Wiki Diagnosis code denial-Medicare

[sidney01@roadrunner.com]

Patient had SBRT treatment for mets pubic bone secondary to prostate ca. C79.51 & C61 was used. We received a denial. Billing called. they referred us to CMS Article A56725 for billing. States may be related to dx issue. I cannot find a replacement diagnosis code. Please advise. Thank you.

 

[sls314]

Patient had SBRT treatment for mets pubic bone secondary to prostate ca. C79.51 & C61 was used. We received a denial. Billing called. they referred us to CMS Article A56725 for billing. States may be related to dx issue. I cannot find a replacement diagnosis code. Please advise. Thank you.

I see that you're in West Virginia. Is Palmetto the MAC for treatment? Palmetto does have an LCD for Radiation Therapies.

Was the pubic bone the site of treatment for the SBRT? According to Palmetto's LCD, SBRT is only covered for bone metastases in the vertebral bodies or paraspinous region there the listed conditions are met. SBRT is not covered for any other bone lesions.

Here's the link to Palmetto's LCD in case you need it:

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=39553

 

[sidney01@roadrunner.com]

I cannot thank you enough for this information! Sorry for the duplicate post. I wasn't sure which area I should enter. Have a nice day!