evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions (A59049)
This article describes the least restrictive coverage possible. Providers must read the entire applicable NCD and related documents in order to correctly understand and apply the following coding guidance. In some cases, depending on the clinical scenario, the same ICD-10-CM diagnosis code describes a condition that may be covered, covered with evidence development only, both, or non-covered.Dementia is a good example here. While the ICD-10-CM diagnosis codes for various types of dementia appear in this article, an eligible diagnosis is onlyoneof the elements required for coverage. NCD Section 220.6.13 for FDG PET for Dementia and Neurodegenerative Diseases has many other required elements for coverage, and they differ by indication. NCD Section 220.6.13.B.1 discusses all of the requirements for a FDG PET scan to be considered medically reasonable and necessary when used in patients who have recently been diagnosed with dementia (documented cognitive decline of at least 6 months), and who meet diagnostic criteria for both Alzheimer's disease (AD) and Fronto-temporal dementia (FTD). NCD Section 220.6.13.B.2 discusses all of the requirements for a FDG PET scan to be considered medically reasonable and necessary when used in patients with mild cognitive impairment (MCI) or early dementia in the context of a CMS-approved clinical trial. NCD Section 220.6.13.C basically states that all other uses of FDG PET for dementia remain non-covered.Reporting GuidelinesProfessional and Technical ComponentsThe procedure codes listed for PET scans represent the global service. Therefore, providers performing only the technical or professional component of the test should use modifier TC or 26, respectively.Clinical TrialFDG PET scans performed in the context of a CMS-approved practical clinical trial utilizing a specific protocol to demonstrate the utility of FDG PET in the diagnosis and treatment of diseaseshould be reportedwith the Q0 modifier (number "0", not letter "O".)
Article - Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions (A59049)
PET and CTIf a PET scanis obtainedand, on the same date of service, diagnostic CT scan(s) are obtained at a separate session, then both the PET scan and the CT scan(s) may be coded individually. If a PET/CT study is performed concurrently on a hybrid PET/CT scanner and an additional diagnostic CT scan is also obtained non-concurrently, it is appropriate to code the PET/CT scan and the diagnostic CT scan(s) separately (whether the diagnostic CT scans are performed on a hybrid PET/CT scanner or on a dedicated CT scanner).To further clarify,the CT component of a PET/CT scan is for concurrently obtained CT scans for attenuation correction and localization and does not include any additional diagnostic CT studies that may be requested.When a diagnostic CT scanis performedconcurrently with a PET scan, the appropriate PET scan and the appropriate diagnostic CT code may be reported. If a medically necessary diagnostic CTis performednon-concurrently with a PET/CT scan, either on the PET/CT scanner or on an independent CT scanner, the appropriate PET/CT procedure code and the diagnostic CT study(s) code may be reported.CPT code 78609 is a non-covered service.HCPCS code A4641 is not an applicable tracer for PET scans.PET Radiopharmaceutical/Tracer codes A9597 or A9598 should only be used when there is no existing dedicated PET tracer code available (referenceMedicare Claims Processing Manual,Chapter 13, Section 60.3.2). Specifically, there are two circumstances that would warrant the use of A9597 or A9598 as follows: (1) After Food and Drug Administration (FDA) approval of a PET oncologic indication, or (2) after CMS approves coverage of a new PET indication, and ONLY if either of those situations requires the use of a dedicated PET radiopharmaceutical/tracer code that is currently non-existent. An appropriate PET CPT code must be on the claim when any PET radiopharmaceutical/tracer code is reported, along with any appropriate modifiers (e.g., Q0 as applicable).Positron Emission Tomography Reference TableCPTTracer/CodeComment
Article - Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions (A59049)
Positron Emission Tomography Reference TableCPTTracer/CodeComment78608FDG/A9552Covered indications: Alzheimers disease/dementias, only when used to differentiate between Alzheimer's Disease and Fronto-temporal dementia, intractable seizures only when used as part of a pre-surgical evaluation.78609Not ApplicableNationally non-coveredNote:This table is not a comprehensive listing of covered indications. Providers should refer to the applicable NCD sections for detailed information regarding covered indications for PET scans.Other CommentsPET scans are covered only when performed at a PET imaging center with a PET scanner that has been approved or cleared by the FDA. When a claim is submitted, the provider is certifying this and must be able to produce a copy of this approval upon request. An official approval letter need not be submitted with the claim.Documentation RequirementsAll documentation must be maintained in the patient's medical record and 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: MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia (A59051)
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, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical Laboratories.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia.To receive a denial, 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 formSelect the appropriate ICD-10-CM code
Article - Billing and Coding: Influenza Diagnostic Tests (A59055)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claimArticle TextTo avoid the overuse of antibiotics and the potential risk of antibiotic resistance, point of care providers should consider testing patients prior to prescribing treatment for a bacterial or influenza infection. Influenza testing (using molecular methods) is recommended for hospitalized patients with suspected influenza. However, testing is not needed for all outpatients with signs and symptoms consistent with influenza before making antiviral treatment decisions, particularly once influenza activity has been documented in the community. The following summary provides a list of the main available types of diagnostics tests:Rapid Antigen Tests:Availableat the point of careYieldsa Flu A and Flu B result in < 30 minutesLess sensitive (50%-70%) and specific (90%-95%) compared to other methods and may require confirmation byreverse transcription-polymerase chain reaction (RT-PCR) or viral culture.Note:the Food and Drug Administration (FDA) now requires that all Rapid influenza diagnostic tests (RIDTs) achieve 80% or higher sensitivity compared with RT-PCR.Centers for Disease Control and Prevention (CDC) recommendations:Use rapid diagnostic tests with high sensitivity and specificity.Collect respiratory tract specimens as early in the illness as possible (within 3-4 days of illness onset).Follow manufacturers instructions, including handling of respiratory specimens, as described in the device package insert.Consider sending respiratory specimens (from symptomatic patients) for RT-PCR to confirm results of RIDTs, especially in the following situations:When community influenza activity is low and the rapid diagnostic test result is positive.When community influenza activity is high and the rapid diagnostic test result is negative.Contact your local or state health department for information about influenza activity.A patient has had recent close exposure (this does NOT include eating cooked meat) to pigs or birds (including poultry) or other animals, and there is concern for infection with a novel influenza A virus.Targeted Molecular Methods:
Article - Billing and Coding: Influenza Diagnostic Tests (A59055)
A patient has had recent close exposure (this does NOT include eating cooked meat) to pigs or birds (including poultry) or other animals, and there is concern for infection with a novel influenza A virus.Targeted Molecular Methods:UsesRT-PCR or other amplification methods to detect viral nucleic acidsResults available in < 24 hours (often in less than 2-4 hours)Detects from 1-2 to up to 20 respiratory pathogens from 1 specimenA positive result (on testing of an upper respiratory tract specimen) in a person who recently received intranasal administration of live attenuated influenza virus vaccine (LAIV) may indicate detection of vaccine virus.Viral Culture:Confirms present active infectionResults available in 3-10 daysMissesopportunity for Oseltamivir (Tamiflu) treatment for positive patientsImmunofluorescence (IF) - Direct (DFA) or Indirect (IFA) Fluorescent Antibody Staining (antigen detection):Moderatesensitivity and high specificityResults available in approximately 2-4 hoursIf a rapid antigen test is performed and then confirmed using PCR, the second test may require the -59 modifier.If a CLIA-waived test is performed, the -QW modifier should be reported for the waived test.Reference:Centers for Disease Control and Prevention.Information for Clinicians on Rapid Diagnostic Testing for Influenza. Accessed 4/27/21.
Article - Billing and Coding: Influenza Diagnostic Tests (A59056)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claimArticle TextTo avoid the overuse of antibiotics and the potential risk of antibiotic resistance, point of care providers should consider testing patients prior to prescribing treatment for a bacterial or influenza infection. Influenza testing (using molecular methods) is recommended for hospitalized patients with suspected influenza. However, testing is not needed for all outpatients with signs and symptoms consistent with influenza before making antiviral treatment decisions, particularly once influenza activity has been documented in the community. The following summary provides a list of the main available types of diagnostics tests:Rapid Antigen Tests:Availableat the point of careYieldsa Flu A and Flu B result in < 30 minutesLess sensitive (50%-70%) and specific (90%-95%) compared to other methods and may require confirmation byreverse transcription-polymerase chain reaction (RT-PCR) or viral culture.Note:the Food and Drug Administration (FDA) now requires that all Rapid influenza diagnostic tests (RIDTs) achieve 80% or higher sensitivity compared with RT-PCR.Centers for Disease Control and Prevention (CDC) recommendations:Use rapid diagnostic tests with high sensitivity and specificity.Collect respiratory tract specimens as early in the illness as possible (within 3-4 days of illness onset).Follow manufacturers instructions, including handling of respiratory specimens, as described in the device package insert.Consider sending respiratory specimens (from symptomatic patients) for RT-PCR to confirm results of RIDTs, especially in the following situations:When community influenza activity is low and the rapid diagnostic test result is positive.When community influenza activity is high and the rapid diagnostic test result is negative.Contact your local or state health department for information about influenza activity.A patient has had recent close exposure (this does NOT include eating cooked meat) to pigs or birds (including poultry) or other animals, and there is concern for infection with a novel influenza A virus.Targeted Molecular Methods:
Article - Billing and Coding: Influenza Diagnostic Tests (A59056)
A patient has had recent close exposure (this does NOT include eating cooked meat) to pigs or birds (including poultry) or other animals, and there is concern for infection with a novel influenza A virus.Targeted Molecular Methods:UsesRT-PCR or other amplification methods to detect viral nucleic acidsResults available in < 24 hours (often in less than 2-4 hours)Detects from 1-2 to up to 20 respiratory pathogens from 1 specimenA positive result (on testing of an upper respiratory tract specimen) in a person who recently received intranasal administration of live attenuated influenza virus vaccine (LAIV) may indicate detection of vaccine virus.Viral Culture:Confirms present active infectionResults available in 3-10 daysMissesopportunity for Oseltamivir (Tamiflu) treatment for positive patientsImmunofluorescence (IF) - Direct (DFA) or Indirect (IFA) Fluorescent Antibody Staining (antigen detection):Moderatesensitivity and high specificityResults available in approximately 2-4 hoursIf a rapid antigen test is performed and then confirmed using PCR, the second test may require the -59 modifier.If a CLIA-waived test is performed, the -QW modifier should be reported for the waived test.Reference:Centers for Disease Control and Prevention.Information for Clinicians on Rapid Diagnostic Testing for Influenza. Accessed 4/27/21.
Article - Sterilization (A59060)
CMS National Coverage PolicyN/AArticle TextSterilization means any medical procedure, treatment or operation for the sole purpose of rendering an individual permanently incapable of reproducing and not related to the repair of a damaged/dysfunctional body part.Under the Medicare Program guidelines the coverage of sterilization is limited to necessary treatment of an illness or injury. An example of necessary treatment is the removal of a uterus or removal of diseased ovaries (bilateral oophorectomy) because of a tumor, or bilateral orchiectomy in the case of prostate cancer.Elective hysterectomy, tubal ligation and vasectomy in the absence of a disease for which sterilization is considered an effective treatment is not covered. In addition, no payment would be made for sterilization procedures if it is a preventive measure e.g., a physician believes pregnancy would cause overall endangerment to a woman's health, or as a measure to prevent the possible development of, or effect on a mental condition, should pregnancy occur. (Section 1862(a)(1)(A) of the Social Security Act and 42 CFR 411.15(k).Claims will be denied on postpay review and payment recouped if the pathological evidence of the necessity to perform any of these procedures to treat an illness or injury is absent and/or when the primary objective is to achieve sterilization.
Article - Billing and Coding: Prostate Cancer Detection with IsoPSA™ (A59066)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Prostate Cancer Detection with IsoPSA™ (A59066)
This article gives guidance for billing, coding and other guidelines in relation to local coverage policyIsoPSATM.General Guidelines for Claims submitted to Part A or Part B MACProcedure 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.Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines:An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions. Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.
Article - Billing and Coding: Prostate Cancer Detection with IsoPSA™ (A59066)
The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary, and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.
Article - Billing and Coding: Prostate Cancer Detection with IsoPSA™ (A59066)
Coding Instructions:To bill for IsoPSA use CPT 0359U.Note: As this test is not a molecular pathology test that would fall under the MolDx program labs are not required to submit a technical assessment for this test and a DEX Z-code is not required on the claim.Documentation Requirements:The patients medical record should include but is not limited to:The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of PSA testingSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Risk factors for prostate biopsy
Article - Billing and Coding: eVox&reg; System and Other Electroencephalograph Testing for Memory Loss (A59086)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TexteVox, BrainView NeuralScan and VoxNeuro are Class II medical devices cleared by theU.S. Food & Drug Administration (FDA)that acquire, display, and store the electrical activity of a patients brain, including electroencephalograph (EEG) and event-related potentials (ERPs), by placing two or more electrodes on the head. These devices map areas of the brain and measure brain activity. Using analytical software the test findings are placed into interpretable results assisting the physician in making a diagnosis and decision about a patients brain function.First Coast has seen the eVoxSystem billed to Medicare using the following Current Procedural Terminology (CPT) codes 92650, 92653, 95816, 95930, 95957 and 96146.Coding GuidanceCPT codes 92650, 92653, 95816, 95930, 95957 and 96146 represent separate services for digital analysis of EEG, EEG recording, and visual and auditory evoked potential testing. The eVoxSystem and similar tests describe a panel of tests that should be billed using the unlisted neurological or neuromuscular diagnostic procedure code. The panel of tests does not accurately reflect the testing, the work units nor the inherent training described by the CPT codes listed above. Therefore, it is incorrect coding to bill the individual CPT codes listed above when performing the eVoxSystem or other electroencephalograph testing for memory loss.When billing for eVoxSystem, BrainView NeuralScan, VoxNeuro or similar systems CPT code 95999 should be reported on the claim with one unit of service. The term for the device (e.g., eVoxSystem,BrainView Neural Scan System, VoxNeuro, etc.) should be reported in the Remarks area of the claim for Part A and the Narrative area of the claim for Part B.Documentation Requirements
Article - Billing and Coding: eVox&reg; System and Other Electroencephalograph Testing for Memory Loss (A59086)
Documentation RequirementsAll documentation must be maintained in the patient's medical record and 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.