Wiki 19083 denials with benign findings

[dingelido]

Hi
We are receiving facility denials from Medicare when 19083 is performed and the lump/mass/abnormal mammo is found to be benign. Lump/mass/abnormal mammo is coded as the reason they came in but then the principal is the benign findings such as fibroadenoma. Any insight on this would be much appreciated. We have the path results at coding so the findings cannot be ignored.
Thank you

 

[thomas7331]

In my experience, some or the MACs and/or Medicare Advantage payers do not import the 'reason for visit' codes into their claims adjudication system on outpatient facility claims, so if the indication for the procedure isn't included as either the principal or a secondary diagnosis, the claim won't clear the NCD/LCD edits. If that's the case, you may need to duplicate the reason for visit diagnosis code into the main list of diagnosis codes in order to get the payer to recognize it.