• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki NCD 80.11 vitrectomy coding confusion

Create Wiki
S

Stenglein

Networker
Messages
28
Location
Frankenmuth, MI
Best answers
0
I am hoping someone is able to clarify the NCD 80.11 for vitrectomy coding for me. I have a claim for a vitrectomy pars plana approach with an ILM peel 67041 with dx code of H35.371 pucker of the macula. It was denied due to NCD 80.11. I read NCD 80.11 and is not making sense to me. If 67041 is to include the removal of the macular pucker, should I be using another code along with the H35.371?. Another denial received, per NCD 80.11, 67036 vitrectomy with dx codes of H43.391(other vitreous opacities) and H43.811 (vitreous degeneration), which I see are deleted per this NCD, yet the descriptor indicates a victrectomy is considered reasonable and necessary for vitreous opacities due to vitreous hemorrhage or other causes. Would anyone able to clarify for me???
 
Vitrectomy

Is it one specific payer? I work for an ASC that does ophthalmology procedures only. I have not had any issues getting either of those codes paid. I have billed 67041 with H35.371 and it was paid. Are you billing facility? physician?
 
Vitrectomy

Previous to my other reply, we just had two 67041 denied for the same reason. After checking with CMS and other ophthalmology offices..it is a CMS issue. CMS sent out NCD last year stating certain dx codes were not applicable for Vitrectomy...macular pucker is one and there is a whole list online. Then on 1/18/18 CMS sent out an MLN putting the ICD-10 back for a Vitrectomy. The payers have not updated their policies as of yet. We are holding those claims until the payers fix this issue. I have all the information if anyone is interested or needs it.
 
Please share the info!!!

dvarn567 said:
Previous to my other reply, we just had two 67041 denied for the same reason. After checking with CMS and other ophthalmology offices..it is a CMS issue. CMS sent out NCD last year stating certain dx codes were not applicable for Vitrectomy...macular pucker is one and there is a whole list online. Then on 1/18/18 CMS sent out an MLN putting the ICD-10 back for a Vitrectomy. The payers have not updated their policies as of yet. We are holding those claims until the payers fix this issue. I have all the information if anyone is interested or needs it.
Click to expand...

I have been battling this confusion since January when the hospitals started breathing down my neck to have our doctors amend our surgery reports to reflect adequate documentation to cover all the TPPV codes!! Its SOOO frustrating!! Not to mention my doctors and clinical staff fussing at me about how ridiculous it is to delete all the codes they listed in the NCD edit!! My provider claims have not been denied -- to my knowledge-- but the hospitals are and they are blaming the provider!!
PLEASE can you send me the info that you have???? My working email is lsolares@cfretina.com I would GREATLY appreciate it!!
 
Tammy Rueter cpc

dvarn567 said:
Previous to my other reply, we just had two 67041 denied for the same reason. After checking with CMS and other ophthalmology offices..it is a CMS issue. CMS sent out NCD last year stating certain dx codes were not applicable for Vitrectomy...macular pucker is one and there is a whole list online. Then on 1/18/18 CMS sent out an MLN putting the ICD-10 back for a Vitrectomy. The payers have not updated their policies as of yet. We are holding those claims until the payers fix this issue. I have all the information if anyone is interested or needs it.
Click to expand...

I would love to have this information we have had the same rejections. If you could email it to tammyrueter@cvsurgicalcenter.com I would really appreciate it. Thanks!
 
Please share

dvarn567 said:
Previous to my other reply, we just had two 67041 denied for the same reason. After checking with CMS and other ophthalmology offices..it is a CMS issue. CMS sent out NCD last year stating certain dx codes were not applicable for Vitrectomy...macular pucker is one and there is a whole list online. Then on 1/18/18 CMS sent out an MLN putting the ICD-10 back for a Vitrectomy. The payers have not updated their policies as of yet. We are holding those claims until the payers fix this issue. I have all the information if anyone is interested or needs it.
Click to expand...

I’d love this info please... it would be GREATLY appreciated... jameyers30@gmail.com thanks so much
 
Denials for Vitrectomy

Hi,

Does anyone have a recent update from CMS on the Diagnosis problem with the vitrectomy procedure? Our office is getting denials as well. Could you please forward the information to me in this thread at Brkcurtin@aol.com. Thank you
 
Ncd 80.11

You should be able to either resubmit or appeal with the CR 10318, TR 2005 dated 01/18/18.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2005OTN.pdf

Per CMS:

Clarification on the implementation of change request (CR) 10318, transmittal 2005 titled, “ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs)”
The Centers for Medicare & Medicaid Services (CMS) has received multiple inquiries related to instructions in change request (CR) 10318 for national coverage determinations (NCDs) 110.21 and 80.11 and wants to clarify as follows.

National Coverage Determination (NCD) 80.11 Vitrectomy and Change Request (CR) 10318

The Vitrectomy National Coverage Determination (NCD) (see NCD Manual section 80.11) implementation instructions recently stated to remove certain diagnosis codes (see change request (CR) 10318, Transmittal (TR) 2005, dated January 18, 2018 (a correction to the initial CR 10318, TR 1975 dated November 9, 2017)).

The Centers for Medicare & Medicaid Services (CMS) carefully reviews all coding revisions. While the review of the Vitrectomy NCD is no exception, we realize that a large number of codes were removed and that has caused some concern among stakeholders. We appreciate all the stakeholders' comments that notified CMS of the effect of the coding changes. As a result, CMS is in the process of a subsequent review of the codes marked for removal in CR 10318.

In the interim, codes included in the covered diagnosis list prior to CR 10318 are coverable. The CMS Medicare Administrative Contractors (MACs) have been notified of this decision. Any claims you and/or the MACs believe were processed in error as a result of CR 10318 will be reprocessed. Further, if you were advised by a MAC to hold NCD 80.11 claims until further notice, please be assured you can submit those claims and they will be processed without regard to CR 10318.

Once CMS has completed its re-review of coding for NCD 80.11 and if changes to CR 10318 are warranted, it will release a subsequent CR as well as directions to its MACs indicating that decision, complete with specific implementation instructions.
 
You must log in or register to reply here.
Top