Gastroenterology Coding Alert

Question: Does Medicare restrict coverage to only the diagnoses listed under the code’s Local Coverage Determination (LCD)? If so, are we able to appeal in order to argue medical necessity with a noncovered diagnosis?

New Hampshire Subscriber

Answer: If you know you are submitting a claim with a diagnosis code that is not covered based on the CPT® code’s LCD, you have a few options. First, you should have the patient sign an advanced beneficiary notice (ABN) when performing this procedure with a diagnosis not covered under the LCD. This way, should you not be successful in getting Medicare to pay for the procedure, you can bill the patient for the service. When the ABN is signed, you should submit the service with a GA (Waiver of liability statement issued as required by payer policy, individual case) modifier, which tells your Medicare carrier that you have a properly executed ABN on file. 

If you submit the claim electronically, you should expect to receive a denial due to medical necessity. Once the claim is denied, appeal the denial on a paper claim. The appeal may include a surgical note, a written explanation from the physician, and even peer-reviewed data that supports performing the procedure for the attached diagnosis. Consider looking to your specialty society webpage for any relevant information.

If you receive a denial at the first appeal, submit the second level of the appeal to the Qualified Independent Contractor (QIC) for reconsideration. This is the first level of appeal that is not processed by the carrier and the appeal is evaluated based on both the LCD as well as clinical guidelines for the procedures. Because clinical guidelines outside the carrier’s LCD will be included in the review, there is a good chance that a well-written and supported appeal will be paid at the reconsideration QIC level. If the QIC denies the appeal, the appeal will then have to be submitted to the third level to the Administrative Law Judge (ALJ).

Tip: If you know that you will be submitting a specific, noncovered diagnosis on a regular basis, you should consider submitting a request to your MAC’s Carrier Advisory Committee (CAC) that the diagnosis be added to the LCD. Just because an appeal is won and the off-LCD diagnosis is won and paid, note that the LCD will not change without going through the CAC and requesting a change.