Description
The focus of this issue is to target claims where the definition of the procedure code includes imaging and imaging was then unbundled.
Affected Code(s)
70010-79999
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 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 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
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §20.9- National Correct Coding Initiative (NCCI)
9. American Medical Association (AMA), Current Procedural Terminology (CPT)
10. The National Correct Coding Initiative Policy Manual for Medicare Services (also known as the Coding Policy Manual), Chapter III Surgery: Integumentary System CPT Codes 10000-19999; Chapter IV Surgery: Musculoskeletal System CPT Codes 20000-29999; Chapter V Surgery: Respiratory, Cardiovascular, Hemic and Lymphatic Systems CPT Codes 30000-39999; Chapter VI Surgery: Digestive System CPT Codes 40000-49999; Chapter VII Surgery: Urinary, Male Genital, Female Genital, Maternity Care and Delivery Systems CPT Codes 50000-59999 ; Chapter VIII Surgery: Endocrine, Nervous, Eye and Ocular Adnexa, and Auditory Systems CPT Codes 60000-69999