Wiki Vascular Surgery Coding - I have noticed for the Vascular

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I have noticed for the Vascular Surgery Dept. we have several claims denied when billing CPT codes: 93880TC, 93970TC, 9388026, 9397026, along with CPT 99203 or any other E/M code with -25. diagnosis codes (1.V72.83) (2. 785.9) (3. 585.6) these claims denied stating not medical necessary. Should we bill claims with an LMN to support the medical necessity of rendering these services. Some of these claims have also denied after the medical documents were sent to support the need for service.
Below are the list of procedure performed that are not payable:
"TECH;CAROTID STUDIES, BILATERAL, INITIAL
TECH;DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION
PROF;CAROTID STUDIES, BILATERAL, INITIAL
PROF;DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION"

Please advise
 
Are you billing 93880-TC and 93880-26? If the equipment is yours and the scan is done in the office you should just bill 93880. Also the vascular scans and office visits are ok to bill together without any modifiers. 9 times out of 10 93880 would have a Dx of 433.10. Also 93880 is only allowed once a year without High grade stenosis and twice a year with high grade stenosis. The Exception is post-op Carotid stent or Carotid endarterectomy. Hope this helps. Feel free to message me if you need more clarification.

Michael D. Reyland, CPC, CIRCC
Surgical Specialists of Georgia
 
Thanks so much for your assistance. However, I would like to clarify the billing scenarios. Example:

Line 1. Billed with as 99214/25 modifier this code pays

Line 2. Billed 93923TC extremity study this code pays

Line 3. Billed 93880TC carotid study bilateral this code denied

Line 4. Billed 93970TC Duplex Scan extremity veins coed denied

Line 5. Billed 9392326 extremity study code paid

Line 6. Billed 93880 carotid study bilateral code denied

Line 7. Billed 9397026 Duplex Scan extremity veins code denied

Dx examples i.e.: 1. 443.9, 2. 781.2 , 3. 459.81

My assessment to the reason for a number of the denials would be some line items are linked to the inappropriate dx and i.e. unspecified code and are not covered by Medicare as not medically necessary. Can you also review codes 93970 and 93923 both considered extremity procedures codes.

I review another claim billed to Medicare listing the same codes above and they were all paid using the -59 modifier on the 90000 series codes.
with appropriate dx of 250.70, 433.10,401.1
 
I also can not understand why you are billing these with TC and then again with -26. If you own the equipment you should just be billing a straight foward 90000 code and if not then strictly with the -26 modifier. As far as dx is concerned if are you connecting the correct dx to the correct code. 781.2 is on the LMRP list for 93880 according to Code Correct. You may also try dx of 785.9.
 
I suggest you review Medicare's LCDs for the denials.
I don't know what State you're in, for Georgia

93923 - of all the Dx you listed only 250.70 and 443.9 are on the LCD list
93970 - only 250.70 is on the LCD list
93880 - only 433.10 and 781.2 are on the LCD list

Could you explain why the TC and 26 modifiers are being used?

Michael D. Reyland, CPC, CIRCC
Surgical Specialists of Georgia
 
Are you billing these tests for the same patient on the same DOS? If so, it may be a case that many states won't allow both venous and arterial studies to be performed on the same day as it would only be medically necessary to study one system, per some LCDs.
 
Ok how I missed that we could only bill these once a yr for asymptomatic or 2x yr post-op, I cant say. But what I'm wondering is are any other practices having the patients come back more frequently than this and just having the patient sign an ABN?
The surgeon says he generally follows asymptomatic every 6 mths and his post-op CEA he scans at 6wks out then every 6mths after that. I believe medically he feels the patients should be followed this way (which is his decision) I just want to make sure we have our ducks in a row from a billing standpoint and unfortunately I'm receiving lots of push back from our front desk because they dont have anyone fill out ABNs at all!
 
Mary Beth,
Which state are you in? If these are claims for medicare patients,that is critical. Some LCDs have a post op diagnosis on their allowed dx list and some don't. The information varies from state to state,so that may be why the info you've recvd from others is new for you,, it may not apply in your state. Its critical to access the LCD for your state and read thru it in its entirety. Do you know who your medicare contractor is in your state? And are these claims processing thru the contractor or a medicare advantage plan?
 
I am in Tennessee and Cahaba took over as our MAC effective Oct 2009. The LCD does say that intraop and postop studies are covered for our carotid patients. However since I noticed this change is seems like they are denying everything after one study regardless off diagnosis or level of disease. Also the other problem is this particular LCD does not clarify what a severe level of stenosis means to them - of course our definition is different. But now I've ended up with a list of denied claims that I'm having to appeal!
 
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