National Coverage Determination (NCD)

Cardiac Catheterization Performed in Other than a Hospital Setting

20.25

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Tracking Information

Publication Number
100-3
Manual Section Number
20.25
Manual Section Title
Cardiac Catheterization Performed in Other than a Hospital Setting
Version Number
1
Effective Date of this Version
08/01/1979
Ending Effective Date of this Version
01/12/2006
Implementation Date
08/01/1979
Implementation QR Modifier Date

Description Information

Benefit Category
Diagnostic Tests (other)


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description
Indications and Limitations of Coverage

Cardiac catheterization performed in a hospital setting for either inpatients or outpatients is a covered service. The procedure may also be covered when performed in a freestanding clinic when the carrier, in consultation with the appropriate Quality Improvement Organization (QIO), determines that the procedure can be performed safely in all respects in the particular facility. Prior to approving Medicare payment for cardiac catheterizations performed in freestanding clinics, carriers must request QIO review of the clinic.

Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
8
Revision History

08/1986 - Replaced PSRO with PRO and emphasized that for procedure to be covered in a freestanding facility, carriers must request PRO review. Effective date NA. (TN 8)

Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Cardiac Catheterization Performed in Other than a Hospital Setting - RETIRED 3 04/10/2023 - N/A View
Cardiac Catheterization Performed in Other than a Hospital Setting 2 01/12/2006 - 04/10/2023 View
Cardiac Catheterization Performed in Other than a Hospital Setting 1 08/01/1979 - 01/12/2006 You are here
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Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.