Percutaneous Coronary Intervention - Medicare Advantage (Revised)

By August 3, 2026: Billing team must update all PCI billing protocols to align with this revised Medicare Advantage policy. (1) In billing software, configure mandatory medical necessity documentation requirements for CPT codes 92920, 92924, 92928, 92930, 92933, 92937, 92941, 92943, 92945, and HCPCS codes C9600-C9608. (2) Ensure all PCI claims include documentation supporting one of the five covered indications: acute coronary syndrome, chest pain despite optimal medical therapy, in-stent restenosis with symptoms/ischemia, recent STEMI (within 45 days) with non-infarct artery involvement, or silent ischemia. (3) For Coronary IVL procedures (CPT 92972, HCPCS C1761, C7571), update templates to require documentation of hemodynamically significant, severely calcified coronary stenosis and vessel preparation purpose prior to PCI. (4) Verify the applicable MAC LCD for your jurisdiction (J5, J8, J6, JK, J15) and cross-reference with CMS Medicare Coverage Database. (5) Training: Instruct providers and prior authorization staff on the five specific indications; claims lacking documented medical necessity will be denied. (6) Review all pending PCI claims to ensure compliance before effective date. Update encounter forms and EMR templates to prompt documentation of calcification status for IVL claims.