evekhm/cms_iom_500 huggingface dataset:
Article - MolDX: Oncotype DX® Colon Cancer Assay Update (A53106)
CMS National Coverage PolicyN/AArticle TextThe Oncotype DX Colon Cancer Assay, developed to predict the recurrence risk for patients with Stage II colon cancer, has been assigned a unique identifier. To bill an Oncotype DX Colon service, please provide the following claim information:CPT code 81525-Oncology (colon), mRNA gene expression of 21 genesEnter 1 in the Days/Unit fieldFor CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.Enter the appropriate DEX Z-Codeidentifier 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 837PBox 19 for paper claimEnter the appropriate DEX Z-Codeidentifier 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 formSelect the appropriate ICD-10-CM code:
Article - Billing and Coding: MolDx: ResponseDX Tissue of Origin® (A53108)
CMS National Coverage PolicyN/AArticle TextTissue of Origin, a microarray-based gene expression assay designed to determine the similarity of unknown or unresolved tumors to cancers from 1 of 15 known tumors of origin, has been assigned a unique identifier. To bill for Tissue of Origin services, please provide the following claim information:CPTcode 81504  Oncology (tissue of origin)Enter 1 in the Days/Unit fieldSelect the appropriate ICD-10-CM diagnosis.Enter 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 837PBox 19 for paper claimEnter 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: MolDX expects this test to ONLY be ordered by the treating physician.
Article - Billing and Coding: Endovascular Repair of Aortic and/or Iliac Aneurysms (A53124)
CMS National Coverage PolicyN/AArticle TextCoding GuidelinesThe Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.Endovascular repair of aortic aneurysms requires the combined effort of radiologists and vascular surgeons. These procedures have several key components:Preservice planning and sizingTreatment Zone definedOpen exposure of the artery to allow delivery of the endovascular prosthesisReporting Bilateral Aneurysm RepairIntroduction of guidewires and cathetersImaging in conjunction with endovascular repairPlacement of the prosthesisReporting ExtensionsEndovascular repair with rupture or for other than rupture repairPreservice Planning and SizingPreprocedure sizing of the aneurysm and selection of the appropriate type of endograft are part of the preservice work included in the endograft CPT codes34701-34708. The preservice planning and sizing should not be reported separately.Treatment Zone DefinedThe CPT Manual defines the treatment zone as the vessels(s) in which an endografts(s), including the main body, docking limb(s), and/or extension(s), is deployed during an operative session. For reporting purposes, the treatment zone for endovascular repair of abdominal aorta and/or iliac arteries extends the entire length of the vessel treated even if the device used does not cover the entire vessel.Services included in the endovascular repair codes include angioplasty and stenting performed within the treatment zone, placing and securing endografts, placement of extensions in the aorta from the renal arteries to the iliac bifurcation, nonselective catheterization, and radiological supervision and interpretation. These services are not to be reported separately.Artery Exposure
Article - Billing and Coding: Endovascular Repair of Aortic and/or Iliac Aneurysms (A53124)
Artery ExposureOpen arterial exposure is performed during endovascular repair of abdominal aorta and/or iliac arteries procedures when a vessel is too small in diameter to accommodate the endograft. As of 2018, the open exposure codes are add-on codes. To report the open exposure of the artery use add-on CPT codes 34812, 34820, 34833, 34834, 34714, 34715, or 34716 dependent upon the artery used. When the same open arterial exposure is used bilaterally, report the open exposure add-on code twice with appropriate anatomical modifier.When reporting surgical exposure of the artery by the same physician who performed the primary endovascular aortic aneurysm repair, use the CPT code specific to the artery (e.g., femoral: 34812, iliac: 34820) and append the -51 modifier (multiple procedures).If an extensive repair or replacement of the exposed artery is required, this should be billed withCPT code 35266 or 35286.Reporting Bilateral Aneurysm RepairReport simultaneous bilateral iliac artery aneurysm repairs with aorto-bi-iliac endograft with CPT code 34705 or 34706.If bilateral iliac artery aneurysms are treated, report with CPT code 34707 or 34708 with -50 modifier.Introduction of Guidewires and CathetersNonselective catheterization is inherent for CPT codes 34701-34708 and is not separately reportable. Selective catheterization of the hypogastric artery(ies), renal artery(ies), and/or arterial families outside the treatment zone of the endograft may be separately reported.Selective catheter introduction should be reported using the appropriate catheterization codes as follows:For repair of a descending thoracic aneurysm use CPT codes 36140, 36200-36218 as appropriate.For repair of an abdominal aortic aneurysm use CPT codes 36200, 36245-36248, and 36140 as appropriate.
Article - Billing and Coding: Endovascular Repair of Aortic and/or Iliac Aneurysms (A53124)
As above, when reporting catheterization by the same physician who performed the endovascular AAA repair, append the -51 modifier to the appropriate catheterization code.Imaging in Conjunction with Endovascular RepairAs of 2018, separate CPT codes for supervision and interpretation of endograft services have been deleted. Most imaging services related to endovascular repair codes are included in the new endograft codes. Services not separately reportable with 34701-34708 include the following, please note: this list may not be all inclusive:Radiological supervision and interpretation,Intraprocedural and completion angiography (e.g., confirm position, detect endoleak, etc.),All intraprocedural imaging (e.g., angiography, rotational CT, etc.) of the aorta and its branches prior to deployment of the endovascular device, andFluoroscopic guidance and mapping used to deliver endovascular components.For repair of a descending thoracic aneurysm use CPT codes 75956-75959 as appropriate.Placement of the ProsthesisSeveral codes may be used when repairing an abdominal aortic and/or iliac artery aneurysm. Use CPT codes 34701, 34702, 34703, 34704, 34705, 34706, 34707, or 34708 for the repair of an abdominal aortic/iliac artery aneurysm (with or without rupture) with an endovascular prosthesis.CPT code 34717 and 34718 describe endovascular repair of the iliac artery using an iliac branched endograft. CPT 34717 is an add on code and is reported in conjunction with CPT codes 34703, 34704, 34705 or 34706. CPT 34718 is a stand alone code and should not be reported with 34703, 34704, 34705 or 34706.Code 34717 may only be reported once per side. For bilateral procedures, report 34717 twice. Do not report modifier 50 in conjunction with 34717.Code 34718 - for bilateral placement of an iliac branched endograft, report modifier 50.
Article - Billing and Coding: Endovascular Repair of Aortic and/or Iliac Aneurysms (A53124)
Code 34718 - for bilateral placement of an iliac branched endograft, report modifier 50.For the replacement of the descending thoracic aneurysm with an endovascular prosthesis use CPT codes 33880-33891.If an iliac artery occlusion device is required CPT code 34808 may be applicable when performed during the same operative setting as the endovascular repair.CPT code 34813 is used if a femoral-femoral prosthetic graft is required during the endovascular repair of the abdominal aortic aneurysm.When the abdominal aortic aneurysm cannot be repaired via an endovascular approach and an open approach must be used to complete the procedure, use CPT codes 34830, 34831, or 34832.Reporting ExtensionsReporting extensions is dependent on the procedure performed rather than the specific device placed. CPT code 34709 is an add-on code for CPT codes 34701-34708 and is reported once per vessel treated regardless of the number of extension modules necessary to complete the procedure. Extensionprosthesis(es) may not be reported separately when placed in the treatment zone. Docking limbs are considered part of the endograft procedure and are not reported separately even when the docking limb used to complete the procedure extends into the external iliac artery. Otherwise, CPT code 34709 is reportable once per vessel when extension of a prosthesis(es) is required in any of the following cases:Above the renal arteries (CPT codes 34701, 34702)Above the renal arteries or below the iliac bifurcation(s) (CPT codes 34703, 34704, 34705, 34706)Below the iliac bifurcation (CPT codes 34707, 34708)CPT codes 34710 and 34711 are used for delayed placement of the extension prosthesis(es) not performed at the same operative session as CPT codes 34701-34709.Endovascular repair with rupture or for other than rupture
Article - Billing and Coding: Endovascular Repair of Aortic and/or Iliac Aneurysms (A53124)
Endovascular repair with rupture or for other than ruptureEndovascular repair in the aortic or iliac arteries for acute rupture is reported using CPT codes 34702, 34704, 34706, or 34708. When reporting these codes, rupture is defined in the CPT manual as clinical and/or radiographic evidence of acute hemorrhage. Contained/stable ruptures or chronic ruptures (also referred to as pseudoaneurysms) are repaired using CPT codes 34701, 34703, 34705, or 34707.Other Billing ConsiderationsOther interventional procedures performed at the time of endovascular abdominal aortic aneurysm repair may be additionally reported (e.g., renal transluminal angioplasty, arterial embolization, intravascular ultrasound, balloon angioplasty of native artery[ies] outside the graft [e.g., aortic or iliac] before and after deployment of the endoprosthesis). The treatment zone includes the entire vessel treated even if the device does not cover the entire vessel. Any stenting performed in the treatment zone of the endograft before, during, or after placement of the endograft is included with the work of endograft placement. There are; however, indications for placement of separate vascular stents outside the treatment zone of the endograft (e.g., iliac, renal arteries). These stent placements are to be coded using CPT codes 37236-37239. Please note CPT codes 37236-32739 include radiological supervision and interpretation.Endovascular repair codes are not to be used to report for treatment of atherosclerotic occlusive disease in the iliac artery(ies).When the endovascular repair of AAA is performed by cooperating physicians, each participant should report the appropriate repair codes and append modifier -62 (co-surgeons) or modifier -80 (assistant surgeon).
Article - Billing and Coding: Endovascular Repair of Aortic and/or Iliac Aneurysms (A53124)
When the endovascular repair of AAA is performed by cooperating physicians, each participant should report the appropriate repair codes and append modifier -62 (co-surgeons) or modifier -80 (assistant surgeon).In situations in which a cardiologist, for example, bills for the supervision (the "S") of the S&I code, and a radiologist bills for the interpretation (the "I") of the code, both physicians should use a -52 modifier indicating a reduced service, e.g., the interpretation only. When a -52 modifier is reported, Novitas recommends submitting supporting documentation or explanation with the claim submission. For additional information on the use of modifier -52, please see our website at Novitas-solutions.com.
Article - Self-Administered Drug Exclusion List: (A53127)
CMS National Coverage PolicyN/AArticle TextMedicare provides only limited benefits for outpatient prescription drugs. The program covers drugs that are furnished incident to a physicians service provided that the drugs are medically reasonable and necessary, approved by the Food and Drug Administration (FDA) and are not usually administered by the patients who take them. Each Medicare Administrative Contractor (MAC) as well as fiscal intermediary and carrier must make its own determinations for determining which drugs will be excluded from coverage. The detailed process for this determination is available in the CMS Internet-Only Manual (IOM) Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Section 50.2.DEFINITIONSIn making these determinations, Novitas Solutions used the following definitions:Self-administeredadministered by the patient to him or herself. This does NOT include administration by spouses, nursing aides, allied health professionals, or physicians. Therefore, oral medications are considered self-administered drugs. However, payment for an oral drug is made as a rare exception when the drug is an oral anti-cancer drug or an oral antiemetic that is given with chemotherapy treatments (See CMS IOM Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 50.5.3 and 50.5.4).Usually self-administeredthe term usually means more than 50 percent of the time for all Medicare beneficiaries who use the drug. Therefore, if a drug is self-administered by more than 50 percent of Medicare beneficiaries, the drug is excluded from coverage and the contractor may not make any Medicare payment for it. In other words, this determination is made by evaluating beneficiaries as a collective whole rather than basing it on an individual drug or individual beneficiary.Acute conditionany condition that the expected course of treatment is less than two weeks.Chronic conditionany condition that requires treatment for more than two weeks.PROCESS OF DETERMINATIONIn making these determinations, Novitas Solutions uses the process prescribed by CMS. The process is summarized as follows.Statistical information is used to make the required decisions. However, when this data is not available the following factors are considered: route of administration, status of the condition, frequency of drug administration.Route of Administration
Article - Self-Administered Drug Exclusion List: (A53127)
Statistical information is used to make the required decisions. However, when this data is not available the following factors are considered: route of administration, status of the condition, frequency of drug administration.Route of AdministrationDrugs delivered intravenously are presumed to be NOT usually self-administered.Drugs injected intramuscularly are presumed to be NOT usually self-administered, although depth and nature of the drug may be considered.Drugs administered subcutaneously are considered to be usually self-administered.Status of the ConditionAcute: any condition that the expected course of treatment is less than two weeks.Chronic condition: any condition that requires treatment for more than two weeks.Frequency of AdministrationInfrequent injection: e.g., drug given monthly or less than once per month.Frequent injections: e.g., drug given one or more times per week or more than once per month.Novitas Solutions arrived at a single determination for each drug listed in this article by reviewing each indication and route of administration for that indication. The relative contribution for each indication to the total use of that drug (i.e., weighted average) was obtained to determine the overall status of administration. For example, if a drug has three indications where the first indication makes up 40% of its use and is usually self-administered, the second and third indications make up 60% of its use and the drug is not usually self-administered for these indications, then the overall determination of that drug is that it is not usually self-administered. Conversely, if the first indication makes up 60% of its use and the drug is usually self-administered, and the second indication makes up 40% of its use and the drug is not usually self-administered, the overall determination made is that the drug is usually self-administered. After the route of administration is determined, the status of the condition and the frequency of administration are assessed. If the condition is acute or if the drug is given less frequently than one time per week, the drug is determined to be not usually self-administered.
Article - Self-Administered Drug Exclusion List: (A53127)
For certain injectable drugs, it is apparent that due to the nature of the condition(s) for which they are self-administered or the usual course of treatment for those conditions, the drugs are, or are NOT, usually self-administered. For example, an injectable drug used to treat migraine headaches is usually self-administered. For these drugs, the rationale for the determination is apparent on its face value.BENEFICIARY APPEALSA beneficiary may appeal the denial if a claim for a particular drug is denied because the drug is subject to the self-administered drug exclusion. Because it is a benefit category denial and not a denial based on medical necessity, an Advance Beneficiary Notice (ABN) is not required. A benefit category denial (i.e., a denial based on the fact that there is no benefit category under which the drug may be covered) does not trigger the financial liability protection provisions of limitation on liability (under Section 1879 of the Act). Therefore, physicians or providers may charge the beneficiary for an excluded drug.PROVIDER AND PHYSICIAN APPEALSA physician accepting assignment may appeal a denial under the provisions found in Chapter 29 of the CMS IOM Publication 100-04,Medicare Claims Processing Manual.For complete information on Medicare Regulations regarding Drugs and Biologicals, please refer to the CMS IOM Publication 100-02,Medicare Benefit Policy Manual, Chapter 15, Section 50.Coding InformationDRUGS AND BIOLOGICALS FURNISHED INCIDENT TO A PHYSICIANS SERVICE ARE SUBJECT TO THE MEDICARE SELF-ADMINISTRATION DRUG EXCLUSION.The evaluation of drugs for addition to the self-administered drug (SAD) list is an ongoing process. This list contains only those drugs and biologicals that are determined to be usually self-administered by the patients and therefore not eligible for Medicare coverage.Route of Administration Modifier
Article - Self-Administered Drug Exclusion List: (A53127)
Route of Administration ModifierThe use of the JA and JB modifiers is required for drugs which have one HCPCS Level II (J or Q) code but multiple routes of administration. Drugs that fall under this category will be marked with an asterisk (*) and must be billed with JA modifier for the intravenous infusion of the drug or billed with the JB modifier for subcutaneous injection form of administration. Absent to the contrary, the Contractor presumes that drugs delivered intravenously are not usually self-administered by the patient. The contractor will process claims with the JA modifier still applying the policy as stated in theMedicare Benefit Policy Manual, Chapter 15, Section 50.2 that not only must the drug be medically reasonable and necessary, but also that the route of administration is medically reasonable and necessary. Subcutaneously administered drugs listed on the Usually Self-Administered list will be denied as a benefit exclusion. Claims for drugs marked with an asterisk (*) billed without either a JA or JB modifier will also be denied.The drugs represented by HCPCS codes J0801 and J0802 are administered by IM or SQ, therefore they require the JB modifier to be reported for SQ administration and they should not have any modifier reported for the IM administration.
Article - Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions (A53134)
CMS National Coverage PolicyInternet-Only Manuals (IOMs):CMS IOM, Publication 100-03,Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 4, Section 220.6.9 FDG PET for Refractory Seizures and Section 220.6.13 FDG Positron Emission Tomography (PET) for Dementia and Neurodegenerative DiseasesCMS IOM, Publication 100-04,Medicare Claims Processing Manual,Chapter 13, Section 60 Positron Emission Tomography (PET) Scans  General InformationSocial 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 TextThe CMSMedicare National Coverage Determinations (NCD) Manual, IOM Publication 100-03, Section 220.6, discusses Positron Emission Tomography (PET) Scans coverage. This Billing and Coding Article provides billing and coding guidance regarding the use of PET scans for several non-oncologic conditions.Specifically, this article addresses the sections listed above in the CMS National Coverage Policy.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered as if they are covered. When billing for non-covered services, use the appropriate modifier.This contractor has listed specific ICD-10-CM diagnosis codes as eligible for coverage of PET non-oncologic claims. However, please note that the ICD-10-CM diagnosis code, as always, is only one piece of information in support of the medical necessity of the service.All requirements of the applicable NCD must be met, and the clinical documentation in the medical record must support that all of the requirements of the NCD have been met. Please see the applicable NCD section for specific information regarding the clinical documentation expected to be found in the medical record to support that all of the requirements of the NCD have been met.