Question LCD denials

bar2ty@yahoo.com

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HELP, Novitas-Medicare NJ-our MAC claims are being denied for LCD- for example R91.1-Solitary Pulmonary Nodule. The px code is 31622 AA X4 QS (bronchoscopy). What is it that our coding team needs to do you prevent the claims from denying? So many of the claims has denied for LCD. For this one the anes used monitored anes care (MAC). Coding keeps coming back with-per the op report, no other dx code-and we are having to adjust off all of these claims. this is just 1 example-I believe the common thread on all the denied claims is the anes used MAC.

Should coding inquire from the facility (op report) what codes they used and if they were paid-and should we use one of the codes from the facility-if it differs from our op report?
Any HELP is appreciated-we have a lot of claims denied for LCD...
 

sls314

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I have been coding anesthesia over seven years and have never seen that modifier. It may have caused the denial.

I agree.

I'm not an anesthesia coder, but I don't see how X4 would be appropriate for the anesthesiologist in OP's scenario.

The example given by AAPC is "Report X4 for time-limited care provided by a specialty-focused clinician. For example, an orthopedic surgeon performing a knee replacement surgery is an episodic, focused service."

(Quote above is from this article: https://www.aapc.com/blog/44395-rep...ttribute-patient-relationships-to-clinicians/ )
 
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HELP, Novitas-Medicare NJ-our MAC claims are being denied for LCD- for example R91.1-Solitary Pulmonary Nodule. The px code is 31622 AA X4 QS (bronchoscopy). What is it that our coding team needs to do you prevent the claims from denying? So many of the claims has denied for LCD. For this one the anes used monitored anes care (MAC). Coding keeps coming back with-per the op report, no other dx code-and we are having to adjust off all of these claims. this is just 1 example-I believe the common thread on all the denied claims is the anes used MAC.

Should coding inquire from the facility (op report) what codes they used and if they were paid-and should we use one of the codes from the facility-if it differs from our op report?
Any HELP is appreciated-we have a lot of claims denied for LCD...
Two possibilities:
  1. Novitas has recently updated its policy for monitored anesthesia care and you're running into an edit there.
  2. The X modifier should be last. Technically MACs should just ignore patient relationship modifiers because reporting is voluntary, but its position may be causing hiccups.
 

LisaAlonso23

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Still need HELP: Novitas-Medicare NJ denying anes claim for LCD-here is an example of how the claim is going to payer: dx K80.50; px 43260 anes code 00732 QK X4 QS. Another example: dx G89.4, cpt 64561, anes code 00300 AA X4 QS

There's an LCD list for MAC diagnoses for Novitas. I recommend downloading it.

When MAC is the method of anesthesia, there should be a diagnosis from the LCD list submitted on the claim if one is documented on the anesthesia record. Novitas does not require the X4 modifier, so I suggest they stop appending it. Some systems are sensitive, and that modifier may be the cause of your problems.
 

missyah20

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With this type of denial you are going to need to look at the patient's secondary diagnosis to see if they have any secondary conditions that are included in the Coding and Billing Article for LCD L35049. Those secondary diagnosis should be included on the claim for any anesthesia codes that fall within this LCD.
 
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