evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Skilled Therapy Services in the SNF PPS Setting (A55503)
CMS National Coverage PolicyN/AArticle TextThis article is to clarify when Physical Therapy (PT), Occupational Therapy (OT) or Speech Therapy (SP) minutes can be captured on a Minimum Data Set (MDS) for patients in a Skilled Nursing Facility (SNF) Prospective Payment System (PPS) stay.Medicare guidelines state that only treatment time requiring the skills of a qualified skilled therapist can be billed as therapy services.The services must be of a level of complexity and sophistication and the patient's condition must be of a nature that requires the knowledge and skills of a therapists to complete the therapy modality.These skilled services must be reasonable and necessary to treat the patient's condition; this includes amount, frequency and duration.Services must not be dependent on the beneficiary's potential for improvement.A service provided by a skilled therapists or therapy assistant does not automatically make it a skilled service. If a service could be completed by an unskilled person or safely self-administered, it would not be considered skilled.Recently, Noridian has noticed an increased use of therapy minutes being captured on the MDS without documentation supporting that these services required the attended time of a qualified skilled therapists. Some of these services include:Electrical StimulationTherapy assistive devices such as:OmnicycleNustepRecumbent stepperVirtual therapy assistive devicesAlthough these modalities can assist in meeting therapy goals, only skilled therapist time should be recorded on the MDS. If all the minutes for these modalities are captured on the MDS, documentation must support why it was medically necessary for the therapist/assistant to be in constant attendance during the entire modality/procedure.Commonly, only some aspects of a therapy modality will be skilled. Generally, a resident receiving electrical stimulation as a therapy modality for pain or muscle strengthening/neuromuscular re-education is an example of such a modality. The portion of time that can be recorded to the MDS would be if the time spent for:Proper electrode placementEstablishing proper settingsRemoval of the electrodesExamining the skin before and after treatmentDocumentation to support skilled services should be sufficient for the medical reviewer to determine when:Skilled staff involvement/attendance is necessaryServices are reasonable and necessary for treatment and to promote the goals of therapyPortion of the treatment time that was skilled
Article - Billing and Coding: Skilled Therapy Services in the SNF PPS Setting (A55503)
Documentation to support skilled services should be sufficient for the medical reviewer to determine when:Skilled staff involvement/attendance is necessaryServices are reasonable and necessary for treatment and to promote the goals of therapyPortion of the treatment time that was skilledThere are rare circumstances where these modalities would require constant supervision or 1:1 time per industry standards, in which case all the minutes would be considered skilled. In these instances, the documentation needs to be very specific and clear as to the reason constant supervision or 1:1 time was needed. Generalized precautions such as fall risk and confusion in most cases will not support the need for constant supervision or 1:1 time. It is also important to remember that documentation by the therapist supporting the need for constant supervision must be supported by the rest of the documentation provided within the chart.
Article - Skilled Therapy Services in the SNF PPS Setting (A55505)
CMS National Coverage PolicyN/AArticle TextThis article is to clarify when Physical Therapy (PT), Occupational Therapy (OT) or Speech Therapy (SP) minutes can be captured on a Minimum Data Set (MDS) for patients in a Skilled Nursing Facility (SNF) Prospective Payment System (PPS) stay.Medicare guidelines state that only treatment time requiring the skills of a qualified skilled therapist can be billed as therapy services.The services must be of a level of complexity and sophistication and the patient's condition must be of a nature that requires the knowledge and skills of a therapists to complete the therapy modality.These skilled services must be reasonable and necessary to treat the patient's condition; this includes amount, frequency and duration.Services must not be dependent on the beneficiary's potential for improvement.A service provided by a skilled therapists or therapy assistant does not automatically make it a skilled service. If a service could be completed by an unskilled person or safely self-administered, it would not be considered skilled.Recently, Noridian has noticed an increased use of therapy minutes being captured on the MDS without documentation supporting that these services required the attended time of a qualified skilled therapists. Some of these services include:Electrical StimulationTherapy assistive devices such as:OmnicycleNustepRecumbent stepperVirtual therapy assistive devicesAlthough these modalities can assist in meeting therapy goals, only skilled therapist time should be recorded on the MDS. If all the minutes for these modalities are captured on the MDS, documentation must support why it was medically necessary for the therapist/assistant to be in constant attendance during the entire modality/procedure.Commonly, only some aspects of a therapy modality will be skilled. Generally, a resident receiving electrical stimulation as a therapy modality for pain or muscle strengthening/neuromuscular re-education is an example of such a modality. The portion of time that can be recorded to the MDS would be if the time spent for:Proper electrode placementEstablishing proper settingsRemoval of the electrodesExamining the skin before and after treatmentDocumentation to support skilled services should be sufficient for the medical reviewer to determine when:Skilled staff involvement/attendance is necessaryServices are reasonable and necessary for treatment and to promote the goals of therapyPortion of the treatment time that was skilled
Article - Skilled Therapy Services in the SNF PPS Setting (A55505)
Documentation to support skilled services should be sufficient for the medical reviewer to determine when:Skilled staff involvement/attendance is necessaryServices are reasonable and necessary for treatment and to promote the goals of therapyPortion of the treatment time that was skilledThere are rare circumstances where these modalities would require constant supervision or 1:1 time per industry standards, in which case all the minutes would be considered skilled. In these instances, the documentation needs to be very specific and clear as to the reason constant supervision or 1:1 time was needed. Generalized precautions such as fall risk and confusion in most cases will not support the need for constant supervision or 1:1 time. It is also important to remember that documentation by the therapist supporting the need for constant supervision must be supported by the rest of the documentation provided within the chart.
Article - Billing and Coding: Peripheral Nerve Stimulation (A55530)
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 TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.Noridian has found the current peer-reviewed data is insufficient to warrant the medical necessity of coverage for Peripheral Nerve Field Stimulation (PNFS), also known as Peripheral Subcutaneous Field Stimulation (PSFS) for any condition. Therefore, this service will not be covered for any condition.To bill for denial, providers must bill CPTcode 64999 for both the trial and permanent insertion of the electrode array when billing for these procedures and report the following information.Part B claimsEnter 1 units of service (UOS)Enter Peripheral Nerve Field Stimulation, PNFS, Peripheral Subcutaneous Field Stimulation, or PSFS adjacent to the CPTcode 64999 and whether the procedure is for a permanent or trial in the comment/narrative field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimPart A claimsEnter 1 UOSEnter Peripheral Nerve Field Stimulation, PNFS, Peripheral Subcutaneous Field Stimulation, or PSFS adjacent to the CPTcode 64999 and whether the procedure is for a permanent or trial in the comment/narrative field/types:Line SV02-7 for 837 in electronic claimBlock 80 on the UB04 claim form
Article - Billing and Coding: Peripheral Nerve Stimulation (A55531)
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 TextThe following billing and coding guidance is to be used with its associated Local Coverage Determination.Noridian has found the current peer-reviewed data is insufficient to warrant the medical necessity of coverage for Peripheral Nerve Field Stimulation (PNFS), also known as Peripheral Subcutaneous Field Stimulation (PSFS) for any condition. Therefore, this service will not be covered for any condition.To bill for denial, providers must bill CPTcode 64999 for both the trial and permanent insertion of the electrode array when billing for these procedures and report the following information.Part B claimsEnter 1 units of service (UOS)Enter Peripheral Nerve Field Stimulation, PNFS, Peripheral Subcutaneous Field Stimulation, or PSFS adjacent to the CPTcode 64999 and whether the procedure is for a permanent or trial in the comment/narrative field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimPart A claimsEnter 1 UOSEnter Peripheral Nerve Field Stimulation, PNFS, Peripheral Subcutaneous Field Stimulation, or PSFS adjacent to the CPTcode 64999 and whether the procedure is for a permanent or trial in the comment/narrative field/types:Line SV02-7 for 837I electronic claimBlock 80 on the UB04 claim form
Article - Billing and Coding: Billing Medicare for the SphenoCath® and Other Similar Devices (A55584)
CMS National Coverage PolicyN/AArticle TextNoridian is issuing coding guidance for billing the use of Dolor Technologies SphenoCathdevice or other similar delivery devices. To bill for use of these devices use CPT64999 as described in CPT Assistant (July 2014. Volume 24, Issue 7, pages 8-9).Source:Internet Only Manual, CMS Pub 100-4 -Medicare Claims Processing Manual,Chapter 12 -Physicians/Nonphysicians Practitioners, Section 50.K:"If the physician performing the medical or surgical procedure also provides the level of anesthesia lower in intensity than moderate sedation, such as a local or topical anesthesia, then themoderatesedation code should not be reported andno separatepayment should be allowed by theA/BMAC (B)."
Article - Billing and Coding: Billing Medicare for the SphenoCath® and Other Similar Devices (A55585)
CMS National Coverage PolicyN/AArticle TextNoridian is issuing coding guidance for billing the use of Dolor Technologies SphenoCathdevice or similar delivery devices. To bill for use of these devices use CPT64999 as described in CPT Assistant (July 2014. Volume 24, Issue 7, pages 8-9).Source:Internet Only Manual, CMS Pub 100-4 -Medicare Claims Processing Manual,Chapter 12 -Physicians/Nonphysicians Practitioners, Section 50.K:"If the physician performing the medical or surgical procedure also provides the level of anesthesia lower in intensity than moderate sedation, such as a local or topical anesthesia, then themoderatesedation code should not be reported andno separatepayment should be allowed by theA/BMAC (B)."
Article - Billing and Coding: MolDX: BCR-ABL (A55595)
CMS National Coverage PolicyN/AArticle TextBreakpoint testing for BCR-ABL1 is commonly performed as a combination or panel of tests (major, minor and other breakpoints). To report multiple tests assigned a single ID, submit CPT code 81479. This guideline includes the following CPTcode combinations:81206 and 8120781206, 81207, and 81208CPT codes 81206, 81207, and 81208 may only be reported when performed as a single test.To submit a claim for BCR-ABL translocation analysis by NGS, use CPT 81479 and one (1) UOS with the assigned DEX Z-code.To report the FDA-approved MRDx BCR-ABL Test, use CPT code 0040U.Refer toBilling and Coding: MolDX: Testing of Multiple Genesfor additional information regarding single-gene and panel testing of genes
Article - Billing and Coding: MolDX: SULT4A1 Genetic Testing (A55596)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) statutory exclusion covers diagnostic testing "except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member".Article TextSulfotransferase 4A1 (SULT4A1) is an enzyme found in the brain that interacts with numerous neuroactive molecules, including some catecholamines and neural steroids. Findings suggest the SULT4A1-1 haplotype of SULT4A1 is associated with enhanced response to antipsychotic drug therapy. At present there is insufficient evidence to support SULT4A1 genotyping to determine medical management. Therefore, the MolDX Team has determined SULT4A1 genetic testing is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, MolDX will also deny panels of tests that include the SULT4A1 gene as a statutorily excluded service.To receive a SULT4A1 test denial, please submit the following claim information:CPTcode 81479An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX HCPCS modifierTo indicate a statutorily excluded service, append with a GY HCPCS modifierFor CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.Enter the appropriate DEX Z-Codeidentifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter the appropriate DEX Z-Codeidentifier adjacent to the CPT code 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 form
Article - Billing and Coding: MolDX: PIK3CA Gene Tests (A55597)
CMS National Coverage PolicyN/AArticle TextThe U.S. Food and Drug Administration (FDA) has approved Piqray (alpelisib) tablets, to be used in combination with the FDA-approved endocrine therapy fulvestrant, to treat postmenopausal women, and men, with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative, PIK3CA-mutated, advanced or metastatic breast cancer (as detected by an FDA-approved test) following progression on or after an endocrine-based regimen.Tosubmit a claim for a PIK3CA targeted gene sequencing service, please submit the following claim information:Enter the appropriate CPT codeSelect the appropriate Diagnosis for the patientEnter DEX Z-Codeidentifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter DEX Z-Code identifier adjacent to the CPT code 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 form
Article - Billing and Coding: MolDX: BCR-ABL (A55600)
CMS National Coverage PolicyN/AArticle TextBreakpoint testing for BCR-ABL1 is commonly performed as a combination or panel of tests (major, minor and other breakpoints). To report multiple tests assigned a single ID, submit CPTcode 81479. This guideline includes the following CPTcode combinations:81206 and 8120781206, 81207, and 81208CPTcodes 81206, 81207, and 81208 may only be reported when performed as a single test.To submit a claim for BCR-ABL translocation analysis by NGS, use CPT81479 and one (1) UOS with the assigned DEX Z-code.To report the FDA-approved MRDx BCR-ABL Test use the CPTcode 0040U.Refer toBilling and Coding: MolDX: Testing of Multiple Genes A58121for additional information regarding single-gene and panel testing of genes.
Article - Billing and Coding: MolDX: SULT4A1 Genetic Testing (A55601)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1862(a)(1)(A) statutory exclusion covers diagnostic testing "except for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member".Article TextSulfotransferase 4A1 (SULT4A1) is an enzyme found in the brain that interacts with numerous neuroactive molecules, including some catecholamines and neural steroids. Findings suggest the SULT4A1-1 haplotype of SULT4A1 is associated with enhanced response to antipsychotic drug therapy. At present there is insufficient evidence to support SULT4A1 genotyping to determine medical management. Therefore, the MolDX Team has determined SULT4A1 genetic testing is not a Medicare benefit and is a statutorily excluded service. In addition to single gene testing, MolDX will also deny panels of tests that include the SULT4A1 gene as a statutorily excluded service.To receive a SULT4A1 test denial, please submit the following claim information:CPTcode 81479An Advance Beneficiary Notice (ABN) is not required for statutorily excluded servicesFor a voluntary issued ABN, append with GX HCPCS modifierTo indicate a statutorily excluded service, append with a GY HCPCS modifierFor CPT non-NOC codes, Labs may either use the SV101-7 or SV202-7 (preferred) or the NTE field to submit this required information.Enter the appropriate DEX Z-Codeidentifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter the appropriate DEX Z-Codeidentifier adjacent to the CPT code 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 form
Article - Billing and Coding: MolDX: PIK3CA Gene Tests (A55602)
CMS National Coverage PolicyN/AArticle TextThe U.S. Food and Drug Administration (FDA) has approved Piqray (alpelisib) tablets, to be used in combination with the FDA-approved endocrine therapy fulvestrant, to treat postmenopausal women, and men, with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative, PIK3CA-mutated, advanced or metastatic breast cancer (as detected by an FDA-approved test) following progression on or after an endocrine-based regimen.To submit a claim for a PIK3CA targeted gene sequencing service, please submit the following claim information:Enter the appropriate CPTcodeSelect the appropriate diagnosis for the patientEnter DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter DEX Z-Code identifier adjacent to the CPT code 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 form
Article - Billing and Coding: MolDX: PTCH1 Gene Testing (A55608)
CMS National Coverage PolicyN/AArticle TextPTCH1 gene testing may be performed during the diagnosis of Nevoid Basal Cell Carcinoma Syndrome (NBCCS). Since the diagnosis of NBCCS is established using clinical diagnostic criteria and carrier testing is not a covered benefit, Noridian has determined that PTCH1 analysis is a statutorily excluded test.To receive a PTCH1 analysis service denial, please submit the following claim information:CPT code 81479An Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientEnter DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for the 837I electronic claimBlock 80 for the UB04 claim form
Article - Billing and Coding: MolDX: NSD1 Gene Tests (A55609)
CMS National Coverage PolicyN/AArticle TextNSD1 gene testing may be performed during the diagnosis of Sotos Syndrome. Since testing is limited to reproductive risk assessment, Noridian has determined NSD1 gene testing is a statutorily excluded service. Noridian will also deny tests that include one or more of NSD1 analysis reported with CPT code 81479 as statutorily excluded tests.To receive a NSD1 analysis service denial, please submit the following claim information:Select appropriate CPT code according to genetic material testsCode 81405 for NSD1 duplication/deletionCode 81406 for NSD1 gene sequencingCode 81479 for combinations of NSD1 analysisAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate a valid ABN is on file for a known statutorily excluded service, append with a GY modifierEnter DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter DEX Z-Code identifier adjacent to the CPT code 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 form
Article - Billing and Coding: MolDX: RPS19 Gene Tests (A55610)
CMS National Coverage PolicyN/AArticle TextRPS19 gene sequencing, deletion/duplication and known familial mutation analysis may be performed during the diagnosis of Diamond-Blackfan Anemia (DBA). Since clinical symptoms and diagnosis usually occur prior to Medicare eligibility and carrier testing is not a covered benefit,the MolDX Teamhas determined RPS19 analysis is a statutorily excluded test. MolDX will also deny tests that include one or more of RPS19 analysis reported with CPT code 81479 as statutorily excluded services.To receive a RPS19 analysis service denial, please submit the following claim information:Select appropriate CPT code according to genetic material testedCode 81405 for gene sequencingCode 81479 for combinations of RPS19 analysisAn Advance Beneficiary Notice (ABN) is not required for statutorily excluded services.For a voluntary issued ABN, append with GX modifierTo indicate aknown statutorily excluded service, append with a GY modifierSelect the appropriate diagnosis for the patientEnter the DEX Z-Code identifier adjacent to the CPT code in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PItem 19 for paper claimEnter the DEX Z-Code identifier adjacent to the CPT code 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 form