evekhm/cms_iom_500 huggingface dataset:
Draft Article - Billing and Coding: Trigger Point Injections (TPI) (DA59487)
CMS National Coverage PolicyN/AArticle TextRefer to the draft Local Coverage Determination (LCD) Trigger Point Injections (TPI) reasonable 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.*C3999 should only be used for ASC outpatient facility claims.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.
Draft Article - Billing and Coding: Trigger Point Injections (TPI) (DA59487)
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-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 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.)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 (TPI) (A59487)
CMS National Coverage PolicyN/AArticle TextRefer to the Local Coverage Determination (LCD) Trigger Point Injections (TPI) reasonable 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.*C3999 should only be used for ASC outpatient facility claims.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.
Article - Billing and Coding: Trigger Point Injections (TPI) (A59487)
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-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 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.)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: Pain Management - injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels (DA52863)
CMS National Coverage PolicyN/AArticle TextThis article containscoding and other guidelinesthat complement the Local Coverage Determination (LCD) for Pain Management.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.All procedures related to pain management procedures performed by the physician/provider performed on the same day must be billed on the same claim.Acupuncture, a non-covered service, prior to January 21, 2020, is reported with CPT codes 97810  97814. Effective January 21, 2020, Medicare will cover all types of acupuncture including dry needling for chronic low back pain within specific guidelines in accordance with NCD 30.3.3.Injection of separate sites (tendon sheath, ligament or ganglion cyst) during the same encounter as trigger point injections should be reported on a separate line of coding and must have the modifier 59 appended. Multiple surgical rules will apply. Modifier 50 should not be reported with CPT codes 20551 or 20612, but may be reported, when appropriate, with CPT codes 20550 and 20526. For an Ambulatory Surgical Center (ASC), the appropriate site modifier (RT and/or LT) should be appended to indicate if the service was performed unilaterally or bilaterally. Bilateral services must be reported on separate lines using an RT and LT modifier (50 modifier should not be used).Multiple injections per day, at the same site, are considered one injection and should be coded with one unit of service (NOS 001).For claims submitted to the Part B MAC
Draft Article - Billing and Coding: Pain Management - injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels (DA52863)
Multiple injections per day, at the same site, are considered one injection and should be coded with one unit of service (NOS 001).For claims submitted to the Part B MACHCPCS DRUG CODESA claim for services rendered in the off-campus-outpatient hospital (19), inpatient hospital (21), on campus-outpatient hospital (22) or emergency room, hospital (23), ambulatory surgery center (24), skilled nursing facility for patients in a part A stay (31), comprehensive inpatient rehabilitation facility (61), and comprehensive outpatient rehabilitation facility (62) must indicate the name of the drug and dosage in item 19 or the electronic equivalent. The HCPCS drug code and dose is not required when CPT 20612 is reported for aspiration and not for injection or when the ICD-10-CM codes reported are M77.11 or M77.12 and there is no injection.The medication being injected, designated by an appropriate HCPCS drug code must be submitted on the same claim, same day of service as the claim for the procedure. Claims for local anesthetic should not be reported. The exceptions to this guideline are:When services are rendered in places of services 19, 21, 22, 23, 61, and 62 there should be no claim for the HCPCS drug code. In addition, drugs packaged in ASC payments should not be separately reported.
Draft Article - Billing and Coding: Pain Management - injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels (DA52863)
When services are rendered in places of services 19, 21, 22, 23, 61, and 62 there should be no claim for the HCPCS drug code. In addition, drugs packaged in ASC payments should not be separately reported.A claim for services rendered in the office or independent clinic, when the physician does not bill for the injectables, must include the name of the drug and dosage in item 19 or the electronic equivalent.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.A procedure note must be legible and include sufficient detail to allow reconstruction of the procedure. Required elements of the note include a description of the techniques employed, and sites(s) of injections, drugs and doses with volumes and concentrations as well as pre- and post-procedural pain assessments.Forinjections of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels, the medical record must include a procedural note documenting the reason for the injection at any particular site. If multiple sites are injected, documentation to substantiate that all the injections are reasonable and necessary must be present.Utilization Guidelines:Injection Tendon Sheath, Ligament, Ganglion Cyst, Carpal and Tarsal Tunnel:Most conditions that require injections into the tendon sheaths, ligaments or ganglion cysts should be resolved with one to three injections.Frequency and Number of Injections or Interventions:
Draft Article - Billing and Coding: Pain Management - injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels (DA52863)
Most conditions that require injections into the tendon sheaths, ligaments or ganglion cysts should be resolved with one to three injections.Frequency and Number of Injections or Interventions:In the diagnostic phase, a patient may receive injections at intervals of no sooner than one week or preferably, two weeks.The number of injections in the diagnostic phase should be limited to no more than two times.Once a structure is proven to be negative, no repeat interventions should be directed at that structure unless there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and validity that implicate the structure.The effect of injected corticosteroids may remain for several weeks. The benefit is attributed to a decrease of local inflammation and perhaps some local anesthetic effect. It is usually not necessary to repeat an injection if there has been a satisfactory response to the first injection. Patients who relapse after a satisfactory response may be candidates for another trial after an appropriate interval. Consideration should be given to the cumulative dose injected and limitations made to avoid steroid complications.In the therapeutic phase (after the diagnostic phase is completed), the frequency should be two months or longer between each injection, provided that there is initial pain relief with diagnostic injections of greater than or equal to (>/=) 75% - 100% with the ability to perform previously painful maneuvers, and a persistent pain relief of greater than or equal to (>/=) 50% with the continued ability to perform previously painful maneuvers is maintained for at least six weeks. The therapeutic frequency must remain at least two months or longer.In the treatment or therapeutic phase, the injections should be repeated only as medically necessary. No more than four per patient per year are anticipated for the majority of patients.
Draft Article - Billing and Coding: Homocysteine Level, Serum (DA56675)
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 claimCMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code RequirementsArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forHomocysteine Level, Serum DL34419.Limitations:Serum homocysteine levels will not be covered other than for suspected B12/folate deficiency, or for risk stratification for the conditions noted in theICD-10-CM Codes that Support Medical Necessitysection of this article. It is covered only once in a lifetime for the initial determination for risk stratification. Subsequent determinations will be covered only if appropriate treatment does not correct the anemia or symptoms.
Draft Article - Billing and Coding: Genetic Testing for Oncology (DA59125)
CMS National Coverage PolicyInternet-Only Manuals (IOMs):CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 16, Section 10 Background, Section 40.8 Date of Service (DOS) for Clinical Laboratory and Pathology Specimens and Section 120.1 Negotiated Rulemaking ImplementationChapter 18 Preventive and Screening ServicesCMS IOM Publication 100-08,Medicare Program Integrity Manual,Chapter 3 Verifying Potential Errors and Taking Corrective ActionsSocial 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, Subchapter B, Part 410 Supplementary Medical Insurance (SMI) Benefits, Section 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: ConditionsCFR, Title 42, Section 414.502 DefinitionsCFR, Title 42, Subpart G, Section 414.507 Payment for clinical diagnostic laboratory tests and Section 414.510 Laboratory date of service for clinical laboratory and pathology specimensCFR, Title 42, Part 493 Laboratory RequirementsCFR, Title 42, Section 493.1253 Standard: Establishment and verification of performance specificationsCFR, Title 42, Section 1395y(b)(1)(F) Limitation on beneficiary liabilityMedicare National Correct Coding Initiative (NCCI) Policy Manual:Chapter 10, Section F Molecular PathologyChapter 10, Section M Medically Unlikely Edits (MUEs)Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39365 Genetic Testing for Oncology. Please refer to the LCD for reasonable and necessary requirements.
Draft Article - Billing and Coding: Genetic Testing for Oncology (DA59125)
Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L39365 Genetic Testing for Oncology. Please refer to the LCD for reasonable and necessary requirements.All instructions provided within the American Medical Association (AMA) Current Procedural Terminology (CPT) Codebook with rules and guidelines from the AMAs CPT Editorial Panel and the Medicare NCCI Policy Manual should be followed when utilizing CPT codes for billing. Proper coding involves interpreting code descriptions provided by these sources as well as any associated parentheticals. The instructions below do not represent the full breadth or depth of instructions found in the CPT Codebook and the Medicare NCCI Policy Manual. Providers that bill Medicare are expected to follow all instructions found in these sources.Molecular code descriptions in the CPT Codebook generally have some or all of the following components:Medical condition under investigationGenetic content to be testedTechnology/methodology used for testingSpecimen type evaluatedProviders must ensure that their use of molecular CPT codes represent the highest level of specificity in what testing was performed. The following reviews each of these components with general tips for each:1. Medical ConditionWhen a code designates coverage of a specific medical condition (e.g., CPT code 81432 - Hereditary breast cancer- related disorders), all genes billed under this code must fall under the description of the medical condition. Even if all the genes described by a CPT code are tested in a claim, the CPT code can only be used if the described medical condition matches the documented disease.2. Genetic ContentCommonly, molecular CPT codes have a gene(s) listed within their coding description. Special attention must be paid to what elements of a gene are analyzed since not all codes describe the analysis of an entire gene. A gene could be tested for a single well-known variant (e.g., CPT code 81210 - V600 variants in theBRAFgene) or the gene could be fully sequenced (e.g., CPT code 81406  full sequence of theBRAFgene). In fact, several codes in the Tier 1 molecular section cover the same gene but differ in what element of that gene they cover.
Draft Article - Billing and Coding: Genetic Testing for Oncology (DA59125)
For instance, the CPT codes 81201, 81202, and 81203 all describe tests for the same gene,APC, but cover different elements of the gene such as full gene sequence, known familial variants or duplication/deletion variants.As stated in the Medicare NCCI Policy Manual Chapter 10, these codes in general should not be billed together. An exception could be inuncommonscenariossuch as billing a code for full gene sequence with another code for duplication/deletion variants when the disease variants cannot be identified by performing full gene sequencing. Procedures reported together must be both medically reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician who is treating the beneficiary and using the results in the management of the beneficiary's specific medical problem.Less commonly, molecular CPT codes are defined by only a test methodology, as is seen in codes for FluorescenceIn SituHybridization (FISH) found in the Surgical Pathology section of the CPT Codebook. In brief, FISH is a technique where a probe (a short, single-stranded nucleic acid sequence) targets a specific genetic sequence and is labeled/tagged with a fluorescent dye. If the target is found, the fluorescent dye becomes attached to that target and can be seen under microscopy or other related imaging. In oncology, FISH probes are used to evaluate many different genes for many different cancers; however, many FISH CPT codes do not specify which genes or which cancers are being evaluated. As a result, special attention must be paid to what unit of service (UOS) is found in the code description.A UOS for FISH testing could be defined in numerous ways, including number of slides evaluated, number of single source specimens evaluated, number of FISH probes used, number of FISH procedures performed, or number of cells counted. For Medicare, both the CPT Codebook and the Medicare NCCI Policy Manual specify which of these UOS applies, and billing for more UOS than were actually performed is not permitted.The NCCI manual states that regardless of how many blocks or slides are created from a surgical, cytologic, or hematologic specimen, testing multiple blocks or slides from the same specimen source (e.g., tube of blood) still is considered as 1 UOS per source specimen.For example: