evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Non-Invasive Peripheral Arterial Vascular Studies (A57593)
Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD.DocumentationAdequate documentation is essential for high-quality patient care and to demonstrate the reasonableness and medical necessity of the study(ies). Documentation must support the criteria as described in the Coverage Indications, Limitations, and/or Medical Necessity section of this LCD. There should be a permanent record of the studies performed and the interpretation. The documentation should include a description of the studies performed and any contrast media and/or radiopharmaceuticals used. Any known significant patient reaction or complications should be recorded. Comparison with prior relevant studies needs to be addressed in the documentation along with both normal and abnormal findings. Variations from normal should be documented along with measurements. The report should address or answer any specific clinical questions. If there are factors that prevent answering the clinical questions, this should be explained in the documentation. Retention of the ultrasound examination images and final interpretation should be consistent both with clinical need and with relevant legal and local health care facility requirements.If the provider of the study is other than the ordering/referring physician/nonphysician practitioner, that provider must maintain a copy of the test results and interpretation, along with copies of the ordering/referring physician/nonphysician practitioners order for the studies. This order is required to provide adequate diagnostic information to the performing provider. The physician/nonphysician practitioner must state the clinical indication/medical necessity for the study in his/her order for the test. The provider is responsible for ensuring the medical necessity of procedures and maintaining the medical record, which must be available to Medicare upon request. Results of all testing must be shared with the referring physician. Non-invasive vascular studies are medically reasonable and medically necessary only if the outcomes will be utilized in the clinical management of the patient.Utilization GuidelinesEach patients condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each study reported to be clearly documented in the patients medical record.Frequency of follow-up studies will be carefully monitored for medical necessity and it is the responsibility of the physician/provider to maintain documentation of medical necessity in the patients medical record.
Article - Billing and Coding: Non-Invasive Peripheral Arterial Vascular Studies (A57593)
Frequency of follow-up studies will be carefully monitored for medical necessity and it is the responsibility of the physician/provider to maintain documentation of medical necessity in the patients medical record.Generally, it is expected that noninvasive vascular studies would not be performed more than once in a year, excluding inpatient hospital (21) and emergency room (23) places of services.Only one preoperative scan is considered reasonable and necessary for bypass surgery. If a more current preoperative scan is indicated for a patient with multiple comorbidities having difficulty being stabilized for surgery or a change in condition, the medical record would need to support the medical necessity of the second scan.In the immediate post-operative period, patients may be studied if re-established pulses are lost, become equivocal, or if the patient develops related signs and/or symptoms of ischemia with impending repeat intervention.The frequency of medically necessary follow-up noninvasive vascular studies post-angioplasty is dictated by the vascular distribution treated.Pre-surgical conduit mapping of the radial artery(ies) should only be accompanied by vein-mapping studies when the arterial studies demonstrate a non-acceptable conduit, or an insufficient conduit is available for multiple bypass procedures.Duplex scanning and physiologic studies may be reimbursed during the same encounter if the physiologic studies are abnormal and/or to evaluate vascular trauma, thromboembolic events or aneurysmal disease. The documentation must support the medical necessity.Assessment of the Ankle brachial indices (ABI) only is considered part of the physical examination and is not covered according to Title XVIII of the Social Security Act section 1862 (a) (7) which excludes routine physical examinations and services from Medicare coverage.Preventive and/or screening services unless covered in Statute are not covered by Medicare.
Article - Billing and Coding: Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies (A57594)
CMS National Coverage PolicyItalicized fontrepresents CMS national NCD language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national NCD language/wording.Title XVIII of the Social Security Act section 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act section 1862 (a) (1) (A) allows coverage and payment of those items or services that are considered to bemedically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act section 1862 (a) (1) (D) excludes Medicare payment for any expenses incurred for items or services that are investigational or experimental.Title XVIII of the Social Security Act section 1862 (a) (7) excludes routine physical examinations and services from Medicare coverage.42 CFR, Section 410.32 Diagnosis x-ray tests, diagnostic laboratory tests, and other diagnostic indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiarys specific medical problem. Tests not ordered by the physician or other qualified non-physician provider who is treating the patient are not reasonable and necessary (see 42 CFR 411.15(k) (1).42 CFR, Section 410.32 (b)Diagnostic x-ray and other diagnostic tests. (1) Basic rule. .. all diagnostic x-ray and other diagnostic tests covered under section 1861(s)(3) of the Act and payable under the physician fee schedule must be furnished under the appropriate level of supervision by a physician as defined in section 1861 of the Act. Services furnished without the required level of supervision are not reasonable and necessary. (see 42 CFR 411.15(k)(1)).CMS Pub. 100-02Medicare Benefit Policy Manual, Chapter 11  End Stage Renal Disease, Section 40  Other Services.Chapter 15  Covered Medical and Other Health Services, Section80  Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests.
Article - Billing and Coding: Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies (A57594)
Chapter 15  Covered Medical and Other Health Services, Section80  Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests.CMS Pub 100-03Medicare National Coverage Determinations (NCD) Manual, Chapter 1  Coverage Determinations Part 1, Section20.14  Plethysmography andPart 4, Sections 220.5 - Ultrasound Diagnostic Procedures,CMS Pub 100-04Medicare Claims Processing Manual, Chapter 7  SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule), Section50  Billing Part B Radiology Services and Other Diagnostic Procedures;Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/ Supplier Claims, Sections 140  Monthly Capitation Payment Methods for Physicians Services Furnished to Patients on Maintenance Dialysis. A.  Services Included in Monthly Capitation Payment and180 - Noninvasive Studies for ESRD Patients - Facility and Physician Services;Chapter 13  Radiology Services and Other Diagnostic Procedures, Sections 10.1 Billing Part B Radiology Services and Other Diagnostic Procedures and20  Payment Conditions for Radiology Services; andChapter 16  Laboratory Services, Section40.2  Payment Limit for Purchased Services, andChapter 23  Fee Schedule Administration and Coding Requirements, Addendum  MPFSDB Record Layouts.CMS Pub 100-08,Medicare Program Integrity Manual, Chapter 13  Local Coverage Determinations, Section 13.5.1  Reasonable and Necessary Provisions in LCDs.CMS Publication 100-09,Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5 - Correct Coding Initiative.
Article - Billing and Coding: Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies (A57594)
Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD.Documentation RequirementsAdequate documentation is essential for high-quality patient care and to demonstrate the reasonableness and medical necessity of the study(ies). Documentation must support the criteria as described in the Coverage Indications, Limitations, and/or Medical Necessity section of this LCD. There should be a permanent record of the performed studies and interpretation. The documentation should include a description of the studies performed and any contrast media and/or radiopharmaceuticals used. Any known significant patient reaction or complications should be recorded. Comparison with prior relevant studies needs to be addressed in the documentation along with both normal and abnormal findings. Variations from normal should be documented along with measurements. The report should address or answer any specific clinical questions. If there are factors that prevent answering the clinical questions, this should be explained in the documentation. Retention of the ultrasound examination images should be consistent both with clinical need and with relevant legal and local health care facility requirements.If the provider of the study is other than the ordering/referring physician/nonphysician practitioner, that provider must maintain a copy of the test results and interpretation, along with copies of the ordering/referring physician/nonphysician practitioners order for the studies. This order is required to provide adequate diagnostic information to the performing provider. The physician/nonphysician practitioner must state the clinical indication/medical necessity for the study in his/her order for the test. The provider is responsible for ensuring the medical necessity of procedures and maintaining the medical record, which must be available to Medicare upon request. Results of all testing must be shared with the referring physician. Non-invasive vascular studies are medically reasonable and medically necessary only if the outcomes will be utilized in the clinical management of the patient.Utilization GuidelinesEach patients condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each study reported to be clearly documented in the patients medical record.Frequency of follow-up studies will be carefully monitored for medical necessity and it is the responsibility of the physician/provider to maintain documentation of medical necessity in the patients medical record.
Article - Billing and Coding: Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies (A57594)
Frequency of follow-up studies will be carefully monitored for medical necessity and it is the responsibility of the physician/provider to maintain documentation of medical necessity in the patients medical record.Generally, it is expected that noninvasive vascular studies would not be performed more than once in a year, excluding inpatient hospital (21) and emergency room (23) places of services.Only one preoperative scan is considered reasonable and necessary for hemodialysis access site surgery. If a more current preoperative scan is indicated for a patient with multiple comorbidities having difficulty being stabilized for surgery or a change in condition, the medical record would need to support the medical necessity of the second scan.Only one limited study is considered reasonable and necessary post operatively within 72 hours of a saphenous vein ablation, whether surgery is performed on one side or bilaterally.Pre-surgical conduit mapping of the radial artery(ies) should only be accompanied by vein-mapping studies when the arterial studies demonstrate a non-acceptable conduit, or an insufficient conduit is available for multiple bypass procedures.Duplex scanning and physiologic studies may be reimbursed during the same encounter if the physiologic studies are abnormal and/or to evaluate vascular trauma, thromboembolic events or aneurysmal disease. The documentation must support the medical necessity.Documentation must be provided supporting the need for more than one imaging study Doppler flow or vessel mapping and arteriogram.Performance of both non-invasive extracranial arterial studies and non-invasive evaluation of extremity veins during the same encounter is not appropriate as a general practice or standing protocol, and therefore, generally would not be expected to be done together. Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same encounter.Preventive and/or screening services unless covered in Statute are not covered by Medicare.
Article - Billing and Coding: Pelvic Floor Dysfunction: Anorectal Manometry and EMG (A57595)
CMS National Coverage PolicyTitle XVIII of the Social Security Act Section 1833 (e). This section states that no payment shall be made to any provider for any claims that lack necessary information to process the claim.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)(7). This section excludes routine physical examinations and services.CMS Pub. 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 1, Section 30.1.1 Biofeedback Therapy for Treatment of Urinary Incontinence.CMS Pub. 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 230.8 Non-Implantable Pelvic Floor Electrical Stimulator.CMS Pub. 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 230.18 Sacral Nerve Stimulation for Urinary Incontinence.42 Code of Federal Regulations, 410.32Italicized font-represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD.Documentation
Article - Billing and Coding: Pelvic Floor Dysfunction: Anorectal Manometry and EMG (A57595)
Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD.DocumentationA complete history and physical containing the following minimum requirements must be in the medical record: complete history to include the following areas- duration and characteristics of the urinary or fecal incontinence, frequency, timing and amount of continent voids and incontinent episodes, precipitants of incontinence, other urinary symptoms, bowel habits, daily fluid intake, alteration in sexual function due to urinary or fecal incontinence, amount and type of perineal pads or protective devices, previous treatments for urinary or fecal incontinence and the effects of that treatment on the incontinence; neurological exam; physical exam of the patient that is usually guided by the history and reason for being seen. This could include a pelvic exam in women to assess for skin condition, genital atrophy, pelvic organ prolapse, pelvic masses, paravaginal muscle tone and any other abnormalities; abdominal exam, genital exam in men, rectal exam to assess perineal sensation, resting and active sphincter tone, fecal impaction, presence of masses and in men, the consistency and contour of the prostate; past surgeries and pregnancy history in females.Utilization GuidelinesAnorectal Manometry and Pelvic Floor Electromyography are diagnostic tests and shouldnotbe performed on a routine basis. Medicare wouldnotexpect to see an Anorectal Manometry billed when the physician is trying to evaluate urinary incontinence. Medicare wouldnotexpect these tests to be billed more thantwicein a lifetime.The CPT Codes for Anorectal Manometry and Pelvic Floor Electromyography are diagnostic. They are not a medically necessary part of physical therapy, rehabilitation, biofeedback, or exercise program treatment plans.
Article - Billing and Coding: Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain (A57596)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act, Section 1862(a)(1)(A) allows coverage and payment for services considered medically reasonable and necessary.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD L36000 Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain.Documentation RequirementsAll documentation must be maintained in the patients medical record and 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 record must include the name of the physician or non-physician practitioner responsible for and providing the care of the patient.
Article - Billing and Coding: Somatosensory Testing (A57597)
CMS National Coverage PolicyItalicized fontrepresents 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 (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessaryinformation to process the claim.Code of Federal Regulations:42 CFR, Section 410.32, indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).CMS Publications:CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic TestsCMS Publication 100-03, Medicare Benefit Policy Manual, Chapter 1, Part 2: Section 160.23 Sensory Nerve Conduction Threshold Tests (sNCTs)CMS Publication 100-04, Medicare Benefit Policy Manual, Chapter 23 - Fee Schedule Administration and Coding Requirements: Section 10 - Reporting ICD Diagnosis and Procedure CodesArticle TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD.Utilization Guidelines
Article - Billing and Coding: Somatosensory Testing (A57597)
It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.The Medicare Physician Fee Schedule Database (MPFSDB) physician supervision indicator for CPT codes 95925, 92526, 95927 and 95938 have Level 21 for the technical component. Level 21 defined as:Procedure may be performed by a technician with certification under general supervision of a physician. Otherwise the procedure must be performed under direct supervision of a physician. Procedure may also be performed by a PT with ABPTS certification without physician supervision.Program Memorandum Transmittal B-01-28/Change Request 850 sets forth revised levels of physician supervision required for diagnostic tests payable under the Medicare Physician Fee Schedule. Effective July 1, 2001, certain codes in the range of CPT 95860-95937 were assigned new supervision levels (21, 22, 6a, 66, 77 or 77a). This implementation date would make it possible for physical therapists to acquire the certification required to perform these services without supervision. A physical therapist who is presently certified by the American Board of Physical Therapy Specialties can perform procedures assigned level of 21, 22, 66, 6a, 77, or 77a without supervision. These numeric levels assigned to the CPT codes are listed in the Medicare Physician Fee Schedule Database (MFSDB).Physical therapists who do not possess the ABPTS (American Board of Physical Therapy Specialties) certification by July 1, 2001, may continue to furnish those tests that require the certification if they have been furnishing such diagnostic tests prior to May 1, 2001.Therefore, if authorized by state law Physical Therapists are allowed the technical portion of the test.