Anesthesia Coding Alert

Question: United Healthcare denies our claims for a Swan-Ganz catheter for hemodynamic monitoring during open heart surgery, stating the catheter isn't medically necessary based on our diagnosis. We're submitting 414.00 as the diagnosis. What are we doing wrong?

Indiana Subscriber

Answer: According to Indiana's Medicare local coverage determination (LCD), 414.00 (Coronary atherosclerosis; of unspecified type of vessel, native or graft) is not a medically necessary diagnosis for 93503 (Insertion and placement of flow directed catheter [e.g., Swan-Ganz] for monitoring purposes). United Healthcare must be following the Medicare guidelines.

Back-up plan: Review the patient's chart and medical history to cull other potential diagnoses that would support medical necessity. Possibilities include 410.xx (Acute myocardial infarction), 415.0 (Acute cor pulmonale), 416.0 (Primary pulmonary hypertension), 428.xx (Heart failure), 518.5 (Pulmonary insufficiency following trauma and surgery), and more. If any of the acceptable diagnoses apply to your patient, talk with your anesthesiologist about whether you can legitimately list it on the claim instead of 414.00