evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Plastic Surgery (A57222)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A). Allows coverage and payment for only those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act, 1833(e). Prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, 1862(a)(10). Coverage of cosmetic surgery is discussed.Medicare On-Line Manual System, Publication 100-02,Medicare Benefit Policy Manual,Chapter 16, 10, 120, and 180.Medicare On-Line Manual System, Publication 100-03,Medicare National Coverage Determinations Manual,Chapter 1, Part 2, 140.2 and 140.4.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Cosmetic surgery is performed to reshape normal structures of the body, for the purpose of improving the patients appearance and self-esteem. Per IOM 100-02 Chapter 16, cosmetic surgery and expenses incurred in connection with such surgery are not covered. This exclusion does not apply to surgery in connection with the treatment of severe burns, facial repair following auto trauma, or similar surgeries for therapeutic purposes or reconstruction.For Reduction Mammoplasty:1. Physicians should document the severity of the symptoms of breast hypertrophy and impact on health related quality of life as measured by an accepted breast specific questionnaire.The beneficiary's medical record must contain the following information and be made available to any authorized Medicare auditor upon request:Height and weightClinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to reduction mammoplasty and the responses to these therapies.The operative report with documentation of the weight of tissue removed fromeach breast, obtained in the operating room.The pathology report of the tissue removed fromeach breast.2. Reasons for denial include:
Article - Billing and Coding: Plastic Surgery (A57222)
2. Reasons for denial include:Surgery is deemed or later determined to be cosmetic in nature. Breast surgery for uncomplicated macromastia, pendulous breasts, or to correct otherwise uncomplicated nipple inversions will be considered cosmetic and not reasonable and necessaryFailure to clearly document persistent signs and symptoms despite a reasonable trial of conservative therapy for a reasonable length of time.Services submitted without a listed diagnosis (ICD-10-CM) code supporting medical necessityUse of any ICD-10-CM codes not listed in the ICD-10-CM Codes That Support Medical Necessity Section below.For all procedures noted within this policy:The medical record must be made available to Medicare or a Medicare auditor upon request.The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.Services billed with a diagnosis code that is not listed in the ICD-10-CM Codes That Support Medical Necessity section of this policy may be considered at redetermination on a case-by-case basis.When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services may be denied as not reasonable and necessary.When requesting a written redetermination, providers must include all relevant documentation with the request. Failure to include such items will likely result in an unfavorable determination. While not required, high quality photographs may be useful in determining medical necessity and may be submitted when the provider feels it is appropriate to do so.
Article - Billing and Coding: Respiratory Care (A57224)
CMS National Coverage PolicyLanguage quoted from the Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, 1861(cc)(1) discusses CORF facility services.Title XVIII of the Social Security Act, 1861(s)(2)(B) provides coverage of services incident to physicians services furnished to hospital patients.Title XVIII of the Social Security Act, 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.42 CFR 485.70-CORF personnel qualifications- lists qualifications for respiratory therapists.Federal Register: December 31, 2002 (Volume 67, Number 251) p 79999-80000 Final rule revisions to payment policies specific to G0237-G0239CMS Manual System, Pub 100-02,Medicare Benefit Policy Manual, Chapter 6, 20.4-20.4.1CMS Manual System, Pub 100-02,Medicare Benefit Policy Manual, Chapter 8, 50.8.2CMS Manual System, Pub 100-02,Medicare Benefit Policy Manual, Chapter 12, 10, 20, 20.1, 20.2, 30, 30.1, and 40.5CMS Manual System, Pub 100-03,Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 240.7 and 240.8
Article - Billing and Coding: Respiratory Care (A57224)
CMS Manual System, Pub 100-03,Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 240.7 and 240.8CMS Manual System, Pub 100-20, One Time Notification, Transmittal 477, dated April 24, 2009, Change Request 6338Title XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1862(a)(7) and 42 Code of Federal Regulations (CFR), 411.15, exclude routine physical examinations.Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.42 CFR 410.32 and 410.33, indicate that diagnostic tests are payable only when ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in such treatment.CMS Manual System, Publication 100-08,Medicare Program Integrity Manual,Chapter 3, 3.2.3.3, Third-party Additional Documentation Request.CMS Manual System, Publication 100-08 ,Medicare Program Integrity Manual,Chapter 15, Enrollment, 15.5.19 - 15.5.19.7 Independent Diagnostic Testing Facilities Standards. See also 42 CFR 410.33.CMS Manual System, Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, 60 and 80, indicate that the technical component of diagnostic tests are not covered as "incident-to" physician healthcare services, but under a distinct coverage category and subject to supervision levels found in the Physician Fee Schedule database. See also 42 CFR 410.32 and 410.33.Ruling of the Administrator 95-1 (HCFA Ruling 95-1), binding on providers, contractors, and Administrative Law Judges, states that by virtue of their licensure and practice, providers are responsible for knowing norms of community practice.CMS Manual System, Publication 100-08,Medicare Program Integrity Manual,Chapter 3, 3.4.1.3., Diagnosis Code Requirement.Article Text
Article - Billing and Coding: Respiratory Care (A57224)
CMS Manual System, Publication 100-08,Medicare Program Integrity Manual,Chapter 3, 3.4.1.3., Diagnosis Code Requirement.Article TextThe following coding and billing guidance is to be used with its associated Local Coverage Determination.There must be a specific written order by the physician or appropriate NPP for all respiratory care (respiratory therapy) services.In order to be considered for reimbursement by Medicare, respiratory therapy services must be fully documented in the medical records. The documentation must clearly indicate that the services rendered were reasonable and medically necessary.Therapeutic procedures (G0237 through G0239) with an individualized physical conditioning and exercise program using proper breathing techniques can be considered for a patient with activity limitations. Please refer to the JE A56152 Local Coverage Article (LCA) Billing and Coding: Pulmonary Rehabilitation Services.Pulmonary Function Testing codes:CPT codes relative to Medicares standards of reasonable and necessary care are: 94070, 94200, 94640, 94726, 94727 and 94729.Spirometry - CPT codes for Spirometry include 94010, 94011, 94012, 94060, 94070, 94150, 94200, 94375, 94726 and 94727. Routine and/or repetitive billing for unnecessary batteries of tests is not clinically reasonable.Lung Volume - CPT codes for lung volume determination are 94013, 94726, 94727 and 94728.Diffusion Capacity - CPT codes for diffusion capacity include 94729.Pulmonary stress testing - CPT codes for pulmonary stress testing include 96417, 96418, 94619 and 96421.CPT 94664 is intended for device demonstration and/or evaluation" and will be usually paid for once per beneficiary for the same provider or group. (Occasional extenuating circumstances, new equipment, etc, may merit two sessions or other repeat training or evaluation. Simple follow-up observation during an E/M exam for pulmonary disease is not a stand-alone procedure, unless the E/M session is not billed).Documentation RequirementsSupportive documentation evidencing the condition and treatment is expected to be documented in the medical record and be available upon request.
Article - Billing and Coding: Respiratory Care (A57224)
Contractors are explicitly authorized to request additional documentation from third parties (e.g. ordering physician) when needed to evaluate the medical necessity of the service and may consider care prior to or subsequent to the service in question.Each claim must be submitted with ICD-10-CM codes that reflect the actual condition of the patient. The mere listing of an ICD-10-CM code alone does not justify the test if the overall context and condition of the patient do not support necessity of the test.All providers of pulmonary function tests should have on file a referral (an order, a prescription) with clinical diagnoses and requested tests. Indications in the primary medical record must be available for review.All equipment and studies should meet minimum standards as outlined by the American Thoracic Society.Spirometry studies, in particular, require 3 attempts to be clinically acceptable.All studies require an interpretation with a written report. Computerized reports must have a physicians signature attesting to review and accuracy.Documentation must be available to Medicare upon request and must be legible. The medical record must document the test results and usage in treatment.American Thoracic Society and the American Lung Association and the American College of Chest Physicians have published guidelines for typical usage of pulmonary function tests which represent typical community norms.Follow up testing which is weekly or monthly is appropriate only when clinically required, such as in periods of acute exacerbation of interstitial lung disease.PFTs are diagnostic, not therapeutic. PFTs are not used to demonstrate breathing exercises.Demonstration/observation of a nebulizer (94664) is usually used once or at rare intervals as a stand-alone procedure code. See Indications and Limitations.
Article - Billing and Coding: Respiratory Care (A57225)
CMS National Coverage PolicyLanguage quoted from the Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, 1861(cc)(1) discusses CORF facility services.Title XVIII of the Social Security Act, 1861(s)(2)(B) provides coverage of services incident to physicians services furnished to hospital patients.Title XVIII of the Social Security Act, 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.42 CFR 485.70-CORF personnel qualifications- lists qualifications for respiratory therapists.Federal Register: December 31, 2002 (Volume 67, Number 251) p 79999-80000 Final rule revisions to payment policies specific to G0237-G0239CMS Manual System, Pub 100-02,Medicare Benefit Policy Manual, Chapter 6, 20.4-20.4.1CMS Manual System, Pub 100-02,Medicare Benefit Policy Manual, Chapter 8, 50.8.2CMS Manual System, Pub 100-02,Medicare Benefit Policy Manual, Chapter 12, 10, 20, 20.1, 20.2, 30, 30.1, and 40.5CMS Manual System, Pub 100-03,Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 240.7 and 240.8
Article - Billing and Coding: Respiratory Care (A57225)
CMS Manual System, Pub 100-03,Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 240.7 and 240.8CMS Manual System, Pub 100-20, One Time Notification, Transmittal 477, dated April 24, 2009, Change Request 6338Title XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act, 1862(a)(7) and 42 Code of Federal Regulations (CFR), 411.15, exclude routine physical examinations.Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.42 CFR 410.32 and 410.33, indicate that diagnostic tests are payable only when ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in such treatment.CMS Manual System, Publication 100-08,Medicare Program Integrity Manual,Chapter 3, 3.2.3.3, Third-party Additional Documentation Request.CMS Manual System, Publication 100-08 ,Medicare Program Integrity Manual,Chapter 15, Enrollment, 15.5.19 - 15.5.19.7 Independent Diagnostic Testing Facilities Standards. See also 42 CFR 410.33.CMS Manual System, Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, 60 and 80, indicate that the technical component of diagnostic tests are not covered as "incident-to" physician healthcare services, but under a distinct coverage category and subject to supervision levels found in the Physician Fee Schedule database. See also 42 CFR 410.32 and 410.33.Ruling of the Administrator 95-1 (HCFA Ruling 95-1), binding on providers, contractors, and Administrative Law Judges, states that by virtue of their licensure and practice, providers are responsible for knowing norms of community practice.CMS Manual System, Publication 100-08,Medicare Program Integrity Manual,Chapter 3, 3.4.1.3., Diagnosis Code Requirement.Article Text
Article - Billing and Coding: Respiratory Care (A57225)
CMS Manual System, Publication 100-08,Medicare Program Integrity Manual,Chapter 3, 3.4.1.3., Diagnosis Code Requirement.Article TextThe following coding and billing guidance is to be used with its associated Local Coverage Determination.There must be a specific written order by the physician or appropriate NPP for all respiratory care (respiratory therapy) services.In order to be considered for reimbursement by Medicare, respiratory therapy services must be fully documented in the medical records. The documentation must clearly indicate that the services rendered were reasonable and medically necessary.Therapeutic procedures (G0237 through G0239) with an individualized physical conditioning and exercise program using proper breathing techniques can be considered for a patient with activity limitations. Please refer to the JF A52770 Local Coverage Article (LCA) Billing and Coding: Pulmonary Rehabilitation Services.Pulmonary Function Testing codes:CPT codes relative to Medicares standards of reasonable and necessary care are: 94070, 94200, 94640, 94726, 94727 and 94729.Spirometry - CPT codes for Spirometry include 94010, 94011, 94012, 94060, 94070, 94150, 94200, 94375, 94726 and 94727. Routine and/or repetitive billing for unnecessary batteries of tests is not clinically reasonable.Lung Volume - CPT codes for lung volume determination are 94013, 94726, 94727 and 94728.Diffusion Capacity - CPT codes for diffusion capacity include 94729.Pulmonary stress testing - CPT codes for pulmonary stress testing include 96417, 96418, 94619 and 96421.CPT 94664 is intended for device demonstration and/or evaluation" and will be usually paid for once per beneficiary for the same provider or group. (Occasional extenuating circumstances, new equipment, etc, may merit two sessions or other repeat training or evaluation. Simple follow-up observation during an E/M exam for pulmonary disease is not a stand-alone procedure, unless the E/M session is not billed).Documentation RequirementsSupportive documentation evidencing the condition and treatment is expected to be documented in the medical record and be available upon request.
Article - Billing and Coding: Respiratory Care (A57225)
Contractors are explicitly authorized to request additional documentation from third parties (e.g. ordering physician) when needed to evaluate the medical necessity of the service and may consider care prior to or subsequent to the service in question.Each claim must be submitted with ICD-10-CM codes that reflect the actual condition of the patient. The mere listing of an ICD-10-CM code alone does not justify the test if the overall context and condition of the patient do not support necessity of the test.All providers of pulmonary function tests should have on file a referral (an order, a prescription) with clinical diagnoses and requested tests. Indications in the primary medical record must be available for review.All equipment and studies should meet minimum standards as outlined by the American Thoracic Society.Spirometry studies, in particular, require 3 attempts to be clinically acceptable.All studies require an interpretation with a written report. Computerized reports must have a physicians signature attesting to review and accuracy.Documentation must be available to Medicare upon request and must be legible. The medical record must document the test results and usage in treatment.American Thoracic Society and the American Lung Association and the American College of Chest Physicians have published guidelines for typical usage of pulmonary function tests which represent typical community norms.Follow up testing which is weekly or monthly is appropriate only when clinically required, such as in periods of acute exacerbation of interstitial lung disease.PFTs are diagnostic, not therapeutic. PFTs are not used to demonstrate breathing exercises.Demonstration/observation of a nebulizer (94664) is usually used once or at rare intervals as a stand-alone procedure code. See Indications and Limitations.
Article - Billing and Coding: MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (A57236)
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, Publication 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, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, 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: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease .To report a Prostate Cancer Genomic Classifier service, please submit the following claim information:Select applicable CPT codeEnter 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 837PItem 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 ICD-10-CM code C61
Article - Billing and Coding: GlycoMark Testing for Glycemic Control (A57237)
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, 60.12 Independent Laboratory Specimen 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 following coding and billing guidance is to be used with its associated Local coverage determination.To receive a GlycoMark test denial, please submit the following claim information:CPTcode 84378 or 84999An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifier
Article - Billing and Coding: GlycoMark Testing for Glycemic Control (A57238)
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, 60.12 Independent Laboratory Specimen 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 GlycoMark Testing for Glycemic Control L36864.To receive a GlycoMark test denial, please submit the following claim information:CPTcode 84378 or 84999An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX modifierTo indicate a statutorily excluded service, append with a GY modifier