| SERIAL NUMBER | Procedure | 1st Qtr | Per Qtr (for next 3 Qtrs) | Requirements while submitting for follow-up Preauth | Requirements while submitting for follow-up Claims |
|---|---|---|---|---|---|
| 13 | FP0013 : Coronary Bypass Surgery | 4,000 | 2,000 | Previous Discharge Summary | [ECG, Clinical History,(PT/INR x 1st 6 months)-Mandatory] |
| 14 | FP0014 : Coronary Bypass Surgery - post Angioplasty | 4,000 | 2,000 | Previous Discharge Summary | [ECG, Clinical History, Clinical Evaluation,(PT/INR x 1st 6 months)-Mandatory] |
| 15 | FP0015 : CABG with IABP Pump | 4,000 | 2,000 | Previous Discharge Summary | [ECG, Clinical History, Clinical Evaluation, X-ray, ECHO,(PT/INR x 1st 6 months)-Mandatory] |
| 16 | FP0016 : CABG with aneurismal repair | 4,000 | 2,000 | Previous Discharge Summary | [ECG, Clinical History, Clinical Evaluation, X-ray, Doppler flow, (PT/INR x 1st 6 months)-Mandatory] |
| 17 | FP0017 : With prosthetic Ring | 4,000 | 2,000 | Previous Discharge Summary | (ECG,ECHO, Clinical Evaluation-Mandatory), PT/INR |
| 18 | FP0018 : Without prosthetic Ring | 4,000 | 2,000 | Previous Discharge Summary | (ECG,ECHO, Clinical Evaluation-Mandatory), PT/INR |
| 19 | FP0019 : Open Pulmonary Valvotomy | 4,000 | 2,000 | Previous Discharge Summary | (ECG,ECHO, Clinical Evaluation-Mandatory), PT/INR |
| 20 | FP0020 : Closed mitral Valvotomy | 4,000 | 2,000 | Previous Discharge Summary | (ECG,ECHO, Clinical Evaluation-Mandatory), PT/INR |
| 21 | FP0021 : Mitral Valvotomy (open) | 4,000 | 2,000 | Previous Discharge Summary | (ECG,ECHO, Clinical Evaluation-Mandatory), PT/INR |
| 22 | FP0022 : Mitral Valve Replacement (with valve) | 4,000 | 2,000 | Previous Discharge Summary | (ECG, ECHO, Inr Level, Clinical Evaluation-Mandatory), PT/INR |
| 23 | FP0023 : Aortic Valve Replacement (with valve) | 4,000 | 2,000 | Previous Discharge Summary | (ECG, ECHO, Inr Level, Clinical Evaluation-Mandatory), PT/INR |
| 24 | FP0024 : Tricuspid Valve Replacement | 4,000 | 2,000 | Previous Discharge Summary | (ECG, ECHO, Inr Level, Clinical Evaluation-Mandatory), PT/INR |
| 25 | FP0025 : Double Valve Replacement (with valve) | 4,000 | 2,000 | Previous Discharge Summary | (ECG, ECHO, Inr Level, Clinical Evaluation-Mandatory), PT/INR |
| 26 | FP0026 : Carotid Embolectomy | 4,000 | 2,000 | Previous Discharge Summary | (Color Doppler, Neurological Evaluation, Clinical Evaluation-Mandatory), CT in first quarter, ECHO, Lipid Profile |
