evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Radiation Therapies (A59350)
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.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, 70.5 Radiation Physics Services (CPT Codes 77300  77399)CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, 200.3 Billing Codes for Intensity Modulated Radiation Therapy (IMRT) and Stereotactic Radiosurgery (SRS), 200.3.1 Billing Instructions for IMRT Planning and Delivery, 200.3.2 Billing for Multi-Source Photon (Cobalt 60-Based) Stereotactic Radiosurgery (SRS) Planning and DeliveryMLN Matters Number: SE18013. Intensity-Modulated Radiation Therapy (IMRT) Planning Services Editing. September 11, 2018.CR9658, July 2016 Update of the Hospital Outpatient Prospective Payment System (OPPS)OIG Report, Audit (A-09-16-02033), 08-15-2018Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Radiation TherapiesL39553.Documentation RequirementsAll documentation must be maintained in the patient's medical record. The documentation must support the medical necessity of the services as specified in this article and it must be 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 and credentials of the physician, non-physician practitioner, dosimetrist, physicist or radiation therapist responsible for and providing the described care for the patient.The submitted medical record must support the use of the selected ICD-10-CM diagnosis code(s). The submitted CPT/HCPCS code(s) must describe the service performed. It is the providers responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM and CPTcode books appropriate to the year in which the service is rendered for the claim(s) submitted.
Article - Billing and Coding: Radiation Therapies (A59350)
For all radiation therapy, the medical record must include the patients primary diagnosis for which the prescribed radiation therapy is needed, the patients history for this illness as well as active co-morbid medical conditions, the patients performance status when applicable and as required by the LCD, any relevant imaging reports, the proposed treatment plan, the number and location and size of tumors that are present, the stage of disease, and the anatomic site of the radiation delivery.For any type of radiation therapy for non-cancer diagnosis coverage (such as, but not limited to epilepsy, trigeminal/facial nerve applications, movement disorders, Parkinsons disease, tremor conditions), it is important to clearly and very specifically document to the prior therapies tried and failed. Names of therapies and durations given and whether improvement or worsening occurred is crucial to support a decision to proceed with aggressive radiation therapy. Failure to document with specificity and precision related to the past diagnostic and attempted treatment for a condition as it relates to a unique beneficiary may well result in a non-coverage decision due to lack of reasonable and necessary standards having been met.For Stereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS), the patients record must support the medical necessity of treatment. Supporting clinical records must include not only the patients medical history and physical examination findings, but also the patients current functional status, as described by an overall performance status score (e.g., Karnofsky Performance Status (KPS) or Eastern Cooperative Oncology Group (ECOG) Performance Status score). A radiation oncologist must evaluate the clinical and technical aspects of the treatment and document this evaluation as well as the resulting management decision. Justification for aggressive local therapy to 1 or more deposits of metastatic cancer for either total disease clearance in the setting of oligometastatic disease or to reduce overall burden of systemic disease for a specifically defined clinical benefit must be documented. In the case of recurrent disease requiring palliation or when tumor cannot be treated as effectively or safely by other radiotherapy methods due to proximity of previously irradiated volumes, documentation to those beneficiary unique facts must be documented in the medical record.
Article - Billing and Coding: Radiation Therapies (A59350)
Medical record documentation maintained by the provider must indicate the medical necessity for radiation oncology procedure as outlined in the LCDL39553 and must include ALL of the following for a radiation oncology procedure which employs inverse planning:The type of radiation therapy that will be delivered must be precisely documented and cannot be inferred from the equipment or technology or computerized optimization being utilized.The type of radiation therapy planning that was ultimately used must be precisely documented and cannot be inferred from the equipment or technology or computerized optimization being utilized.A treatment plan/prescription must be present and must define the goals and requirements of the treatment, including the specific dose constraints for the target(s) and nearby critical structures.A statement by the treating physician documenting the special advantages and genuine need for performing the specified radiation therapy delivery type and planning type on the patient in question, especially in comparison to conventional forward treatment planning and/or delivery. With IMRT planning and delivery documentation, the physician must address the other organs at risk (OAR) or adjacent critical structures.Review by the radiation oncologist of the radiologic images of the target and all critical structures with representative isodose distributions that characterize the three-dimensional (3D) dose. The document containing this review must be signed with credentials and dated.Radiation oncologist review of dose-volume histograms for all targets and critical structures specifically documented as reviewed or authenticated via signature with credentials and date.Description of the number and location of each treatment step/rotation or portal to accomplish the treatment plan.Documentation of dosimetric verification of treatment setup and delivery, signed by both the radiation oncologist and the medical physicist with a legible signature and credentials and date.For compensator-based radiation therapy delivery, the unique compensator design should be documented for each step or portal.Documentation of fluence distributions recomputed in a phantom, or an equivalent methodology consistent with patient specific treatment verification.Target verification methodology documentation to include documentation of the clinical treatment volume (CTV) and the planning target volume (PTV); documentation of immobilization/patient positioning, and means of dose verification and secondary means of verification.Other procedures performed during the episode of care must have documentation that supports the professional and technical components by identifying the place of service, the date of service, the supervising physician, and proof of work provided.
Article - Billing and Coding: Radiation Therapies (A59350)
Other procedures performed during the episode of care must have documentation that supports the professional and technical components by identifying the place of service, the date of service, the supervising physician, and proof of work provided.If applicable, when billing for respiratory management simulation, documentation must be present that identifies structures that move between high- and low-dose regions due to respiration. The documentation must include the medical necessity of this service. This is more extensive documentation than what would occur with just a simulation note since it is part of the isodose planning process. Since the work occurs over several days and involves the therapists, the dosimetrist, the physicist and the physician, the narrative supporting this service would and should appear in several documents. The simulation note should document the physician review of respiratory motion management set-up and use at the time of simulation. The treatment plan document must indicate that the physician created and intended to cover the target volume in all phases of respiratory motion.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.CPT/HCPCS code(s) may be subject to National Correct Coding Initiative (NCCI) edits. Please refer toNCCI Policy Manualfor correct coding guidelines and specific applicable code combinations prior to billing Medicare.
Draft Article - Billing and Coding: Lab: Special Histochemical Stains and Immunohistochemical Stains (DA56838)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.1 Independent Laboratory Specimen Drawing, 60.2. Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Lab: Special Histochemical Stains and Immunohistochemical Stains DL35922.Hematoxylin and eosin (H&E) staining provides excellent detail required for tissue-based diagnosis. This is NOT a separate service, as pathology services include routine H&E staining.Some physicians, groups, laboratories and hospitals submit global claims for the services described in the related LCD. In other instances, there are separate individuals or entities providing the professional and the technical services. It is the obligation of each party to recognize that they are responsible for the medical necessity of the services submitted.To report special histochemical stains and/or immunohistochemical stains services, please submit the following claim information:Select the appropriate CPTcodeEnter 1 unit of service (UOS)
Draft Article - Billing and Coding: Lab: Immunohistochemistry (IHC) Indications for Breast Pathology (DA53704)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.Article TextBased on recommendations from the College of American Pathologists (CAP), the American Society of Clinical Oncologists (ASCO) and the National Comprehensive Cancer Network (NCCN), hormone receptor assays, estrogen receptor (ER), progesterone receptor (PR), and Her-2/neu are the only current biomarkers that demonstrate standardized value in breast cancer pathology evaluation. Although other biomarkers, such as Ki-67, PI3K, and gene expression assays, have been studied, no proven standardized value has been established. Therefore, this A/B MAC will allow ER, PR, and Her2 testing by IHC for patients with primary invasive breast cancers and recurrent or metastatic cancers.To report an IHC service for an ER, PR, Her2, submit the following claim information:CPTCodeSpecimenUOS88342First single/multiplex stain188341Each additional2To report morphometric analysis,select 1of the following codes based on the type of morphometric analysis:CPTCodeService TypeUOS88360Manual388361Computer-assisted3Note: a unit of service applies to a single separately identifiable specimen.
Draft Article - Billing and Coding: Scalp Cooling for the Prevention of Chemotherapy-Induced Alopecia (DA59371)
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.CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2,110.6Scalp Hypothermia During Chemotherapy to Prevent Hair Loss is not a barrier to coverage or to pricing/payment of the Category III Temporary CPTcodes for professional/facility services related to scalp cooling (CPTCodes 0662T and 0663T). The NCD, while very old, serves as a benefit category/policy statement. As indicated in the NCD, the cap itself is considered a supply. Supplies are coverable incident to a physicians professional service and/or hospital outpatient service, meaning that payment for supplies is packaged into the payment for professional services and hospital facility service.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Scalp Cooling for the Prevention of Chemotherapy-Induced AlopeciaDL39573.Documentation RequirementsAll documentation must be maintained in the patients medical record and available to the contractor upon request.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 directed in the related LCD.
Article - Billing and Coding: Scalp Cooling for the Prevention of Chemotherapy-Induced Alopecia (A59371)
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.CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2,110.6Scalp Hypothermia During Chemotherapy to Prevent Hair Loss is not a barrier to coverage or to pricing/payment of the Category III Temporary CPTcodes for professional/facility services related to scalp cooling (CPTCodes 0662T and 0663T). The NCD, while very old, serves as a benefit category/policy statement. As indicated in the NCD, the cap itself is considered a supply. Supplies are coverable incident to a physicians professional service and/or hospital outpatient service, meaning that payment for supplies is packaged into the payment for professional services and hospital facility service.Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Scalp Cooling for the Prevention of Chemotherapy-Induced AlopeciaL39573.Documentation RequirementsAll documentation must be maintained in the patients medical record and available to the contractor upon request.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 directed in the related LCD.
Draft Article - Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound (DA59374)
CMS National Coverage PolicyTitle 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) DL39575 Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound.
Article - Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound (A59374)
CMS National Coverage PolicyTitle 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) L39575 Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound.
Draft Article - Billing and Coding: Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH) (DA57926)
CMS National Coverage PolicyN/AArticle TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD)L38378-Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH).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.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.
Draft Article - Billing and Coding: MolDX: Molecular Biomarker Testing for Risk Stratification of Cutaneous Squamous Cell Carcinoma (DA59380)
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.CMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Biomarker Testing for Risk Stratification of Cutaneous Squamous Cell Carcinoma.To receive a denial, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate 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 the appropriate 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 formSelect the appropriate ICD-10-CM code
Draft Article - Billing and Coding: MolDX: Molecular Biomarker Testing for Risk Stratification of Cutaneous Squamous Cell Carcinoma (DA59382)
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.CMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Biomarker Testing for Risk Stratification of Cutaneous Squamous Cell Carcinoma.To receive a denial, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate 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 the appropriate 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 formSelect the appropriate ICD-10-CM code
Draft Article - Billing and Coding: MolDX: Molecular Biomarker Testing for Risk Stratification of Cutaneous Squamous Cell Carcinoma (DA59386)
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.CMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Molecular Biomarker Testing for Risk Stratification of Cutaneous Squamous Cell Carcinoma.To receive a denial, please submit the following claim information:Select appropriate CPTcodeEnter 1 unit of service (UOS)Enter the appropriate 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 837PItem19 for paper claimEnter the appropriate 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 formSelect the appropriate ICD-10-CM code
Draft Article - Billing and Coding: Urine Drug Testing (DA55001)
CMS National Coverage PolicyN/AArticle TextThis article contains coding that complements the Local Coverage Determination (LCD) for Urine Drug Testing.Coding Guidelines: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. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Draft Article - Billing and Coding: Urine Drug Testing (DA55030)
CMS National Coverage PolicyN/AArticle TextThis article contains coding that complements the Local Coverage Determination (LCD) for Urine Drug Testing.Coding Guidelines: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. For diagnostic tests, report the results of the test if known; otherwise the symptoms prompting the performance of the test should be reported.