Wiki Anesthesia issue

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beachgrl62

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Have any of you had trouble, especially most recently, with Medicare covering anesthesia for usual procedures? I am getting many denials lately saying something does not meet medical necessity. It refers to an LCD for MAC sedation but the patient did not receive that type of anesthesia. Getting very frustrated! Thanks for your help/input!
 
I have not experienced this with traditional Medicare, but have experienced it with Humana. All of the colonoscopies and EGD's were denying against the MAC LCD even though MAC was not used. Their system has an edit in place since MAC is "typically" used for these procedures. We scan notes to our provider rep, and all claims have been reprocessed and paid.
Hope this is helpful. Thanks!!
 
Would either of you help with this: One of other offices is getting denials from Aetna to claims stating the anesthesia (01991/01992) is inclusive to the procedure (62310/62311) even though they are billed separately and are separate entities. Reason given is CCI edits; it's NOT denied for medical necessity. As far as I can tell the edits are only for when both services are performed by the same physician. Aetna is the worst; I could not find a policy for this on the Aetna webiste either. Would either of you know how I would go about appealing this. thanks.
 
We have had the same situation with Aetna. We asked for a policy on this from our provider rep, and we were told that the policy has been in effect for 3-4 years and is no longer available online. We tried appeal after appeal, with no resolution. The claim with Aetna ended up being adjusted.
We have the same issue with Health America, they have very specific guidelines where this CPT will be paid.
It is our understanding, per our Anesthesiologists, that when these pain blocks are done general anesthesia should not be required. There are of course situations where it might be, but generally should be able to be performed without.
Hope this is helpful.
Thanks!
 
When you appealed Aetna, did you site that CCI edits allow separate billing by separate physicians? My boss would like to appeal with something posted somewhere in writing. What did you use?
 
is it for post op pain? if so, append -59. althu CCI said not separately payable but -59 can override AND your note must be justified that procedure was done per surgeon request.
 
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