evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   The Common Working File (CWF) maintains the number of counseling sessions rendered to a beneficiary.  By entering the beneficiarys Medicare beneficiary identifier, providers have the capability to view the number of sessions a beneficiary has received for  this service via inquiry through CWF.   12.8 - Provider Access to Smoking and Tobacco-Use Cessation Counseling Services Eligibility Data  (Rev.3848, Issued: 08-  25-17, Effective: 09 -26-17, Implementation: 09-  26-17)  Providers may access coverage period remaining counseling sessions and a next eligible date, when there are no remaining sessions, through the 270/271 eligibility inquiry and response transaction.   20  Billing Requirements for Coverage of Kidney Disease Patient Education Services  (Rev. 1876; Issued:  12- 18-09; Effective Date:  01 -01-10; Implementation Date:  04- 05-10)  Effective for claims with dates of service on and after January 1, 2010, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) determines that kidney disease patient education services are covered when provided to patients with stage IV chronic kidney disease (CKD).  See Pub. 100- 02, chapter 15, section 310, for complete coverage guidelines.   Contractors shall pay for kidney disease education (KDE) services  that meet the following conditions:    No more than 6 sessions of KDE services are provided in a lifetime,   Is provided in increments of 1 hour.  In order to bill for a session, a session must be at least 31 minutes in duration.  A session that lasts at least 31 minutes, but less than 1 hour still constitutes 1 session.   Is provided either individually or in a group setting of 2 to 20 individuals who need not all be Medicare beneficiaries.    Furnished, upon the referral of the physician managing the beneficiarys kidney condition, by a qualified person meaning a:
(Medicare Claims Processing Manual)
 Furnished, upon the referral of the physician managing the beneficiarys kidney condition, by a qualified person meaning a:   o physician, physicians assistant, nurse practitioner, or clinical nurse specialist;   o hospital, critical access hospital (CAH), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF), home health agency (HHA), or hospice, that is located in a rural area, or   o hospital or CAH that is paid as if it were located in a rural area (hospital or CAH reclassified as rural under section 42 CFR 412.103).  NOTE:   A renal dialysis facility (Type of Bill (TOB) 72x) is precluded from providing KDE services.   20.1  Additional Billing Requirements Applicable to Claims Submitted to Fiscal Intermediaries (FIs)  (Rev. 1876; Issued:  12- 18-09; Effective Date:  01 -01-10; Implementation Date:  04- 05-10)  The FI will reimburse for KDE services when services are rendered in a rural area and submitted on the following TOBs: 12X, 13X, 22X, 23X, 34X, 75X, 81X, 82X, and 85X.   NOTE:   FIs shall use the actual geographic location, core based statistical area (CBSA) to identify facilities located in rural areas.  In addition, KDE services are covered when claims containing the above mentioned TOBs are received from section 401 hospitals .  Revenue code 0942 should be reported when billing for KDE services in the following: SNFs, HHAs, CORFs, hospices, and CAHs.  Hospital outpatient departments bill for this service under any valid/appropriate revenue code. They are not required to report revenue code 0942.  Hospices report this service on a separate claim from any hospice services. Hospice claims billed for revenue code 0942 that contain any other services will be returned to the provider. In addition, hospices report value code 61 or G8 when billing for KDE services.   NOTE:   KDE services are not covered when services are submitted on TOB 72X.
(Medicare Claims Processing Manual)
NOTE:   KDE services are not covered when services are submitted on TOB 72X.  20.2 - Healthcare Common Procedure Coding System (HCPCS) Procedure Codes and Applicable Diagnosis Codes  (Rev.  2998, Issued: 07- 25-14, Effective: Upon implementation of ICD -10; 01- 01-12 - ASC X12, Implementation: 08- 25-2014 -  ASC X12; Upon Implementation of ICD -10)  Effective for services performed on and after January 1, 2010, the following new HCPCS codes have been created for KDE services when provided to patients with stage IV CKD.    G0420:  Face -to-face educational services related to the care of chronic kidney disease; individual, per session, per one hour    G0421:   Face -to-face educational services related to the care of chronic kidney disease; group, per session, per one hour   When billing for KDE services the applicable ICD diagnosis code shall be used:    If ICD -9-CM is applicable, ICD -9-CM -  585.4 (chronic kidney disease, Stage IV (severe)), or    If ICD -9-CM is applicable, ICD -10-CM  N18.4 (Chronic Kidney Disease, stage 4.  NOTE :  Claims with HCPCS codes G0420 or G0421 and ICD -9 code 585.4, if applicable, or, if ICD -10 is applicable, ICD -10 code N18.4 that are billed for KDE services are not allowed on a professional and institutional claim on the same service date.   20.3 - Medicare Summary Notices (MSNs) and Claim Adjustment Reason Codes (CARCs)  (Rev.  2998, Issued: 07- 25-14, Effective: Upon implementation of ICD -10; 01- 01-12 - ASC X12, Implementation: 08- 25-2014 -  ASC X12; Upon Implementation of ICD -10)  The following messages are used by Medicare contractors when denying non- covered services associated with KDE services  when provided to patients with stage IV CKD:   When denying claims for KDE services billed without diagnosis code 585.4 contractors shall use:   MSN 16.10 -  Medicare does not pay for this item or service.
(Medicare Claims Processing Manual)
When denying claims for KDE services billed without diagnosis code 585.4 contractors shall use:   MSN 16.10 -  Medicare does not pay for this item or service.    CARC 167 -  This (these) diagnosis(es) is (are) not covered.  NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   When denying claims for KDE services when submitted for more than 6 sessions contractors shall use:    MSN 15.22 -  The information provided does not support the need for this many services or items in this period of time so Medicare will not pay for this item or service.    CARC 119 -  Benefit maximum for this time period or occurrence has been reached.   When denying claims for KDE services when two claims are billed (professional and institutional) on the same service date, contractors shall use:   MSN 15.5  The information provided does not support the need for similar services by more than one doctor during the same time period.   CARC 18  Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO).   A/B MACs (A) shall deny KDE services when rendered in an urban area unless:    The provider is a hospital on the section 401 list or    The claim is submitted on TOB 85X.  A/B MACs (A) shall deny payment for KDE services when submitted on TOB 72X. Use the following messages:    MSN 21.6  This item or service is not covered when performed, referred or ordered by this provider.   CARC 170  Payment is denied when performed/billed by this type of provider in this type of facility. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   20.4 - Advance Beneficiary Notice (ABN) Information  (Rev. 1876; Issued:  12- 18-09; Effective Date:  01 -01-10; Implementation Date:  04- 05-10)  If a signed ABN was provided, contractors shall use Group Code PR (Patient Responsibility) and the liability falls to the beneficiary.   If an ABN was not provided, contractors shall use Group Code CO (Contractual Obligation) and the liability falls to the provider.
(Medicare Claims Processing Manual)
If an ABN was not provided, contractors shall use Group Code CO (Contractual Obligation) and the liability falls to the provider.   30 - Hyperbaric Oxygen (HBO) Therapy  (Rev. 187, 05- 28-04)  30.1 - Billing Requirements for HBO Therapy for the Treatment of Diabetic Wounds of the Lower Extremities  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Hyperbaric Oxygen Therapy is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. Effective April 1, 2003, a National Coverage Decision expanded the use of HBO therapy to include coverage for the treatment of diabetic wounds of the lower extremities. For specific coverage criteria for HBO The rapy, refer to the National Coverage Determinations Manual, Chapter 1, section 20.29.  NOTE: Topical application of oxygen does not meet the definition of HBO therapy as stated above. Also, its clinical efficacy has not been established. Therefore, no Medicare reimbursement may be made for the topical application of oxygen.    Billing Requirements for A/B MACs  (A)  Claims for HBO therapy should be submitted using the ASC X12 837 institutional claim format or, in rare cases, on Form CMS -1450.  a. Applicable Bill Types   The applicable hospital bill types are 11X, 13X and 85X.  b. Procedural Coding    99183  Physician attendance and supervision of hyperbaric oxygen therapy, per  session.    G0277  Hyperbaric oxygen under pressure, full body chamber, per 30 -minute  interval.   NOTE: Code G0277 is not available for use other than in a hospital outpatient department. In skilled nursing facilities (SNFs), HBO therapy is part of the SNF PPS payment for beneficiaries in covered Part A stays.   For hospital inpatients and critical access hospitals (CAHs) not electing Method I, HBO therapy is reported under revenue code 940 without any HCPCS code. For inpatient services, if ICD -10 is applicable, show ICD -10-PCS code 5A05121.  For CAHs electing Method I, HBO therapy is reported under revenue code 940 along with HCPCS code 99183.  c. Payment Requirements for A/B MACs  (A)
(Medicare Claims Processing Manual)
For CAHs electing Method I, HBO therapy is reported under revenue code 940 along with HCPCS code 99183.  c. Payment Requirements for A/B MACs  (A)  Payment is as follows:  A/B MAC (A) payment is allowed for HBO therapy for diabetic wounds of the lower extremities when performed as a physician service in a hospital outpatient setting and for inpatients. Payment is allowed for claims with valid diagnosis codes as shown above w ith dates of service on or after April 1, 2003. Those claims with invalid codes should be denied as not medically necessary.   For hospitals, payment will be based upon the Ambulatory Payment Classification (APC) or the inpatient Diagnosis Related Group (DRG). Deductible and coinsurance apply.   Payment to Critical Access Hospitals (electing Method I) is made under cost reimbursement. For Critical Access Hospitals electing Method II, the technical component is paid under cost reimbursement and the professional component is paid under the Physician Fee Schedule.   II. A/B MAC (B) Billing  Requirements   Claims for this service should be submitted using the ASC X12 837 professional claim format or Form CMS -1500.  The following HCPCS code applies:    99183  Physician attendance and supervision of hyperbaric oxygen therapy, per session.    G0277  Hyperbaric oxygen under pressure, full body chamber, per 30-minute  interval.    a. Payment Requirements for A/B MACs (B)   Payment and pricing information will occur through updates to the Medicare Physician Fee Schedule Database (MPFSDB). Pay for this service on the basis of the MPFSDB. Deductible and coinsurance apply. Claims from physicians or other practitioners where assignment was not taken, are subject to the Medicare limiting charge.   III. Medicare Summary Notices (MSNs)   Use the following MSN Messages where appropriate:   In situations where the claim is being denied on the basis that the condition does not meet our coverage requirements, use one of the following MSN Messages:   Medicare does not pay for this item or service for this condition. (MSN Message 16.48)   The Spanish version of the MSN message should read:   Medicare no paga por este articulo o servicio para esta afeccion.
(Medicare Claims Processing Manual)
Medicare no paga por este articulo o servicio para esta afeccion.   In situations where, based on the above utilization policy, medical review of the claim results in a determination that the service is not medically necessary, use the following MSN message:   The information provided does not support the need for this service or item. (MSN Message 15.4)   The Spanish version of the MSN message should read:   La informacion proporcionada no confirma la necesidad para este servicio o articulo.   IV. Remittance Advice Notices   Use appropriate existing remittance advice remark codes and claim adjustment reason codes at the line level to express the specific reason if you deny payment for HBO therapy for the treatment of diabetic wounds of lower extremities.    30.2 Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)  (Rev.3921, Issued: 11-17 -17, Effective: 04 -03-17, 12 -18-17)  CMS considers topical oxygen therapy (TOT) to be a method whereby a local supply of oxygen is applied to a wound.  I. Billing Requirements for A/B MACs (A)  Claims for HBO therapy should be submitted using the ASC X12 837 institutional claim format or, in rare cases, on Form CMS -1450.  II.   Payment Requirements for A/B MACs (A)  As of April 3, 2017, Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by the local contractors. NOTE:  Regardless of whether an A/B MAC (A) has made a determination to cover this service, there shall be no coverage for any separate or additional physicians professional services related to this procedure.   III.  Billing Requirements for A/B MACs (B)  As of April 3, 2017, Medicare coverage of topical oxygen for the treatment of chronic wounds will be determined by the local contractors. NOTE:  Regardless of whether an A/B MAC (B) has made a determination to cover this service, there shall be no coverage for any separate or additional physicians professional services related to this procedure.   40  Sacral Nerve Stimulation  (Rev. 125, 03- 26-04)
(Medicare Claims Processing Manual)
40  Sacral Nerve Stimulation  (Rev. 125, 03- 26-04)  A sacral nerve stimulator is a pulse generator that transmits electrical impulses to the sacral nerves through an implanted wire.  These impulses cause the bladder muscles to contract, which gives the patient ability to void more properly.  40.1  Coverage Requirements  (Rev. 125, 03- 26-04)  Effective January 1, 2002, sacral nerve stimulation is covered for the treatment of urinary urge incontinence, urgency- frequency syndrome and urinary retention.  Sacral nerve stimulation involves both a temporary test stimulation to determine if an implantable stimulator would be effective and a permanent implantation in appropriate candidates.  Both the test and the permanent implantation are covered.   The following limitations for coverage apply to all indications:   o Patient must be refractory to conventional therapy (documented behavioral, pharmacologic and/or surgical corrective therapy) and be an appropriate surgical candidate such that implantation with anesthesia can occur.   o Patients with stress incontinence, urinary obstruction, and specific neurologic diseases (e.g., diabetes with peripheral nerve involvement) that are associated with secondary manifestations of the above three indications are excluded.   o Patient must have had a successful test stimulation in order to support subsequent implantation.  Before a patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement through test stimulation.  Improvement is meas ured through voiding diaries.   o Patient must be able to demonstrate adequate ability to record voiding diary data such that  clinical results of the implant procedure can be properly evaluated.   40.2  Billing Requirements (Rev. 125, 03- 26-04)  40.2.1  Healthcare Common Procedural Coding System (HCPCS)  (Rev. 11789, Issued:01- 19-23, Effective Date: 02- 21-23, Implementation Date: 02- 21-23)
(Medicare Claims Processing Manual)
40.2.1  Healthcare Common Procedural Coding System (HCPCS)  (Rev. 11789, Issued:01- 19-23, Effective Date: 02- 21-23, Implementation Date: 02- 21-23)   64561 -  Percutaneous implantation of neurostimulator electrodes; sacral   nerve (transforaminal placement)  64581 - Incision for implantation of neurostimulator electrodes; sacral nerve  (transforaminal placement)  64585 -  Revision or removal of peripheral neurostimulator electrodes  64590 - Incision and subcutaneous placement of peripheral   neurostimulator pulse generator or receiver, direct or inductive   coupling  64595 -  Revision or removal of peripheral neurostimulator pulse generator  or receiver  A4290 -  Sacral nerve stimulation test lead, each  C1767 -  Generator, neurostimulator (implantable)  C1778 -  Lead, neurostimulator (implantable)                        C1820 -  Generator, neurostimulator (implantable), with rechargeable  battery and charging system -  effective 01/01/20 for NCD230.18 with  CR11655  C1883 -  Adaptor/extension, pacing lead or neurostimulator lead  (implantable)  C1897 -  Lead, neurostimulator test kit (implantable)  E0752 -  Implantable neurostimulator electrodes, each  E0756 -  Implantable neurostimulator pulse generator    NOTE :  The "C" codes listed above are only applicable when billing under the hospital   outpatient prospective payment system (OPPS).  They should be reported in place of codes  A4290, E0752 and E0756.  40.2.2  Payment Requirements for Test Procedures (HCPCS Codes 64585, 64590 and 64595)  (Rev.  2998, Issued: 07- 25-14, Effective: Upon implementation of ICD -10; 01- 01-12 - ASC X12, Implementation: 08- 25-2014 -  ASC X12; Upon Implementation of ICD -10)  Payment is as follows:   Hospital outpatient departments  OPPS    Critical access hospital (CAH) -  Reasonable cost
(Medicare Claims Processing Manual)
Payment is as follows:   Hospital outpatient departments  OPPS    Critical access hospital (CAH) -  Reasonable cost    Comprehensive outpatient rehabilitation facility -  Medicare physician fee schedule (MPFS)    Rural health clinics/federally qualified health centers (RHCs/FQHCs) - All inclusive rate, professional component only.  The technical component is outside the scope of the RHC/FQHC benefit.  Therefore, the provider of that technical service bills their A/B MAC (B) using the ASC X12 837 professional claim format or Form CMS -1500 and payment is made under the MPFS.  For provider -based RHCs/FQHCs payment for the technical component is made as indicated above based on the type of provider the RHC/FQHC is based with.   Deductible and coinsurance apply.   40.2.3  Payment Requirements for Device Codes A4290, E0752 and E0756 (Rev. 125, 03- 26-04)  Payment is made on a reasonable cost basis when these devices are implanted in a CAH.   40.2.4  Payment Requirements for Codes C1767, C1778, C1820, C1883 and C1897 (Rev. 11789, Issued:01- 19-23, Effective Date: 02- 21-23, Implementation Date: 02- 21-23)    Only hospital outpatient departments report these codes.  Payment is made under OPPS.   40.3  Bill Types (Rev.  2998, Issued: 07- 25-14, Effective: Upon implementation of ICD -10; 01- 01-12 - ASC X12, Implementation: 08- 25-2014 -  ASC X12; Upon Implementation of ICD -10)  The applicable bill types for test stimulation procedures are 13X, 71X, 73X, 75X and 85X.   The RHCs and FQHCs bill you under bill type 71X and 73X for the professional component. The technical component is outside the scope of the RHC/FQHC benefit. The provider of that technical service bills their A/B MAC (B) using the ASC X12 837 professional claim format or the Form CMS -1500.
(Medicare Claims Processing Manual)
The technical component for a provider -based RHC/FQHC is typically furnished by the provider. The provider of that service bills you under bill type 13X, or 85X as appropriate using their outpatient provider number (not the RHC/FQHC provider number since t hese services are not covered as RHC/FQHC services.) Effective 4/1/06, type of bill 14X is for non-patient laboratory specimens and is no longer applicable for test stimulation procedures.   The applicable bill types for implantation procedures and devices are 11X, 13X, and 85X.   40.4  Revenue Codes  (Rev.10881; Issued: 08- 06-2021; Effective: 09- 07-2021; Implementation: 09- 07- 2021)   The applicable revenue code for the test procedures is 920 except for RHCs/FQHCs who  report these procedures under revenue code 521.   Revenue codes for the implantation can be performed in a number of revenue centers within a hospital such as operating room (360) or clinic (510). Therefore, instruct your hospitals to report these implantation procedures under the revenue center where they are performed.   The applicable revenue code for the device codes C1767, C1778, C1883, C1897, and C1820 provided in a hospital outpatient department is 272, 274, 275, 276, 278, 279, 280, 289, 290 or 624 as appropriate. The applicable revenue code for device codes A4290, E0752 and  E0756 provided in a CAH is 290.  40.5  Claims Editing  (Rev. 125, 03- 26-04)  Nationwide claims processing edits for pre or post payment review of claim(s) for sacral nerve stimulation are not being required at this time.  Contractors may develop local medical review policy and edits for such claim(s).   50  Deep Brain Stimulation for Essential Tremor and Parkinsons Disease  (Rev. 128, 03- 26-04)
(Medicare Claims Processing Manual)
50  Deep Brain Stimulation for Essential Tremor and Parkinsons Disease  (Rev. 128, 03- 26-04)  Deep brain stimulation (DBS) refers to high- frequency electrical stimulation of anatomic regions deep within the brain utilizing neurosurgically implanted electrodes.  These DBS electrodes are stereotactically placed within targeted nuclei on one (unilateral) or both (bilateral) sides of the brain.  There are currently three targets for DBS -- the thalamic ventralis intermedius nucleus (VIM), subthalamic nuc leus (STN) and globus pallidus interna (GPi).   Essential tremor (ET) is a progressive, disabling tremor most often affecting the hands.  ET may also affect the head, voice and legs.  The precise pathogenesis of ET is unknown.  While it may start at any age, ET usually peaks within the second and sixth decades.  Beta-adrenergic blockers and anticonvulsant medications are usually the first line treatments for reducing the severity of tremor.  Many patients, however, do not adequately respond or cannot tolerate these medications.  In these medically refractory ET patients, thalamic VIM DBS may be helpful for symptomatic relief of tremor.   Parkinsons disease (PD) is an age -related progressive neurodegenerative disorder involving the loss of dopaminergic cells in the substantia nigra of the midbrain.  The disease is characterized by tremor, rigidity, bradykinesia and progressive postural ins tability.  Dopaminergic medication is typically used as a first line treatment for reducing the primary symptoms of PD.  However, after prolonged use, medication can become less effective and can produce significant adverse events such as dyskinesias and other motor function complications.  For patients who become unresponsive to medical treatments and/or ha ve intolerable side effects from medications, DBS for symptom relief may be considered.   50.1  Coverage Requirements  (Rev. 128, 03- 26-04)  Effective on or after April 1, 2003, Medicare will cover unilateral or bilateral thalamic VIM DBS for the treatment of ET and/or Parkinsonian tremor and unilateral or bilateral STN or GPi DBS for the treatment of PD only under the following conditions: