Part B Insider (Multispecialty) Coding Alert

Published on Sun Nov 16, 2003 PDF

 Prepare to battle more attempts to end 00142 coverage

If your practice performs cataract surgeries or provides anesthesia for them, you could have a fight on your hands.
 
Last spring, Part B carrier Noridian came out with a new draft local medical review policy for monitored anesthesia care (MAC) in which Noridian said it would no longer cover MAC along with lens surgery (00142). Specifically, Noridian included that code on a list of codes that it would consider medically unnecessary with MAC. With MAC, an anesthesiologist must be continually present to monitor the patient's vital signs.
 
After ophthamologists and anesthesiologists formed a united front against the new policy, Noridian backed off in April, saying it would shelve the policy for now, according to Lee Broadston, president and CEO of BCS Inc. in Waconia, Minn. Since then, he's billed for many of these procedures across a number of regions and hasn't had any trouble.
 
And yet many coders still worry that CPT 00142 will come back on the carriers' radar screens. Part B Carrier Trailblazer was denying claims for MAC with cataract surgery recently, says Teresa Garcia with San Antonio, Texas-based Tejas Anesthesiology. But after Tejas contacted the carrier, Trailblazer blamed a computer glitch for the denials. Now "all our cataracts are getting paid," Garcia says.
 
But "it's my understanding the carriers are going to regroup and make another attack at it," says Scott Groudine, associate professor of anesthesiology with Albany Medical Center in Albany, N.Y. Even though Noridian had to back off its draft LMRP, "nobody thinks it's going away forever." For one thing, 00142 is among the most high-volume codes Medicare reimburses, and the carriers see an opportunity to save money. They may try a different approach, but the goal of cutting back claims for 00142 will remain.
 
But anesthesiologists and ophthamologists will continue to fight any denials. "If you're operating on somebody's eye, you're not in a position to monitor somebody's vital signs," Groudine says.
 
If the carriers do start questioning claims for 00142, it's important for coders to make sure they include secondary or tertiary diagnoses, Broadston says. These could include secondary diagnoses of diabetes, obesity or hypertension.