evekhm/cms_iom_500 huggingface dataset:
Draft Article - Billing and Coding: Genetic Testing for Oncology (DA59123)
MEN1 (multiple endocrine neoplasia I) (e.g., multiple endocrine neoplasia type 1, Wermer syndrome), full gene sequence81405Adrenal Gland Tumors, Multiple Endocrine Neoplasia, Type 1, Neuroendocrine Tumors of the Gastrointestinal Tract (Well-Differentiated Grade 1/2), Neuroendocrine and Adrenal Tumors -Lung and Thymus, Neuroendocrine Tumors of the Pancreas (Well-Differentiated Grade 1/2), Neuroendocrine and Adrenal Tumors - Well-Differentiated Grade 3 Neuroendocrine TumorsNF2 (neurofibromin 2 [merlin]) (e.g., neurofibromatosis, type 2), duplication/deletion analysis81405Malignant Peritoneal Mesothelioma, Malignant Pleural MesotheliomaRET (ret proto-oncogene) (e.g., multiple endocrine neoplasia, type 2A and familial medullary thyroid carcinoma), targeted sequence analysis (e.g., exons 10, 11, 13-16)81405Ampullary Adenocarcinoma, Extrahepatic Cholangiocarcinoma, Intrahepatic Cholangiocarcinoma, Gallbladder Cancer, Erdheim-Chester Disease, Langerhans Cell Histiocytosis, Rosai-Dorfman Disease, Multiple Endocrine Neoplasia, Type 2A, Neuroendocrine and Adrenal Tumors -Pheochromocytoma/Paraganglioma, Pancreatic Adenocarcinoma, Medullary Thyroid CancerRPS19 (ribosomal protein S19) (e.g., Diamond-Blackfan anemia), full gene sequence81405Myelodysplastic SyndromesSDHB (succinate dehydrogenase complex, subunit B, iron sulfur) (e.g., hereditary paraganglioma), full gene sequence81405
Draft Article - Billing and Coding: Genetic Testing for Oncology (DA59123)
81405Myelodysplastic SyndromesSDHB (succinate dehydrogenase complex, subunit B, iron sulfur) (e.g., hereditary paraganglioma), full gene sequence81405Gastrointestinal Stromal Tumors (GIST),Neuroendocrine and Adrenal Tumors - Pheochromocytoma/Paraganglioma, Soft Tissue Sarcoma - Carney-Stratakis syndrome (Gastric GIST and Paraganglioma), Hereditary Renal Cell CarcinomaSDHC (succinate dehydrogenase complex, subunit C, integral membrane protein, 15kDa) (e.g., hereditary paraganglioma-pheochromocytoma syndrome), full gene sequence81405Neuroendocrine and Adrenal Tumors - Pheochromocytoma/Paraganglioma, Soft Tissue Sarcoma - Carney-Stratakis Syndrome (Gastric Gastrointestinal Stromal Tumor and Paraganglioma), Hereditary Renal Cell CarcinomaSMAD4 (SMAD family member 4) (e.g., hemorrhagic telangiectasia syndrome, juvenile polyposis), duplication/deletion analysis81405Hereditary Cancer Testing Criteria: Juvenile Polyposis SyndromeSTAT3 (signal transducer and activator of transcription 3 [acute-phase response factor]) (e.g., autosomal dominant hyper-IgE syndrome), targeted sequence analysis (e.g., exons 12, 13, 14, 16, 17, 20, 21)81405Myelodysplastic Syndromes, T-Cell Lymphomas - Hepatosplenic T-Cell Lymphoma, T-Cell Lymphomas - T-Cell Large Granular Lymphocytic LeukemiaSTK11 (serine/threonine kinase 11) (e.g., Peutz-Jeghers syndrome), full gene sequence81405Ampullary Adenocarcinoma, Pancreatic Adenocarcinoma, Hereditary Cancer Testing Criteria: Breast Cancer, Ovarian Cancer, Pancreatic Cancer, and Peutz-Jeghers Syndrome
Draft Article - Billing and Coding: Genetic Testing for Oncology (DA59123)
81405Ampullary Adenocarcinoma, Pancreatic Adenocarcinoma, Hereditary Cancer Testing Criteria: Breast Cancer, Ovarian Cancer, Pancreatic Cancer, and Peutz-Jeghers SyndromeTSC1 (tuberous sclerosis 1) (e.g., tuberous sclerosis), duplication/deletion analysis81405Neuroendocrine Tumors of the Pancreas (Well-Differentiated Grade 1/2),Neuroendocrine and Adrenal Tumors - Well-Differentiated Grade 3 Neuroendocrine Tumors, Uterine Sarcoma, Encapsulated Glioma, Hereditary Renal Cell CarcinomaWT1 (Wilms tumor 1) (e.g., Denys-Drash syndrome, familial Wilms tumor), full gene sequence81405Chronic Myeloid Leukemia, Malignant Peritoneal Mesothelioma, Malignant Pleural Mesothelioma, Myelodysplastic Syndromes, Wilms Tumor (Nephroblastoma), Acute Myeloid LeukemiaZEB2 (zinc finger E-box binding homeobox 2) (e.g., Mowat-Wilson syndrome), full gene sequence81405Acute Myeloid Leukemia - Blastic Plasmacytoid Dendritic Cell Neoplasm (BPDCN)BRAF (B-Raf proto-oncogene, serine/threonine kinase) (e.g., Noonan syndrome), full gene sequence81406Ampullary Adenocarcinoma,B-Cell Lymphomas - Splenic Marginal Zone Lymphoma, Adult Gliomas, Chronic Myeloid Leukemia, Gastrointestinal Stromal Tumors (GIST), Extrahepatic Cholangiocarcinoma, Intrahepatic Cholangiocarcinoma, Gallbladder Cancer, Erdheim-Chester Disease, Langerhans Cell Histiocytosis, Rosai-Dorfman Disease, Pancreatic AdenocarcinomaBTK (Bruton agammaglobulinemia tyrosine kinase) (e.g., X-linked agammaglobulinemia), full gene sequence81406
Draft Article - Billing and Coding: Genetic Testing for Oncology (DA59123)
BTK (Bruton agammaglobulinemia tyrosine kinase) (e.g., X-linked agammaglobulinemia), full gene sequence81406Chronic Lymphocytic Leukemia/Small Lymphocytic LymphomaCDH1 (cadherin 1, type 1, E-cadherin [epithelial]) (e.g., hereditary diffuse gastric cancer), full gene sequence81406Gastric Cancer, Hereditary Cancer Testing Criteria: Breast Cancer and Ovarian CancerMAP2K1 (mitogen-activated protein kinase 1) (e.g., cardiofaciocutaneous syndrome), full gene sequence81406Erdheim-Chester Disease, Langerhans Cell Histiocytosis, Rosai-Dorfman DiseaseMAP2K2 (mitogen-activated protein kinase 2) (e.g., cardiofaciocutaneous syndrome), full gene sequence81406Erdheim-Chester Disease, Langerhans Cell Histiocytosis, Rosai-Dorfman DiseaseMUTYH (mutY homolog [E. coli]) (e.g., MYH-associated polyposis), full gene sequence81406Colorectal CarcinomaNF2 (neurofibromin 2 [merlin]) (e.g., neurofibromatosis, type 2), full gene sequence81406Malignant Peritoneal Mesothelioma, Malignant Pleural MesotheliomaPTPN11 (protein tyrosine phosphatase, non-receptor type 11) (e.g., Noonan syndrome, LEOPARD syndrome), full gene sequence81406Chronic Myeloid Leukemia, Myelodysplastic Syndromes,Juvenile Myelomonocytic LeukemiaRAF1 (v-raf-1 murine leukemia viral oncogene homolog 1) (e.g., LEOPARD syndrome), full gene sequence81406Erdheim-Chester Disease, Langerhans Cell Histiocytosis, Rosai-Dorfman DiseaseRET (ret proto-oncogene) (e.g., Hirschsprung disease), full gene sequence81406
Draft Article - Billing and Coding: Genetic Testing for Oncology (DA59123)
RET (ret proto-oncogene) (e.g., Hirschsprung disease), full gene sequence81406Ampullary Adenocarcinoma, Extrahepatic Cholangiocarcinoma, Intrahepatic Cholangiocarcinoma, Gallbladder Cancer, Erdheim-Chester Disease, Langerhans Cell Histiocytosis, Rosai-Dorfman Disease, Multiple Endocrine Neoplasia, Type 2A and B, Neuroendocrine and Adrenal Tumors - Pheochromocytoma/Paraganglioma, Pancreatic Adenocarcinoma, Medullary Thyroid CancerSDHA (succinate dehydrogenase complex, subunit A, flavoprotein [Fp]) (e.g., Leigh syndrome, mitochondrial complex II deficiency), full gene sequence81406Neuroendocrine and Adrenal Tumors - Pheochromocytoma/Paraganglioma, Hereditary Renal Cell CarcinomaSMAD4 (SMAD family member 4) (e.g., hemorrhagic telangiectasia syndrome, juvenile polyposis), full gene sequence81406Hereditary Cancer Testing Criteria: Juvenile Polyposis SyndromeTSC1 (tuberous sclerosis 1) (e.g., tuberous sclerosis), full gene sequence81406Neuroendocrine Tumors of the Pancreas (Well-Differentiated Grade 1/2), Neuroendocrine and Adrenal Tumors - Well-Differentiated Grade 3 Neuroendocrine Tumors, Uterine Sarcoma, Encapsulated Glioma, Hereditary Renal Cell CarcinomaTSC2 (tuberous sclerosis 2) (e.g., tuberous sclerosis), duplication/deletion analysis81406Neuroendocrine Tumors of the Pancreas (Well-Differentiated Grade 1/2), Neuroendocrine and Adrenal Tumors - Well-Differentiated Grade 3 Neuroendocrine Tumors, Uterine Sarcoma, Encapsulated Glioma, Hereditary Renal Cell CarcinomaNOTCH1 (notch 1) (e.g., aortic valve disease), full gene sequence81407T-Lymphoblastic Leukemia/Lymphoma
Draft Article - Billing and Coding: Genetic Testing for Oncology (DA59123)
NOTCH1 (notch 1) (e.g., aortic valve disease), full gene sequence81407T-Lymphoblastic Leukemia/LymphomaTSC2 (tuberous sclerosis 2) (e.g., tuberous sclerosis), full gene sequence81407Neuroendocrine Tumors of the Pancreas (Well-Differentiated Grade 1/2), Neuroendocrine and Adrenal Tumors - Well-Differentiated Grade 3 Neuroendocrine Tumors, Uterine Sarcoma, Encapsulated Glioma, Hereditary Renal Cell CarcinomaATM (ataxia telangiectasia mutated) (e.g., ataxia telangiectasia), full gene sequence81408Ampullary Adenocarcinoma, Pancreatic Adenocarcinoma, Prostate Cancer, Hereditary Cancer Testing Criteria: Breast Cancer, Ovarian Cancer, and Pancreatic CancerNF1 (neurofibromin 1) (e.g, neurofibromatosis, type 1), full gene sequence81408Gastrointestinal Stromal Tumors (GIST), Myelodysplastic Syndromes, Neuroendocrine Tumors of the Pancreas (Well-Differentiated Grade 1/2), Neuroendocrine and Adrenal Tumors - Pheochromocytoma/Paraganglioma, Neuroendocrine and Adrenal Tumors - Well-Differentiated Grade 3 Neuroendocrine Tumors, Soft Tissue Sarcoma - Embryonal rhabdomyosarcoma, Soft Tissue Sarcoma - Malignant peripheral nerve sheath tumor, Neurofibroma, Chronic Myelomonocytic Leukemia, Juvenile Myelomonocytic Leukemia, Hereditary Cancer Testing Criteria: Breast Cancer and Ovarian CancerUtilization ParametersGenetic testing for hereditary cancer syndromes is considered germline testing, and therefore only permitted once per beneficiarys lifecycle.The following tests are germline tests:
Draft Article - Billing and Coding: Genetic Testing for Oncology (DA59123)
Utilization ParametersGenetic testing for hereditary cancer syndromes is considered germline testing, and therefore only permitted once per beneficiarys lifecycle.The following tests are germline tests:812028121581217812938129681299813088131881322813538143281433814358143681437814380101U0102U0103U0129U0130U0131U0132U0133U0134U0135U0162U0238UDocumentation 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(s) must describe the service performed.The medical record must demonstrate that the treating clinician who is responsible for the management of the patients cancer or substantiated suspicion of cancer is the same person as the ordering clinician.The medical record must include documentation to support an established diagnosis of cancer or a substantiated suspicion of cancer.The medical record must include documentation of how the test results will directly impact the management of the patients specific medical problem.The medical record must clearly document the communication and discussion of pre-test and post-test counseling and the risk associated with genetic testing.The medical record from the ordering clinician must clearly indicate all tests that are to be performed.
Draft Article - Billing and Coding: Peripheral Venous Ultrasound (DA52993)
CMS National Coverage PolicyInternet Only Manuals (IOMs):CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 4, Section 20.6.2 Use of Modifiers -50, -LT and -RTChapter 12, Section 40.7.B Billing Instructions for Bilateral SurgeriesSocial 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.Medicare National Correct Coding Initiative (NCCI) Policy Manual:Chapter XI Medicine Evaluation and Management ServicesCode of Federal Regulations (CFR) References:CFR, Title 42, Volume 2, Chapter IV, Part 410.32(a) Ordering diagnostic testsArticle TextThis Billing and Coding Article provides billing and coding guidance for Proposed Local Coverage Determination (LCD) DL35451 Peripheral Venous Ultrasound. 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.Note:When an uninterpretable study results in performing another type of study, only the successful study should be billed.Note:Multiple duplex scans plus noninvasive physiologic studies of the upper and lower extremities (93970, 93971, 93922 and 93923) and 93924-93931 cannot be billed on the same day.The use of a simple hand-held or other Doppler device that does not produce hard copy data or that produces a record that does not permit analysis of bidirectional vascular flow, is considered to be part of the physical examination of the vascular system and is not separately reported.
Draft Article - Billing and Coding: Peripheral Venous Ultrasound (DA52993)
CPT code 93971Consistent with the LCD, doppler ultrasound scanning is the current standard for the preoperative evaluation of reflux in patients with chronic venous insufficiency.Correct coding guidelines indicate that CPT code 93971 should be used to report either a limited bilateral or a complete unilateral study. It would not be appropriate to report -50 modifier with CPT code 93971 for a limited bilateral study.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.Images of all relevant areas, both normal and abnormal, should be recorded and stored in a retrievable format (electronic preferred).A signed final report of the ultrasound findings and impression should be included in the patients medical record and is the definitive documentation of the study. The final report should include but is not limited to the following demographic components:A description of examination findings, using appropriate anatomic and ultrasound terminology. (Use of acronyms and abbreviations should be avoided)The concluding statements or summary of the report should include these components:An impression, conclusion, or summary statementA specific diagnosis or differential diagnosis, if appropriateA recommendation for follow-up studies, if clinically applicableAn accounting of any failure to include standard views or other necessary components (as listed in the appropriate practice parameter)If prior relevant imaging studies were reviewed, a statement of comparison should be includedDetails concerning any provider-to-provider communication in cases in which a delay in communication may have an adverse effect on the patients outcome.An order from the treating physician/nonphysician practitioner as required by CFR, Title 42, Volume 2, Chapter IV, Part 410.32(a) Ordering diagnostic tests.The medical record for patients with known venous thrombosis on therapy should reflect what clinical change occurred and how the change in thrombus burden will alter treatment.
Draft Article - Billing and Coding: Peripheral Venous Ultrasound (DA57125)
CMS National Coverage PolicyInternet Only Manuals (IOMs):CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 4, Section 20.6.2 Use of Modifiers -50, -LT and -RTChapter 12, Section 40.7.B Billing Instructions for Bilateral SurgeriesSocial 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.Medicare National Correct Coding Initiative (NCCI) Policy Manual:Chapter XI Medicine Evaluation and Management ServicesCode of Federal Regulations (CFR) References:CFR, Title 42, Volume 2, Chapter IV, Part 410.32(a) Ordering diagnostic testsArticle TextThis Billing and Coding Article provides billing and coding guidance for Proposed Local Coverage Determination (LCD) DL33693 Peripheral Venous Ultrasound. 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.Note:When an uninterpretable study results in performing another type of study, only the successful study should be billed.Note:Multiple duplex scans plus noninvasive physiologic studies of the upper and lower extremities (93970, 93971, 93922 and 93923) and 93924-93931 cannot be billed on the same day.The use of a simple hand-held or other Doppler device that does not produce hard copy data or that produces a record that does not permit analysis of bidirectional vascular flow, is considered to be part of the physical examination of the vascular system and is not separately reported.
Draft Article - Billing and Coding: Peripheral Venous Ultrasound (DA57125)
CPT code 93971Consistent with the LCD, doppler ultrasound scanning is the current standard for the preoperative evaluation of reflux in patients with chronic venous insufficiency.Correct coding guidelines indicate that CPT code 93971 should be used to report either a limited bilateral or a complete unilateral study. It would not be appropriate to report -50 modifier with CPT code 93971 for a limited bilateral study.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.Images of all relevant areas, both normal and abnormal, should be recorded and stored in a retrievable format (electronic preferred).A signed final report of the ultrasound findings and impression should be included in the patients medical record and is the definitive documentation of the study. The final report should include but is not limited to the following demographic components:A description of examination findings, using appropriate anatomic and ultrasound terminology. (Use of acronyms and abbreviations should be avoided)The concluding statements or summary of the report should include these components:An impression, conclusion, or summary statementA specific diagnosis or differential diagnosis, if appropriateA recommendation for follow-up studies, if clinically applicableAn accounting of any failure to include standard views or other necessary components (as listed in the appropriate practice parameter)If prior relevant imaging studies were reviewed, a statement of comparison should be includedDetails concerning any provider-to-provider communication in cases in which a delay in communication may have an adverse effect on the patients outcome.An order from the treating physician/nonphysician practitioner as required by CFR, Title 42, Volume 2, Chapter IV, Part 410.32(a) Ordering diagnostic tests.The medical record for patients with known venous thrombosis on therapy should reflect what clinical change occurred and how the change in thrombus burden will alter treatment.
Draft Article - Billing and Coding: Fluid Jet System Treatment for LUTs/BPH (DA56797)
CMS National Coverage PolicyN/AArticle TextThis article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Fluid Jet System Treatment for LUTS/BPH.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.
Draft Article - Billing and Coding: Trigger Point Injections (TPI) (DA59498)
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.CMSInternet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16,180 Services Related to and Required as a Result of Services Which Are Not Covered Under MedicareArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forTrigger Point Injections DL39671.The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or Outpatient Prospective Payment System (OPPS) packaging edits. Please refer to theNCCI requirements.Coding GuidanceProviders should refer to the applicable American Medical Association (AMA) CPTManual 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 TPIs and does not apply to dry needling or acupuncture.Modifier 50- bilateral should NOT be reported with CPTcodes 20552 or 20553.Utilization ParametersNo more than 3 TPI sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed.CPT20552 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 Ambulatory Surgery Center (ASC) or outpatient facility claims.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.