Quality Medical Management/Emergency Medicine Specialists
Other Articles Published by: Steve Verno
The following is a question asked on the Medical Association of Billers'
"I have been receiving LCD (LCD L34325) denial from Medicare for Autonomic
Nervous System Testing (ANS) claims stating that "These are non-covered services
because this is not deemed a 'medical necessity' by the payer". I used limb
pain, hypertension, shoulder pain for these claims and I was getting paid
with ICD 9 codes but Insurance keeps denying same diagnosis with ICD 10 stating
above reason. Can anyone know what the appropriate diagnosis codes (LCD L34325)
based on Noridian Medicare?
We are not given sufficient information to address the question. We don't
know the CPT or ICD codes nor do we know if medical necessity was established.
We don't know if the medical conditions shown above are documented in the
medical record (because we don't have access to the medical record). We don't
know if the date of service was pre- or post- October 1, 2015. This would
determine which diagnosis code set is to be used. When a claim is denied a
denial code is appended to the line item and the denial code was not submitted
so it is difficult for us to know the reason for the denial. The Local Coverage
Determination (LCD L34325) that you reference is under Noridian and has to
do with Nervous System Studies - Autonomic Function, Nerve Conduction and
Electromyography. The coverage guidelines may be found at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34325&ContrId=364.
The LCD is very lengthy, but I did not find anything that says this service
is not covered. There are thirty-one (31) CPT codes that are listed in the
LCD. Were any of these CPT codes submitted on the claim? The LCD also shows
1,222 ICD-10 codes that support medical necessity. We don't know if any of
these codes were submitted on the claim and linked to the appropriate CPT
There are limb pain diagnosis codes listed which are anatomically referenced
as left, right or unspecified. Unspecified Limb Pain (M79.069), according
to the LCD does NOT support medical necessity. Since incomplete information
was provided, our answer will be general.
Can you appeal this denial? It could be possible that the denial was correct
and if so, there is nothing to appeal or dispute. If you are establishing
medical necessity and linking the proper ICD-10 to the proper CPT code then,
yes you can appeal the denial.
Appealing or disputing a covered service denial isn't hard to do, but it
takes investigative skills. First, look at the medical record to see what
service was provided and documented. Next, look at the health plan's coverage
determinations. This will show what CPT codes are supported and what diagnosis
codes support medical necessity.
Last, look at the patient's health benefit manual to see if this service
is listed as a covered service. If it is shown as a non-covered service, then
an appeal or dispute won't work. Proving that this is a covered service is
your best tool to dispute a covered service denial. Next review the claim,
could the problem be a simple data entry problem? Could this be an internet
coding or a medical necessity issue?
What is an internet coding problem? That is where someone goes to an association
website, an internet forum or an internet listserve and asks for someone to
provide them with a CPT code or diagnosis code or both. This can be very dangerous
because the person providing an answer may not be a trained medical coder
and their answer may not be 100% true accurate and correct.
Last, you cannot assume that because you were paid once that future claims
will be paid. The claim that was paid may have slipped past the insurance
payer's front end edits. It could be possible that the claims that being reviewed
now are going through a different process. This would concern me. In the next
few months or years you may be the subject to an audit by the insurance payer
for overpayment on the first claim.
Stay tuned for more billing tips. If you have billing questions, please
send them to the Medical Association of Billers. Please make sure that you
include sufficient information so that a complete and accurate answer can
be provided and of course, no patient, doctor names, test or homework questions.
Never Give Up and Never
Steven Verno, CMBS-I CMMB NREMT-P
Source: Medical Association of Billers - www.e-medbill.com
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