evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services (A57520)
Psychotherapy services (CPT codes 90832-90838) are time-based codes. Start and stop times or total times must be documented for CPT codes 90832, 90834, and 90837. For psychotherapy services performed with an E/M service (CPT codes 90833, 90836, and 90838), it is recognized that the psychotherapy time may not be continuous in a combined psychotherapy with an E/M service. However, since psychotherapy is a time-based code, the expectation would be documentation of the start and stop times or total time of the psychotherapy with an E/M service and documentation of the start and stop times or total time devoted to psychotherapy. The total time does not include the E/M time. Also note that when psychotherapy is performed with an E/M by the same physician or NPP, the documentation should show that they are separately identifiable services. Psychotherapy times are for face-to-face services with the patient. The patient must be present for all or some of the service. In reporting, choose the code closest to the actual time (i.e., 16-37 minutes for CPT codes 90832 and 90833, 38-52 minutes for CPT codes 90834 and 90836, and 53 or more minutes for CPT codes 90837 and 90838). Do not report psychotherapy of less than 16 minutes duration.Prolonged services may not be reported when psychotherapy services billed with an E/M service (i.e., add-on CPT codes 90833, 90836, 90838) are reported. For CPT code 90837 (psychotherapy, 60 minutes with patient), a physician or other qualified health care professional can report a prolonged service code if the psychotherapy service, not performed with an E/M service, is 90 minutes or longer involving direct patient contact.The psychoanalysis CPT code 90845 is not time-related, but the service is usually 45 to 50 minutes in duration. The code may be billed once for each daily session regardless of the time involved.The CPT/HCPCS Group 1 codes G0017 and G0018 are for all non-facility places of service (POS) other than Office.Documentation Requirements
Article - Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services (A57520)
The CPT/HCPCS Group 1 codes G0017 and G0018 are for all non-facility places of service (POS) other than Office.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.When the documentation of time is relevant for coding and payment purposes, time may be documented with start and stop times or with total time.
Article - Billing and Coding: MolDX: Immunohistochemistry (IHC) Indications for Breast Pathology (A57523)
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.Article TextBased on recommendations from the College of American Pathologists, the American Society of Clinical Oncologists (ASCO), and the National Comprehensive Cancer Network (NCCN), hormone receptor assays, estrogen receptor (ER), progesterone receptor (PR), and Her-2/neu are the only current biomarkers that demonstrate standardized value in breast cancer pathology evaluation. Although other biomarkers, such as Ki-67, PI3K, and gene expression assays, have been studied, no proven standardized value has been established. Therefore, MolDX will allow ER, PR, and Her2 testing by IHC for patients with primary invasive breast cancers and recurrent or metastatic cancers.To report an IHC service for an ER, PR, Her2, submit the following claim information:CPT CodeSpecimenUOS88342First single/multiplex stain188341Each additional2To report morphometric analysis,select oneof the following codes based on the type of morphometric analysis:CPT CodeService TypeUOS88360Manual388361Computer-assisted3Note: a unit of service applies to a single separately identifiable specimen.
Article - Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) (A57526)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1 Clinical Laboratory ServicesCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 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 TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Diagnostic Tests (MDT) L35160.To report a Molecular Diagnostic Test service, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formNOTE:When entering the DEX Z- Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: MolDX: Molecular Diagnostic Tests (MDT) (A57527)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA) 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1 Clinical Laboratory ServicesCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 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 TextThe information in this article contains billing, coding, or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Diagnostic Tests (MDT) L36256.To report a Molecular Diagnostic Test service, please submit the following claim information:Select appropriate 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 formNOTE:When entering the DEX Z- Codeon the SV101-7 documentation field for Part B claims please do not add additional characters and/or information on the line.
Article - Billing and Coding: Transcranial Magnetic Stimulation (A57528)
CMS National Coverage PolicyLanguage quoted from Centers for Medicare and 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 Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1862(a)(1) (D) prohibits the payment for clinical care items and services for research and experimentation which are not reasonable and necessary.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD)for Transcranial Magnetic Stimulation.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:
Article - Billing and Coding: Transcranial Magnetic Stimulation (A57528)
All documentation must be maintained in the patients medical record and 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 medical record documentation must support the medical necessity of the services as directed in the related LCD.The attending physician must monitor and document the patient's clinical progress during treatment. The attending physician must use evidence-based validated depression monitoring scales such as the Geriatric Depression Scale (GDS), the Personal Health Questionnaire Depression Scale (PHQ-9), the Beck Depression Scale (BDI) Hamilton Rating Scale for Depression (HAM-D), the Montgomery Asberg Depression Rating Scale (MADRS), the Quick Inventory of Depressive Symptomatology (QIDS) or the Inventory for Depressive Symptomatology Systems Review (IDS-SR) to monitor treatment response and the achievement of remission of symptoms.Utilization Guidelines:In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.The treatment must be provided by use of a device approved or cleared by the FDA for the purpose of supplying transcranial magnetic stimulation.It is expected that the services would be performed as indicated by current medical literature and standards of practice. Services performed in excess of established parameters may be subject to review for medical necessity.Retreatment may be considered for patients who met the guidelines for initial treatment and subsequently developed relapse of depressive symptoms if the patient responded to prior treatments as evidenced by a greater than 50% improvement in standard rating scale measurements for depressive symptoms or if there were a relapse after remission [e.g., (GDS), PHQ-9, BDI, HAM-D, MADRS, QIDS or IDS-SR score]. A repeat treatment program is allowed as above.Maintenance therapy is not covered.The TMS treatment planning service (CPT code 90867) may be reported once per treatment episode.
Article - Billing and Coding: Allergy Testing (A57531)
CMS National Coverage PolicyInternet-Only Manuals (IOMs):CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 12, Section 200 Allergy Testing and ImmunotherapySocial 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) L33261 Allergy Testing. 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.Consistent with the related LCD, CPT code 82785 Gammaglobulin [immunoglobulin]; IgE is not appropriate in most general allergy testing. Please refer to the LCD for details on medically reasonable and necessary guidelines.It is not usually necessary to report CPT code 86003 Allergen specific IgE; quantitative or semiquantitative, crude allergen extract (in vitro testing) in addition to skin testing. Please see the related LCD for medically reasonable and necessary guidelines.Documentation Requirements: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 medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.Prior to performance of allergy testing, there must be evidence in the medical record that a history has been obtained, indicating the possible presence of allergy.
Article - Billing and Coding: Allergy Testing (A57531)
This history should support that attempts to narrow the area of investigation were taken so that the minimal number of necessary skin tests might deliver a diagnosis.The history should support that the selection of antigens was based on the patient specific history and physician examination.The medical record must indicate which allergy test(s) were used, the interpretation(s), and measurement (in mm) of reaction size of both wheal and erythema response or a standardized grading system in vivo testing (as applicable).
Article - Billing and Coding: Somatosensory Testing (A57540)
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 Text
Article - Billing and Coding: Somatosensory Testing (A57540)
Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33958 Somatosensory Testing. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceQuantitative Sensory Testing (QST) performed with portable hand-held devices (e.g., current, vibration, thermal perception, or tactile) does not represent somatosensory evoked potential testing and should not be billed using the somatosensory codes (95925, 95926, 95927, or 95938). QST testing is considered part of the evaluation and management service, and therefore, should not be billed separately.When billing for intraoperative somatosensory testing during spinal surgeries, procedure code 95940 (Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance ,each 15 minutes [List separately in addition to code for primary procedure]) or G0453 (Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient (attention directed exclusively to one patient), each 15 minutes list in addition to primary procedure]) should be billed in conjunction with the study performed (95925, 95926, or 95927, or 95938). It would not be acceptable for the performing neurosurgeon to bill for the intraoperative monitoring, as another provider performs this while the surgery is in progress. Intraoperative monitoring performed by a technician is not separately reimbursable. It is not expected that intraoperative testing would be necessary for routine lumbar or cervical root decompression.Multiple services and/or the bilateral procedure modifiers do not apply, as the code descriptors for these services include stimulation of any/all peripheral nerves or skin sites".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.Documentation Requirements
Article - Billing and Coding: Somatosensory Testing (A57540)
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.There should be evidence in the medical record that the test results were noted and influenced or contributed to the patients course of treatment.Documentation that the service was performed must be included in the patients medical record. This documentation should include a hard copy computer generated recording of the test results along with the physicians interpretation. The physicians SEP report should note which nerves were tested, latencies at various testing points, and an evaluation of whether the resulting values are normal or abnormal.If the provider of somatosensory testing is other than the ordering/referring physician/nonphysician practitioner, the provider of the service must maintain a copy of the test results and interpretation, along with copies of the ordering/referring physician/nonphysician practitioners order for the studies.
Article - Billing and Coding: Autonomic Function Testing (A57551)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833 (e). This section states that no payment shall be made to any provider for any claims that lack necessary information to process the claim.Title XVIII of the Social Security Act section 1862 (a)(1)(A). This section allows coverage and payment of those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act section 1862 (a)(7). This section excludes routine physical examinations and services.CMS Manual System, Pub 100-08,Medicare Program Integrity Manual, Chapter 3, Part 3.2.3 Requesting Addition Documentation During Prepayment and Post-payment review.42 CFR Section 410.32(a) indicates diagnostic tests are payable only when the physician who is treating the beneficiary for a specific medical problem uses the results in such treatment.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD.Documentation RequirementsMedical record documentation maintained by the performing provider must clearly support the medical necessity for ANS testing as well as the test reports and interpretation. Supportive documentation showing medically reasonable and necessary indications as outlined in this LCD are expected to be documented in the medical record and be available upon request. This documentation includes, but is not limited to, relevant medical history, physical examination and results of pertinent diagnostic tests or procedures used to rule out more common causes of autonomic signs or symptoms.General professional standards with FDA clearance apply for all equipment used in ANS testing.Utilization GuidelinesDiagnostic testing may be allowed once to confirm or exclude specific autonomic disease. For patients with diagnosed autonomic disorders, repeat testing is governed by a change in clinical status or response to a therapeutic intervention. If a repeat test is needed, it is not expected to exceed once per year.Providers who perform these tests on an unusually high proportion of their patients, or at frequencies exceeding once per year may be subject to medical review.Providers who do not have tilt tables and are using the code range 95921-95924 may be subject to medical review.
Article - Billing and Coding: Coronary Computed Tomography Angiography (CCTA) (A57552)
CMS National Coverage PolicyItalicized font 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 (SSA):Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1862 (a)(7) excludes routine physical examinations.Code of Federal Regulations: 42 CFR Section 410.32  Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostics tests: Conditions. This indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary.CMS Publications:CMS Publication 100-03,National Coverage Determination Manual, Chapter 1- Coverage Determinations Part 4, 220.1 Computed Tomography (CT)CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 13  Radiology Services and Other Diagnostic Procedures, 20 Payment Conditions for Radiology ServicesArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD Coronary Computed Tomography Angiography (CCTA).