Wiki When an ICD9 is not on LCD's

[Texascoder64]

When an ICD9 is not listed on the LCD does that mean you can never prove medical necessity? For example: Pilar cyst 704.41 for Excision 114xx
This is a common denial - would a secondary dx help, or are we out of luck and should have done an ABN on this because the ICD9 is not on the LCD.

Maybe doing a 11100 for the punch would be better cpt of choice?

 

[Pam Warren]

If the diag is not on the LCD, it's not considered medically necessary by CMS, even if your provider thought so.

I wouldn't change the procedure code just to get payment... you didn't do a punch biopsy, you did an excision of a benign cyst, correct?

 

[Texascoder64]

yes Pam, the provider documentation states it was a full thickness excision, but I question that this really was a FTE as some cysts can be removed by other methods.
If it was done by method of punch and billed as 11100, would this diagnosis be allowed? Also, I also question why the cysts could not be removed by this method CPT 10060 or 10061.
Often there are multiple ones on the pt's scalp.

I need a standard guideline to give the providers for pilar cysts, so we can do an ABN ahead of time for this diagnosis.

Thank you