Trial Diagnosis   For PILD claims with procedure code 0275T with dates of service on or after January 9, 2014, or for claims with procedure code G0276 with dates of service on or after January 1, 2015, contractors shall pay for PILD only when billed with the ICD -9 diagnosis of V70.7 (ICD -9) or Z00.6 (ICD -10) in either the primary or secondary positions.  The following messages shall be used when Medicare contractors return PILD claims, billed without the clinical trial diagnosis, as unprocessable:   Claims Adjustment Reason Code B22:  This payment is adjusted based on the diagnosis.   Remittance Advice Remark Code N704: "Alert: You may not appeal this decision but can resubmit this claim/service with corrected information if warranted."   330.2 - Claims Processing Requirements for PILD for Outpatient Facilities  (Rev. 3811, Issued: 07- 25-17, Effective: 12 -07-16, Implementation: 06- 27-17)   Hospital Outpatient facilities shall bill for percutaneous image -guided lumbar decompression (PILD) procedure code 0275T effective on or after January 9, 2014, or procedure code G0276 effective on or after January 1, 2015, for lumbar spinal stenosis (LSS) on a  13X or 85X TOB.  Refer to Section 69 of this chapter for further guidance on billing under CED.   Effective for dates of service on or after December 7, 2016, Medicare will cover PILD under CED for beneficiaries with LSS who are enrolled in a CMS -approved prospective longitudinal study for PILD procedures using a FDA -approved/cleared device that comple ted a CMS -approved randomized, controlled clinical trial (RCT) that met the criteria listed in the January 2014 NCD (see CR 8757, transmittal # 2959, dated May 16, 2014).    Hospital outpatient procedures for PILD shall be covered when billed with:
(Medicare Claims Processing Manual)
Hospital outpatient procedures for PILD shall be covered when billed with:    ICD-9 V70.7 (ICD -10 Z00.6) and Condition Code 30.  Modifier Q0   An 8 -digit clinical trial identifier number listed on the CMS Coverage with Evidence Development website   Hospital outpatient procedures for PILD shall be rejected when billed without:    ICD-9 V70.7 (ICD -10 Z00.6) and Condition Code 30.  Modifier Q0   An 8 -digit clinical trial identifier number listed on the CMS Coverage with Evidence Development website   Claims billed by hospitals not participating in the trial /registry, shall be rejected with the following message:   CARC: 50 - These are non -covered services because this is not deemed a medical necessity by the payer.   RARC N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.  Group Code Contractual Obligation (CO)  MSN 16.77  This service/item was not covered because it was not provided as part of a qualifying trial/study. (Este servicio/artculo no fue cubierto porque no estaba incluido como parte de un ensayo clnico/estudio calificado.)  340  Transcatheter Edge -to-Edge Repair (TEER) for Mitral Valve Regurgitation  (Rev.  10985; Issued:09-08-21, Effective:01-19- 21; Implementation:10 -08-21)   Transcatheter Edge- to-Edge Repair (TEER) of the mitral valve (previously named Transcatheter Mitral Valve Repair (TMVR)) is used in the treatment of mitral regurgitation (MR).  TEER approximates the anterior and posterior mitral valve leaflets by grasping them with a clipping device in an approach similar to a treatment developed in cardiac surgery called the Alfieri stitch.
(Medicare Claims Processing Manual)
The most recent reconsideration of NCD 20.33 (TEER for Mitral Valve Regurgitation (previously named TMVR)) is effective for claims with dates of service on and after January 19, 2021.  It expands coverage of mitral valve TEER procedures for the treatment of functional MR and maintains coverage of TEER for the treatment of degenerative MR, through coverage with evidence development (CED) and with mandatory registry participation.  It also makes changes to the criteria for the heart team and hospital, and to the registry questions/criteria and the trial requirements and outcomes.  For more detailed information see Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 20.33.  For services furnished between August 7, 2014 and January 19, 2021, the CMS covered TMVR for MR when furnished under CED when the treatment was furnished for an FDA-approved indication with an FDA-approved device as follows: (1) Treatment of significant, symptomatic, degenerative MR when furnished according to an FDA-approved indication and all CMS coverage criteria are met, and, (2) TMVR for MR uses not expressly listed as FDA -approved indications but only within the context of an FDA-approved, randomized clinical trial that meets all CMS coverage criteria. TMVR was non-covered outside CED or for non-MR indications.   Historical Note: For claims processing instructions from August 7, 2014, through January 19, 2021, please see the following links:   Change request (CR) 9002, Transmittal (TN) 178, issued December 5, 2014, informed Medicare Administrative Contractors to pay for TMVR under CED and revised the NCD manual to add NCD 20.33: https://www.cms.gov/Regulations- and-Guidance/Guidance/Transmittals/Downloads/R178NCD.pdf.   CR 9002, TR 3142, issued December 5, 2014, implemented the initial NCD for TMVR, effective August 7, 2014. TR 3241 rescinded and replaced TN 3142 on April 25, 2014:  https://www.cms.gov/Regulations- and-Guidance/Guidance/Transmittals/Downloads/R3241CP.pdf .