evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Biomarkers for Oncology (A52986)
The claim must contain one of the corresponding ICD-10-CM codes listed in the ICD-10-CM Codes that Support Medical Necessity Group 1 below.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.The medical record documentation must support the medical necessity of the services as stated in the LCD. Specifically, the medical record should reflect whether any biomarker ordered is diagnostic, prognostic or predictive, as well as be able to clearly correlate any test result with given interventions(e.g., particular selection of chemotherapy).
Article - Billing and Coding: Non-Invasive Cerebrovascular Arterial Studies (A52992)
CMS National Coverage PolicyPlease refer to the related LCD, L35397.Article TextCoding GuidelinesPlease refer to the Novitas Local Coverage Determination (LCD), Non-Invasive Cerebrovascular Arterial Studies, L35397 for reasonable and necessary requirements and frequency limitations.The HCPCS/CPT 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.Note:When an uninterpretable study results in performing another type of study, only the successful study should be billed.When billing these proceduresafter a carotid endarterectomy, provide in the narrative the date of the surgery and the verbiage "carotid endarterectomy."Duplex post-interventional follow-up studies are typically limited in scope and unilateral in nature. The "complete/bilateral" duplex scan codes should seldom be used, while the "unilateral or limited study" codes should be used (except for the patient who had bilateral intervention).Do not report procedure codes 93890-93893 in conjunction with code 93888.All non-invasive vascular study CPT codes are considered bilateral codes unless otherwise indicated in the CPT definition. The 150% payment adjustment for bilateral procedures does not apply. Modifier -50 and/or the anatomic modifiers, -LT/-RT should not be used.Append the modifier 52 to report a unilateral study as appropriate. Information explaining the reduced service should be included in Item 19 of the CMS-1500 form or the electronic equivalent. Any appropriate documentation may be submitted with the claim to support the reduced service.
Article - Billing and Coding: Peripheral Venous Ultrasound (A52993)
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 Local Coverage Determination (LCD) L35451 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.
Article - Billing and Coding: Peripheral Venous Ultrasound (A52993)
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.
Article - Billing and Coding: Routine Foot Care (A52996)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35138 (Routine Foot Care). Please refer to the LCD for reasonable and necessary requirements.Coverage 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.It is not appropriate to report procedure codes 11305-11308 for the removal of corns and calluses of the feet. Removal of these lesions is considered to be routine foot care and must be reported with procedure codes 11055-11057, paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus). Services must be reported using the procedure code that most accurately describes the procedure performed.When reporting routine foot care services that needs to meet one of the exclusions, one of the following applicable Q modifiers identifying the class findings must be included on the claim.Q7  1 Class A findingsQ8  2 Class B findingsQ9  1 Class B and 2 Class C findingsFor all claims for foot-care services, report a foot/toe location modifier (when appropriate). The following are valid HCPCS modifiers:Left foot - LTFirst toe, left foot - TASecond toe, left foot - T1Third toe, left foot - T2Fourth toe, left foot - T3Fifth toe, left foot - T4Right foot - RTFirst toe, right foot - T5Second toe, right foot - T6Third toe, right foot - T7Fourth toe, right foot - T8Fifth toe, right foot - T9If a significant separately identified evaluation and management service is provided on the same day as routine foot care, the -25 modifier should be appended.
Article - Billing and Coding: Routine Foot Care (A52996)
If a significant separately identified evaluation and management service is provided on the same day as routine foot care, the -25 modifier should be appended.Report only one of CPT codes 11055-11057 for each date of service. Total the number of keratotic lesions debrided and select the most appropriate CPT code. Example: if one lesion is debrided on the right foot and two lesions are debrided on the left foot, code 11056 (two to four lesions) would be the most appropriate CPT code.When reporting one of the ICD-10-CM codes that fall under the "active care requirement", the date that the beneficiary was last seen by the M.D., D.O., or qualified NPP, responsible for treating the underlying condition must be reported in line 19 of the CMS-1500 claim form or the electronic equivalent.
Article - Billing and Coding: Surgical Treatment of Nails (A52998)
CMS National Coverage PolicyInternet-Only Manuals (IOMs):CMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 23, Section 20.9 National Correct Coding Initiative (NCCI)National Correct Coding Initiative (NCCI) Citation:Medicare NCCI Policy Manual,Chapter 1, General Correct Coding Policies for Medicare National Correct Coding Initiative Policy ManualChapter 3, Surgery: Integumentary System CPT codes 10000-19999 for Medicare National Correct Coding Initiative Policy ManualSocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L34887 Surgical Treatment of Nails. 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.The description of CPT codes 11730, 11732 and 11750 indicates partial or complete avulsion or excision of a nail plate. When CPT code 11730, 11732 or 11750 is reported, it represents all services performed on that nail for that date of service (DOS). When lateral and medial sides of a nail are involved, do not report a separate code for each border.Procedure code 11750 (Excision of nail and nail matrix, partial or complete, [e.g., ingrown or deformed nail] for permanent removal) requires the removal of the full length or the entire nail plate, with destruction or permanent removal of the matrix by any means.
Article - Billing and Coding: Surgical Treatment of Nails (A52998)
Reporting CPT codes 11730 or 11732 (removal of nail plate) with CPT code 11750 (removal of nail bed) and or 11765 (excision of nail fold toe) for the same digit on the same DOS is not correct coding.Reporting CPT code 11750 (removal of nail bed) with CPT code 11765 (excision of nail fold toe) for the same digit on the same DOS is not correct coding.CPT code 11765 requires an excision of a wedge of the skin of the nail fold from the involved side of the toe. Reporting CPT code 11765 for the removal of a small piece of the skin and/or the nail without local anesthesia is not correct coding.Procedure code 11730 (Avulsion of nail plate, partial or complete, simple; single) is reported when removing part of the nail plate or the entire nail plate.Claims must include the nail on which the procedure is performed using one of the modifiers listed in the Coding Information section below to identify the digit in order for payment to be considered.For services performed on different nails:If CPT procedure codes 11730, 11750, or 11765 are performed on different nails, report the procedure performed with one unit of service (UOS) and append with the appropriate identifying digit modifiers.For every subsequent avulsion, CPT 11732 is reported as the add-on code with one UOS and the appropriate identifying digit modifier appended.Utilization Parameters
Article - Billing and Coding: Surgical Treatment of Nails (A52998)
Utilization ParametersCPT codes 11730 and 11732 for nail avulsion will be denied if billed for the same finger less than 4 months (16 weeks) or the same toe less than 8 months (32 weeks) following a previous avulsion.A medically reasonable and necessary repeat avulsion of the same nail within 16 weeks (finger) or 32 weeks (toe) of a previous avulsion of the same nail, will be considered upon redetermination. The medical record must support the service, for example, there is an ingrown nail of the opposite border or a new significant pathology on the same border recently treated.CPT code 11750 for nail excision permanent removal will be denied if billed for the same finger or toe following a previous excision.For a medically reasonable and necessary repeat nail excision on the same finger or toe, report modifier KX (Requirements specified in the medical record have been met). The medical record documentation must be specific as to the indication, such as ingrown nail of the opposite border or new significant pathology on the same border previously treated.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.The following information must be clearly documented in the patients medical record:
Article - Billing and Coding: Surgical Treatment of Nails (A52998)
Complete detailed description of the pre-operative findings. Include the patients symptoms, the physical examination documenting the severity of the nail infection, injury or deformity, and the assessment and plan containing the rationale why surgical treatment is being selected over other treatment options.Method of obtaining anesthesia (if not used, the reason for not using it).A complete detailed description of the procedure performed.Identify the specific digit(s) and make note to the nail margin(s) involved on which the procedure was performed.Postoperative observation and treatment of the surgical site (e.g., minimal bleeding, sterile dressing applied).Postoperative instructions given to the patient and any follow-up care (e.g., soaks, antibiotics, follow-up appointments).
Article - Billing and Coding: Wound Care (A53001)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35125, Wound Care. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceClaims must be submitted with an ICD-10-CM code that represents the reason the procedure was done. The ICD-10-CM code must be billed to the highest level of specificity for that code set. The ICD-10-CM code must be linked to the appropriate procedure code.Active Wound Care Management  CPT codes 97597, 97598, 97602, 97605, 97606, 97607, and 97608
Article - Billing and Coding: Wound Care (A53001)
Currently, code 97602 is a status B (bundled) code for physicians services; therefore, separate payment is not allowed for this service.A therapist acting within their scope of practice and licensure performing active wound care management services must add the appropriate therapy modifierto the CPT code billed. In addition, the therapy Revenue Code must be submitted for that service. If a non-therapist performs the service, no therapy modifiers are used and a non-therapy Revenue Code must be submitted for the service. Please see MM10176 for more information.For debridement codes 97597, 97598, or 97602:Debridement should be coded with either selective or non-selective CPT codes (97597, 97598, or 97602) unless the medical record supports a surgical debridement has been performed.Dressings applied to the wound are part of the services for CPT codes 97597, 97598 and 97602 and they may not be billed separately.It is not appropriate to report CPT code 97602 in addition to CPT code 97597 and/or 97598 for wound care performed on the same wound on the same date of service.Code(s) 97597, 97598 and 97602 should not be reported in conjunction with code(s) 11042-11047 for the same wound. The wound depth debrided determines the appropriate code.For example, when only biofilm on the surface of a muscular ulceration is debrided, then codes 97597-97598 would be appropriate. If muscle substance was debrided, then the 11043-11046 series would be appropriate, depending on the area.
Article - Billing and Coding: Wound Care (A53001)
Codes 97602, 97605, 97606, 97607 and 97608 include the application of and the removal of any protective or bulk dressings. However, if only a dressing change is performed without any active wound procedure as described by these debridement codes, these debridement codes should not be reported.Generally, whirlpool is a component of CPT codes 97597/97598 and should not be reported separately during the same encounter. Only when there is a separately identifiable service being treated by the therapist, and the documentation supports this treatment, would the service be considered for payment utilizing modifier -59 or a more specific modifier as appropriate (e.g., LT, RT, -XS, etc.).Surgical Debridement  CPT codes 11000-11012 and 11042-11047
Article - Billing and Coding: Wound Care (A53001)
Surgical Debridement  CPT codes 11000-11012 and 11042-11047Dressings applied to the wound are part of the service for CPT codes 11000-11012 and 11042-11047 and may not be billed separately.Medicare does not separately reimburse for dressing changes or patient/caregiver training in the care of the wound. It is only appropriate to provide an Advance Beneficiary Notice of Non-coverage (ABN) for services that are anticipated to be denied due to the absence of medical necessity. Based on this information, an ABN for a dressing change is not appropriate since the costs of the dressing change are packaged into other procedures billed.Debridement of Necrotizing Soft Tissue Infections (CPT codes 11004-11006, and 11008) are inpatient only procedure codes.The CPT guidelines give direction for reporting single wound debridements (CPT codes 11042-11047) that are at different layers in different parts of the wound, and debridement of wounds at the same and different levels. The depth reported for a single wound is the deepest depth of tissue removed. When debridement at the same depth is performed on two or more wounds, the surface areas of the wounds are combined. When the depth of debridement is not the same, the surface areas are not combined.For example, for the debridement codes 11042-11047, when the entire wound surface is debrided, then the measurement of the wound should be taken after the actual debridement procedure is performed. When only a portion of a wound surface is debrided, report the measurement of the area that was actually debrided. If the surface area, depth, and measurement listed in the code descriptor were not performed, then it would not be appropriate to report that code.CPT codes 11042, 11043, 11044, 11045, 11046, and 11047 are used to report surgical removal (debridement) of devitalized tissue from wounds.Use appropriate modifiers when more than one wound is debrided on the same day.
Article - Billing and Coding: Wound Care (A53001)
The use of CPT codes 11042-11047 is not appropriate for the following services: washing bacterial or fungal debris from feet, paring or cutting of corns or calluses, incision and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Report these procedures, when they represent covered, reasonable and necessary services using the CPT/HCPCS code that most closely describes the service supplied.The CPT code selected should reflect the level of debrided tissue (e.g., skin, subcutaneous tissue, muscle and/or bone), not the extent, depth, or grade of the ulcer or wound.For example, CPT code 11042 defined as debridement, subcutaneous tissue should be used if only necrotic subcutaneous tissue is debrided, even though the ulcer or wound might extend to the bone. In addition, if only fibrin is removed, this code would not be billed.Debridement of tissue in the surgical field of another musculoskeletal procedure is not separately reportable. However, debridement of tissue at the site of an open fracture or dislocation may be reported separately with CPT codes 11010-11012.For example, debridement of muscle and/or bone (CPT codes 11043-11044, 11046-11047) associated with excision of a tumor of bone is not separately reportable. Similarly, debridement of tissue (e.g., CPT codes 11042, 11045, 11720-11721, 97597, 97598) superficial to, but in the surgical field, of a musculoskeletal procedure is not separately reportable.The debridement code submitted should reflect the type and amount of tissue removed during the procedure as well as the depth, size, or other characteristics of the wound. Submitting documentation substantiating depth of debridement when billing the debridement procedure described by CPT code 11044 is encouraged.For example, if a wound involves exposed bone but the debridement procedure did not remove bone, CPT code 11044 cannot be billed.