Attachment 4 Code Set Example Specialty.pdf
PDF 305 KB Posted
- Attached to
- RFI #2 Veteran Affairs Code Sets Requirement
- Solicitation number
- 36C10G26Q0088
About this file
This document is a Cardiology Community Care Referral Guideline (CCRG) code set establishing allowable services for Veterans Administration specialty care referrals to community providers.
The guideline permits outpatient evaluation and management services related to the specific referred condition without prior authorization, provided services are FDA-approved, medically necessary, customary for the specialty, evidence-based, and within generally accepted medical standards. Allowable services include: (1) up to 5 cardiac-related diagnostic imaging tests under VA CodeSet 00002.0001, 00006.0003, and 00008.0007, with example codes 75571, 75572, 75557, and 93306; (2) up to 15 cardiac-related diagnostic labs under VA CodeSet 00003.0002, with example codes 80061, 82465, 83718, and 84484; (3) up to 10 cardiac-related diagnostic studies such as stress tests and echocardiograms under VA CodeSet 00004.0006, with example codes 93000 and 93015; and (4) up to 6 device interrogations and programming procedures for devices including AICDs, pacemakers, and ventricular assist devices under VA CodeSet 00005.0009, with example codes 93288 and 93279. For physician-administered medications not listed on the PAL (Preferred Adjunctive List), community providers must review VA-published Clinical Documentation Instructions (CDI) or the VA Formulary Advisor for specific Criteria for Use (CFU). If a medication is absent from all locations, an RFS (Request for Service) must be submitted prior to administration.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C10G26Q0088 0001 Code Sets RFI Amendment 0001.pdf | ||
| Attachment 2 RFI 2 Questions.pdf | ||
| 36C10G26Q0088.docx | DOCX document | |
| Attachment 3 Code Set Example Procedure.pdf | ||
| Attachment 1 Draft Performance Work Statement Code Sets.pdf |
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Text version
Code Set EXAMPLE: Cardiology Community Care Referral Guideline (CCRG)
ALLOWABLE SERVICES RELATED TO THIS SPECIALTY THAT DO NOT REQUIRE PRIOR
AUTHORIZATION
Outpatient evaluation and management (E/M) services related to the specific condition noted on the consult/referral order within the duration of 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, evidence-based, within generally accepted standards of medical practice, and within the authorization duration.
1) Up to 5 cardiac-related diagnostic imaging tests
Code Set: VA CodeSet 00002.0001, VA CodeSet 00006.0003, VA CodeSet 00008.0007 Quantity Limit: 5
i) Example coding: 75571, 75572, 75557, 93306
2) Up to 15 cardiac-related diagnostic labs
Code Set: VA CodeSet 00003.0002 Quantity Limit: 15
i) Example coding: 80061, 82465, 83718, 84484
3) Up to 10 cardiac-related diagnostic studies (e.g., stress tests, echocardiograms)
Code Set: VA CodeSet 00004.0006 Quantity Limit: 10
i) Example coding: 93000, 93015
4) Up to 6 device interrogations and/or programming (e.g., AICD, pacemaker, ventricular assist device) Code Set: VA CodeSet 00005.0009 Quantity Limit: 6
i) Example coding: 93288, 93279
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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