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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
MO
MODOI-MRF-CPT-93458-319
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Missouri Department of Commerce and Insurance (DCI) & CMS TiC Payer MRF Index
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St. Louis County, MO
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Filing / IDR Window: 2026-11-27
[MODOI-MRF-CPT-93458-319] Mo Anthem Blue Cross Blue Shield MO MRF Rate Disparity: Urology & Lithotripsy / Endourology Surgery Center (CPT 52356)
Commercial payer TiC MRF rate disparity audit and ERISA clinical appeal package for Mo Urology & Lithotripsy Ambulatory Surgery Centers (CPT 52356 Cystourethroscopy with Ureteroscopy, Laser Lithotripsy & Indwelling Stent, CPT 50590 Extracorporeal Shock Wave Lithotripsy ESWL, CPT 52000 Diagnostic Cystourethroscopy, and CPT 52601 Transurethral Electrosurgical Resection of Prostate TURP) across Anthem Blue Cross Blue Shield MO & Blue KC.
Cohort MRF 75th-Pct Value
$1,535,000
Target % of Medicare
219.0% MPFS
Statutory Authority
MO-GPCI-2026 (RSMo § 376.383 (12% Prompt-Pay))
ERISA / Timely-Filing Window
120 Days
1. Commercial Payer TiC MRF Allowed-Amount Benchmarks (API #02)
| CPT / DRG Code | Clinical Procedure Description | Unit | Cohort Claims | MRF 25th Pct | MRF Median (QPA) | MRF 75th Pct |
|---|---|---|---|---|---|---|
| CPT-93458 | Left Heart Catheterization with Coronary Angiography | CLAIM | 500 | $1,144.60 | $2,657.80 | $3,317.40 |
| CPT-93306 | Transthoracic Echocardiography Complete with Doppler | CLAIM | 240 | $1,659.67 | $3,853.81 | $4,810.23 |
| CPT-99214-25 | Level 4 Established Patient Outpatient E/M with Separately Identifiable Modifier 25 | CLAIM | 1,200 | $115.00 | $172.00 | $204.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Signature Medical Group Orthopedic ASC St. LouisBJC HealthCare West County Surgery CenterSaint Luke's Surgicenter Lee's SummitColumbia Orthopaedic GroupOrthopedic & Sports Medicine Center