Wiki CPT 33285

[PatriciaR]

Can someone please offer some knowledge on this cpt code. 33285. (This is for Professional claims) NY state(NYC)

We have been billing Empire BCBS( Mainly mediblue) for this service both inpatient and outpatient. Under BCBS policy the dx that we have been billing Z86.73 or R55 are allowed per their policy but we have been getting denials stating " The submitted code is disallowed because the procedure is non-reimbursable."

Has anyone else had this denial or has anyone received payment for this?? This is an active code per CMS so I am not understanding why we keep getting denied.

 

[cpc2007]

Good morning I see you posted this question a couple of weeks ago, but if you are still looking for assistance, I found this section about medical necessity from the Empire BCBS Medical Policy for CPT 33285 which can be found at the following link (https://www.empireblue.com/medicalpolicies/guidelines/gl_pw_d083845.htm):

Medically Necessary:

The use of implantable ambulatory event monitors is considered medically necessary for individuals who have a history of cryptogenic stroke and had a previous non-diagnostic trial of external ambulatory event monitoring.

The use of implantable ambulatory event monitors is considered medically necessary for individuals with recurrent syncope who have all of the following:

• Age greater than or equal to 40; and
• History of multiple (three or more) syncopal episodes of undetermined etiology in the past 2 years; and
• Previous diagnostic evaluation, including history, physical exam, electrocardiogram, orthostatic blood pressure measurements and echocardiogram, has not yielded a diagnosis; and
• Previous non-diagnostic trial of external ambulatory cardiac event monitoring of not less than 14 days continuously.

I would discuss the denials with Empire BCBS, but I suspect that in addition to supplying a medically necessary diagnosis such as R55 or Z86.73 that you also need to submit documentation to show that the requirements of paragraph 1 were met for the patient with diagnosis Z86.73 and the requirements of paragraph 2 were met for the patient with diagnosis R55. The patient's age will be a given, but showing the frequency of episodes, previous diagnostic testing, and prior trial of a non-implantable cardiac monitor (i.e., a cardiac event monitor of 14 days or more) would not be in a procedure report typically. Those details would be supported most likely in your physician's H&P note for the patient prior to deciding to implant the monitor.

I hope that helps!

Kim
www.codingmastery.com