evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: MolDX: Pharmacogenomics Testing (A58324)
Bipolar disorder, current episode mixed, moderateNeuropsychiatricF31.63Bipolar disorder, current episode mixed, severe, without psychotic featuresNeuropsychiatricF31.64Bipolar disorder, current episode mixed, severe, with psychotic featuresNeuropsychiatricF31.71Bipolar disorder, in partial remission, most recent episode hypomanicNeuropsychiatricF31.73Bipolar disorder, in partial remission, most recent episode manicNeuropsychiatricF31.75Bipolar disorder, in partial remission, most recent episode depressedNeuropsychiatricF31.77Bipolar disorder, in partial remission, most recent episode mixedNeuropsychiatricF40.11Social phobia, generalizedNeuropsychiatricF41.0Panic disorder [episodic paroxysmal anxiety]NeuropsychiatricF41.1Generalized anxiety disorderNeuropsychiatricF41.3Other mixed anxiety disordersNeuropsychiatricF41.8Other specified anxiety disordersNeuropsychiatricF43.11Post-traumatic stress disorder, acuteNeuropsychiatricF43.12Post-traumatic stress disorder, chronicNeuropsychiatricF60.5Obsessive-compulsive personality disorderNeuropsychiatricF90.0Attention-deficit hyperactivity disorder, predominantly inattentive typeNeuropsychiatricF90.1Attention-deficit hyperactivity disorder, predominantly hyperactive typeNeuropsychiatricF90.2Attention-deficit hyperactivity disorder, combined typeNeuropsychiatricF90.8Attention-deficit hyperactivity disorder, other type
Article - Billing and Coding: MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (A58343)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claimCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, 50.5 Jurisdiction of Laboratory Claims, 60.1.2 Independent Laboratory Specimen Drawing, 60.2 Travel AllowanceCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 10 Reporting ICD Diagnosis and Procedure CodesCMS Internet-Only Manuals, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, 80.1.2 A/B MAC (B) Contacts With Independent Clinical LaboratoriesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease L38292.To report a Prostate Genomic Classifier service, please submit the following claim information:Select applicable CPTcodeEnter 1 unit of service (UOS)Enter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part B claim field/types:Loop 2400 or SV101-7 for the 5010A1 837PBox 19 for paper claimEnter the appropriate DEX Z-Code identifier adjacent to the CPTcode in the comment/narrative field for the following Part A claim field/types:Line SV202-7 for 837I electronic claimBlock 80 for the UB04 claim formSelect ICD-10-CM code C61
Article - Billing and Coding: Chiropractic Services (A58345)
CMS National Coverage PolicyInternet-Only Manuals (IOMs)CMS IOM Publication 100-02,Medicare Benefit Policy Manual,Chapter 15, Sections 30.5 Chiropractors Services, 240 Chiropractic Services  General, 240.1  Coverage of Chiropractic Services, 240.1.1  Manual Manipulation, 240.1.2  Subluxation May Be Demonstrated by X-Ray or Physicians Exam, 240.1.3  Necessity for treatment, 240.1.4  Location of Subluxation, and 240.1.5  Treatment ParametersCMS IOM Publication 100-04,Medicare Claims Processing Manual,Chapter 12, Section 220 Chiropractic ServicesChapter 30, Financial Liability ProtectionsSocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Chiropractic Services.Coding GuidanceNotice: It is not appropriate to bill Medicare for services that are not covered as if they are covered. When billing for non-covered services, use the appropriate modifier.When billing for Chiropractic services:Report the initial treatment or date of exacerbation.Specify the precise spinal location and level of subluxation.Report the date of X-ray if an X-ray is used to demonstrate subluxation.Report the level of subluxation using the appropriate ICD-10-CM code.In addition to reporting the ICD-10-CM code for the level of subluxation, report any other pertinent ICD-10-CM codes.All treatments must be categorized as acute subluxation, chronic subluxation or maintenance therapy. An exacerbation of a previous injury should be categorized into either "acute" or "chronic" (e.g., an identifiable re-injury would fall under acute).The following modifiers should be reported with CPT codes 98940, 98941, and 98942 as is appropriate to each patient's situation:
Article - Billing and Coding: Chiropractic Services (A58345)
The following modifiers should be reported with CPT codes 98940, 98941, and 98942 as is appropriate to each patient's situation:AT  Acute treatmentGA  Waiver of liability statement issued as required by payer policy, individual case. Authorization has been provided to notify the beneficiary of the likelihood that services rendered will be denied as not reasonable and medically necessary under Medicare guidelines.GZ  Item or service expected to be denied as not reasonable and necessaryFor Medicare purposes, the AT modifier shall now be used only when chiropractors bill for active/corrective treatment.Every chiropractic claim (those containing CPT codes 98940, 98941, or 98942) with a date of service on or after October 1, 2004 is to include the AT modifier if active/corrective treatment is being performed; orThe AT modifier should not be appended to the service if maintenance therapy is being performed. Contractors shall deny a chiropractic claim (containing CPT codes 98940, 98941, or 98942) with a date of service on or after October 1, 2004, that does not contain the AT modifier.The mere presence of the AT modifier does not indicate that the service(s) are medically necessary. Reasonable and necessary requirements as addressed in the Medicare Internet-Only Manuals must be met.Reasons for DenialExcluded from Medicare coverage is any service other than manual manipulation for the treatment of subluxation of the spine. The chiropractor is not required to bill excluded services. However, if the beneficiary requests Medicare be billed, the provider must bill services to Medicare in order to obtain a denial for secondary insurance purposes. The following are examples (not an all-inclusive list) of services excluded from Medicare coverage when performed by a chiropractor; the beneficiary is responsible for payment.Laboratory testsX-raysOffice visits (history and physicals)PhysiotherapyTractionSuppliesInjectionsDrugsEKGs or any diagnostic studyOrthopedic devicesNutritional supplements/counselingAny service ordered by the chiropractorDocumentation Requirements
Article - Billing and Coding: Chiropractic Services (A58345)
Laboratory testsX-raysOffice visits (history and physicals)PhysiotherapyTractionSuppliesInjectionsDrugsEKGs or any diagnostic studyOrthopedic devicesNutritional supplements/counselingAny service ordered by the chiropractorDocumentation 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: Facet Joint Interventions for Pain Management (A58350)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16, 180 Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, 10.1 Billing Part B Radiology Services and Other Diagnostic Procedures and 20 Payment Conditions for Radiology Services.Article Text
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A58350)
The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forFacet Joint Interventions for Pain Management L38765.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to NCCI edits or Hospital Outpatient Prospective Payment System (OPPS) packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and National Provider Identifier (NPI) of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise, the symptoms prompting the performance of the test should be reported.Coding Guidance:Providers should refer to the applicable AMA CPTManual to assist with proper reporting of these services.This article applies only to cervical/thoracic or lumbar facet procedures and does not apply to other joint procedures (such as sacral injections, sacroiliitis, epidural or other spinal procedures).Diagnostic and Therapeutic Injections:Each facet level in the spinal region is composed of bilateral facet joints (i.e., there are 2 facet joints per level, 1 on the right side and 1 on the left). Unilateral or bilateral facet interventions may be performed during the facet joint procedure (a diagnostic nerve block, a therapeutic facet joint (intra-articular) injection, a medial branch block injection, or the medial branch radiofrequency ablation (neurotomy) in 1 session. A bilateral intervention is still considered a single level intervention.Each unilateral or bilateral intervention at any level should be reported as 1 unit, with bilateral intervention signified by appending the modifier -50.Regions:
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A58350)
Each unilateral or bilateral intervention at any level should be reported as 1 unit, with bilateral intervention signified by appending the modifier -50.Regions:An anatomic spinal region for paravertebral facet joint block (diagnostic or therapeutic), is defined as cervical\thoracic (CPTcodes 64490, 64491, 64492) or lumbar\sacral (CPTcodes 64493, 64494, 64495) per the American Medical Association (AMA) CPTManual.Levels:64490 (cervical or thoracic) or 64493 (lumbar or sacral) reports a single level injection performed with image guidance (fluoroscopy or computed tomography (CT)). Procedures performed under ultrasound guidance are not covered.64491 or 64494 describes a second level which should be reported separately in addition to the code for the primary procedure. 64491 should be reported in conjunction with 64490 and 64494 should be reported in conjunction with 64493.64492 or 64495 describes a third and additional levels and should be listed separately in addition to the code for the primary procedure and the second level procedure and cannot be reported more than once per day. 64492 should be reported in conjunction with 64490/64491 and 64495 should be reported in conjunction with 64493/64494.Laterality:Bilateral paravertebral facet injection procedures 64490 through 64495 should be reported with modifier 50.One to 2 levels, either unilateral or bilateral, are allowed per session per spine region (i.e., 2 unilateral or 2 bilateral levels per session).For services performed in the Ambulatory Surgery Center (ASC), physicians must continue using modifier 50. Only the ASC facility itself must report the applicable procedure code on 2 separate lines, with 1 unit each and append the -RT and -LT modifiers to each line.KX modifier requirements:
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A58350)
KX modifier requirements:The KX modifier should be appended to the line for all diagnostic injections. In most cases the KX modifier will only be used for the 2 initial diagnostic injections. If the initial diagnostic injections do not produce a positive response as defined by the related LCD and indicative of identification of the pain generator, and it is necessary to perform additional diagnostic injections, append the KX modifier to the line. Aberrant use of the KX modifier may trigger focused medical review.Therapeutic injections:Documentation of why patient is not a candidate for radiofrequency ablation (RFA) must be submitted for therapeutic treatment.Chemodenervation of nerve:Codes 64633, 64634, 64635, 64636 are reported per joint, not per nerve. Although 2 nerves innervate each facet joint, only 1 unit per code may be reported for each joint denervated, regardless of the number of nerves treated (AMA CPTManual 2020).Each unilateral or bilateral intervention at any level should be reported as 1 unit, with bilateral intervention signified by appending the modifier -50.Region:An anatomic spinal region for thermal facet joint denervation is defined as cervical/thoracic (CPTcodes 64633 and 64634) or lumbar/sacral (CPTcodes 64635 and 64636) per the AMA CPTManual.For neurolytic destruction of the nerves innervating the T12-L1 paravetebral facet joint, use 64633.Levels:64633 or 64635 describes a single level destruction by neurolytic agent performed with image guidance (fluoroscopy or CT).64634 or 64636 describes each additional level which should be reported separately in addition to the code for the primary procedure. 64634 should be used in conjunction with 64633 and 64636 should be used in conjunction with 64635.Laterality:For bilateral procedures report modifier 50 on each line in which the intervention was of a bilateral nature.
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A58350)
Laterality:For bilateral procedures report modifier 50 on each line in which the intervention was of a bilateral nature.For services performed in the ASC, physicians must continue using modifier 50. Only the ASC facility itself must report the applicable procedure code on 2 separate lines, with 1 unit each and append the -RT and -LT modifiers to each line.Non-thermal facet joint denervation (including chemical, low grade thermal energy (<80 degrees Celsius or any other form of pulsed radiofrequency) should not be reported with CPTcodes 64633, 64634, 64635 or 64636. These services should be reported with CPTcode 64999. Code 64999 is non-covered when used to report non-thermal facet joint denervation.If facet joints are injected with biologicals or other substances not designated for this use the entire claim will deny per Medicare Benefit Policy Manual, chapter 16, 180.Use of moderate or deep sedation, general anesthesia, and monitored anesthesia care (MAC) is usually unnecessary or rarely indicated for these procedures and not routinely reimbursable and, therefore, may be denied. In exceptional circumstances if the medical necessity of sedation is unequivocal and clearly documented in the medical record, individual consideration may be considered on appeal.Documentation RequirementsThe patients medical record should include, but is not limited to:
Article - Billing and Coding: Facet Joint Interventions for Pain Management (A58350)
The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visitRelevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
Article - Billing and Coding: Computed Tomography Cerebral Perfusion Analysis (CTP) (A58354)
CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, 20 Payment Conditions for Radiology ServicesCMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 20.9 National Correct Coding Initiative (NCCI) and 30 Services Paid Under the Medicare Physicians Fee ScheduleArticle TextThe information in this article contains billing, coding or other guidelines that complements the Local Coverage Determination (LCD) for Computed Tomography Cerebral Perfusion Analysis (CTP) L38769.Documentation Requirements:The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD (seeCoverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, the reason for the tests, an interpretive report and copies of images. The computerized image reconstruction data should also be maintained.
Article - Billing and Coding: Non-Invasive Fractional Flow Reserve (FFR) for Ischemic Heart Disease (A58359)
CMS National Coverage PolicyN/AArticle TextThe information in the Supplemental Instructions Article contains billing, coding, or other guidelines that complement the Noridian LCD for Non-Invasive Fractional Flow Reserves for Stable Ischemic Heart Disease.Procedure codes may be subject to National Correct Coding Initiative edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.As this service constitutes post-procedure analysis of a previously performed study (CCTA), the name and NPI of the referring/ordering physician that submitted imaging data for FFRct review must be reported on the claim.An Advance Beneficiary Notice of Non-coverage may be used for services that are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04,Medicare Claims Processing Manual, Chapter 30for complete instructions.The patients medical record must document all of the following:The clinical findings that led to the initial performance of the CCTA, and the CCTA must be fully reviewed before the performance of FFRct. (as evidenced by the submission of the Coronary Computed Tomographic Angiography Report)Description of symptoms consistent with stable ischemic heart disease.Body mass indexFractional Flow Reserve analysis report&mdash;&mdash;&mdash;panel&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;panel&mdash;&mdash;&mdash;Coding Information
Article - Billing and Coding: Colon Capsule Endoscopy (A58362)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states thatno payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38777 Colon Capsule Endoscopy (CCE). Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.For the purposes of this Article, ICD-10-CM codeZ53.8indicates that the instrument colonoscopy has been attempted and was incomplete and Z53.09 indicates the procedure is contraindicated when a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training determined from an evaluation of the patient that optical colonoscopy cannot be safely attempted.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: Facet Joint Interventions for Pain Management (A58364)
CMS National Coverage PolicyN/AArticle Text&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;panel&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;Refer to the Local Coverage Determination (LCD) L38773 Facet Joint Interventions for Pain Management, for reasonable and necessary requirements and frequency limitations.The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.General Guidelines for Claims submitted to Part A or Part B MAC:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.