Medicare complex medical review CPT list

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
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