Description
Documentation will be reviewed to determine if External Counterpulsation (ECP) Therapy meets Medicare coverage criteria and documentation requirements.
Affected Code(s)
G0166
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Establishing Good Cause for Reopening
7. 42 CFR §410.32(b)(3) – Levels of Supervision
8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
9. Medicare National Coverage Determination (NCD) Manual, Chapter 1- Coverage Determinations, §20.20 – External Counterpulsation (ECP) Therapy for Severe Angina
10. Medicare Benefit Policy Manual, Chapter 6, §20.5.3 – Coverage of Outpatient Therapeutic Services Incident to a Physician’s Service Furnished on or After January 1, 2020 – Changes to Supervision Requirements
11. Medicare Claims Processing Manual, Chapter 32 – Billing Requirements for Special Services, §130 – External Counterpulsation (ECP) Therapy
12. AMA CPT Codebook