Wiki LCD Denials

[bar2ty@yahoo.com]

Medicare Novitas (NJ) keeps denying most of our claims for dx code not on LCD #A57361 (Monitored Anesthesia Care)
example: anes code billed: 01916 QY X4 QS
procedure: 36252, Intra arterial catheter & infusion pump
dx listed on claim: S35.403A; K66.1
POS: ER
our coding team said: no other dx code available, but when I review anes medical records-the patient has hx of ESRD and HTN (drug listed hydralazine). Coding did not list these dx on the claim.

Questions:
Should the HTN (I10) & ESRD (N18.6) codes be listed on the claim even though it is not the primary dx?

I also notice that on another claim modifier QS was not added and the claim was paid & none of the dx codes were on the lcd list. Is it REQUIRED that QS be added on the claim, because it could be a factor why all these claims are denying for dx not on LCD# A57361?

 

[jkyles]

Hi there, if the anesthesia provider performed monitored anesthesia care you'd need to include modifier QS. [Edit - but yes, you should include the dx codes from the anesthesia record on the anesthesia claim ]

 

[LisaAlonso23]

I code anesthesia for clients across the country. If the state a client is in has a MAC (monitored anesthesia care) LCD list, I make sure to submit a co-morbidity diagnosis documented on the anesthesia record that appears on that state’s LCD list in order to prove medical necessity for the use of MAC anesthesia. I suggest downloading the MAC LCD list for your state and proving it to all coders in your office to use as a reference. I keep mine open while coding.

 

[bar2ty@yahoo.com]

Need help:
Patient has history of hypertension, should a Z86 category or I10 category code be on claim?

 

[jkyles]

Hi there, it's going to depend on a few factors. I recommend reviewing the ICD-10-CM guidelines for the definition of personal history. For example

Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring.

 

[LisaAlonso23]

Need help:
Patient has history of hypertension, should a Z86 category or I10 category code be on claim?

Often times, providers use "history" to describe a current condition that is ongoing. If it's documented that the patient is receiving meds for the HTN, then the correct code is I10. If the HTN was resolved, use the history code. If you cannot determine if it's a current or past condition, query the provider.