Wiki CPT 64415 and S42.021A

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rfarnham91

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Hello everyone! I really hope this is the right forum to post this question. I apologize if it isn't.
I am still relatively new when it comes to coding but I recently started a job in denials management. The job has been a great way to dip my toes in understanding insurance payor policies and CMS guidelines. There is this one claim that has me stumped. CPT 64415 was denied per CMS policies due to incorrect DX. The main dx is S42.021A and the secondary are Z88.0 and Z79.01. Normally when I look up the article in the CMS database and will have the dx code for either allowed or not. However when I looked at Billing and Coding: Nerve Blockade for Treatment of Chronic Pain and Neuropathy the cpt code is listed however not any of the dx are listed at all. I'm not sure if I am looking up the wrong article or what else I am missing. Like I said, I am still very green but I want to get to the bottom of this and learn from this as well. If there is any further information needed please ask. I kept this as vague as possible to protect patient information. Thanks!

Here is the website of the article on the cms database
 
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rfarnham91 said:
I did and sadly the dx code is still not listed :(
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If it's not one of the 495 diagnosis codes listed under "ICD-10-CM Codes that Support Medical Necessity," then CMS does not consider that diagnosis to support medical necessity for the service.

Unfortunately, there's likely not anything you can do about that. Was an ABN signed before the service?
 
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Was this service done in Maine? The link in your original post is for a Noridian LCD. Be sure you're looking at the LCD for the correct MAC, because there could be differences.
 
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sls314 said:
Was this service done in Maine? The link in your original post is for a Noridian LCD. Be sure you're looking at the LCD for the correct MAC, because there could be differences.
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This was done in Massachusetts and the insurance is commercial which is Tufts which is a MA based insurance. I live in Maine and still learning how different MA. For example I didn't know healthcare is required in MA however in ME it is not lol
 
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sls314 said:
If it's not one of the 495 diagnosis codes listed under "ICD-10-CM Codes that Support Medical Necessity," then CMS does not consider that diagnosis to support medical necessity for the service.

Unfortunately, there's likely not anything you can do about that. Was an ABN signed before the service?
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I just looked in the pt record and I don't see anything but doesn't mean it's not there so I will ask about that, thanks!
 
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rfarnham91 said:
This was done in Massachusetts and the insurance is commercial which is Tufts which is a MA based insurance. I live in Maine and still learning how different MA. For example I didn't know healthcare is required in MA however in ME it is not lol
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Just to clarify to make sure I'm assisting you properly - is this a Medicare Advantage or commercial patient? Tufts has a Medicare Advantage product. Tufts also has commercially insured products.

It's a very important distinction - Medicare Advantage and commercial plans can have very different approaches working the denials. From your original post, it seemed like you were researching for a Medicare (or Medicare Advantage) patient.
 
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Also, for future reference, the MAC for Maine and Massachusetts is NGS.

The CMS LCD links you provided above were for Noridian, and would only be applicable for the states under Noridian's jurisdiction, which is predominately on the West Coast.

While working denials, if you need to pull up an LCD, you want to be sure that you're looking at the LCD for NGS. One way you can do this is by narrowing your search on the CMS MCD to a specific state (see screenshot below).

Another way you can do this is by going to the NGS website directly: https://www.ngsmedicare.com/medical-policies


Also, here's a direct link to the NGS LCD applicable to CPT 64415 from the CMS MCD. (I know you said it was a commercial patient, but just in case the patient actually is Medicare Advantage and/or you just want to look at the NGS LCD): https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57452




ngs.png
 
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sls314 said:
Just to clarify to make sure I'm assisting you properly - is this a Medicare Advantage or commercial patient? Tufts has a Medicare Advantage product. Tufts also has commercially insured products.

It's a very important distinction - Medicare Advantage and commercial plans can have very different approaches working the denials. From your original post, it seemed like you were researching for a Medicare (or Medicare Advantage) patient.
Click to expand...
This is Tufts commercial insurance
 
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sls314 said:
Also, for future reference, the MAC for Maine and Massachusetts is NGS.

The CMS LCD links you provided above were for Noridian, and would only be applicable for the states under Noridian's jurisdiction, which is predominately on the West Coast.

While working denials, if you need to pull up an LCD, you want to be sure that you're looking at the LCD for NGS. One way you can do this is by narrowing your search on the CMS MCD to a specific state (see screenshot below).

Another way you can do this is by going to the NGS website directly: https://www.ngsmedicare.com/medical-policies


Also, here's a direct link to the NGS LCD applicable to CPT 64415 from the CMS MCD. (I know you said it was a commercial patient, but just in case the patient actually is Medicare Advantage and/or you just want to look at the NGS LCD): https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57452




View attachment 6819
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I will check this out as this can be helpful. I am just scratching my head between the CMS database and codify I don't see this cpt code being covered by the dx
 
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rfarnham91 said:
I will check this out as this can be helpful. I am just scratching my head between the CMS database and codify I don't see this cpt code being covered by the dx
Click to expand...

It's probably not covered for that diagnosis. Sometimes there's nothing you can do about a denial, and you reach the end of any reasonable efforts you can make.

One last thing I'd investigate is whether the claim was coded correctly. Did they miss a diagnosis code that was documented in the medical record? You can't just add any random diagnosis after the fact to get paid, of course.
However, if a covered diagnosis truly was documented in the record and was left off the claim in error, it can be added to the claim.
 
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That is what I feel I may come to the conclusion. I was so determined because my supervisor gave me the task to compile an appeal. I will now check and see if the coding was done correctly. Thank you so much for your help. I am still so green at this and trying really hard to not pull my hair out haha because I do enjoy problem solving with denials.
 
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We need to start with who performed this service (surgeon or anesthesiologist) and why. There's not enough information to determine if the coding is correct to begin with.

Generally, if a surgeon performed this block intraoperatively, it's bundled.

If it was performed for post-op pain by an anesthesiologist, we would need to know if the anesthesia provider also performed the anesthesia service for accurate, compliant coding.

If this block was performed for acute traumatic pain or post-operative pain, the diagnosis is incorrect, as nerve blocks are performed for pain only. The diagnosis provided is not appropriate.
 
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Agree with Lisa.
Sometimes when folks are newer, they get hyper-focused on just "fixing the edit" and not looking at the bigger picture. However, sometimes we have to ask ourselves, was this even coded correctly to begin with? It does not make a lot of sense that someone with a displaced fracture of the clavicle would get this when it was not in conjunction with an ORIF. So, I bet as Lisa suggests above, it probably shouldn't be coded if the surgeon did it while also doing 23515.

You need to question:
Who did it
What was done at the same time (if more than one CPT same session)
When was it done
Where was it done
Why was it done
 
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