Wiki Help!!!-Humana is denying

[clarkin15]

Humana is denying code 93880 based on Medicare LCD's, and the hospital is billing with dx 298.9. Can this be changed?
Also, code 93306 is being denied because it can't be billed as outpatient and I'm not sure why.

Clinical History: Confusion, dizziness.

Technique: Multiplanar, multiecho and spin-echo imaging of the brain was performed utilizing standard pulse sequence. Axial FLAIR, T2 and diffusion-weighted pulse sequences were obtained as well as axial gradient-echo and sagittal T1- weighted pulse sequence.
In the right periventricular white matter, there is an approximately 1.3 cm area of decreased signal within the white matter. On the same image slice located laterally, there is a gray-matter abnormality measuring approximately 2.2 cm in width. An additional 2.3 cm abnormal focus of increased signal in the right periatrial region is noted. On the T1-weighted pulse sequences, this has some increased signal suggesting at least a small amount of hemorrhagic inversion. No shift of the midline structures. No signficant mass effect.
There is flow void in the itnernal carotid arteries and basilar artery. Seventh and eighth nerve complexes appear normal.

Impressionl: Abnormal signal in the right cerebral hemisphere raises the possiblity of embolic type infarcts. At least some component of hemmorrhage in the right periatrial region. Cannot completely exclude the possibility of metastatic disease.

So then he got a Carotid Duplex Scan
History: Dizziness
Findings: Gray-scale and color duplex exam of the carotids performed

There is mild intimal wall thickening of the common carotid arteries bilaterally. Minimal atheromatous plaque involving the carotid bulbs. Antegrade flow in the vertebrals.

Peak systoclic velocity left common carotid artery 106.6cm/sec and within the left itnernal carotid artery 87.3 cm/sec. Peak systolic velocity in the right common carotid artery 85.9 cm.sec and within the right internal carotid artery 34.4 cm/sec.

Impression: Atheromatous plaque in the carotid bulbs and mild intimal wall thickenig of the common carotid arteries but no elevated velocities to suggest hemodynamically significant stenosis.

Any help would be appreaciated!!!

 

[ajs]

Humana is denying code 93880 based on Medicare LCD's, and the hospital is billing with dx 298.9. Can this be changed?
Also, code 93306 is being denied because it can't be billed as outpatient and I'm not sure why.

Clinical History: Confusion, dizziness.

Technique: Multiplanar, multiecho and spin-echo imaging of the brain was performed utilizing standard pulse sequence. Axial FLAIR, T2 and diffusion-weighted pulse sequences were obtained as well as axial gradient-echo and sagittal T1- weighted pulse sequence.
In the right periventricular white matter, there is an approximately 1.3 cm area of decreased signal within the white matter. On the same image slice located laterally, there is a gray-matter abnormality measuring approximately 2.2 cm in width. An additional 2.3 cm abnormal focus of increased signal in the right periatrial region is noted. On the T1-weighted pulse sequences, this has some increased signal suggesting at least a small amount of hemorrhagic inversion. No shift of the midline structures. No signficant mass effect.
There is flow void in the itnernal carotid arteries and basilar artery. Seventh and eighth nerve complexes appear normal.

Impressionl: Abnormal signal in the right cerebral hemisphere raises the possiblity of embolic type infarcts. At least some component of hemmorrhage in the right periatrial region. Cannot completely exclude the possibility of metastatic disease.

So then he got a Carotid Duplex Scan
History: Dizziness
Findings: Gray-scale and color duplex exam of the carotids performed

There is mild intimal wall thickening of the common carotid arteries bilaterally. Minimal atheromatous plaque involving the carotid bulbs. Antegrade flow in the vertebrals.

Peak systoclic velocity left common carotid artery 106.6cm/sec and within the left itnernal carotid artery 87.3 cm/sec. Peak systolic velocity in the right common carotid artery 85.9 cm.sec and within the right internal carotid artery 34.4 cm/sec.

Impression: Atheromatous plaque in the carotid bulbs and mild intimal wall thickenig of the common carotid arteries but no elevated velocities to suggest hemodynamically significant stenosis.

Any help would be appreaciated!!!

First, need to know what area of the country you are in since LCDs are regional and can be different. The 298.9 is definitely a problem as a dx with that scan, there are specific dx codes that are allowed by Medicare for it. You would need to talk to someone in the hospital coding department to find out why they are using that code vs. one that would reflect what is in the documentation.

Second I don't know why 93306 would be denied due to outpatient POS. Was the Echocardiography done outpatient at the hospital? Or was it at a radiology office or in the physician office? Need a bit more info....

 

[clarkin15]

The hospital is in Colorado. I agree, I don't think 298.9 should be used, I just wanted a second opinion. Also yes, the 93306 was done outpatient at the hospital.

 

[ajs]

The hospital is in Colorado. I agree, I don't think 298.9 should be used, I just wanted a second opinion. Also yes, the 93306 was done outpatient at the hospital.

I think the problem with the 93306 may be related to a dx code rather than the POS. This procedure code is allowed in the out patient setting...recheck dx codes for both procedures and make sure they are appropriate with the LCD guidelines. You should be able to pull up the allowable dx codes from Trailblazer since they are the local carrier for Medicare there.