| Complex Medical Review | |||||
| Refer to the additional documentation request (ADR) letter for detailed documentation requirements You could download the entire excel here. http://medicare.fcso.com/wrapped/274351.zip |
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| Line of Business |
Jurisdiction | Provider Type |
Description | Date Implemented |
Date Last Revised |
| Part B | JN | All Specialties |
Amniotic Membrane-Sutureless Placement on the Ocular Surface, 65778 utilization parameter |
29-06-2015 | N/A |
| Part B | JN | All Specialties |
Anesthesia 00740, 00810 billed with Diagnosis V16.0, V18.51-V18.59, V69.1, V76.41, V76.50-V76.52 if no surgery billed |
22-06-2009 | 30-10-2014 |
| Part A | JN | 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 014x Hospital – Laboratory Services Provided to Non-patients 022x Skilled Nursing – Inpatient (Medicare Part B only) 023x Skilled Nursing – Outpatient 074x Clinic – Outpatient Rehabilitation Facility (ORF) 075x Clinic – Comprehensive Outpatient Rehabilitation Facility (CORF) 085x Critical Access Hospital |
Biofeedback, 90911 billed on the same date of service as 97010-97530, G0283 with Diagnosis 599.82, 625.6, 787.60-787.63, 788.31, 788.32 or 788.38 |
04-06-2013 | N/A |
| Part B | JN | All Specialties |
Biofeedback, 97010-97530, G0283 Billed Same Day With 90911 & Diagnosis 599.82, 625.6, 787.60-787.63, 788.31, 788.32 or 788.38 |
04-06-2013 | N/A |
| Part A | JN | 013x Hospital Outpatient 021x Skilled Nursing – Inpatient (Including Medicare Part A) 075x Clinic – Comprehensive Outpatient Rehabilitation Facility (CORF) 085x Critical Access Hospital |
Bisphosphonates Iv & Monoclonal Antibodies In The Treatment Of Osteoporosis And Their Other Indications J3489 and J0897 utilization parameter |
16-10-2011 | 06-01-2014 |
| Part B | JN | All Specialties |
Bisphosphonates IV & Monoclonal Antibodies in the Treatment of Osteoporosis and Their Other Indications J3489 utilization parameter |
01-07-2013 | 21-07-2014 |
| Part B | JN | All Specialties |
Bone Mineral Density Studies 77080 utilization parameter |
14-06-2004 | 05-03-2012 |
| Part B | Florida | All Specialties |
Chelation Therapy, J0600 |
07-04-2011 | N/A |
| Part B | JN | All Specialties |
Circulating Tumor Cell Testing 86152, 86153 utilization parameter |
20-03-2012 | 07-01-2013 |
| Part B | Florida | All Specialties |
Critical Care Services Utilization Parameter, 99291 |
18-02-2013 | 21-01-2014 |
| Part B | Florida | All Specialties |
Critical Care Services, 99291, Place of Service Other Than 21, 22 or 23 |
18-02-2013 | 21-01-2014 |
| Part B | Florida | All Specialties |
Destruction by Neurolytic Agent 64640, 64632 utilization parameter with diagnosis 355.6 |
20-04-2006 | 26-01-2010 |
| Part B | JN | All Specialties |
Dialysis (AV Fistula & Graft) Vascular Access Maintenance, 35475 and 35476 billed same date of service |
09-10-2012 | N/A |
| Part A | JN | 011x Hospital Inpatient (Including Medicare Part A) 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 085x Critical Access Hospital |
Dialysis Vascular Access Maintenance, 35475 and 35476 billed same date of service |
08-10-2012 | 26-03-2013 |
| Part B | Florida | All Specialties |
Drug Threshold |
10-06-2013 | 11-04-2014 |
| Part B | Florida | Specialties 11, 14, 20, 33 |
Drug Threshold |
10-06-2013 | 03-07-2013 |
| Part B | Florida | All Specialties |
Duplex Scan of Lower Extremity, 93925, 93926 Utilization Parameter, Excluding Place of Service 21 & 23 |
22-05-2006 | 16-10-2013 |
| Part B | Florida | Specialties 01, 12, 37, 41, 48 | Evaluation and Management, 99215 |
18-01-2013 | 22-07-2013 |
| Part B | Florida | All Specialties |
Evaluation and Management 99201-99205, 99211-99215 billed with Modifier 24 |
18-05-2012 | 31-07-2014 |
| Part B | Florida | Specialty 11 |
Evaluation and Management, 99223 |
21-10-2014 | 20-08-2015 |
| Part B | Florida | Specialty 11 |
Evaluation and Management, 99233 |
24-10-2014 | 20-08-2015 |
| Part B | JN | All Specialties |
EEG Special Tests & Routine EEG Codes 95950, 95951, 95953, 95956 if routine EEG not billed in previous 90 days |
07-10-2013 | N/A |
| Part B | JN | All Specialties |
EEG Special Tests Utilization Parameter, 95950, 95951, 95953, 95956, 95957 |
07-10-2013 | N/A |
| Part B | JN | All Specialties |
External Counterpulsation G0166 utilization parameter |
27-01-2005 | 23-06-2006 |
| Part B | JN | All Specialties |
Herceptin Utilization Parameter, J9355 |
06-02-2013 | N/A |
| Part A | JN | 013x Hospital Outpatient 021x Skilled Nursing – Inpatient (Including Medicare Part A) 023x Skilled Nursing – Outpatient 085x Critical Access Hospital |
Herceptin, J9355 utilization parameter |
06-02-2013 | N/A |
| Part B | Puerto Rico |
All Specialties |
Home Domiciliary Visits, 99348-99350 |
22-01-2014 | N/A |
| Part B | JN | All Specialties |
Infliximab (Remicade), J1745 billed with or without GA Modifier & Diagnosis 446.7 |
23-04-2012 | 26-10-2012 |
| Part A | JN | 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 014x Hospital – Laboratory Services Provided to Non-patients 021x Skilled Nursing – Inpatient (Including Medicare Part A) 022x Skilled Nursing – Inpatient (Medicare Part B only) 023x Skilled Nursing – Outpatient 075x Clinic – Comprehensive Outpatient Rehabilitation Facility (CORF) 085x Critical Access Hospital |
Long-Term Wearable Electrocardiographic Monitoring (WEM) 0296T-0297T |
09-10-2012 | 26-03-2013 |
| Part B | JN | All Specialties |
Long-Term Wearable Electrocardiographic Monitoring (WEM), 0295T, 0296T, 0297T, 0298T |
09-10-2012 | N/A |
| Part B | JN | All Specialties |
Low Density (LDL) Apheresis, 36516 |
04-09-2012 | 21-01-2015 |
| Part B | JN | All Specialties |
Manipulation Under Anesthesia 23700, 24300, 27570 utilization parameter |
25-01-2010 | N/A |
| Part A | JN | 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 085x Critical Access Hospital |
Manipulation Under Anesthesia, 23700, 24300 or 27570 same date of service. |
25-01-2010 | 26-03-2013 |
| Part B | JN | All Specialties |
Molecular Pathology Procedures for Human Leukocyte Antigen (HLA) Typing, 81374 Billed With Diagnosis 720.0 |
07-10-2013 | N/A |
| Part B | JN | All Specialties |
Molecular Pathology Procedures, 81287, 81400-81408 |
07-10-2013 | 19-02-2014 |
| Part A | JN | 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 014x Hospital – Laboratory Services Provided to Non-patients 018x Hospital – Swing Beds 021x Skilled Nursing – Inpatient (Including Medicare Part A) 022x Skilled Nursing – Inpatient (Medicare Part B only) 023x Skilled Nursing – Outpatient 071x Clinic – Rural Health 072x Clinic – Hospital Based or Independent Renal Dialysis Center 073x Clinic – Freestanding 075x Clinic – Comprehensive Outpatient Rehabilitation Facility (CORF) 077x Clinic – Federally Qualified Health Center (FQHC) 083x Ambulatory Surgery Center 085x Critical Access Hospital |
Molecular Pathology Procedures, 81400-81408 |
07-10-2013 | 01-01-2015 |
| Part A | JN | 013x Hospital Outpatient 085x Critical Access Hospital |
Monitored Anesthesia Care (MAC) For Interventional Pain Management Services, 01991-01992 billed with GA and QS modifier |
25-01-2010 | 26-03-2013 |
| Part B | JN | All Specialties |
Monitored Anesthesia Care 01991/01992 With Specific Procedures & With QS Modifier |
25-01-2010 | N/A |
| Part B | PR/USVI | Ambulance | Non-emergency Ambulance Transport, A0425, A0428 billed with dialysis facility transport modifier |
15-12-2009 | 31-08-2015 |
| Part B | Florida | All Specialties |
Non-Invasive Evaluation of Extremity Veins, 93965, 93970, 93971 Utilization Parameter, Excluding Place of Service 21 & 23 |
22-05-2006 | 24-11-2009 |
| Part B | Florida | All Specialties |
Non-Invasive Extracranial Arterial Studies 93875, 93880, 93882 utilization parameter, excluding place of service 21 & 23 |
25-09-2006 | 04-10-2013 |
| Part B | Florida | All Specialties |
Noninvasive Physiologic Studies of Upper or Lower Extremity Arteries, 93922-93924 Utilization Parameter, Excluding Place of Service 21 & 23 |
24-11-2009 | N/A |
| Part B | JN | All Specialties |
Ocular Photodynamic Therapy with Verteporfin, 67221, 67225, J3396 Billed With or Without GA Modifier & Diagnosis 362.41 |
23-04-2012 | 12-08-2013 |
| Part A | FL | 013x Hospital Outpatient 085x Critical Access Hospital |
Ocular Photodynamic Therapy, 67221-25, J3395-96 with diagnosis 362.41 |
10-01-2001 | 03-04-2013 |
| Part A | PR/USVI | 013x Hospital Outpatient 085x Critical Access Hospital |
Ocular Photodynamic Therapy, 67221-25, J3395-96 with diagnosis 362.41 |
16-02-2009 | 03-04-2013 |
| Part B | JN | All Specialties |
Physician Recertification of Home Health Services G0179 utilization parameter |
29-06-2007 | N/A |
| Part B | JN | All Specialties |
PROLIA AND XGEVA Utilization Parameter, J0897 |
14-10-2013 | N/A |
| Part B | JN | All Specialties |
Psychiatric Diagnostic Evaluation and Psychotherapy Services, 90839, 90840 |
04-06-2013 | N/A |
| Part A | JN | 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 022x Skilled Nursing – Inpatient (Medicare Part B only) 023x Skilled Nursing – Outpatient 071x Clinic – Rural Health 075x Clinic – Comprehensive Outpatient Rehabilitation Facility (CORF) 076x Clinic – Community Mental Health Center 077x Clinic – Federally Qualified Health Center (FQHC) 085x Critical Access Hospital |
Psychiatric Evaluation And Psychotherapy Services, 90839, 90840 |
04-06-2013 | 01-01-2015 |
| Part A | JN | 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 085x Critical Access Hospital |
Radiation Therapy For Basal Cell And Squamous Cell 77401-77404, 77406, 77785, 77786, 77789 with specific diagnosis codes |
13-02-2011 | 01-01-2015 |
| Part B | JN | All Specialties |
Radiation Therapy for T1 Basal & Squamous Cell Carcinoma’s Billed With Specific Diagnosis, 77401-77406, 77785, 77786, 77789, G6003, G6004, G6005, G6006 |
13-02-2011 | 01-01-2015 |
| Part B | JN | All Specialties |
Reduction Mammaplasty, 19318 |
02-02-2009 | N/A |
| Part B | Florida | All Specialties |
Refilling & Maintenance of Portable Pump 96521 billed without J9000-J9999 |
21-04-2011 | 09-05-2011 |
| Part A | Florida | 013x Hospital Outpatient 021x Skilled Nursing – Inpatient (Including Medicare Part A) 023x Skilled Nursing – Outpatient 071x Clinic – Rural Health |
Remicade, J1745 with diagnosis codes 556.0-556.3, 556.5, 556.6, 556.8, 556.9 and 714.2 |
26-07-2000 | 26-03-2013 |
| Part A | PR/USVI | 013x Hospital Outpatient 021x Skilled Nursing – Inpatient (Including Medicare Part A) 023x Skilled Nursing – Outpatient 071x Clinic – Rural Health |
Remicade, J1745 with diagnosis codes 556.0-556.3, 556.5, 556.6, 556.8, 556.9 and 714.2 |
16-02-2009 | 26-03-2013 |
| Part B | JN | All Specialties |
Rituximab (Rituxan), J9310 Billed With Diagnosis 340 |
08-06-2012 | N/A |
| Part B | Puerto Rico |
All Specialties |
Screening & Diagnostic Mammography 76641 & 76642 billed with 77056 or G0204; 77056 billed without 76641 & 76642 |
27-03-2012 | 13-05-2015 |
| Part A | JN | 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 085x Critical Access Hospital |
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) 77371, G0173, G0251, G0339 or G0340 with dx 185 |
30-09-2009 | 01-01-2015 |
| Part B | JN | All Specialties |
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT), 77371-77373, G0339-G0340 |
05-10-2009 | N/A |
| Part B | JN | All Specialties |
Surgical Management of Morbid Obesity, 43848 |
02-02-2009 | N/A |
| Part B | Florida | Specialties 01, 08, 48 |
Therapy Services Billed With Modifier GO or GP |
15-05-2013 | N/A |
| Part B | Puerto Rico |
Specialty 25 |
Therapy Services Billed With Modifier GP |
24-07-2012 | 11-10-2012 |
| Part A | JN | 11X TOB – Inpatient Hospital services |
Threshold Editing |
04-10-2007 | 7/22/20014 |
| Part A | JN | 12X TOB – Hospital Based or Inpatient Part B services |
Threshold Editing |
04-10-2007 | 18-06-2014 |
| Part A | JN | 14X TOB – Other Hospital services |
Threshold Editing |
05-03-1998 | 16-07-2012 |
| Part A | JN | 13X TOB – Outpatient services |
Threshold Editing |
05-03-1998 | 16-07-2012 |
| Part A | JN | 18X TOB – Hospital Swing Beds |
Threshold Editing |
04-10-2007 | 16-07-2012 |
| Part A | JN | 22X TOB – SNF Hospital Based or Inpatient Part B services |
Threshold Editing |
04-10-2007 | 16-07-2012 |
| Part A | JN | 23X TOB – SNF Outpatient services |
Threshold Editing |
05-03-1998 | 16-07-2012 |
| Part A | JN | 71X TOB – Rural Health Clinic (Outpatient) services |
Threshold Editing |
04-10-2007 | 16-07-2012 |
| Part A | JN | 74X TOB – Outpatient Rehabilitation Facility (ORF) services |
Threshold Editing |
05-03-1998 | 16-07-2012 |
| Part A | JN | 75X TOB – Comprehensive Outpatient Rehabilitation Facility (CORF) services |
Threshold Editing |
05-03-1998 | 16-07-2012 |
| Part A | JN | 76X TOB – Clinic or Hospital Based Renal Dialysis Facility services |
Threshold Editing |
05-03-1998 | 16-07-2012 |
| Part A | JN | 85X TOB – Critical Access Hospital (CAH) services |
Threshold Editing |
04-10-2007 | 16-07-2012 |
| Part A | JN | 21X TOB – Inpatient SNF services |
Threshold Editing |
04-10-2007 | 16-07-2012 |
| Part A | JN | 72X TOB – Clinic ESRD services |
Threshold Editing |
04-10-2007 | 16-07-2012 |
| Part B | Florida | All Specialties |
Transthoracic Echocardiography (TTE) 93306, 93307 utilization parameter, excluding place of service 21 & 23 |
25-05-2004 | 31-01-2011 |
| Part B | JN | All Specialties |
Vertebroplasty, Vertebral Augmentation, 20225, 20250, 20251 same date of service 22510-22515, 22520-22525 |
31-03-2014 | 01-01-2015 |
| Part B | JN | All Specialties |
Viscosupplementation for Knee J7325 utilization parameter |
01-01-2010 | N/A |
