Wiki Medicare 92083 denials

[cierras]

I am an auditor with an eye consulting company and had a physician reach out regarding 92083 getting denied on every patient.

Looking through the documentation all patients had Fourth Nerve Palsy and visual discomfort (which is an approved code with cms for 92083).
Interp/Report/Documentation, everything is there. CMS is saying there is no medical necessity. At first I thought maybe visual comfort was being taken as a symptom of fourth nerve palsy but how else would this test get covered without that DX?

Am I missing something? Anybody have any insight on why this would be getting denied for medical necessity?

 

[Cheezum51]

That really isn't an appropriate test for that problem since those patients do not typically have a visual field problem. A more appropriate test would be a sensorimotor exam 92060 to document the deviation in various positions of gaze and distances.
If I was auditing those claims, I would deny payment for the 92083 as well. The test isn't "medically necessary, reasonable or appropriate" (Per Medicare criteria) for that diagnosis.
Just because a diagnosis code is on an LCD for a test doesn't mean that it would be approved.

Tom Cheezum, OD, CPC, COPC