draft first coast service options local coverage

DRAFT FIRST COAST SERVICE OPTIONS

LOCAL COVERAGE DETERMINATION CODING GUIDELINES

LCD Number

IDTF

Contractor Name

First Coast Service Options, Inc.

Contractor Number

09102 – Florida 09202 – Puerto Rico 09302 – Virgin Islands

LCD Title

Independent Diagnostic Testing Facility (IDTF)

Coding Guidelines

Desk and Site Reviews All new IDTF applications shall receive (1) a thorough desk review, and (2) a mandatory site review prior to the carrier’s enrollment of the applicant and issuance of a billing number. The general purpose of both reviews is to determine whether the information listed on Attachment 2 of the CMS-855B is correct, verifiable, and in accordance with IDTF regulatory and manual requirements. Site Visits for Mobile Units and Electronic Monitoring Services Mobile units are required to list their geographic service area. They can be site visited by the following methods: 1) The mobile unit may visit the office of the site reviewer, or 2) The site reviewer can obtain an advance schedule of the locations the IDTF will be visiting and conduct the site visit at one of those locations. Transtelephonic and electronic monitoring services (e.g., 24-hour ambulatory EKG monitoring; pacemaker monitoring and cardiac event detection) should be classified as IDTFs and must meet all IDTF requirements. These entities require a supervisory physician who performs general supervision. Final enrollment of a transtelephonic or electronic monitoring service as an IDTF requires a site visit. Interpreting Physicians An Independent Diagnostic Testing Facility (IDTF) is not restricted to billing only the technical component of diagnostic services. In certain situations, an IDTF can bill for both the technical component of the diagnostic test and interpretative services. This approach is referred to as billing “globally”. The interpretative services must be performed by a licensed practitioner who is allowed to perform the service. If the interpreting practitioner is an employee of the IDTF, the IDTF must submit a Reassignment of Benefits, Form CMS-855R, which has been signed by the practitioner, in accordance with the Medicare Program Integrity Manual (PIM) Chapter 10, sections 4.19 and 7. If the interpreting practitioner is a contractor performing the interpretation on the premises that the IDTF owns or leases, the IDTF must submit a Reassignment of Benefits, Form CMS-855R, which has been signed by the practitioner, in accordance with PIM Chapter 10, sections 41.19 and 7. In no instance may a group of physicians reassign its benefits to the IDTF. Only individual practitioners may reassign their benefits. When enrolling or updating information, the IDTF shall list all physicians for whose diagnostic test interpretations it will bill. This includes physicians who are providing purchased interpretations to the IDTF (in accordance with CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 1, Section 30.2), as well as physicians who are reassigning their benefits to the IDTF. The carrier will ensure and document the following: • All physicians listed are enrolled in Medicare. • All interpreting physicians who are reassigning their benefits to the IDTF have the right to do so. • All required CMS-855R forms have been submitted. • The interpreting physicians listed are qualified to interpret the types of tests (codes) listed. [In accordance with this CMS

requirement (CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 10, Section 4.19.3),

of 35Coding Guidelines IDTF Independent Diagnostic Testing Facility

3/8/2009http://www.cms.hhs.gov/mcd/lcd_attachments/29956_1/IDTF.1_codeguideDRAFT.htm

FCSO Medicare requires that the interpreting physician for a test billed by the IDTF meet the same qualification requirements as the supervising physician for that IDTF test as listed in the ‘Credentialing Matrix’.]

Note: The applicant cannot bill globally for interpreting physicians not listed. If an interpreting physician has been recently added or changed, the new interpreting physician must have met all of the interpreting physician requirements at the time any tests were performed. Off-Site Interpretations If an IDTF wants to bill for an interpretation performed by an independent practitioner off the premises of the IDTF, it must meet all instructions identified in the CMS Manual System, Pub 100-4, Medical Claims Processing Manual, Chapter 1, concerning purchased interpretations. In this scenario, there is no reassignment of benefits because the purchaser of the test is also considered the supplier of the test. When the technical component of a test is performed by the IDTF and the interpreting practitioner is the practitioner who ordered the test, the IDTF cannot bill for the interpretation. The interpreting practitioner must bill the interpretation since the IDTF cannot bill the interpretation when the interpreting physician is the referring physician. Purchased Diagnostic Tests and Jurisdictional Pricing Services that are reimbursed under the Medicare Physician Fee Schedule (MPFS) are reimbursed by the payment locality where the service is furnished and by the zip code. Effective for claims received on or after April 1, 2004, carriers must use the zip code of the location where the service was rendered to determine carrier jurisdiction over the claim and the correct payment locality. When a physician, practitioner, or supplier furnishes services in payment localities that cover more than one carrier’s service area (e.g., the provider has separate offices in multiple localities and/or multiple carriers), separate claims must be submitted to the appropriate carrier for processing. Effective April 1, 2004, providers may not submit a global billing code on paper or electronic claims when one component of the service has been purchased. Only one service facility location (name, address and zip code) can be indicated in item 32 on the CMS-1500 form. Claims received with global services will be returned as unprocessable. Effective January 25, 2005, suppliers (including laboratories, physicians and independent diagnostic testing facilities [IDTFs]) must bill their local carrier for all purchased diagnostic tests/interpretations, regardless of the location where the purchased service was rendered. Purchased Technical Components A physician may bill for the technical component of a diagnostic test that he/she purchased from another physician, medical group or supplier. However, in order to purchase a diagnostic test from another physician, medical group, or supplier, the purchaser must perform the interpretation (professional component). Additionally, the physician or supplier that furnished the technical component must be enrolled in the Medicare program. Purchased Interpretations A person or entity that provides diagnostic tests may submit the claim, and (if assignment is accepted) receive the Part B payment, for diagnostic test interpretations which that person or entity purchases from an independent physician or medical group if: • The tests are initiated by a physician or medical group which is independent of the person or entity providing the tests and of

the physician or medical group providing the interpretations; • The physician or medical group providing the interpretations does not see the patient; and • The purchaser (or employee, partner, or owner of the purchaser) performs the technical component of the test. The

interpreting physician must be enrolled in the Medicare program. No formal reassignment is necessary. • The purchaser must keep on file the name, the provider identification number and address of the interpreting physician. Note: This does not remove the requirement that when an entity either purchases an interpretation or a test, they must perform the other component in order to be paid for the purchased component. In order to price claims correctly and apply purchase price limitations, global billing is not acceptable for claims received on the Form CMS-1500 or on the ANSI X12N 837 electronic format. Each component must be billed as a separate line item (or on a separate claim). Effective for claims with dates of service on or after January 25, 2005, suppliers (including laboratories, physicians, and IDTFs) must submit claims for all purchased diagnostic tests/interpretations to their local carrier, regardless of the location where the purchased service was furnished.

Credentialing Matrix

CPT/HCPCS CODES

LEVEL OF [PHYSICIAN] SUPERVISION

SUPERVISING PHYSICIAN [AND INTERPRETING PHYSICIAN] QUALIFICATION/PROFICIENCY REQUIREMENTS

TECHNICIAN QUALIFICATION REQUIREMENTS

51725 2 Board Certified by the American Board of Medical Specialties (ABMS) Urologist Urology or OB/GYN Personally Trained Staff

51726 2 Board Certified (ABMS) Urologist Urology or OB/GYN Personally Trained Staff











54240 2 Board Certified (ABMS) Urologist Credentialed by ARDMS: RVT or CCI: RVS

54250 1 Board Certified (ABMS) Urologist Credentialed by ARDMS: RVT or CCI: RVS

59025 1 Board Certified (ABMS) Obstetrics/Gynecology Registered Nurse (RN)

70010 3 Board Certified (ABMS) RadiologistState License: General Radiographer or Medical Physicist






70130 1 Board Certified (ABMS) Radiologist State License: General Radiographer or Medical Physicist




















70332 3 Board Certified (ABMS) Radiologist State License: General Radiographer

70336 1 Board Certified (ABMS) RadiologistCredentialed by ARRT: MR or ARMRIT: MRI

70350 1 Board Certified (ABMS) Radiologist State License: General Radiographer70355 1 Board Certified (ABMS) Radiologist State License: General Radiographer






70390 3 Board Certified (ABMS) Radiologist State License: General Radiographer

70450 1 Board Certified (ABMS) RadiologistState License: General Radiographer or Medical Physicist and ARRT: R.T.-CT




























71010 1 Board Certified (ABMS) Radiologist State License: General Radiographer71015 1 Board Certified (ABMS) Radiologist State License: General Radiographer71020 1 Board Certified (ABMS) Radiologist State License: General Radiographer71021 1 Board Certified (ABMS) Radiologist State License: General Radiographer71022 1 Board Certified (ABMS) Radiologist State License: General Radiographer71023 3 Board Certified (ABMS) Radiologist State License: General Radiographer71030 1 Board Certified (ABMS) Radiologist State License: General Radiographer71034 3 Board Certified (ABMS) Radiologist State License: General Radiographer71035 1 Board Certified (ABMS) Radiologist State License: General Radiographer71040 3 Board Certified (ABMS) Radiologist State License: General Radiographer71060 3 Board Certified (ABMS) Radiologist State License: General Radiographer71100 1 Board Certified (ABMS) Radiologist State License: General Radiographer71101 1 Board Certified (ABMS) Radiologist State License: General Radiographer71110 1 Board Certified (ABMS) Radiologist State License: General Radiographer71111 1 Board Certified (ABMS) Radiologist State License: General Radiographer71120 1 Board Certified (ABMS) Radiologist State License: General Radiographer71130 1 Board Certified (ABMS) Radiologist State License: General Radiographer

State License: General Radiographer or



71250 1 Board Certified (ABMS) Radiologist Medical Physicist and ARRT: R.T.-CT

















































Credentialed by ARRT: MR or ARMRIT:



72194 2 Board Certified (ABMS) Radiologist MRI















73000 1 Board Certified (ABMS) Radiologist or Orthopaedic Surgeon

State License: General Radiographer or Medical Physicist

























Board Certified (ABMS) Radiologist or State License: General Radiographer or



73110 1 Orthopaedic Surgeon Medical Physicist










State License: General Radiographer or Medical Physicist and ARRT: R.T.-CT








Credentialed by ARRT: MR or ARMRIT: MRI




























73560 1 Board Certified (ABMS) Radiologist, Orthopaedic Surgeon or Podiatrist

















74210 3 Board Certified (ABMS) Radiologist State License: General Radiographer74220 3 Board Certified (ABMS) Radiologist State License: General Radiographer74230 3 Board Certified (ABMS) Radiologist State License: General Radiographer74240 3 Board Certified (ABMS) Radiologist State License: General Radiographer74241 3 Board Certified (ABMS) Radiologist State License: General Radiographer74245 3 Board Certified (ABMS) Radiologist State License: General Radiographer74246 3 Board Certified (ABMS) Radiologist State License: General Radiographer74247 3 Board Certified (ABMS) Radiologist State License: General Radiographer74249 3 Board Certified (ABMS) Radiologist State License: General Radiographer74250 2 Board Certified (ABMS) Radiologist State License: General Radiographer74251 3 Board Certified (ABMS) Radiologist State License: General Radiographer74260 3 Board Certified (ABMS) Radiologist State License: General Radiographer74270 3 Board Certified (ABMS) Radiologist State License: General Radiographer74280 3 Board Certified (ABMS) Radiologist State License: General Radiographer74283 3 Board Certified (ABMS) Radiologist State License: General Radiographer74290 1 Board Certified (ABMS) Radiologist State License: General Radiographer74291 1 Board Certified (ABMS) Radiologist State License: General Radiographer74300 3 Board Certified (ABMS) Radiologist State License: General Radiographer74301 3 Board Certified (ABMS) Radiologist State License: General Radiographer74305 3 Board Certified (ABMS) Radiologist State License: General Radiographer74320 3 Board Certified (ABMS) Radiologist State License: General Radiographer74327 3 Board Certified (ABMS) Radiologist State License: General Radiographer74328 3 Board Certified (ABMS) Radiologist State License: General Radiographer74329 3 Board Certified (ABMS) Radiologist State License: General Radiographer74330 3 Board Certified (ABMS) Radiologist State License: General Radiographer

74400 2 Board Certified (ABMS) Radiologist or Urologist State License: General RadiographerBoard Certified (ABMS) Radiologist or



74410 2 Urologist State License: General Radiographer

74415 2 Board Certified (ABMS) Radiologist or Urologist State License: General Radiographer









74710 1 Board Certified (ABMS) Radiologist or Urologist


74740 3 Board Certified (ABMS) Radiologist or Gynocologist


74742 3 Board Certified (ABMS) Radiologist or Gynocologist


74775 3 Board Certified (ABMS) Radiologist or Gynocologist State License: General Radiographer





75600 3 Board Certified (ABMS) Radiologist [or Vascular Surgeon] State License: General Radiographer




75635 2 Board Certified (ABMS) Radiologist State License: General Radiographer or Medical Physicist and ARRT: R.T.-CT



























75801 3 Board Certified (ABMS) Radiologist State License: General Radiographer75803 3 Board Certified (ABMS) Radiologist State License: General Radiographer75805 3 Board Certified (ABMS) Radiologist State License: General Radiographer75807 3 Board Certified (ABMS) Radiologist State License: General Radiographer75809 3 Board Certified (ABMS) Radiologist State License: General Radiographer




















76000 3 Board Certified (ABMS) Radiologist or in the field related to the Primary Procedure State License: General Radiographer



76080 3 Board Certified (ABMS) Radiologist State License: General Radiographer76098 1 Board Certified (ABMS) Radiologist State License: General Radiographer76100 1 Board Certified (ABMS) Radiologist State License: General Radiographer76101 2 Board Certified (ABMS) Radiologist State License: General Radiographer76102 2 Board Certified (ABMS) Radiologist State License: General Radiographer76120 2 Board Certified (ABMS) Radiologist State License: General Radiographer76125 2 Board Certified (ABMS) Radiologist State License: General Radiographer76150 1 Board Certified (ABMS) Radiologist State License: General Radiographer76350 2 Board Certified (ABMS) Radiologist State License: General Radiographer





76506 1 Board Certified (ABMS) Radiologist or Neurologist

Credentialed by ARDMS: RDMS-NE or ARRT:R.T.-S

76510 2 Board Certified (ABMS) Opthalmologist, Radiologist or Optometrist

Credentialed by ARDMS: RDMS-OP or JCAHPO: COT or COMT










Credentialed by ARDMS: ROUB or RDMS-OP or JCAHPO: COT or COMT

Board Certified (ABMS) Opthalmologist, Credentialed by ARDMS: ROUB or RDMS-



76519 1 Radiologist or Optometrist OP or JCAHPO: COT or COMT

76529 1 Board Certified (ABMS) Opthalmologist or Radiologist

Credentialed by ARDMS: ROUB or RDMS-OP or JCAHPO: COT or COMT

76536 1 Board Certified (ABMS) Radiologist or Neurologist

Credentialed by ARDMS: RDMS or ARRT: R.T.-S

76604 1 Board Certified (ABMS) Radiologist Credentialed by ARDMS: RDMS or ARRT:R.T.-S

76645 1 Board Certified (ABMS) Radiologist Credentialed by ARDMS: RDMS or ARRT: R.T.-BS

76700 1 Board Certified (ABMS) Radiologist Credentialed by ARDMS RDMS or ARRT: R.T.-S

76705 1 Board Certified (ABMS) Radiologist Credentialed by ARDMS: RDMS or ARRT: R.T.-S




76800 1 Board Certified (ABMS) Radiologist Credentialed by ARDMS: RDMS-NE or ARRT: R.T.-S

76801 1 Board Certified (ABMS) Radiologist Credentialed by ARDMS: RDMS-OB/GYN or ARRT: R.T.-S


















76828 1 Board Certified (ABMS) Radiologist Credentialed by ARDMS: RDMS-OB/GYN or ARRT: R.T.-S Credentialed by ARDMS: RDMS-OB/GYN



76830 1 Board Certified (ABMS) Radiologist or ARRT: R.T.-S







76880 1 Board Certified (ABMS) Radiologist or Podiatrist

Credentialed by ARDMS: RDMS or ARRT: R.T.-S




Credentialed by ARDMS: RDMS or ARRT: R.T. - S

76946 3 Board Certified (ABMS) Radiologist Credentialed by ARDMS: RDMS-OB/GYN or ARRT: R.T. - S

76970 1 Board Certified (ABMS) Radiologist Credendentialed by ARDMS: RDMS or ARRT:R.T.-S

76975 3 Board Certified (ABMS) Radiologist Credendentialed by ARDMS: RDMS or ARRT:R.T.-S


Credendentialed by ARDMS: RDMS or ARRT:R.T.-S or- BD








77031 3 Board Certified (ABMS) Radiologist State License: General Radiographer77032 3 Board Certified (ABMS) Radiologist State License: General Radiographer

77051 1 Board Certified (ABMS) Radiologist

State License: General Radiographer and ARRT: R.T.-M and Facility Must be FDA Certified to Perform Mammography



77053 3 Board Certified (ABMS) Radiologist State License: General Radiographer and ARRT: R.T.-M

77054 3 Board Certified (ABMS) Radiologist State License: General Radiographer and ARRT: R.T.-M












Physician Service Code - Must be performed by a physician








77078 1 Board Certified (ABMS) RadiologistState License: General Radiographer and ARRT: R.T.-CT

77079 1 Board Certified (ABMS) RadiologistState License: General Radiographer and ARRT: R.T.-CT

77080 1 Board Certified (ABMS) Radiologist or Internal Medicine Specialist

State License: General Radiographer and ARRT: R.T.-BD








77417 1 Board Certified (ABMS) Radiologist State License: General Radiographer or medical physicist

78000 1 Board Certified (ABMS) Nuclear Medicine or Radiology ARRT: N or NMTCB: CNMT
























78300 1 Board Certified (ABMS) Nuclear Medicine, Radiology or Podiatrist ARRT: N or NMTCB: CNMT

78305 1 Board Certified (ABMS) Nuclear Medicine, Radiology or Podiatrist ARRT: N or NMTCB: CNMT





78414 1 Board Certified (ABMS) Nuclear Medicine, Cardiology or Radiology ARRT: N or NMTCB: CNMT













91000 2 Board Certified (ABMS) Gastroenterologist Registered Nurse (RN)





91022 2 Board certified (ABMS) Gastroenterologist Registered Nurse (RN)










91120 2 Board Certified (ABMS) Gastroenterologist Colorectal Surgeon Registered Nurse (RN)

91122 2 Board Certified (ABMS) Gastroenterologist Colorectal Surgeon Registered Nurse (RN)



92060 1 Board Certified (ABMS) Ophthalmologist, Neurologist or Optometrist Credentialed by JCAHPO: COT or COMT




92100 9

Board Certified (ABMS) Ophthalmologist or Optometrist/Physician Supervision concept does not apply


92120 9



92130 9



92135 1 Board Certified (ABMS) Ophthalmologist or Optometrist Credendentialed by JCAHPO: COT or COMT

92136 1 Board Certified (ABMS) Ophthalmologist or Optometrist Credentialed by JCAHPO: COT or COMTBoard Certified (ABMS) Ophthalmologist,



92235 2 Neurologist or Optometrist Credentialed by JCAHPO: COT or COMT









92286 1 Board Certified (ABMS) Ophthalmologist, Neurologist or Optometrist

Credentialed by JCAHPO: COT or COMT or OPS: CRA

92541 5 Board Certified (ABMS) Neurologist or Otolaryngologist Licensed Audiologist












92557 5 Board Certified (ABMS) Neurologist or Otolaryngologist

Physician Service Code – must be performed by a physician










Board Certified (ABMS) Neurologist or Physician Service Code – must be performed



92569 5 Otolaryngologist by a physician












92586 9

Board Certified (ABMS) Neurologist or Otolaryngologist/Concept of physician supervision does not apply Licensed Audiologist





Physician service code - must be performed by a physician


Physician Service Code - must be performed by a physician










93000 1 Board Certified (ABMS) Internist or Cardiologist

RN, LPN, or State licensed Paramedic or credentialed by CCI: CCT


RN, LPN, or State licensed Paramedic or credentialed by CCI: CCT

93010 9

Board Certified (ABMS) Internist or Cardiologist/Concept of physician supervision does not apply

Professional component only code - must be performed by a physician


RN, State licensed Paramedic or credentialed by CCI: CCT

93014 9

Board Certified (ABMS) Internist or Cardiologist/Concept of physician supervision does not apply




93015 2 Board Certified (ABMS) Internist or Cardiologist - ACLS certified






93018 9 Board Certified (ABMS) Cardiologist/ Physician Supervision concept does not apply











Professional component code - must be performed by a physician

93224 1 Board Certified (ABMS) CardiologistRN, State licensed Paramedic or credentialed by CCI: CCT





93228 0 Board Certified (ABMS) CardiologistProfessional component only code – service must be performed by a physician

93229 1 Board Certified (ABMS) CardiologistState Licensed: RN or Paramedic or credentialed by CCI: CCT











RN, State licensed Paramedic or credentialed



93270 1 Board Certified (ABMS) Cardiologist by CCI: CCT





93279 2 Board Certified (ABMS) CardiologistState Licensed: RN or Paramedic, or credentialed by CCI: CCT





















93303 1 Board Certified (ABMS) Cardiologist Credentialed by ARDMS: RDCS or CCI: RCS








93313 3 Board Certified (ABMS) CardiologistPhysician Service Code - must be performed by a physician



93316 3 Board Certified (ABMS) CardiologistPhysician Service Code - must be performed by a physician





93350 2 Board Certified (ABMS) CardiologistCredentialed by ARDMS: RDCS or CCI: RCS, RN or State licensed Paramedic

93351 2 Board Certified (ABMS) CardiologistState Licensed RN or Paramedic, or Credentialed by ARDMS: RDCS or CCI: RCS

93352 9 Board Certified (ABMS) CardiologistPhysician service code – service must be performed by a physician

[93501 3

Board Certified (ABMS) Cardiologist with Level 2 Training (minimum) as outlined by the ACC/AHA Task Force 3 Credentialed by: ARRT: CI or CCI: RCIS

93508 3


93510 3


93511 3


93526 3


93527 3


93529 3


93530 3


93531 3


93532 3


93533 3


Board Certified (ABMS) Cardiologist with Level 2 Training (minimum) as outlined by



93555 3 the ACC/AHA Task Force 3 Credentialed by: ARRT: CI or CCI: RCIS

93556 3


93561 3


93562 3


93571 3


93572 3

Board Certified (ABMS) Cardiologist with Level 2 Training (minimum) as outlined by the ACC/AHA Task Force 3 Credentialed by: ARRT: CI or CCI: RCIS]

93660 1 Board Certified (ABMS) CardiologistCredentialed by CCI: CCT, RCIS, RCS or ARDMS: RDCS or RN

93701 1 Board Certified (ABMS) Cardiologist Demonstrates Proficiency

93720 1 Board Certified (ABMS) Pulmonologist Credentialed by ARDMS: RVT or CCI: RVS93721 1 Board Certified (ABMS) Pulmonologist Certified by ARDMS: RVT, CCI: RVS

93740 1 Board Certified (ABMS) CardiologistCredentialed by CCI: CCT, State licensed Paramedic or RN

93770 1 Board Certified (ABMS) CardiologistCredentialed by CCI: CCT, State licensed Paramedic or RN

93784 1 Board Certified (ABMS) Cardiologist, Internal Medicine or Family Practice

Credentialed by CCI: CCT, State licensed Paramedic or RN





93790 9

Board Certified (ABMS) Cardiologist, Internal Medicine or Family Practice/ Physician supervision concept does not apply


93875 1

Board Certified (ABMS) Radiologist, Neurologist[,] or Cardiologist [or Vascular Surgeon] - refer to FCSO LCD 93875 Non-invasive Extracranial Arterial Studies for additional credentialing [training] requirements

Credentialed by ARDMS: RVT, ARRT: VS or CCI: RVS

93880 1



93882 1



93886 1

Board Certified (ABMS) Radiologist, Neurologist[,] or Cardiologist [or Vascular Surgeon]


93888 1



Board Certified (ABMS) Radiologist,



93890 1 Neurologist[,] or Cardiologist [or Vascular Surgeon]


93892 1



93893 1



93922 1

Board Certified (ABMS) Radiologist, Cardiologist[,] or Podiatrist [or Vascular Surgeon]


93923 1



93924 1



93925 1



93926 1



93930 1 Board Certified (ABMS) Radiologist[,] or Cardiologist [or Vascular Surgeon]










93975 1 Board Certified (ABMS) Radiologist [or Vascular Surgeon]








93980 1 Board Certified (ABMS) Radiologist[,] or Urologist [or Vascular Surgeon]


93981 1 Board Certified (ABMS) Radiologist[,] or Urologist [or Vascular Surgeon]




94010 1 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist or RN



94016 9 Board Certified (ABMS) Pulmonologist/ Physician supervision concept does not apply



94070 2 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist or RN 94150 1 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist



94200 1 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 94240 1 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 94250 1 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 94260 1 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 94350 1 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 94360 1 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 94370 1 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 94375 1 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 94400 2 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 94450 2 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist





94664 2 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist or RN 94680 2 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 94681 2 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 94690 1 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 94720 1 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 94725 1 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 94750 1 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 94760 1 Board Certified (ABMS) Pulmonologist Demonstrates proficiency 94761 1 Board Certified (ABMS) Pulmonologist Demonstrates proficiency 94762 1 Board Certified (ABMS) Pulmonologist Demonstrates proficiency 94770 1 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 94772 1 Board Certified (ABMS) Pulmonologist State License: Respiratory Therapist 95028 2 Board Certified (ABMS) Otolaryngologist Registered Nurse (RN) 95044 2 Board Certified (ABMS) Otolaryngologist Registered Nurse (RN) 95052 2 Board Certified (ABMS) Otolaryngologist Registered Nurse (RN) 95056 2 Board Certified (ABMS) Otolaryngologist Registered Nurse (RN)

95060 3 Board Certified (ABMS) Otolaryngologist, Ophthalmologist or Optometrist Registered Nurse (RN)

95065 3 Board Certified (ABMS) Otolaryngologist Registered Nurse (RN) 95070 2 Board Certified (ABMS) Otolaryngologist Registered Nurse (RN) 95071 2 Board Certified (ABMS) Otolaryngologist Registered Nurse (RN)

95805 1

Board Certified (ABMS) Pulmonologist, Neurologist or [Physician] Certified by the American Board of Sleep Medicine (ABSM)[: Sleep Medicine or ABMS: Sleep Medicine]

Credentialed by BRPT: RPSGT[,] or ABRET: R. EEG T. (Polysomnography)[, CRT: SDS or RRT: SDS]

95806 1

Board Certified (ABMS) Pulmonologist, Neurologist or Certified by the American Board of Sleep Medicine (ABSM)

Credentialed by BRPT: RPSGT or ABRET: R. EEG T. (Polysomnography)

95807 1

Board Certified (ABMS) Pulmonologist, Neurologist or [Physician] Certified by the American Board of Sleep Medicine (ABSM) [: Sleep Medicine or ABMS: Sleep Medicine]


95808 1



Board Certified (ABMS) Pulmonologist,



ACh

Highlight

95810 1

Neurologist or [Physician] Certified by the American Board of Sleep Medicine (ABSM) [: Sleep Medicine or ABMS: Sleep Medicine]


95811 1



95812 1 Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EEG T95813 1 Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EEG T95816 1 Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EEG T95819 1 Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EEG T95822 1 Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EEG T95824 1 Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EEG T95827 1 Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EEG T

95830 9 Board Certified (ABMS) Neurologist/ Physician Supervision concept does not apply


95860 6A Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EP T.95861 6A Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EP T.95863 6A Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EP T.95864 6A Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EP T.95867 6A Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EP T.95868 6A Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EP T.95869 6A Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EP T.95870 6A Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EP T.95872 66 Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EP T.95875 3 Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EP T.

95900 7A

Board Certified (ABMS) Neurologist or Podiatrist - General supervision level applices if PT not certified

Credentialed by AAET: R. EDT., ABRET: R. EP T. or State Licensed Physical Therapist with ABPTS certification or Qualified Physical Therapist

95903 7A



95904 7A



95921 2 Board Certified (ABMS) Neurologist Credentialed by AAET: R. EDT95922 3 Board Certified (ABMS) Neurologist Credentialed by AAET: R. EDT95923 3 Board Certified (ABMS) Neurologist Credentialed by AAET: R. EDT

95925 21 Board Certified (ABMS) NeurologistCredentialed by ABRET: R. EPT or R. EEG T.

95926 21 Board Certified (ABMS) Neurologist or Podiatrist

Credentialed by ABRET: R. EPT or R. EEG T.







ACh

Highlight

95933 7A

Board Certified (ABMS) Neurologist -General supervision level applices if PT not certified

Credentialed by AAET: R. EDT., State licensed Physical Therapist with ABPTS certification or Qualified Physical Therapist

95934 7A



95936 7A

Board Certified (ABMS) Neurologist -General supervision level applices if PT not certified


95937 7A



95950 1 Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EEG T95951 1 Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EEG T95953 1 Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EEG T95954 3 Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EEG T95956 1 Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EEG T95957 1 Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EEG T95958 3 Board Certified (ABMS) Neurologist Credentialed by ABRET: R. EEG T

96103 4 Psychiatrist, Clinical psychologist or qualified independent psychologist












G0106 3 Board Certified Gastroenterologist

State License: General Radiographer and Credentialed by ARRT: R.T.-N or NMTCB: CNMT

G0130 1 Board Certified (ABMS) RadiologistState License: General Radiographer and Credentialed by ARRT: R.T.-BD

G0202 1 Board Certified (ABMS) Radiologist






G0235 1 Board Certified (ABMS) Nuclear Medicine or Radiology

State License: General Radiographer and Credentialed by ARRT: R.T.-N or NMTCB: CNMT

G0248 1 Board Certified (ABMS) Cardiologist Registered Nurse (RN) G0249 1 Board Certified (ABMS) Cardiologist Demonstrates Proficiency

G0389 1 Board Certified (ABMS) RadiologistARDMS: RDMS – Abdomen or ARRT: R.T.-S

Board Certified (ABMS) Physician Certified by the American Board of Sleep Medicine Credentialed by BRPT: RPSGT or ABRET:



Key for IDTF Table Abbreviations

American Association of Electrodiagnostic Technologists (AAET) http://www.aaet.info/resources/job_descriptions_for_edxtech.cfm Registered Electrodiagnostic Technologist (R. EDT.)

[American Board of Medical Specialties (ABMS) http://www.abms.org/]

American Board of Registration of Electroencephalographic and Evoked Potential Technologists (ABRET) http://www.abret.org/exam_info/eligibility.php Registered Electroencephalographic technologist (R. EEG T.) Registered Evoked Potential Technologist (R.EP T.)

[American Board of Sleep Medicine (ABSM) www.absm.org]

American Registry of Diagnostic Medical Sonographers (ARDMS) |http://www.ardms.org/aboutardms/overview.htm Registered Diagnostic Cardiac Sonographer (RDCS) Registered Diagnostic Medical Sonographer (RDMS) Registered Vascular Technologist (RVT)

American Registry of Magnetic Resonance Imaging Technologists (ARMRIT) http://www.armrit.org/ Certified Magnetic Resonance Imaging Technologist

G0398 1 (ABSM) R. EEG T. (Polysomnography)

G0399 1

Board Certified (ABMS) Physician Certified by the American Board of Sleep Medicine (ABSM)


G0400 1

Board Certified (ABMS) Physician Certified by the American Board of Sleep Medicine (ABSM)


Q0035 1 Board Certified (ABMS) CardiologistCredentialed by CCI: CCT, State licensed Paramedic or RN

0067T 1 Board Certified (ABMS) Gastroenterologist or Radiologist


0145T 1 Board Certified (ABMS) Cardiologist or Radiologist
















The American Registry of Radiologic Technologists (ARRT) http://www.arrt.org/index.html Certified Magnetic Resonance Imaging Technologist (ARRT: MR) Certified and Registered Technologist -Bone Densitometry (R.T-BD) Certified and Registered Technologist-Breast Sonography (R.T.-BS) [Certified and Registered Technologist – Cardiac Interventional Radiography (ARRT: CI) Certified and Registered Technologist -Computed Tomography (R.T.-CT) Certified and Registered Technologist -Magnetic Resonance Imaging (R.T.-MR) Certified and Registered Technologist-Mammography (R.T.-M) Certified and Registered Technologist-Nuclear Medicine Technology (R.T.-N) Certified and Registered Technologist-Radiography (R.T.-R) Certified and Registered Technologist –Sonograpy (R.T.-S) Certified and Registered Technologist –Vascular Sonography (R.T.-VS)

The Board of Certification of the Ophthalmic Photographers’ Society http://www.opsweb.org/Certif/Certif.html Certified Retinal Angiographer (CRA)

Board of Registered Polysomnographic Technologists (BRPT) http://www.brpt.org/ Registered Polysomnographic Technologist (RPSGT)

Cardiovascular Credentialing International (CCI) http://www.cci-online.org/ Certified Cardiographic Technician (CCT) Registered Cardiac Sonographer (RCS) Registered Cardiovascular Invasive Specialist (RCIS) Registered Vascular Specialist (RVS)

Joint Commission on Allied Health Personnel in Ophthalmology (JCAHPO) http://www.jcahpo.org/newsite/certificationhome.htm JCAHPO offers three levels of certification: Certified Ophthalmic Assistant (COA) Certified Ophthalmic Technician (COT) (Intermediate Level) Certified Ophthalmic Medical Technologist (COMT) (Advanced Level)

National Board for Respiratory Care (NBRC) http://www.nbrc.org Certified Pulmonary Function Technologist (CPFT) Registered Pulmonary Function Technologist (RPFT) Certified Respiratory Therapist (CRT)[: Sleep Disorder Specialist (SDS)] Registered Respiratory Therapist (RRT)[: Sleep Disorder Specialist (SDS)]

Nuclear Medicine Technology Certification Board (NMTCB) http://www.nmtcb.org/ Certified Nuclear Medicine Technologist (CNMT)

Revision History

Date Revision

MM/DD/YYYY 1 – Revisions include: ‘Interpreting Physicians’ section revised to add language to indicate that an interpreting physician for a test billed by the IDTF is required to meet the same qualification requirements as the supervising physician for that test. In this regard, the ‘Credentialing Matrix’ was revised to change the title of column ‘Supervising Physician Qualification/Proficiency Requirements’ to “Supervising Physician and Interpreting Physician Qualification Requirements”. The ‘Credentialing Matrix’ was revised to delete CPT codes 76800 and 95806, as



Document formatted: 01/27/2008 (JG/st)

these codes have been added to the List of Medicare Noncovered Services LCD and to add the following CPT codes: 93501, 93508, 93510, 93511, 93526, 93527, 93529, 93530, 93531, 93532, 93533, 93555, 93556, 93561, 93562, 93571 and 93572 and the following requirements : Level of Physician Supervision ‘3’, Supervising Physician and Interpreting Physician Qualification Requirements ‘Board Certified (ABMS) Cardiologist with Level 2 Training (minimum) as outlined by the ACC/AHA Task Force 3’ and Technician Qualification Requirements ‘Credentialed by ARRT: CI or CCI: RCIS’: The ‘Supervising Physician and Interpreting Physician Qualification Requirements’ section of ‘Credentialing Matrix’ was revised for CPT codes 95805, 95807, 95808, 95810 and 95811 to read ‘Board Certified (ABMS) Physician Certified by ABSM: Sleep Medicine or ABMS: Sleep Medicine’ and associated technician qualification requirements revised to read: Credentialed by BRPT: RPSGT, ABRET: R. EEG T. (Polysomnography), CRT: SDS or RRT: SDS. In addition, “Vascular Surgeon” was added to the ‘Supervising Physician and Interpreting Physician Qualification Requirements’ section of ‘Credentialing Matrix’ for select CPT codes. The effective date of this revision is based on date of service.

02/02/2009 – Florida 03/02/2009 – Puerto Rico/Virgin Islands

Original

Coding Guidelines revised to add two sections, ‘Desk and Site Reviews’ and ‘Site Visits for Mobile Units and Electronic Monitoring Services’.



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