evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents (A53049)
The vial/package must be a single-use vial/package.The units billed must correspond with the smallest dose (vial) available for purchase from the manufacturer/supplier that could provide the appropriate dose for the patient.The left-over amount must actually be discarded and may not be used for another patient regardless of whether or not that other patient has Medicare.A situation in which the JW modifier is not permitted is when the actual dose of the drug or biological administered is less than the billing unit. For example, one billing unit for a drug is equal to 10mg of the drug in a single use vial. A 7mg dose is administered to a patient while 3mg of the remaining drug is discarded. The 7mg dose is billed using one billing unit that represents 10mg on a single line item. The single line item of 1 unit would be processed for payment of the total 10mg of drug administered and discarded. Billing another unit on a separate line item with the JW modifier for the discarded 3mg of drug is not permitted because it would result in overpayment. Therefore, when the billing unit is equal to or greater than the total actual dose and the amount discarded, the use of the JW modifier is not permitted.JZ Modifier RequirementEffective 07/01/2023, providers must report the JZ modifier (Zero drug amount discarded/not administered to any patient) when there is no wastage to report. This must be reported on all claims that bill for drugs separately payable under Part B when there is no discarded amount from single-dose containers or single-use packages. For the amount administered, the claim line must include the billing and payment code, the JZ modifier showing no discarded amounts, and the number of units administered in the units field.The JW and JZ modifier policy does not apply for drugs that are not separately payable, such as packaged OPPS or ASC drugs, or drugs administered in the FQHC or RHC setting or to drugs assigned status indicator N (Items and Services Packaged into APC Rates) under the OPPS. Similarly, the JW and JZ modifiers do not apply to drugs assigned payment indicator N1 (ASC).
Article - Billing and Coding: Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents (A53049)
Coding GuidanceThe HCPCS/CPT code(s) may be subject to NCCI edits. This information does not take precedence over NCCI edits. Please refer to the NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.All injection claims must include the specific name of the drug and dosage. Identification of the drug enables proper payment for the services.Services related to non-covered services or drugs are also not covered (e.g., administration services).When the drug is purchased by the beneficiary, or when the drug was supplied without charge by the manufacturer, it should NOT be billed to Medicare by the provider, even with a submitted charge of $0.00.Reporting the Appropriate Number of UnitsIf the "J" code descriptor can be multiplied to reflect the dosage being administered, use the J-code, with the appropriate number of units which reflect the dosage given.It is not appropriate to use the "J" code with a multiplier in the units field when there is another "J" code which more closely describes the amount given.It is not appropriate to bill for the full amount of a drug when it has been split between two or more patients. Bill only for the amount given to each beneficiary.Reporting Not Otherwise Classified (NOC) Code(s)Please refer to Billing and Coding Articles A59073, Complex Drug Administration Coding for information regarding billing NOC codes.
Article - Billing and Coding: Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents (A53049)
Reporting Not Otherwise Classified (NOC) Code(s)Please refer to Billing and Coding Articles A59073, Complex Drug Administration Coding for information regarding billing NOC codes.Reporting Evaluation and Management (E/M) Visit on the Same Day as Drug Administration ServicesThe E/M service for CPT code 99211 cannot be paid if it is billed with a drug administration service. This includes a chemotherapy or nonchemotherapy drug infusion service, as well as a therapeutic or diagnostic injection code.When a medically necessary, significant and separately identifiable E/M service (which meets a higher complexity level than CPT code 99211) is performed, in addition to drug administration service(s), the appropriate E/M CPT code should be reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required.Please refer to the CMS IOM Publication 100-04, Chapter 12, Sections 20.3.B, 30.5.C, D, F, 30.6.6 and 30.6.7.D for additional information on E/M services furnished on the same day as drug administration services.Please refer to Billing and Coding Articles A59073, Complex Drug Administration Coding for information regarding chemotherapy and nonchemotherapy drug administration codes.
Article - Billing and Coding: Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents (A53049)
Reporting Multiple Infusions or InjectionsWhen administering multiple infusions, injections, or combinations, only one "initial" drug administration service code should be reported per patient per day, unless protocol requires that two separate IV sites must be used. The initial code is the code that best describes the key or the primary reason for the encounter and is reported irrespective of the order in which the infusions or injections occur.If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, the subsequent or concurrent code from the appropriate section should be reported (e.g., the first IV push given subsequent to an initial one-hour infusion is reported using a subsequent IV push code).Report separate codes for each parenteral method of administration employed when therapy is administered by different techniques. Medications (e.g., antibiotics, steroidal agents, antiemetics, narcotic analgesics) administered independently or sequentially as supportive management of chemotherapy or certain monoclonal antibody administration should be separately reported using CPT codes 96360, 96361, 96365 or 96379 as appropriate. Report the specific service as well as the code(s) for the specific substance or drug(s) provided.There is no code for concurrent administration of chemotherapeutic drugs. Multiple drugs given at the same session are considered to be sequential, rather than concurrent. The services are reported with CPT code 96411 for IV push administration of additional drugs/substances at the same session and CPT code 96417 for IV infusion administration of additional drugs/substances at the same session.Modifier EJ  Subsequent Dose in a SeriesTo distinguish between the initial dose of a drug and subsequent doses of that same drug used in a sequential series in the treatment of a condition, the modifier EJ should be used to identify the subsequent doses. Do not report an initial dose of a drug with the EJ modifier.
Article - Billing and Coding: Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents (A53049)
Reporting Infusion Time(s) and FluidWhen reporting codes for which infusion time is a factor, use the actual time over which the infusion is administered. Services leading up to the infusion and to conclude the infusion are included in the infusion service and not separately reported. The services include starting the IV and monitoring the patient post-infusion. Standard clinical practice is to document the actual start and stop times in the patients medical records. This would ensure that the times are accurate in the event there are interruptions or delays during the infusion process. Flow sheets kept by personnel during infusion services help to identify proper infusion times. Time may be documented with start and stop times or with total time.The first hour initial codes are defined as "up to one hour". This eliminates the need to report the 52 modifier to inform Medicare of durations of less than one hour.Report the additional hour of chemotherapy administration with CPT code 96415 for infusion intervals of greater than 30 minutes beyond one hour increments. Report CPT code 96415 in conjunction with the initial chemotherapy administration CPT code 96413.The fluid used to administer the drug(s) is considered incidental hydration and is not separately reportable. An infusion consisting of three substances in a single bag is not intended to be reported as three separate infusion services.Do not report the initial hydration CPT code 96360 if performed as a concurrent infusion service. Report the additional hour of hydration with CPT code 96361 to identify hydration furnished as a secondary or subsequent service after a different initial service is administered through the same IV access.Report the additional hour or additional sequential CPT code 96366, 96367, 96375 or 96376 (as applicable) to identify therapeutic, prophylactic or diagnostic nonchemotherapy drug infusion or injection when provided as a secondary or subsequent service in association with chemotherapy administration CPT code 96413.Report the additional sequential infusion chemotherapy administration CPT code 96417 in conjunction with the initial chemotherapy administration CPT code 96413. Report CPT code 96417 only once per sequential infusion.
Article - Billing and Coding: Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents (A53049)
Report the additional sequential infusion chemotherapy administration CPT code 96417 in conjunction with the initial chemotherapy administration CPT code 96413. Report CPT code 96417 only once per sequential infusion.Report irrigation CPT code 96523 if it is the only service provided that day. If there is an E/M visit or other drug administration service provided on the same day, payment for CPT code 96523 is included in the payment for the other service.Report CPT code 36593 for declotting a catheter or port.Please refer to Billing and Coding Articles A59073, Complex Drug Administration Coding for additional information regarding chemotherapy and nonchemotherapy drug administration codes.
Article - Billing and Coding: Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents (A53049)
Services Not Separately ReportableIf performed to facilitate an infusion or injection of a drug or biological, the following are included and are not reported separately:Use of local anesthesiaIV startAccess to indwelling IV, subcutaneous catheter or portFlush at conclusion of infusionStandard tubing, syringes and suppliesPreparation of chemotherapy agent(s)Biosimilar ModifiersEffective on April 1, 2018, providers and suppliers will no longer be required to report modifiers with HCPCS codes for biosimilars (reference the CMS Transmittal 3966, CR 10454).Compounded DrugsCompounded drugs are drugs not reconstituted as labeled in order to create a combination of drugs or vary the concentration/volume. As such, compounded medications do not have a National Drug Code (NDC) number, an average sales price (ASP) or an average wholesale price (AWP). Compounded drugs are contractor priced on invoice.Compounded medications created by a pharmacist in accordance with the Federal Food, Drug and Cosmetic Act may be covered under Medicare. A compounded drug is defined as a combination of drugs mixed by a pharmacist. This definition does not include a simple reconstitution of a drug as directed by the package insert. Compounded drugs that are self-administered are not a covered Medicare service.Coding Guidance:Compounded drugs should be reported with HCPCS code J7999 on a single claim line.Place quantity = 1 on the line billed for J7999.Enter the name, total dose (in mg or mcg) of each drug of the refill, and invoice amount in Box 19 of the CMS 1500 or the appropriate comment loop of electronic claims.Covered compounded single or combination drugs should be billed on a single detail line.
Article - Billing and Coding: Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents (A53049)
Do not list the drug separately from the dosage, such as morphine bupivacaine baclofen sufentanil 20mg 6mg 4mcg 5mcg. This format will be denied.List each drug with the applicable dosing amount, for example morphine 20mg, bupivacaine 6 mg, baclofen 4 mcg, sufentanil 5 mcg.The ICD-10-CM code used on each detailed line must represent the condition treated by the drug(s) billed on that detail line.Drug doses used in narrative description must be in mgs or mcgs only. Do not report gs.Use of Infusion PumpsMedicare will consider infusion pumps and associated services medically reasonable and necessary for the conditions listed in the Medicare National Coverage Determination Manual Pub.100-03, Chapter 1, Section, 280.14.The use of compounded drugs has been especially prevalent in the filling of infusion pumps. The following methods are appropriate when billing for drugs used in infusion pumps:When submitting a claim for compounded drug(s) for a single agent or a combination of agents, providers must use HCPCS code J7999. Even though the compound is similar to or includes a drug with a specific HCPCS code, providers must use HCPCS code J7999, Compounded drug, not otherwise classified, for reimbursement of the compounded drug.The KD modifier must be appended to indicate the drug will be administered through Durable Medical Equipment (DME) such as an infusion pump.When a non-compounded drug is used (a true off the shelf product without compounding), the specific HCPCS code for the drug may be used.Note:Compounded drugs and/or combination drugs used in infusion pumps should be reported with HCPCS code J7999 andappended with modifier KD to indicate the drugs were infused through DME.Documentation Requirements
Article - Billing and Coding: Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents (A53049)
Note:Compounded drugs and/or combination drugs used in infusion pumps should be reported with HCPCS code J7999 andappended with modifier KD to indicate the drugs were infused through DME.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.
Article - Billing and Coding: Home Health Speech-Language Pathology (A53052)
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.Title XVIII of the Social Security Act, 1835(a)(2)(A) addresses procedure for payment of claims of providers of services.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 5, 20 HCPCS Coding Requirement, 20.1 Discipline Specific Outpatient Rehabilitation Modifiers - All Claims, and 20.2 Reporting of Service Units With HCPCSCMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, 6.2.4 CodingArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Home Health Speech-Language Pathology L34563Coding Guidelines1.When billing for a Z code as a diagnosis code, documentation should include (if applicable) the name of the orthotic/prosthetic device, date the patient received the device, and the date training/teaching began.2. For the purpose of the related LCD, diagnosis code R68.89 should be used when treating memory disturbances not associated with mental disorders (e.g., post cerebrovascular accident (CVA)).3. As of July 1999, speech-language pathologist (SLP)must report time spent with the patient in 15-minute increments. The following code should be used for SLP:G0153- Speech-Language Pathology*Note:Other HCPCS codes found in thisarticleare for informational and descriptive use only.Re-evaluationSpeech/hearing treatment (CPT92507)Regardingspeech generating devices (SGDs), use CPT92607 for selection and prescription; use CPT92609 for adaptation and training.Note:Current Procedural Terminology (CPT) does not define a re-evaluation code for Speech-Language Pathology: use the evaluation code.Glossary of terms commonly used in Speech Language PathologyAmelioration  to make or become better.Articulation  vocal tract movements for speech sound production; involves accuracy in placement of the articulators, timing, direction of movements, force extended, speed or response, and neutral integration of all events.
Article - Billing and Coding: Home Health Speech-Language Pathology (A53052)
Articulation  vocal tract movements for speech sound production; involves accuracy in placement of the articulators, timing, direction of movements, force extended, speed or response, and neutral integration of all events.Audition  the sense or act of hearing.Compensation - to make up for or offset; counterbalance; making up for a deficiency or loss.Fluency  smoothness with which sounds, syllables, words and phrases are joined together during oral language; lack of hesitations or repetitions in speaking.Morphology  study of how morphemes (smallest meaningful unit of a language) are put together to form words; indicates how words are formed and provides a bridge between phonology and syntax.Phonology  study of the sound system of a language, including pauses and stress.Pragmatics  study of the rules underlying the functional use of language.Resonance - sympathetic or forced vibration of the air in the cavities above, below, in front of, or behind the source of a sound.Semantics  1) study of meaning in language which includes the relation between language, thoughts, and behavior; 2) study of meaning of speech forms, especially of the development and changes in meaning of words and word groups; 3) study of the development of the meaning of words, its goals is to account for the knowledge a native speaker has which enables him to judge some sentences as meaningful, some as ambiguous, and some as anomalous.Syntax  1) the internal structure of language including the order in which the element of a language can occur and the relationships among the elements in an utterance; 2) rules that dictate the acceptable sequences, combination, and function of words in a sentence; 3) the way in which words are put together in a sentence to convey meaning.
Article - Billing and Coding: CPT Code 97755 - Assistive Technology Assessment (A53053)
CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claimArticle TextCPTcode 97755, assistive technology assessment (for example, to restore, augment or compensate for an existing function, optimize functional tasks and/or maximize environmental accessibility), direct 1-on-1 contact with written report, each 15 minutes, is related to the following local coverage determinations (LCDs): Outpatient Physical Therapy (L34428) Outpatient Occupational Therapy (L34427) Home Health-Occupational Therapy (L34560) Home Health-Physical Therapy (L34564)This is an assessment code, per each 15 minutes, and must be accompanied by a written report explaining the nature and complexity of the assistive technology needed by the patient. This can include: testing multiple components/systems to determine optimal interface between client and technology applications and determining the appropriateness of commercial (off the shelf) components/systems. If the service provided by a physical or occupational therapist is more clearly defined by another CPTcode (for example, 97535 self-care/home management training), it should be used instead.It would be inappropriate to use the CPTcode 97755 for services other than for those who have lost the use of their limbs and who can benefit from new technology advancements. CPT97755 should only be billed by occupational and physical therapists that have the additional knowledge and expertise of the assistive technology that is required for these individuals.For rationale, clinical example and description of CPT97755, please refer to CPT2004 Changes: An Insider's View, American Medical Association (2003).
Article - Home-Based Fall Evaluations and Interventions (A53055)
CMS National Coverage PolicyN/AArticle TextThe goal of this article is to provide a framework for the communication of information that both clinicians and Medicare need to make patient-centered decisions.Services provided by HHAs under the 32x bill type are reimbursed under the Home Health Prospective Payment System (HH PPS), while those delivered under the 34x bill type are reimbursed as Part B Outpatient Rehabilitation Services. Part B Outpatient Rehabilitation Services (with the exception of those furnished by or under arrangements with a hospital) are subject to the financial limitations described in the CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 5, Section 10.2.Thisarticle underscores the importance of a comprehensive evaluation of the circumstances surrounding the documented fall event(s). It is important that a comprehensive examination and evaluation including a detailed history as well as neurological/sensory, musculoskeletal, and vascular/cardiopulmonary systems reviews be documented. Palmetto GBA is addressing this need through an approach called Going Beyond Diagnosis(GBD). GBD promotes use of the International Classification of Functioning Disability and Health (ICF) to capture and organize the information necessary to support the clinical and administrative needs of HHAs performing home-based fall evaluations and interventions.
Article - Hospice: Documenting Weight Loss for Beneficiaries with Non-Neoplastic Conditions (A53056)
CMS National Coverage PolicyN/AArticle TextWeight has long been used as a measure of nutritional status. Both absolute body weight and changes in body weight have prognostic significance. The documentation of absolute body weight provides information at a specified point in time, while changes in body weight allow clinicians to gauge a given patient's response to treatment over time.If hospice organizations record percent weight loss as an indicator of nutritional status, this A/B HHH MAC expects to see supporting documentation of the absolute weights used to calculate the percent decrease. The reporting of absolute weights strengthens documentation of percent change in weight over time (e.g., > 10% weight loss over the last 6 months with weight decreasing from 110 pounds to 95 pounds). This A/B HHH MAC encourages hospice providers to include absolute weights in their responses to additional documentation requests (ADRs).Unsupported percent weight loss in the medical record may result in a denial if other documentation does not lend support to impaired nutritional status.