Per the CPT® Reference Guide for Cardiovascular Coding, authored by the AMA and the American College of Cardiology, 9334 should not be used when complex congenital heart disease is suspected but not found on echocardiographic evaluation or for ‘simple’ congenital anomalies.īack to Top Notice 3: Upcoming Apple Health Core Connections Provider Webinars.Payment for add-on codes may depend upon the appropriateness of the application of such codes related to the approved primary code.When receiving such requests, NIA will review the medical necessity for both the PET scan and the CT scan and issue UM determinations on both codes. The CT code should be appended with a modifier 59 to ensure proper payment. Under this situation one is instructed by CPT to bill using both the PET CPT code and the CT scan code describing the body region and procedure performed. A PET fusion study is where a PET scan and a diagnostic CT scan are performed on the same machine simultaneously. These codes are NOT to be used for a study typically called PET fusion. Accordingly, we are expanding the list of “Allowable Billable Groupings” to take this into account. If a PET scan is clinically indicated, use of either series of codes is acceptable. NIA’s tumor imaging clinical guidelines does not make a distinction between which technique is used. When an ordering physician requests a PET scan, they won’t know whether or not an older machine will be used without the CT component. The 78814 series describes a PET scan where CT technology is used to better “focus” the PET scanning.Instead, we will make a determination as to whether the PET scan itself is indicated and then expect the imaging facility to bill in a fashion that accurately describes what was performed. NIA will not be making a medical necessity determination as to which of these codes are appropriate.*Please note: Services rendered in an Emergency Room, Observation Room, surgery center or hospital inpatient setting are not managed by NIA.ĭiagnostic CT Colonoscopy (Virtual Colonoscopy, CT Colonography)Ĭoronary Artery Ca Score, Heart Scan, Ultrafast CT Heart, Electron Beam CTĬT Heart congenital studies, non-coronary arteries There may be some codes not listed in this matrix that are included as part of Centene’s contract with NIA but no prior auth is required. This UM Matrix includes a listing of the codes managed by NIA (require Prior authorization). If the exact match does not occur, the charge should be adjudicated accordingly. If a family of CPT codes is not listed in this matrix, an exact match is required between the authorized CPT code and the billed CPT code. This assumes that the member is eligible at the time of the service, that appropriate rebundling rules are applied, that the claim includes an appropriate diagnosis code for the CPT code and that the service is performed within the date of service validity period.Ĭodes that are submitted by facilities using CMS Outpatient PPS logic (C codes) are also not incorporated into this table. The “Allowable Billed Groupings” is meant to outline that if a given procedure is authorized, that any of the listed procedures codes could be submitted on a claim representing that service. The inclusion of a code(s) also doesn’t imply that the service would be approved, only that if we received a request for that service, it would be managed by NIA. The codes listed are set up utilizing what would be seen on a professional HCFA 1500 claim. The matrix below contains all those CPT-4 codes NIA manages on behalf of its clients. ![]() This matrix is designed to assist in the resolution of claims adjudication and claims questions related to those services managed by NIA. NIA has developed the following matrix in an effort to help its clients set up their claim processing systems. _ Notice 1: Holiday ScheduleĬoordinated Care will be closed due to Holiday for the following dates:īack to Top Notice 2: Utilization Review Matrix-NIA Thank you for being our partner in care to collectively improve the health of our members. Please call our Provider Services team with questions about these announcements or if you need more information: 1-87. Upcoming Apple Health Core Connections Provider Webinars.
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