Denied for Medical Necessity Stab phlebectomy of varicose veins

chasgiv4

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I've exhausted myself trying to research how to code this for medical necessity. We have been receiving major denials from mostly Medicare but as well other payers. :confused:

CPT 37765
ICD-10 I83.811

I've also appealed with all the possible documentation hoping for payment but still denied.

The ICD-10 code is a pain code but I don't know where to go from here.

Can anyone help?
 

CodingKing

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I83.811 is just the presence of varicose veins which would lead one to believe its cosmetic with no indication of complications which are typically required for coverage.

You would want to check for LCD in you area for more detailed information

https://www.cms.gov/medicare-coverage-database/

For instance there are several active LCD's based on region or MAC

ACTIVE

L33454 Varicose Veins of the Lower Extremities
L33575 Varicose Veins of the Lower Extremity, Treatment of
L33762 Treatment of varicose veins of the lower extremity
L34010 Treatment of Varicose Veins of the Lower Extremities
L34082 Varicose Veins of the Lower Extremity, Treatment of
L34209 Treatment of Varicose Veins of the Lower Extremities
L34536 Treatment of Varicose Veins of the Lower Extremities
L34924 Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities
 

chasgiv4

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Thank you for your response.

Under the L33575 for Illinois it shows the CPT of 37765 and more includes the ICD-10 I83.811 which as it states includes pain. Wouldn't pain be a reason for medical necessity?

I have looked up the documentation you provided in the CMS website and am assuming I just need to follow the guidelines simply. Is there a more in depth ICD-10 code I should be using rather than pain?
 

CodingKing

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Sorry i totally read the diagnosis code wrong (pains of staring at a screen all day)

Any chance one of the following dx codes that do not support Medical Necessity are also included?
[FONT=&quot]I78.0
I78.1
I78.8
I78.9
I87.001
I87.002
I87.003
I87.011
I87.012
I87.013
I87.021
I87.022
I87.023
I87.031
I87.032
I87.033
I87.091
I87.092
I87.093
[/FONT]
 

prayercoder

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Varicose vein denials

Many insurers require prior authorization for this procedure. Double check and see if this is required by your payer.
Also, as stated below provider a more accurate code that indicates medical necessity vs cosmetic.

For those that have already denied, you may be able to appeal and provide office notes that show medical necessity, and of course, that would have to be documented.

Hope this helps.
 

cyndies

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Re: Stab Phleb Code 37765

Try using ICD10 Code: I87.2 venous (peripheral) insufficiency, unspecified

We bill this with CPT 37765 and MCR pays.
 

CodingKing

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Try using ICD10 Code: I87.2 venous (peripheral) insufficiency, unspecified

We bill this with CPT 37765 and MCR pays.

Its never a good idea to put a code on just because Medicare pays. The documentation would need to support the diagnosis used.
 
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how to bill Medicare Stab Phlebotomy Bilateral 11 incisions each leg?

I know MCR uses modifier 50 for bilateral, so do i put cpt 37765 (since it was only 11 each leg) with a 50? Since we all know 37765 rt and 37765 lt will deny for MUE (right?). and enconder says 37765 is 1 extremity so i dont combine and get 22 and use 37766... so is option A right? 37765 w/ 50 modifier and i double the price?
 
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