Description
Documentation will be reviewed to determine if Computed Tomography (CT) Coronary Angiography meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.
Affected Code(s)
CPT 75574
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(7)- Routine physical checkups
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
4. 42 CFR §405.929- Post-Payment Review
5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
6. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
7. 42 CFR §405.986- Good Cause for Reopening
8. 42 CFR §410.32, Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
9. 42 CFR §411.15(a)(1)- Particular services excluded from coverage; Routine physical checkups
10. Medicare National Coverage Determinations Manual, Chapter 1, Part 4 (Sections 200 – 310.1) Coverage Determinations §220.1- Computed Tomography (CT) §A- General, and §F- Computed Tomographic Angiography (CTA)
11. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6.1- Definitions.
12. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
13. CGS Local Coverage Determination LCD L33947- Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA); Effective 10/01/2015; Revised 10/05/2023
14. CGS Local Coverage Article LCA A56451- Billing and Coding: Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA); Effective 10/01/2016; Revised 11/16/2023
15. First Coast Local Coverage Determination LCD L33282- Computed Tomographic Angiography of the Chest, Heart and Coronary Arteries; Effective 10/01/2015; Revised 10/01/2019; Retired 2/23/2023
16. First Coast Local Coverage Article LCA A57061- Billing and Coding: Computed Tomographic Angiography of the Chest, Heart, and Coronary Arteries; Effective 10/03/2018; Revised 10/01/2022; Retired 2/23/2023
17. NGS Local Coverage Determination LCD L33559- Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA); Effective 10/01/2015; Revised 4/01/2022
18. NGS Local Coverage Article LCA A56737- Billing and Coding: Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA); Effective 08/01/2019; Revised 10/01/2023
19. Palmetto Local Coverage Determination LCD L33423- Cardiac Computed Tomography and Angiography (CCTA); Effective 10/01/2015; Revised 4/06/2023
20. Palmetto Local Coverage Article LCA A56691- Billing and Coding: Cardiac Computed Tomography and Angiography (CCTA); Effective 07/11/2019; Revised 10/01/2023
21. WPS Local Coverage Determination LCD L35121- Coronary Computed Tomography Angiography (CCTA); Effective 10/01/2015; Revised 11/30/2023
22. WPS Local Coverage Article LCA A57552- Billing and Coding: Coronary Computed Tomography Angiography (CCTA); Effective 11/28/2019; Revised 10/01/2023
23. AMA CPT Codebook