Wiki 36475 & 36476 Veins / CMS billing

[cniland]

Hi.

We've been getting a lot of zero pays for add-on code 36476 when it is billed with 36475, both from Medicare and some other commercial payers. I think part of the problem is on the 2018 CMS Fee schedule, there is no amount listed for 36476. (This is also the case the 37799, where we are seeing some denials as well. Even though NCCI edits tell you to bill 37799 for Stab Phlebectomies of less than 10 stabs.)

Is anyone else having this problem?

The denials are inconsistent. It's usually denied for CO-45 or for bundling. I like to give appeals with the amount we are owed, which is why I was thinking the fee schedule had something to do with the denials. I'm coding for an ASC facility.

Thank you. I appreciate any and all feedback.

 

[thomas7331]

36476 is a status N (packaged) code under OPPS, so zero payment on the line for this code is correct for Medicare and any payers that follow Medicare OPPS reimbursement methodology. Most add-on codes are status N and do not get separate payment on ASC or outpatient hospital facility claims. The APC rate that is assigned to the base code includes the prospective estimated reimbursement for any add-on codes. It is not a denial, it is just the way that Medicare calculates the rate for these types of claims. The payment assigned 36475 is the full payment for both codes. 37799 does have an APC rate assigned, so Medicare should pay it, but other payers may have a different process for this one since it is an unlisted code.

 

[cniland]

Thanks for the reply. I appreciate your insight.

I thought that because 36476 was considered a Type I add-on code (and it was billed with the primary procedure 36475) it would be eligible for reimbursement per CMS guidelines. And since most of our commercial payers do reimburse both codes, I was confused.

Also, "37799 does have an APC rate assigned" - This is a silly question, but where did you see that? I'm trying to locate how much that should pay. I have the 2018 CMS fee schedule, but where else should I be looking for guidance for these issues?

Thanks again.

 

[thomas7331]

I'm looking at the OPPS information on the CMS web site. Actually, I was mistaken about 37799 - as I look again, it does have an assigned APC under OPPS for outpatient facility reimbursement, but is excluded from payment to ASCs (see addendum EE). Here's where you can access the files for ASC payment rates and status indicator assignments:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html

Is this the 2018 fee schedule you're using?