Anesthesia denial 01939-01942

[whitey86]

01939-01942 are being denied by MCR, UHC Commercial and Peoples Health no matter what P1-P4. The main procedures that we are doing are RFA's 64633-64636, Implants and Explants of SCS, vertebroplasty/kyphoplasty and sacroplasty. The majority of our patient's anesthesia dx is F41.8 and F41.9 (MCR LCD A57361). Even though the dx code is on the LCD when we add it the claim will get paid but come back and recoup. When we don't put the anesthesia dx code it denies. UHC and Peoples Health, I call for denials verification reason and I am referred back to MCR A57361. Documentation looks like this. Example of coding: 01940 QZ, QS, P2 Modifier G8 does get added for implants and GA is added when the pt signs an ABN. I'm not sure how else to code the claims. They have already stopped paying anesthesia for ESI's, DMBB's, Transforaminal's.


I'm at a loss.

 

[jkyles]

Unfortunately anxiety alone isn't covered for anesthesia. From Novitas' LCD for FJI: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34892&ver=123

The use of Moderate Sedation for RFA or cyst rupture/aspiration will be considered in individual cases with documentation of medical necessity such as a longstanding well-documented history of inability to cooperate, medical conditions that would prohibit performance of the procedure, or inability to remain motionless. Patient anxiety or preference alone is not sufficient justification. Routine use of Moderate Sedation or Monitored Anesthesia Care (MAC) or use of General Anesthesia or Deep Sedation for RFA is not considered reasonable and necessary.

The other issue is the note seems to treat MAC and moderate sedation as the same thing. Moderate sedation is reported with the 9915- codes, not an anesthesia code. But in this scenario it isn't an option. In addition, if anesthesia provider does perform MAC that would otherwise be covered, such as for a patient who has a movement disorder, the mention of moderate sedation is going to get a denial.

Finally, when does the patient get the ABN? Based on the note, the conversation about the risks started after someone started the IV and there was additional conversation after the patient was brought to the OR. The ABN conversation must happen and the patient make their decision before the procedure begins.