MCR Denied 36901 as medically unlikely-Please help

Henson65

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I am new to this IVR coding world and Medicare has denied this OP not coded as 36901 as medically unlikely....any help is greatly appreciated. This was coded by a previous coder and I'm battling with the correct CPT code.

Coding assigned: 36901 and 36907 ICD-10 T82.858A T82.868A N18.6 and Z99.2

Summary
Access type: Right Brachial A-Basilic V arm non-transposed AVF
Right unilateral upper extremity fistulogram
Subclavian vein: angioplasty
Contrast type: Omnigpague 18cc (LOCM 300-399mg/ml iodine, 1ml)
Closure type-sutured

Technique:
The patient as brought to the endovascular suite, placed in a supine position and draped in routine sterile fashion. All aspects of the time-out verification were satisfactorily completed prior to the beginning of the procedure. The right upper extremity was prepped using Chloraprep. Moderate sedation/analgesic(conscious sedation) administered with critical care nurse to monito the level of consciousness and physiological status for the total of 30 min(s) using 100 mcg Fentanyl and 1 mg versed. The lower basilic vein was accessed in an antegrade fashion using an 18 gauge needle. A guide wire was introduced through the needle. The needle was removed and a 4-FR sheath was advanced. The sheath was flushed and fistulogram was performed. After carefully reviewing the diagnostic fistulogram, it was decided to proceed with intervention. The 4-Fr sheath was removed and upsized for 7-Fr sheath.

Intervention:
A catheter was placed over the wire in the subclavian vein. A 12 mm x40mm balloon angioplasty was performed on the vessel

Hemostasis:
All wires, catheters and sheaths were removed. The puncture site was sutured.

Findings:
Subclavian vein: occluded

Post Intervention Findings:
The residual stenosis is 40% in subclavian vein

Conclusions:
Successful, uncomplicating recanalization and treatment of outflow central venous occlusion at right subclavian vein with high pressure 12 mm balloon angioplasty as described above

This access is ready for use as needed. Given the high likelihood of recurrent stenosis/occlusion, it is recommended that this patient be clinically evaluated for possible repeat intervention in 3 months. From our standpoint, this access is useable. There is a superficial segment near the arterial anastomosis in the antecubital fossa involving the median cubital vein/ lower basilic vein that courses over the medial epicondyle that is easily palpable and of sufficient caliber before plunging far too deep in the upper arm basilic vein component. We recommend that using this portion should be attempted now. To facilitate cannulation the desired cannulation zones were marked on the skin with a magic marker. Depending on how this goes, a decision to revisit superficialization/transportation surgery can be reconsidered. If access continues to give difficulty and is never going to be transposed/superficialized, then access ligation at the arterial anastomosis is recommended to lessen likelihood/severity of recurrent symptomatic right subclavian vein occlusion.
 

thomas7331

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All of the coding on this looks correct to me. Regarding the denial, a 'medically unlikely' statement usually means that the frequency or number of units of a particular code on a given date exceeds the usual number that is clinically likely. In this case, if they have denied 36901, then I suspect that they have already paid your provider, or another provider, for that same code on this same date and that a second repeat procedure is unlikely. You may wish to check your records or account to see if perhaps this was a duplicate billing, or else contact Medicare and get clarification as to when, or to whom this was paid. If in fact this was done twice on the same day and the records support the medical necessity of the second procedure, you can appeal the denial with the supporting documentation. Or if none of these cases apply, then you may just need get additional information from Medicare regarding the denial. I don't believe that this is a denial due to a problem with the coding from what I can see above. Hope this helps some.
 
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Henson65

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All of the coding on this looks correct to me. Regarding the denial, a 'medically unlikely' statement usually means that the frequency or number of units of a particular code on a given date exceeds the usual number that is clinically likely. In this case, if they have denied 36901, then I suspect that they have already paid your provider, or another provider, for that same code on this same date and that a second repeat procedure is unlikely. You may wish to check your records or account to see if perhaps this was a duplicate billing, or else contact Medicare and get clarification as to when, or to whom this was paid. If in fact this was done twice on the same day and the records support the medical necessity of the second procedure, you can appeal the denial with the supporting documentation. Or if none of these cases apply, then you may just need get additional information from Medicare regarding the denial. I don't believe that this is a denial due to a problem with the coding from what I can see above. Hope this helps some.
Thomas,
Thank you for your help on this...so from what you have said, I imagine the problem is that I code/bill for the ASC and the provider bills separately. I would imagine the provider has been paid and that is why this is kicking up as "medically unlikely". I just assumed there was a specific code issue, but now it all make sense. Thank you again for replying, I truly appreciate it!!!
 
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