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
|
|