Medicare Local Coverage Determinations: My Experience with an LCD – A Valuable Lesson Learned:

by: Sara M. Lamb

In our practice, cardiothoracic anesthesiology, we typically bill for transesophageal echocardiograms (TEEs), which are performed intraoperatively by our anesthesiologists during certain cardiac procedures. For these procedures, the indication for the TEE is typically mitral, aortic, or tricuspid valve regurgitation and/or stenosis. In some cases, such as a pericardial window creation, I usually find pericardial effusion documented as the indication. Some other procedures we perform with TEEs are ventricular assist device implantations or heart transplants. In these cases, cardiomyopathy or heart failure is usually specified as the indication—and that is where the billing gets tricky for Medicare claims.

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Due to the Medicare LCD Revision L16446 VA, effective 01/19/2010, TTE and TEE procedures are only covered for the ICD-9-CM codes listed, which they have determined to support medical necessity. (Cardiomyopathy isn’t one of them; neither is heart failure.) It’s a lengthy list of covered diagnoses, but be careful. Some of the diagnosis codes are covered for one part of the TEE, but not the other. One important note here: it clearly states on the LCD that “the medical record must support the ICD-9-CM code reported on the claim. Medical records, including the permanent image, need not be submitted with the claim. However, these records must be furnished to Medicare upon request.” So be absolutely certain the documentation is clear, the record is complete and your coding is accurate.

The difficulty in billing Medicare for TEEs is you have to check the LCD and your documentation thoroughly. If there’s a covered diagnosis and a non-covered diagnosis both clearly documented in the record, I would rather submit the one that’s covered— and get the reimbursement our providers are entitled to. Check any LCD denials you have received as well. We received a denial based on this LCD, and after researching it I found the diagnosis code submitted on the claim was one listed as covered for the procedure. I submitted a redetermination for this particular claim and received subsequent reimbursement.

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