Buckeye (OH)Commercial Clinical Policy

CARDIAC SAFETY & QUALITY PROGRAM Form

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CARDIAC SAFETY & QUALITY PROGRAM

Indications

(10001) Is the procedure an AICD (Automated Implantable Cardioverter Defibrillator)? 
(10002) Is the procedure an ICD (Implantable Cardioverter Defibrillator)? 
(20001) Is the procedure a Leadless Pacemaker? 
(30001) Is the procedure a Pacemaker? 
(40001) Is the procedure a Revision of ICD or Pacemaker? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

NA

Last Reviewed

NA

Original Document

  Reference



buckeye health plan

TurningPoint

CARDIAC SAFETY & QUALITY PROGRAM

TURNINGPOINT’S UTILIZATION MANAGEMENT & PRECERTIFICATION CONTACT INFORMATION: Web Portal Intake: http://www.myturningpoint-healthcare.com Telephonic Intake: (844) 378-3707 | (614) 407-3447 Facsimile Intake: (614) 678-8227

Prior Authorization for medical necessity and appropriate length of stay (when applicable) has been delegated to TurningPoint Healthcare Solutions, LLC. and will be required for the following surgical procedures (and codes listed below) in both inpatient and outpatient settings:

CARDIAC

  • ✓ AICD/ICD
  • ✓ Leadless Pacemaker
  • ✓ Pacemaker
  • ✓ Revision or replacement of ICD or Pacemaker
  • ✓ CABG (non-emergent only)
  • ✓ Coronary Angioplasty & Stents
  • ✓ Non-Coronary Angioplasty & Stents

NOTE: The Coding sets identified below are subject to quarterly additions/deletions per CMS guidelines. To account for these changes, or any inadvertent omissions directly related to the procedures on the TurningPoint Clinical Scope of Services, codes may be added or deleted throughout the term of the program. Please check the following website to view the most current list of codes: www.buckeyehealthplan.com/providers.

CPT Coding 0075T 33211 33229 33243 33274 36218 37248 92943 0076T 33212 33230 33244 33275 36906 37249 92944 33202 33213 33231 33249 33510 37236 92928 33203 33214 33233 33262 33511 37237 92929 33206 33221 33236 33263 33512 37238 92933 33207 33225 33237 33264 33513 37239 92934 33208 33227 33240 33270 33514 37246 92937 33210 33228 33241 33271 33516 37247 92938

HCPCS Coding C1721 C1785 C1876 C1895 C1900 C2621 C9603 C9607 C1722 C1786 C1877 C1896 C2617 C9600 C9604 C9608 C1777 C1874 C1880 C1898 C2619 C9601 C9605 G0448 C1779 C1875 C1882 C1899 C2620 C9602 C9606

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