evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA) (A56737)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) forCardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA).Coding Information: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.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the attached LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed.The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, the reason for the tests, an interpretive report and copies of images. The computerized image reconstruction data should also be maintained.Documentation must be available to Medicare upon request.
Article - Billing and Coding: Cardiovascular Nuclear Medicine (A56743)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Cardiovascular Nuclear Medicine (A56743)
This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Cardiovascular Nuclear Medicine.Coding Information: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.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.Medical records must substantiate the medical necessity of the services, including a clinical diagnosis and the specific reason for the study.All segments of the service must have a formal interpretation and report.The referral order must include the medical indication for the study, and be kept on file in the patient's medical record.When CPT code 78472 and add-on code 78496 are submitted with perfusion codes 78451-78454, the formal reports must document that simultaneous cardiac function studies using the first pass technique were performed and that the laboratories are equipped to perform such studies.When a blood pool scan is performed to assess ejection fraction prior to implantation of defibrillator or biventricular pacemaker, the record must document the intended plan for insertion and the result of the test.When billing for the purchase of radiopharmaceutical(s), a copy of the bill indicating the dosage administered, unit price per dose, name and total charge of the radiopharmaceutical must be on file in the patient's medical record and available on request.Utilization Guidelines:
Article - Billing and Coding: Cardiovascular Nuclear Medicine (A56743)
Utilization Guidelines:Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the past two years would be reimbursable; otherwise tests repeated in the absence of changes in cardiac signs or symptoms will be considered not medically necessary.
Article - Billing and Coding: Intensity Modulated Radiation Therapy (IMRT) (A56746)
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 TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L36773 Intensity Modulated Radiation Therapy (IMRT). Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice: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.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 provider must indicate the medical necessity for IMRT as outlined in the LCD L36773 and must include all of the following for IMRT planning and delivery:
Article - Billing and Coding: Intensity Modulated Radiation Therapy (IMRT) (A56746)
The treatment plan/prescription must define the goals and requirements of the treatment, including the specific dose constraints for the target(s) and nearby critical structures.A statement by the treating physician documenting the special need for performing IMRT on the patient in question, rather than performing conventional or three-dimensional treatment planning and delivery. The physician must address the other organs at risk or adjacent critical structures.Review (signed and dated) by the radiation oncologist of the CT or MRI based images of the target and all critical structures with representative isodose distributions that characterize the three-dimensional dose.Radiation oncologist review of dose-volume histograms for all targets and critical structures.Description of the number and location of each treatment step/rotation or portal to accomplish the treatment plan.Documentation of dosimetric verification of treatment setup and delivery, signed by both the radiation oncologist and the medical physicist.For compensator-based IMRT, the unique compensator design should be documented for each step or portal.Documentation of fluence distributions recomputed in a phantom, or an equivalent methodology consistent with patient specific IMRT treatment verification.Target verification methodology documentation to include documentation of the clinical treatment volume (CTV) and the planning target volume (PTV); documentation of immobilization and patient positioning, and means of dose verification and secondary means of verification.Other procedures performed during the episode of care must have documentation that supports the professional and technical components as applicable by identifying the place of service, the date of service, the supervising physician, and proof of work provided.
Article - Billing and Coding: Magnetic Resonance Angiography (MRA) (A56747)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Magnetic Resonance Angiography (MRA) (A56747)
This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) forMagnetic Resonance Angiography (MRA).National Coverage Provisions:Magnetic Resonance Angiography (MRA) is a non-invasive diagnostic test that is an application of MRI. By analyzing the amount of energy released from tissues exposed to a strong magnetic field, MRA provides images of normal and diseased blood vessels as well as visualization and quantification of blood flow through these vessels.(CMS Publication 100-03,Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 220.2A.1).Contrast-enhanced MRA (CE-MRA) involves blood flow imaging after the patient receives an intravenous injection of a contrast agent. Gadolinium, a non-ionic element, is the foundation of all contrast agents currently in use. Gadolinium affects the way in which tissues respond to magnetization, resulting in better visualization of structures when compared to un-enhanced studies. Unlike ionic (i.e. iodine-based) contrast agents used in conventional contrast angiography (CA), allergic reactions to gadolinium are extremely rare. Additionally, gadolinium does not cause the kidney failure occasionally seen with ionic contrast agents. Digital subtraction angiography (DSA) is a computer-augmented form of CA that obtains digital blood flow images as contrast agent courses through a blood vessel. The computer subtracts bone and other tissue from the image, thereby improving visualization of blood vessels. Physicians elect to use a specific MRA or CA technique based upon clinical information from each patient(CMS Publication 100-03,Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 220.2A.1).(Please note that since the publication by CMS of the preceding narrative, it has been noted that gadolinium-based contrast agents may also be nephrotoxic, especially in patients with pre-existing renal disease.)The related local coverage determination and this article are a restatement of the National Coverage Determination for MRI and MRA documented in CMS Publication 100-03,Medicare National Coverage Determinations Manual,Part 4: 220.2.A.2 Magnetic Resonance Imaging (MRI). Restrictions noted in Medicare National Coverage Determinations are binding on all Medicare contractors and providers.MRA (MRI for Blood flow)
Article - Billing and Coding: Magnetic Resonance Angiography (MRA) (A56747)
MRA (MRI for Blood flow)Currently covered indications include using MRA for specific conditions to evaluate flow in internal carotid vessels of the head and neck, peripheral arteries of lower extremities, abdomen and pelvis, and the chest. Coverage is limited to MRA units that have received FDA premarket approval, and such units must be operated within the parameters specified by the approval. In addition, the services must be reasonable and necessary for the diagnosis or treatment of the specific patient involved.(CMS Publication 100-03,Medicare National Coverage Determinations Manual,Chapter 1, Part 4, Section 220.2.B.2).
Article - Billing and Coding: Magnetic Resonance Angiography (MRA) (A56747)
Effective April 15, 2003, studies have proven that MRA is effective for evaluating flow in internal carotid vessels of the head and neck. However, not all potential applications of MRA have been shown to be reasonable and necessary.Peripheral Arteries of Lower ExtremitiesEffective April 15, 2003, studies have proven that MRA of peripheral arteries is useful in determining the presence and extent of peripheral vascular disease in lower extremities. This procedure is non-invasive and has been shown to find occult vessels in some patients for which those vessels were not apparent when CA was performed.Medicare will cover either MRA or CA to evaluate peripheral arteries of the lower extremities. However, both MRA and CA may be useful in some cases.Pre-operative Evaluation of Patients Undergoing Elective Abdominal Aortic Aneurysm (AAA) Repair
Article - Billing and Coding: Magnetic Resonance Angiography (MRA) (A56747)
Effective July 1, 1999, MRA is covered for pre-operative evaluation of patients undergoing elective AAA repair if the scientific evidence reveals MRA is considered comparable to CA in determining the extent of AAA, as well as in evaluating aortoiliac occlusion disease and renal artery pathology that may be necessary in the surgical planning of AAA repair. These studies also reveal that MRA could provide a net benefit to the patient. If preoperative CA is avoided, then patients are not exposed to the risks associated with invasive procedures, contrast media, end-organ damage, or arterial injury.ii. Imaging the Renal Arteries and the Aortoiliac Arteries in the Absence of AAA or Aortic DissectionEffective July 1, 2003, MRA coverage is expanded to include imaging the renal arteries and the aortoiliac arteries in the absence of AAA or aortic dissection. MRA should be obtained in those circumstances in which using MRA is expected to avoid obtaining CA, when physician history, physical examination, and standard assessment tools provide insufficient information for patient management, and obtaining an MRA has a high probability of positively affecting patient management. However, CA may be ordered after obtaining the results of an MRA in those rare instances where medical necessity is demonstrated.(CMS Publication 100-03,Medicare National Coverage Determinations Manual,Chapter 1, Part 4, Section 220.2.B.2.c).Chesti. Diagnosis of Pulmonary EmbolismCurrent scientific data has shown that diagnostic pulmonary MRAs are improving due to recent developments such as faster imaging capabilities and gadolinium-enhancement. However, these advances in MRA are not significant enough to warrant replacement of pulmonary angiography in the diagnosis of pulmonary embolism for patients who have no contraindication to receiving intravenous iodinated contrast material. Patients who are allergic to iodinated contrast material face a high risk of developing complications if they undergo pulmonary angiography or computed tomography angiography. Therefore, Medicare will cover MRA of the chest for diagnosing a suspected pulmonary embolism when it is contraindicated for the patient to receive intravascular iodinated contrast material.ii. Evaluation of Thoracic Aortic Dissection and Aneurysm
Article - Billing and Coding: Magnetic Resonance Angiography (MRA) (A56747)
ii. Evaluation of Thoracic Aortic Dissection and AneurysmStudies have shown that MRA of the chest has a high level of diagnostic accuracy for pre-operative and post-operative evaluation of aortic dissection of aneurysm. Depending on the clinical presentation, MRA may be used as an alternative to other non-invasive imaging technologies, such as transesophageal echocardiography and CT. Generally, Medicare will provide coverage only for MRA or for CA when used as a diagnostic test. However, if both MRA and CA of the chest are used, the physician must demonstrate the medical need for performing these tests.While the intent of thispolicy is to provide reimbursement for either MRA or CA, CMS is also allowing flexibility for physicians to make appropriate decisions concerning the use of these tests based on the needs of individual patients. CMS anticipates, however, low utilization of the combined use of MRA and CA. As a result, CMS encourages contractors to monitor the use of these tests and, where indicated, requires evidence of the need to perform both MRA and CA.(CMS Publication 100-03,Medicare National Coverage Determinations Manual,Chapter 1, Part 4, Section 220.2.B.2.d).All other uses of MRA are nationally non-covered unless coverage is specifically indicated.Coding Information:
Article - Billing and Coding: Magnetic Resonance Angiography (MRA) (A56747)
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.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Article - Billing and Coding: White Cell Colony Stimulating Factors (A56748)
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.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forWhite Cell Colony Stimulating Factors L37176.
Article - Billing and Coding: Intravesical Instillation of Bacillus Calmette-Guérin (BCG) (A56754)
CMS National Coverage PolicyN/AArticle TextDue to the current shortage of Bacillus Calmette-Gurin (BCG) for intravesical instillation it may be necessary to maintain ongoing treatment for bladder cancer with this product at less than the Food and Drug Administration (FDA) label dose of 81 mg (1 vial) per instillation. In response to this situation, Centers for Medicare and Medicaid Services (CMS) has created a new HCPCS code by which to report BCG which will allow for reporting of doses less than 1 vial per instillation. HCPCS code J9030BCG live intravesical instillation, 1 mgbecomes effective 7/1/2019 and replaces HCPCS code J9031BCG intravesical per instillation. HCPCS code J9031BCG intravesical per instillationwill no longer be payable by Medicare as of 7/1/2019. HCPCS code J9030 should be reported with the number of units corresponding to the units being equal to the number of milligrams actually instilled per treatment, as the unit equals 1 mg for the new code.For updates on the current shortage of BCG live intravesical:https://www.ashp.org/Drug-Shortages/Current-Shortages
Article - Billing and Coding: Home Health - Psychiatric Care (A56756)
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, Pub. 100-04, Medicare Claims Processing Manual, Chapter 10, 40.2 HH PPS ClaimsCMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, 6.2.4 Coding and 6.2.7 Medical Review of Home Health Demand BillsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Home Health - Psychiatric Care L34561.Diagnostic CriteriaA Patient must have a diagnosis as defined in the Diagnostic and Statistical Manual of Mental Health Disorders, 5th Edition, DSM-5. This diagnosis must match the diagnosis that the ordering physician is treating and/or for which the patient was hospitalized. This diagnosis must be fully documented and available in the medical record.The DSM-5 has combined Axis III with Axes I and II. Clinicians should continue to list medical conditions that are important to the understanding or management of an individual's mental disorder as opposed to personality disorders, mental retardation, general medical conditions, psychosocial and environmental problems and global assessment of functioning.Billing When Separate Visits Were Made for Medical and Psychiatric Nursing CarePsychiatric nursing care is not separately billable from non-psychiatric nursing care. Both of these services constitute skilled nursing care and may be furnished by the psychiatric nurse, in the course of a single visit. Therefore, visits will not be covered for 1 nurse to provide psychiatric nursing care and another to provide non-psychiatric nursing care, unless the non-psychiatric nursing care is of such a highly specialized and technical nature, that the service could not be safely rendered by the psychiatric nurse (e.g., infusion therapy).
Article - Billing and Coding: Non-Invasive Vascular Studies (A56758)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Non-Invasive Vascular Studies.National Coverage Provisions:42 CFR Section 410.33, Independent Diagnostic Testing Facilities:The supervising physician must evidence proficiency in the performance and interpretation of each type of diagnostic procedure performed by the IDTF. The proficiency may be documented by certification in specific medical specialties or subspecialties or by criteria established by the carrier for the service area in which the IDTF is located. See 42 CFR Section 410-33 (2) (b).Nonphysician personnel. Any nonphysician personnel used by the IDTF to perform tests must demonstrate the basic qualifications to perform the tests in question and have training and proficiency as evidenced by licensure or certification by the appropriate State health or education department. In the absence of a State licensing board, the technician must be certified by an appropriate national credentialing body. The IDTF must maintain documentation available for review that these requirements are met. See 42 CFR Section 410-33 (2)(c).