Wiki Assistance with CPT 29877

[csavitz]

We billed 29877 to Amerihealth/Medicaid. Dx codes listed were M17.11 and M98.861. Claim was denied as diagnosis codes were inconsistent with procedure. I ran this by our coding department and they say that the Dx codes are correct. I did find a CMS bulletin for Medicare where M17.11 would not support medical necessity of 29877, but I cannot find anything like this for medicaid. Has anyone encountered this before and possibly has a list of Dx codes that would support medical necessity of this code? I have not gotten any responses from Amerihealth on this issue. Any help would be appreciated. Thank you!

 

[nsteinhauser]

Medicaid follows Medicare as far as the CMS Billing+Coding Articles (used to be NCD's and LCD's), at least in our state they do. CMS Article A52369 says M17.11 doen't support medical necessity, like you found. It looks like no "pain" or osteoarthritis diagnoses are covered. If you use those dx codes, you have to add the -GA or -GZ modifier to the procedure to indicate that you have a signed ABN or don't have a signed ABN.
I don't have the time to search but there's nothing listed for 'covered diagnosis' codes in this article. Figures. I'm thinking codes for NON-OSTEO arthritis maybe would be covered (rheumatoid, infectious, etc.) but not sure. Sorry - not any help.
Anyone else out there know what diagnosis codes would be covered?