Help with LHC, FFR, IVUS

Chelsea1

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Our Dr. did a LHC with a FFR and IVUS. I billed
93454, 26
93571, 26, LM
92978, 26, LM
Primary diagnosis used for all three was R94.39

Medicare is denying 93571 and 92978 for dx.

Any help would be appreciated and if so, where may I find the information regarding these two codes?
 

cpc2007

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You can search the Medicare database to see if they have published either a National Coverage Determination (NCD) or a Local Coverage Determination (LCD) for your code (here is a link to the site: https://www.cms.gov/medicare-covera...&KeyWordSearchType=And&bc=gAAAAAAAAAAAAA==&=&). You can also consider speaking with a representative at Medicare to ask if they have an unpublished policy for criteria that meets medical necessity for these procedures and see what information they may be willing to share.

I did a search at the link above to see if an NCD was available which would apply to Medicare patients nationwide but came up empty. I wasn't sure what locality/MAC you were billing to try for an LCD search but you may want to check there to see if R94.39 is a code that supports med necessity for these procedures. The code is fairly generic (abnormal result of other specified cardiovascular function test) and it sounds like they are denying for med necessity. Sometimes a generic code like R94.39 is all you have supported in the documentation, and payable or not, that is what your documentation supports and therefore what you have to bill. Typically, though, when a physician decides to do IVUS or FFR in a particular coronary artery, they find something on the cath that requires further investigation. So I would verify that the R94.39 was the most specified diagnosis available in the documentation or if more specific findings like CAD, ventricular dysfunction, etc discovered during the cath are documented and might better support the med necessity for the additional testing.
 
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