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Is Medicare Denying Your 'Abnormal Bleeding' Claims?

Published on Tue Feb 24, 2004

Find out why CMS now pays for 863.91-863.99

When you use truncated diagnosis codes, you get denials. When Medicare uses truncated diagnosis codes, you get denials, too. That's why CMS added ICD9 Codes 863.91-863.99 as payable diagnoses for two abnormal bleeding tests covered under laboratory National Coverage Determinations (NCDs).

Before the change, Medicare denied fecal-occult blood tests (FOBT) or prothrombin time (PT) that physicians ordered for many injury-with-intestinal-bleeding diagnoses. That's because CMS had listed 863.0-863.9 (Injury to gastrointestinal tract) as payable diagnoses, leaving 863.9 truncated -- a four-digit code that required a fifth digit. "With the correction, any wound with bleeding into the intestinal tract will justify ordering a PT or FOBT test," says Laurie Castillo, MA, CPC, CPC-H, CCS-P, president of Professional Coding and Compliance Consulting in Manassas, Va.

CMS Adds 6 Codes to 'Covered' List

CMS added the remaining six codes under subcategory code 863.9x (Injury to gastrointestinal tract; other and unspecified gastrointestinal sites, with open wound into cavity) to the NCD covered diagnoses codes for FOBT and PT effective Jan. 1, 2004.:

 

  • 863.91 -- Pancreas, head
     
  • 863.92 -- Pancreas, body
     
  • 863.93 -- Pancreas, tail
     
  • 863.94 -- Pancreas, multiple and unspecified sites
     
  • 863.95 -- Appendix
     
  • 863.99 -- Other.

    FOBT and PT NCDs Listed Truncated Codes

    CMS' original NCDs for FOBT and PT listed 863.0-863.9 as covered diagnoses. "But because 863.9 requires a fifth digit, you won't get paid for it if you list it as a four- digit code," Castillo says.

    The problem arose when, because of the truncated listing, "our contractor ... included only the unspecified-site code 863.90 in the list of covered diagnoses rather than the full range of codes 863.90-863.99," according to CMS.

    Once the omission appeared in the NCD edit software introduced Jan. 1, 2003, CMS had to justify adding the omitted codes by demonstrating that the codes represent the narrative indications for the tests. According to a CMS memo (available at http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=97), the agency had to determine "whether [863.91-863.99] were an appropriate translation of an existing indication."

    The memo completes that task, stating that wounds at any of the sites included in 863.91-863.99 could cause bleeding into the intestinal tract, an indication for FOBT. Such wounds could also produce signs and symptoms of abnormal bleeding, indicating the need for a PT test.

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