Wiki MCR Denied the Claim as Routine Exam

[nurse2010]

Hi,

What would be your next step if Medicare denies the claim as routine exam?

Is there a specific guidelines when routine exams for Endoscopy Anesthesia becomes a routine exam?

What if it is indeed within the annual routine exam, and the said procedure is repeated because they suspected something and had to do another endoscopy.

Please help.

Thank you.

 

[coderchick]

Hi,

What would be your next step if Medicare denies the claim as routine exam?

Is there a specific guidelines when routine exams for Endoscopy Anesthesia becomes a routine exam?

What if it is indeed within the annual routine exam, and the said procedure is repeated because they suspected something and had to do another endoscopy.

Please help.

Thank you.

You should contact your Medicare intermediary for that state (who process your medicare claims) and get more detail why claim denied, and the correct way to rebill if not you may have to appeal. Or go on the medicare website

 

[jdrueppel]

nurse2010,

I'm assuming this procedure was done under MAC. Check you local MC carriers LCDs for a Monitored Anesthesia Care Policy. It's quite likely MC has denied because the diagnosis you reported is not a covered diagnosis per this LCD. I usually see these denied as "not medically necessary", however, dependent on the diagnosis submitted (i.e. V76.51), Medicare would possibly deny as routine care.

If this truly was a routine exam without a covered diagnosis per your carrier's LCD AND you did not obtain an ABN then this is a non-covered service and you would have to write off.

If I need to elaborate on any of these points send me a private message with your contact information.

Julie, CPC

 

[nurse2010]

It's not on MAC... I might just contact the local carrier.

Thank you so much for your replies.

Have a great one!