Wiki Medicare MPPR and Cardiac Caths

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katfitzpat

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Hello -
Need some assistance:
I have several diagnostic cardiac catherizations performed prior to a coronary stent placement for patients who are transferred emergently to the facility where my cardio MDs perform the procedures.

I am having one private insurance denying payments to the diagnostic cath's (93458-2659). Denial states procedure code has been identified as primary procedure code subject to Medicare MPPR rule.
The coro stent placements are being paid but the diagnostic caths are paid $0 with this denial reason.

In my research, I could not locate anywhere where 93458 is listed as subject to MPPR.
Does anyone have a bulletin (I have CR 7848) where this code is listed as subject to this rule?
I'm also having trouble accepting the $0 pay amount as well and am trying to put together my appeal.

Thank you in advance for any information or resource you can share with me!
 
The CCLV is subject to MPPR but it shouldn't be $0 payment, it should be half of the allowable. What MAC do you guys have out in California?

CMS MPPR MLN Matters

As far as I know there isn't a list of procedures that are subject to MPPR, but most of them are especially in situations like this where there are two "main" procedure codes submitted. Do you submit the 93458 with the XU modifier?
 
Our MAC here in No Cali is Noridian.

I did not use the modifier -XU because I used a -59 to unbundle from the stent procedure.

The denials are from a private insurance and agree with you about the $0 pay.
I am preparing my appeals today to request at least 50% payment for the diagnostic cath procedure.

Thanks for your input - I appreciate it!
Wish me luck! :)
 
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