evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Allergy Testing (A57473)
Part B providers indicate the actual number of tests (one for each antigen) in Box 24G of the 1500 claim form. (CMS Pub 100-04Medicare Claim Processing Manual, Chapter 26  Completing and Processing Form CMS-1500 Data Set, Section 10.4  Provider of Service or Supplier Information, Rev. 3881, Issued: 10-13-17, Item 24G). On EMC claims enter the number in the service field.Interpretation of CPT codes: 95004, 95017, 95018, 95024, 95027, 95028, 95044, 95052, and 95065 requires the number of tests which were performed. Enter 1 unit for each test performed. For example, if 18 scratch tests are done, code 95004, 95017 or 95018 with 18 like services. If 36 are done, code 95004, 95017 or 95018 with 36 like services.When photo patch tests (e.g. CPT code 95052) are performed (same antigen/same session) with patch or application tests, only the photo patch testing should be reported. Additionally, if photo testing is performed including application or patch testing, the code for photo patch testing (CPT code 95052) is to be reported, not CPT code 95044 (patch or application tests) and CPT code 95056 (photo tests).Non-covered services include, but are not limited to, the following services:a. Sublingual Intracutaneous and subcutaneous Provocative and Neutralization Testing:Effective October 31, l988, sublingual intracutaneous and subcutaneous provocative and neutralization testing and neutralization therapy for food allergies are excluded from Medicare coverage because available evidence does not show that these tests and therapies are effective.(CMS Pub 100-03Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2 Section 110.11  Food Allergy Testing and Treatment (Rev. 1, 10-03-03).
Article - Billing and Coding: Allergy Testing (A57473)
b. Challenge Ingestion Food Testing: Challenge ingestion food testing has not been proven to be effective in the diagnosis of rheumatoid arthritis, depression, or respiratory disorders. Accordingly, its use in the diagnosis of these conditions is not reasonable and necessary within the meaning of 1862(a)(1) of the Act, and no program payment is made for this procedure when it is so used. (CMS Pub 100-03Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2 Section 110.12 Challenge Ingestion Food Testing (Rev. 1, 10-03-03).c. Cytotoxic Food Tests:Prior to August 5, l985, Medicare covered cytotoxic food tests as an adjunct to in vivo clinical allergy tests in complex food allergy problems. Effective August 5, l985, cytotoxic leukocyte tests for food allergies are excluded from Medicare coverage because available evidence does not show that these tests are safe and effective.(CMS Pub 100-03Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2 Section 110.13 Cytotoxic Food Tests Rev. 1, 10-03-03).Allergy testing is covered when clinically significant symptoms exist, and conservative therapy has failed. Allergy testing includes the performance, evaluation, and reading of cutaneous and mucous membrane testing, along with the physician taking a history including immunologic history, performing the physical examination, deciding on the antigens to be used, and interpreting results.Counseling and prescribing treatment should be reported using a visit.Do not report Evaluation and Management (E/M) services for test interpretation and report.Standard skin testing is the preferred method when allergy testing is necessary. Each test should be billed as one unit of service per procedure code, not to exceed two strengths per each unique antigen. The number of antigens should be individualized for each patient based on history and environmental exposure.A visit to an allergist, which yields a diagnosis of specific allergy sensitivity but does not include immunotherapy, should be coded according to the level of care rendered.
Article - Billing and Coding: Allergy Testing (A57473)
A visit to an allergist, which yields a diagnosis of specific allergy sensitivity but does not include immunotherapy, should be coded according to the level of care rendered.CPT procedure code 95060 is payable in place of service that include office, outpatient hospital (off-campus/on-campus), inpatient hospital, and emergency room  hospital settings.Hospital Inpatient Claims:Effective January 1, 2006, CMS is differentiating single allergy tests (per test) from multiple allergy tests (per visit) by assigning these services to two different APCs. CMS is assigning single allergy tests to newly established APC 0381 and maintaining multiple allergy tests in APC 0370.Hospitals should report charges for the CPT codes that describe single allergy tests (or where CPT instructions direct providers to specify the number of tests) to reflect charges per test rather than per visit and bill the appropriate number of units of these CPT codes to describe all of the tests provided.Coding Guidelines
Article - Billing and Coding: Allergy Testing (A57473)
Per the CMS PubNational Correct Coding Initiative(NCCI)Policy Manual for Medicare Services, Chapter 11- Medicine Evaluation and Management Services, CPT codes 90000-99999, K. Allergy Testing and Immunotherapy.If percutaneous or intracutaneous (intradermal) single test (CPT codes 95004 or 95024) and "sequential and incremental" tests (CPT codes, 95017, 95018, or 95027) are performed on the same date of service, both the "sequential and incremental" test and single test codes may be reported if the tests are for different allergens or different dilutions of the same allergen. The unit of service to report is the number of separate tests. A single test and a sequential and incremental test for the same dilution of an allergen should not be reported separately on the same date of service. For example, if the single test for an antigen is positive and the physician proceeds to sequential and incremental tests with three additional different dilutions of the same antigen, the physician may report one unit of service for the single test code and three units of service for the sequential and incremental test code.Photo patch tests (CPT code 95052) consist of applying a patch(s) containing allergenic substance(s) (same antigen/same session) to the skin and exposing the skin to light. Physicians should not unbundle this service by reporting both CPT code 95044 (patch or application tests) plus CPT code 95056 (photo tests) rather than CPT code 95052.Evaluation and management (E/M) codes reported with allergy testing or allergy immunotherapy are appropriate only if a significant, separately identifiable service is performed. If E/M services are reported, modifier 25 should be utilized.
Article - Billing and Coding: Allergy Testing (A57473)
Evaluation and management (E/M) codes reported with allergy testing or allergy immunotherapy are appropriate only if a significant, separately identifiable service is performed. If E/M services are reported, modifier 25 should be utilized.In general, allergy testing is not performed on the same day as allergy immunotherapy in standard medical practice. Allergy testing is performed prior to immunotherapy to determine the offending allergens. CPT codes for allergy testing and immunotherapy are generally not reported on the same date of service unless the physician provides allergy immunotherapy and testing for additional allergens on the same day. Physicians should not report allergy testing CPT codes for allergen potency (safety) testing prior to administration of immunotherapy. Confirmation of the appropriate potency of an allergen vial for immunotherapy is an inherent component of immunotherapy. Additionally, allergy testing is an integral component of rapid desensitization kits (CPT code 95180) and is not separately reportable.The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.
Article - Billing and Coding: Botulinum Toxin Type A & Type B (A57474)
CMS National Coverage PolicyTitle XVIII of the Social Security Act section 1862 (a)(1)(A). This section allows coverage and payment of those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act section 1862 (a)(7). This section excludes routine physical examinations and services.Title XVIII of the Social Security Act section 1833 (e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated Local Coverage Determination (LCD) L34635 Botulinum Toxin Type A & Type B.Reasons for DenialPayment will not be made for any spastic condition not listed under Codes That Support Medical Necessity such as:Use of botulinum toxin for the treatment of irritable colon, biliary dyskinesia, headaches, craniofacial wrinkles or any treatment of other spastic conditions not listed as covered in this policy are considered to be experimental (including the treatment of smooth muscle spasm).Use of botulinum toxin for patients receiving aminoglycosides, which may interfere with neuromuscular transmission; orUse of botulinum toxin for patients with chronic paralytic strabismus, except to reduce antagonistic contractor in conjunction with surgical repair.Treatment exceeding accepted dosage parameters unless supported by individual medical record review as well as treatments where the goal is to improve appearance rather than function.The corresponding surgery code was not billed.Coding GuidelinesClaim submission must include a diagnosis code.An E & M service will be allowed if documentation supports the patient's condition required a significant, separately identifiable E/M service, above and beyond the procedure performed. Append modifier 25 to the E&M CPT code.To bill medically necessary electromyography guidance, report the appropriate following CPT code(s):92265 Needle oculoelectromyography, one or more extraocular muscles, one or both eyes, with Interpretation and report95873 Electrical stimulation for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure)95874 Needle electromyography for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure)
Article - Billing and Coding: Botulinum Toxin Type A & Type B (A57474)
Medicare provides payment for the discarded drug/biological remaining in a single use drug product after administering what is reasonable and necessary for a patients condition. The rules for billing discarded portions of botulinum toxin are the same as for other drug/biologicals and can be found in the IOM 100-04 Chapter 17, section 40.Effective January 1, 2017 (CR 9603) JW Modifier is required to identify unused drugs or biologicals and providers must record the discarded amounts of drugs and biologicals in the patients medical record.Effective July 1, 2023 (CR 13056) JZ Modifier is required on all claims that bill for drugs separately payable under Medicare Part B when there are no discarded amounts from single-dose containers or single-use packages.Medicare will allow payment for one injection per site regardless of the number of injections made into the site. The site description is included in the CPT code description. Payment will be based on the Medicare Physician Fee Schedule and National Correct Coding Initiative.Documentation RequirementsDocumentation should include the following elements:Support for the medical necessity of the botulinum toxin (type A or type B) injectionA covered diagnosisDosage and frequency of the injectionsSupport for the medical necessity of electromyography procedures performed in conjunction with botulinum toxin type A injections to determine the proper injection site(s)Support of the clinical effectiveness of the injectionsSpecific site(s) injectedThe Medical Record must support the treatment of chronic migraine headaches, with a history of 15 or more headache days a month, 8 which have migraine features.
Article - Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) (A57476)
CMS National Coverage PolicyItalicizedfont represents CMS national language/wording copied directly from CMS Manuals or CMS transmittals. Contractors are prohibited from changing national language.Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment of those services that are considered to be medically reasonable and necessary.Title XVIII of the Social Security Act section 1862 (a) (1) (D). This section states that no Medicare payment may be made under part A or part B for any expenses incurred for items or services that are investigational or experimental.Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim, which lacks the necessary information to process the claim.42 CFR, Section 410.32Diagnosis x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. (a) Ordering diagnostic tests. All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses ther results in the management of the beneficiarys specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.42 CFR, Section 411.15(k)(1) states any services that are not reasonable and necessary are excluded from coverage.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) L34636GuidelinesThe HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This information does not take precedence over CCI edits. Please refer to CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.1. CPT codes for Holter monitoring services (CPT codes 93224-93227) are intended for up to 48 hours of continuous recording.
Article - Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) (A57476)
The documentation in the progress notes must reflect medical necessity for the service.These services may be reported globally with CPT codes 93224. Use the date of physician review as the date of service (DOS).When submitting claims for the recording only (CPT code 93225) or for the analysis with report only (CPT code 93226) use the date the service was performed as the DOS.When submitting claims for physician review and interpretation (CPT code 93227) use the date the service was performed as the DOS.For less than 12 hours continuous recording, modifier -52 (reduced services) should be appended.2. List the diagnosis code(s) indicating the reason for the test.3. The physician interpreting the test must be identified on the claim form with his/her sequence number in Box 24K.4. The codes describing technical work may be billed by an independent diagnostic testing facility (IDTF) if they meet all requirements listed in the code descriptions and coverage requirements. They may bill the total component only if the physician interpreting the test is employed or contracted by the IDTF and is not billing for the interpretation separately. The physician's name and address must be on record with our WPS Provider Enrollment Department. A letter should be sent by the physician assigning all monies collected by the IDTF for the professional codes to the billing IDTF. If a letter is not on file, professional services billed by the IDTF will be denied.5. Do not use the "TC" or "26" modifier with the codes 93224-93229, 93268, 93270, 93271, or 93272, listed in the CPT/HCPCS section of the LCD.6. For the same dates of service, either the wearable patient monitor or the up to 48-hour monitor will be covered (not both).External Mobile Cardiac Telemetry MonitorsCPT codes 93228 and 93229 describe wearable mobile cardiovascular telemetry services. Providers are instructed to bill one (1) unit of procedure code 93228 and/or 93229 per a course of treatment that includes up to 30 consecutive days of cardiac monitoring.CPT code 93229 is the technical component of this service and includes all of the following within a course of treatment that includes up to 30 consecutive days of cardiac monitoring:
Article - Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) (A57476)
Patient hook-up and patient-specific instruction and educationTransmission and receipt of ECGAnalysis of ECG by nonphysician personnelMedical chart documentation including daily report, patient and/or physician interaction and response, and summary report at the end of the monitoring episodeEquipment maintenanceAll supplies necessary for completion of the monitoring.CPT code 93228 is the professional component of this service and includes review and interpretation of each 24-hour cardiac surveillance as well as 24-hour availability and response to monitoring events within a course of treatment that includes up to 30 consecutive days of cardiac monitoring.The following documentation requirements apply to all claims reporting CPT code 93228 and/or 93229:The date of service must be reported as the date the patient was initially placed on the monitor.A monitoring episode (one to 30 consecutive days) is reported as a unit of one.Any additional claims reporting procedure code 93228 or 93229 for ECG arrhythmia detection and alarm system within an episode of care (one to 30 days after an initial service) will be denied.Types of monitoring and coverage:
Article - Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) (A57476)
Types of monitoring and coverage:CPT Codes 93224-93227Continuous up to 48-hour Monitoring (CPT codes 93224-93227), includes a coverage period of up to 48-hours for one unit of service. No other EKG monitoring codes can be billed simultaneously with these codes.CPT Codes 93241-93248Long-term continuous recorders continuously record and store for greater than 48 hours and up to 7 days or for greater than 7 days up to 15 days. No other EKG monitoring codes can be billed simultaneously with these codes and services represented by these codes are non- covered for inpatient or outpatient observation care. (Refer to current CPT codebook)CPT codes 93268-93272Cardiac event monitor technology varies among different devices. For patient-activated event monitors, the patient initiates recording when symptoms appear or when instructed to do so by a physician (e.g., following exercise). For self-sensing automatically triggered monitors, an EKG is automatically recorded when the device detects an arrhythmia, without patient intervention. Some devices permit a patient to transmit EKG data transtelephonically (i.e., via telephone) to a receiving center where the data is reviewed. A technician may be available at these centers to review transmitted data 24 hours per day. In some instances, when the EKG is determined to be outside certain pre-set criteria by a technician or other non-physician, a physician is available 24 hours per day to review the transmitted data and make clinical decisions regarding the patient. These services are known as 24-hour attended monitoring". In other instances, transmitted EKG data is reviewed at a later time and are, therefore, considered "non-attended." (CMS Pub 100-03, Medicare National Coverage Determinations (NCD) Manual,Chapter 1, Part 1, 20.15 Electrocardiographic Services).The person receiving the transmission must be a technician, nurse, or a physician trained in interpreting ECG's and abnormal rhythms.A physician must be available 24 hours a day for immediate consultation to review the transmission in case of significant symptoms or ECG abnormalitiesNationally Non-Covered IndicationsThe following indications are non-covered nationally unless otherwise specified below:
Article - Billing and Coding: Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) (A57476)
The time-sampling mode of operation of ambulatory EKG cardiac event monitoring/recording.Separate physician services other than those rendered by an IDTF unless rendered by the patient'sattending or consulting physician.Home EKG services without documentation of medical necessity.Emergency EKG services by a portable x-ray supplier without a physician in attendance at the time ofthe service or immediately thereafter.24-hour attended coverage used as early post-hospital monitoring of patients discharged after MI unless provision is made for such 24-hour attended coverage in the manner described in section 4 above.(CMS Pub 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1- Coverage Determinations, 20.15 Electrocardiographic Services)
Article - Billing and Coding: Mohs Micrographic Surgery (A57477)
CMS National Coverage PolicyItalicizedfont represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording.Social Security ActTitle XVIII of the Social Security Act (SSA):Title XVIII of the Social Security Act, Sections 1861 [s] [1], only physicians (MD/DO) may perform this procedure.Title XVIII of the Social Security Act, 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.Title XVIII of the Social Security Act, Section 1833(e), this section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Publications:CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15  Covered Medical and Other Health Services, 30 - Physician Services.CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16  General Exclusions From Coverage, 120 - Cosmetic Surgery.CMS Pub. 100-04, Medicare Claims Processing Manual,Chapter 12  Physicians/Nonphysician Practitioners, 40-40.6, Surgeons and Global Surgery.CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 12  Physicians/Nonphysician Practitioners, 60, Payment for Pathology Services.CMS Transmittal No. 434, Pub. 100-04, Medicare Claims Processing Manual, Change Request #3458, January 14, 2005, Addition of CLIA Edits to Certain Health Care Procedure Coding System (HCPCS) Codes for Mohs Surgery.CMS Transmittal No, 857, effective date October 3, 2018 Change Request 10901 Local Coverage Determinations (LCDs) Implementation date January 8, 2019.Article Text