Attachment 3 Code Set Example Procedure.pdf
PDF 307 KB Posted
- Attached to
- RFI #2 Veteran Affairs Code Sets Requirement
- Solicitation number
- 36C10G26Q0088
About this file
This document is a Community Care Referral Guideline (CCRG) code set example for cardiac catheterization procedures provided through the VA's community care network. The guideline establishes allowable services that do not require prior authorization when delivered by in-network community providers to veterans.
The guideline permits up to two interventional cardiology visits (initial and follow-up) related to the cardiac catheterization procedure, provided all services are related to the referred condition, FDA-approved, medically necessary, and within generally accepted standards of medical practice. Allowable services include pre-procedure medical and basic cardiac clearance (such as history and physical, labs, EKG, CXR, and echocardiogram), anesthesia services related to the procedure, and up to one cardiac catheterization primary procedure with percutaneous interventions. The guideline provides specific VA code sets and example CPT codes for each service category. For physician-administered medications not listed on the Preferred Allowance List (PAL), community providers must comply with VA-published Clinical Documentation Improvement (CDI) guidelines or the VA Formulary Advisor for Criteria for Use. Medications not appearing in any VA resource require submission of a Request for Service (RFS) prior to administration.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C10G26Q0088 0001 Code Sets RFI Amendment 0001.pdf | ||
| 36C10G26Q0088.docx | DOCX document | |
| Attachment 4 Code Set Example Specialty.pdf | ||
| Attachment 2 RFI 2 Questions.pdf | ||
| Attachment 1 Draft Performance Work Statement Code Sets.pdf |
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Text version
Code Set EXAMPLE: Cardiac Catheterization Community Care Referral Guideline (CCRG)
ALLOWABLE SERVICES RELATED TO THIS SPECIALTY THAT DO NOT REQUIRE PRIOR
AUTHORIZATION
Outpatient evaluation and management (E/M) services allow for up to 2 interventional cardiology visits (initial and follow-up visit) related to the cardiac catheterization procedure noted on the consult/referral order within the duration noted on the VA authorization.
The scope of services must be related to the referred condition on the consult/referral order, FDA-approved, medically necessary, considered usual and customary for the specialty or subspecialty, test, or procedure, evidence-based, within generally accepted standards of medical practice, and within the authorization duration.
1. Pre-procedure medical and basic cardiac clearance provided by the specialist's office, as clinically indicated (including H+P, labs, EKG, CXR, and echo when not done previously at the VA within the required procedure timeframe) NOTE: cardiac testing or evaluation outside of the above CXR and EKG will require an RFS for a general cardiology referral Code Set: VA CodeSet 000019.0001 Quantity Limit: N/A
2. Anesthesia services related to this procedure
Code Set: VA CodeSet 00004.0008 Quantity Limit: N/A Example coding: 00450, 00454, 01620, 01638, 01760, 01832, 01920, 99152, 99156
3. Up to 1 cardiac catheterization primary procedure with percutaneous interventions, as clinically indicated Code Set: VA CodeSet 00005.0007 Quantity Limit: 1 Example coding: 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92975, 92977, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, C1874, C1875, C1876, C1877
PHYSICIAN-ADMINISTERED MEDICATIONS: FDA-approved medications not listed on the PAL can be provided for the indicated use under a specialty care referral at an in-network location. For medications that ARE NOT LISTED on the PAL: Community providers must review and adhere to the VA published CDI prior to providing physician-administered medications to a Veteran.
* If a CDI is absent, community providers must review and adhere to the VA Formulary Advisor for any specific VA Criteria for Use (CFU).
* If a medication is not listed in any location, an RFS must be submitted prior to providing the physician-administered medication.
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