evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions (A53134)
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 (A53134)
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 (A53134)
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: Independent Diagnostic Testing Facility (IDTF) (A53252)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 60, Services and Supplies Furnished Incident to a Physician/NPP professional service, Section 80, Requirements for Diagnostic Xray, Diagnostic Laboratory, and Other Diagnostic TestsCMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 1, Section 10.1.1 Payment Jurisdictions Among A/B MACS (B) for Services Paid Under the Physician Fee Schedule and Anesthesia Services, Section 30.2 Assignment of Providers Right to PaymentChapter 35, Independent Diagnostic Testing Facility (IDTF)CMS IOM Publication 100-08,Medicare Program Integrity Manual,Chapter 3, Section 3.2.3.3 Third-Party Additional Documentation RequestChapter 10, Section 10.2.2.4 Independent Diagnostic Testing Facilities (IDTFs)Social 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.Code of Federal Regulations (CFR) References:CFR, Title 42, Chapter IV, Part 410 410.32(a) Ordering diagnostic testsCFR, Title 42, Chapter IV, Part 410 410.33 Independent diagnostic testing facilityArticle Text
Article - Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
Article TextThis Billing and Coding Article provides billing and coding guidance for Independent Diagnostic Testing Facilities (IDTFs). Diagnostic testing performed in an IDTF must follow the supervision and credentialing guidelines set forth in this Local Coverage Article. All enrolling IDTFs must meet the supervising physician qualification/proficiency requirements and technician qualification requirements at the time of their enrollment.Coding GuidanceIDTFs are required to report the exact CPT/HCPCS codes/procedures they intend to perform when enrolling with the CMS-855B form. If an IDTF which is already enrolled wants to perform additional CPT or HCPCS code tests that were not originally specified on its CMS-855B and that are for procedure types and supervision levels similar to its previously allowed codes, the contractor shall have the IDTF amend its CMS-855B to add the additional codes and equipment listing. A new site visit is not required. However, if the enrolled IDTF will be performing CPT or HCPCS codes for different types of procedures, or with different supervision levels, a new site visit is required. Claims submitted with procedure codes not reported on the CMS-855B form and reviewed by the contractor will be denied.Each IDTF will have a specific and unique list of CPT/HCPCS codes for which it can be paid by the contractor, and it is the responsibility of the IDTF to obtain specific contractor approval to bill each CPT/HCPCS code that it intends to bill. Based on equipment and personnel requirements, IDTFs are required to submit a list of all procedure codes performed by the facility to Medicare Provider Enrollment. The codes and equipment should be listed on Attachment 2, Section 1 of Enrollment Application Form CMS-855B.Desk and Site ReviewsAll new IDTF applications shall receive a thorough desk review, and a mandatory site review prior to the contractor's enrollment of the applicant and issuance of a billing number. The general purpose of both reviews is to determine whether the information listed on Attachment 2 of the CMS-855B is correct, verifiable, and in accordance with IDTF regulatory and manual requirements.Site Visits for Mobile Units and Electronic Monitoring ServicesMobile units are required to list their geographic service area. They can be site visited by the following methods:
Article - Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
The mobile unit may visit the office of the site reviewer,ORThe site reviewer can obtain an advance schedule of the locations the IDTF will be visiting and conduct the site visit at one of those locations.
Article - Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
Transtelephonic and electronic monitoring services (e.g., 24-hour ambulatory EKG monitoring; pacemaker monitoring and cardiac event detection) should be classified as IDTFs and must meet all IDTF requirements. These entities require a supervisory physician who performs general supervision. Final enrollment of a transtelephonic or electronic monitoring service, such as an IDTF, requires a site visit.Additional information may be found in CMS Internet-Only Manual (IOM) Publication 100-04,Medicare Claims Processing Manual, Chapter 35, Independent Diagnostic Testing Facility (IDTF).Supervising PhysiciansAn IDTF must have one or more supervising physicians who are responsible for the direct and ongoing oversight of the quality of the testing performed, the proper operation and calibration of the equipment used to perform tests, and the qualifications of non-physician personnel who use the equipment.Not every supervising physician has to be responsible for all these functions. These responsibilities may be divided among the supervising physicians. For example, one supervising physician may be responsible only for the operation and calibration of the equipment, while other supervising physicians responsible for test supervision and/or the qualifications of the non-physician personnel.Additional information may be found in the CMS IOM Publication 100-02, Chapter 15, Section 80 and 42 CFR 410.32(b) and 410.33.Non-Physician PersonnelThe contractor does not establish a credentialing service, but the contractor is authorized to determine which organizations it recognizes. For example, the use of the word national in the organizations name does not, in itself, meet Medicare standards for national credentialing.The supervising physician and non-physician personnel credentialing requirements are listed below in the Credentialing Matrix.Additional information may be found in the CMS IOM Publication100-02, Chapter 15, Sections 80.2, 80.3, and 190 as well as 42 CFR 410.33.Interpreting PhysiciansAn IDTF is not restricted to billing only the technical component of diagnostic services. In certain situations, an IDTF can bill for both the technical component of the diagnostic test and interpretative services. This approach is referred to as billing "globally". The interpretative services must be performed by a licensed practitioner who is allowed to perform the service.
Article - Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
When enrolling or updating information, the IDTF shall list all physicians for whose diagnostic test interpretations it will bill. This includes physicians who are providing purchased interpretations to the IDTF (in accordance with CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual, Chapter 1, Section 30.2), as well as physicians who are reassigning their benefits to the IDTF. The contractor will ensure and document the following:
Article - Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
All physicians listed are enrolled in Medicare.All interpreting physicians who are reassigning their benefits to the IDTF have the right to do so.All required CMS-855R forms have been submitted.The interpreting physicians listed are qualified to interpret the types of tests (codes) listed. In accordance with this CMS requirement (CMS Manual System, Pub. 100-08,Medicare Program Integrity Manual, Chapter 15, Section 15.5.19.3).
Article - Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
Note:The applicant cannot bill globally for interpreting physicians not listed.If an interpreting physician has been recently added or changed, the new interpreting physician must have met all of the interpreting physician requirements at the time any tests were performed.Off-Site InterpretationsIf an IDTF wants to bill for an interpretation performed by an independent practitioner off the premises of the IDTF, it must meet all instructions identified in the CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual, Chapter 1, concerning purchased interpretations. In this scenario, there is no reassignment of benefits because the purchaser of the test is also considered the supplier of the test.When the technical component of a test is performed by the IDTF and the interpreting practitioner is the practitioner who ordered the test, the IDTF cannot bill for the interpretation. The interpreting practitioner must bill the interpretation since the IDTF cannot bill the interpretation when the interpreting physician is the referring physician.Purchased Diagnostic Tests and Jurisdictional PricingServices that are reimbursed under the Medicare Physician Fee Schedule (MPFS) are reimbursed by the payment locality where the service is furnished and by the zip code. Contractors must use the zip code of the location where the service was rendered to determine contractor jurisdiction over the claim and the correct payment locality.When a physician, practitioner, or supplier furnishes services in payment localities that cover more than one contractor's service area (e.g., the provider has separate offices in multiple localities and/or multiple contractors), separate claims must be submitted to the appropriate contractor for processing.Providers may not submit a global billing code on paper or electronic claims when one component of the service has been purchased. Only one service facility location (name, address and zip code) can be indicated in item 32 on the CMS-1500 form. Claims received with global services will be returned as unprocessable.Suppliers (including laboratories, physicians, and IDTFs) must bill their local contractor for all purchased diagnostic tests/interpretations, regardless of the location where the purchased service was rendered.Purchased Technical ComponentsA physician may bill for the technical component of a diagnostic test that he/she purchased from another physician, medical group or supplier. However, in order to purchase a diagnostic test from another physician, medical group, or supplier, the purchaser must perform the interpretation (professional component). Additionally, the physician or supplier that furnished the technical component must be enrolled in the Medicare program.Purchased Interpretations
Article - Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
Purchased InterpretationsA person or entity that provides diagnostic tests may submit the claim and, if assignment is accepted, receive the Part B payment, for diagnostic test interpretations which that person or entity purchases from an independent physician or medical group if:
Article - Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
The tests are initiated by a physician or medical group which is independent of the person or entity providing the tests and of the physician or medical group providing the interpretations;The physician or medical group providing the interpretations does not see the patient;The purchaser (or employee, partner, or owner of the purchaser) performs the technical component of the test. The interpreting physician must be enrolled in the Medicare program. No formal reassignment is necessary; ANDThe purchaser must keep on file the name, the provider identification number and address of the interpreting physician.
Article - Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
Note:This does not remove the requirement that when an entity either purchases an interpretation or a test, they must perform the other component in order to be paid for the purchased component.In order to price claims correctly and apply purchase price limitations, global billing is not acceptable for claims received on the Form CMS-1500 or on the ANSI X12N 837 electronic format. Each component must be billed as a separate line item (or on a separate claim).Suppliers (including laboratories, physicians, and IDTFs) must submit claims for all purchased diagnostic tests/interpretations to their local contractor, regardless of the location where the purchased service was furnished.Additional Services/SuppliesAdditional services/items (e.g., radiopharmaceutical agents, special contrast agents, medications, etc.) related to, or generally considered required for, performing a diagnostic test are also payable to an IDTF if they are commonly separately reimbursed to a physician in a physicians office setting.An IDTF can bill these practitioner services when they are performed by a qualified practitioner in accordance with coverage, payment, and general billing rules, and in accordance with the reassignment of benefit and purchased test rules.These additional services/items which are necessary for the performance of specific diagnostic tests may be billed by an IDTF if approval is granted by the contractor for the IDTF to bill for the specific test(s) that require such items/services. For example, some procedures require an injection of a joint for arthrography and would be allowed if the procedure is integral to the diagnostic test the IDTF is permitted to perform.However, an IDTF is not allowed to bill for surgical procedures that are clearly not related to or required for a diagnostic test.At the time that the IDTF requests contractor approval to perform the tests, the IDTF must identify all such items/services that it intends to bill in conjunction with specific tests.JW and JZ ModifiersWhen billing for Part B drugs and biologicals (except those provided under a competitive acquisition program [CAP]), the use of the JW modifier to identify unused drugs or biologicals from single use vials or single use packages that are appropriately discarded is required. The discarded amount shall be billed on a separate claim line using the JW modifier. Providers are required to document the discarded drug or biological in the patients medical record.
Article - Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
Any amount wasted must be clearly documented in the medical record and should include the date and time, amount of medication wasted, and the reason for the wastage.The use of the JZ modifier (attesting that there were no discarded amounts) is required on claims to report there are no discarded amounts of unused drugs or biologicals from single use vials or single use packages.Claims for drugs separately payable under Medicare Part B from single-dose containers are required to report either the JW or JZ modifier, to identify any discarded amounts or to attest that there are no discarded amounts, respectively.
Article - Billing and Coding: Independent Diagnostic Testing Facility (IDTF) (A53252)
The JW and JZ modifier policy does not apply for drugs that are not separately payable, such as packaged OPPS or ASC drugs, or drugs administered in the FQHC or RHC setting.The JW and JZ modifiers do not apply to drugs assigned status indicator N (Items and Services Packaged into APC Rates) under the OPPS. Similarly, the JW and JZ modifiers do not apply to drugs assigned payment indicator N1 (ASC).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.Medical record documentation maintained by the IDTF must include the information listed below and be available upon request:Written order from the treating physician, andHard copy documentation of the test results and interpretation.The IDTF must maintain documentation to demonstrate the required physician supervision requirements were met. Also, the IDTF must maintain documentation of sufficient physician resources during all hours of operation to assure that the required physician supervision is furnished.Multi-state entities must maintain evidence that supervising physicians are licensed to practice in the state(s) where the diagnostic tests are performed and the technicians performing the diagnostic test(s) are credentialed appropriately in each state in which services are performed in accordance with requirements outlined in this article.Documentation maintained by the IDTF must support that the personnel performing the diagnostic test(s) have the training and proficiency as evidenced by current licensure or certification as outlined in this article. This documentation must contain verification by the supervising physician(s).Physician Supervision of Diagnostic ProceduresSupervision LevelDescription01Procedure must be performed under the general supervision of a physician.02Procedure must be performed under the direct supervision of a physician.03Procedure must be performed under the personal supervision of a physician.04Physician supervision policy does not apply when procedure is furnished by a qualified, independent psychologist or a clinical psychologist. Otherwise the procedure must be performed under the general supervision of a physician.05