evekhm/cms_iom_500 huggingface dataset:
Draft Article - Billing and Coding: Trigger Point Injections (DA59553)
CMS National Coverage PolicyN/AArticle TextRefer to the draft Local Coverage Determination (LCD) DL37913Trigger Point Injectionsreasonable and necessary requirements and frequency limitations.The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to theNCCI requirements.Coding GuidanceProviders should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.This policy applies only to trigger point injections and does not apply to dry needling or acupuncture.Modifier 50- bilateral should not be reported with CPT codes 20552 or 20553.Utilization ParametersNo more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed.CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle.MedicationThe drug used for the injection must be on the same claim as the trigger point administration.The medication used with the injection is reported with a HCPCS Drug code J-code or a revenue code.Unclassified drugs billed with J3490, J3590, J9999 or C9399* must also include name of drug and dosage to Box 19 of the CMS-15000 paper form or electronic equivalent.*C9399 should only be used for ASC, inpatient or outpatient facility claims.Documentation Requirements
Draft Article - Billing and Coding: Trigger Point Injections (DA59553)
All 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.The procedural report should clearly document the indications and medical necessity for the injections, the name and units of the injectant used, the location of the TPIs, along with the pre and post percent (%) pain relief achieved immediately post-injection.The patients medical record should include, but is not limited to:The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visitRelevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Documentation to support the medical necessity of the procedure(s).When documenting the TPI procedure, there must be specific information to indicate the location of trigger points treated, the muscles injected, medication injected, amount of medications used, and the post-procedure plan.Use of BiologicalsThere are currently no FDA approved biologicals for use as trigger point injectable agents. The inclusion of biological and/or other non-FDA approved substances in the injectant may result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180Medicare Benefit Policy Manual (cms.gov). Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.Use of AnesthesiaNo anesthesia codes should be billed in conjunction with 20552 or 20553.
Article - Billing and Coding: Trigger Point Injections (A59553)
CMS National Coverage PolicyN/AArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD.Refer to the draft Local Coverage Determination (LCD) L37913Trigger Point Injectionsreasonable and necessary requirements and frequency limitations.The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to theNCCI requirements.Coding GuidanceProviders should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.This policy applies only to trigger point injections and does not apply to dry needling or acupuncture.Modifier 50- bilateral should not be reported with CPT codes 20552 or 20553.Utilization ParametersNo more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed.CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle.MedicationThe drug used for the injection must be on the same claim as the trigger point administration.The medication used with the injection is reported with a HCPCS Drug code J-code or a revenue code.Unclassified drugs billed with J3490, J3590, J9999 or C9399* must also include name of drug and dosage to Box 19 of the CMS-15000 paper form or electronic equivalent.*C9399 should only be used for ASC, inpatient or outpatient facility claims.Documentation Requirements
Article - Billing and Coding: Trigger Point Injections (A59553)
All 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.The procedural report should clearly document the indications and medical necessity for the injections, the name and units of the injectant used, the location of the TPIs, along with the pre and post percent (%) pain relief achieved immediately post-injection.The patients medical record should include, but is not limited to:The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visitRelevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Documentation to support the medical necessity of the procedure(s).When documenting the TPI procedure, there must be specific information to indicate the location of trigger points treated, the muscles injected, medication injected, amount of medications used, and the post-procedure plan.Use of BiologicalsThere are currently no FDA approved biologicals for use as trigger point injectable agents. The inclusion of biological and/or other non-FDA approved substances in the injectant may result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180Medicare Benefit Policy Manual (cms.gov). Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.Use of AnesthesiaNo anesthesia codes should be billed in conjunction with 20552 or 20553.
Draft Article - Billing and Coding: MolDX: Molecular Testing for Solid Organ Allograft Rejection (DA58207)
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 Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 - A/B MAC (B) Contacts With Independent Clinical LaboratoriesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle Text
Draft Article - Billing and Coding: MolDX: Molecular Testing for Solid Organ Allograft Rejection (DA58207)
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Testing for Solid Organ Allograft Rejection DL38680.INTERPRETATIVE AND EDUCATIONAL INFORMATIONThe below section provides additional interpretative and educational content to help providers and other stakeholders better understand the intent of the existing coverage criteria language of the policy. Reasonable and necessary thresholds for coverage are defined in the policy Coverage Criteria section and are not altered by the article language.Intended use requirementsTests within scope of the policy must comply with the stated requirements of the coverage criteria of the policy. The policy lists intended uses, that when met, can allow for coverage of services within scope of the policy, provided all other listed requirements are also met. Of note, the analysis of the evidence in the policy reflects the underlying value proposition of the test as one that can preclude an unnecessary tissue biopsy. This is therefore reflected in the intended use section of the coverage criteria.The four intended uses that are established in the policy all require that the physician is concerned about at least one of the following: rejection (and would otherwise obtain a biopsy to evaluate the allograft), the adequacy of immunosuppression (and would otherwise obtain a biopsy to evaluate the allograft or is considering doing so), the probability of rejection with concerning clinical information (clinical pre-tests/information that inform whether a subsequent biopsy would likely be avoided), and/or the results of an inconclusive biopsy (wherein the test may subsequently preclude another biopsy).In all scenarios presented the patients must be in consideration for a tissue biopsy or additional biopsy (such that the test prevents this when the biopsy won't likely be of benefit) OR require allograft evaluation because ofa prioriconcern for rejection or rejection risk due to clinical or biological factors (pre-test). No other intended uses are allowed by the policy.This leads to the following conclusions:
Draft Article - Billing and Coding: MolDX: Molecular Testing for Solid Organ Allograft Rejection (DA58207)
This leads to the following conclusions:-If a biopsy is performed, the test and the biopsy cannot be performed simultaneously or within a short window of time such that the test cannot reasonably inform medical management regarding the biopsy. Performance of the test simultaneously with biopsy or within a very narrow window of time from biopsy such that the results would not be available prior to the biopsy being performed would infer that the biopsy is performed regardless of test result and therefore the test has no impact on patient management. This is not consistent with the policy language.-Per policy, one of the intended uses of the molecular test is For further evaluation of allograft status for the probability of allograft rejection after a physician-assessed pretest.A pre-test is defined here as other physiologic/laboratory/clinical evidence consistent with rejection or risk of rejection wherein additional evaluation is subsequently warranted. Therefore, the information that leads to the use of the test must pre-exist the performance of the test. The results of the pre-test must be available to the treating clinician to inform the need for a molecular test or biopsy. Performing the test before such conditions exist, or to establish such a condition cannot be interpreted to be in compliance with the policy.-Although most coverage criteria are relevant tofor causetests, if a patient population exists such that they are at particularly high risk for rejection, and the pre-test clinical information would otherwise indicate a biopsy to evaluate the allograft health based on the risk of that population, the use of these services may fit within the intent of the policy coverage criteria language and analysis rationale.An example of this may be in heart allografts within the first year of transplant that would otherwise get a tissue biopsy due to evaluated pre-test risk. As such, the use of a molecular test for surveillance (protocol) testing can only be reasonably seen as compliant with the policy if the patient would otherwise receive a surveillance (protocol) biopsy. Providers must demonstrate that such a practice (for protocol biopsies) would otherwise be performed to meet policy requirements. Other uses of surveillance testing are not compliant with the policy language and would require policy reconsideration for inclusion.Additional billing information
Draft Article - Billing and Coding: MolDX: Molecular Testing for Solid Organ Allograft Rejection (DA58207)
Additional billing information-For a given patient encounter, only one molecular test for assessing allograft rejection status (within scope of this policy) may be billed. Any additional molecular tests billed after the first will be denied. Of note, services that include multiple components are considered a single service by MolDX and should be registered as such, in alignment with established MolDX practice.-Different Z-Code identifiers must be used for protocol vs for-cause testing. This will allow this contractor to better understand the intended use of the test.To report a service, please submit the following claim information:
Draft Article - Billing and Coding: MolDX: Molecular Testing for Solid Organ Allograft Rejection (DA58207)
Select CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Codeidentifier 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-Codeidentifier 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 codeCovered services can be identified on theDEX registry (dexzcodes.com).
Draft Article - Billing and Coding: Cataract Extraction (DA59556)
CMS National Coverage PolicyItalicizedfont represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording.Title XVIII of the Social Security Act 1862(a)(7) excludes routine physical examinations.Title XVIII of the Social Security Act, 1862 (a)(1)(A) allows coverage and payment for only those services that are 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, 1833(e) prohibits Medicare Payment for any claim which lacks the necessary information to process the claim.Code of Federal Regulations 42 CFR CH.IV [411.15(b)(2)&(3)and(o)(1)&(2)] Services excluded from coverageCode of Federal Regulations 42 CFR CH. IV [416.65] Covered surgical proceduresCMS Manual System, Pub 100-03,Medicare National Coverage Determinations Manual, Chapter 1, Part 1, 80.10, Phaco-Emulsification Procedure-Cataract ExtractionCMS Manual System, Pub 100-04,Medicare Claims Processing ManualChapter 12, 40.6, 40.7, Claims for Multiple Surgeries, Claims for Bilateral SurgeriesArticle Text
Draft Article - Billing and Coding: Cataract Extraction (DA59556)
This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy DL39716 Cataract Extraction.General Guidelines for Claims submitted to Part A or Part B MAC:Procedure 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 GuidelinesAn 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.
Draft Article - Billing and Coding: Cataract Extraction (DA59556)
Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.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.Documentation RequirementsThe following documentation must be present in the medical chart:The patients medical record should include but is not limited to:
Draft Article - Billing and Coding: Cataract Extraction (DA59556)
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 pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)For Cataract Surgery Patients:
Draft Article - Billing and Coding: Cataract Extraction (DA59556)
The patient's chief complaint which conveys the symptoms, such as blurred vision, reduced contrast sensitivity or complaints of glare which are associated with impaired functionality.A unique statement indicating the specific symptomatic (i.e., causing the patient to seek medical attention) impairment of visual function resulting in the patient's inability to function satisfactorily while performing Activities of Daily Life. Such activities typically include, but are not limited to, reading, viewing television, driving, or meeting vocational or recreational expectations. The patients own words should be included in the statement where possible. If desired, completion of a VF-14 or VF-8R visual activities questionnaire (1 for each eye) may be used.A best-corrected Snellen visual acuity at distance (and near if the primary visual impairment is at near) as determined by a careful refraction performed under standard testing conditions as appropriate must be recorded to establish the inability to correct the patient's visual impairment with a tolerable change to glasses or contact lenses. Neither uncorrected visual acuity nor corrected acuity with the patients current prescription will satisfy this requirement. The refraction may be performed by the surgeon or by suitably trained staff in the surgeons practice as permitted by law.A degree of lens opacity that correlates with the impairment of best-corrected visual acuity when cataract is determined to be the most likely primary cause of visual compromise after a full ophthalmic evaluation. This statement shall be supported by documented symptoms and physical findings in the medical record indicating that the patient's impairment of visual function is not believed to be correctable with a tolerable change in glasses or contact lenses.When concomitant ocular disease(s) is/are present that potentially affect visual function (e.g., macular degeneration or diabetic retinopathy), the statement should indicate that cataract is believed to be significantly contributing to the patients visual impairment or a statement indicating the medical condition or circumstance and the specific reason for surgical intervention (e.g., "Cataract surgery is being performed to establish clear media for the treatment [or monitoring] of diabetic retinopathy).
Draft Article - Billing and Coding: Cataract Extraction (DA59556)
A statement that the patient desires surgical correction, and that the risks, benefits, and alternatives have been explained. When the surgery is not being performed to improve vision, there should be a statement that the patient understands that the surgery is being performed to address the specified medical condition or circumstance. For example, "cataract is impairing treatment and monitoring of diabetic retinopathy due to poor visualization of the retina" (or similar explanatory language). If vision is not expected to improve, the statement should include the patient's understanding of that fact.An appropriate preoperative ophthalmologic evaluation, which includes a comprehensive ophthalmologic exam (or its equivalent components occurring over a series of visits). Certain examination components may be appropriately excluded based on the specific condition and/or urgency of surgical intervention.Results and interpretation of specialized ophthalmic studies that are not expected to be routinely performed for routine cataract surgery with clear statements/explanation of the reasons they are needed to establish or exclude medical necessity.