Wiki PSA Denials

[TammyHF]

Is anyone getting denial for PSA claim after 10/1/2016 for using the new ICD 10 code R97.20 Elevated prostate specific antigen [PSA]?

 

[Coder2468]

Yes, I have. I received a Medicare denial just a few days ago for PSA 84153. Medicare denied for no medical necessity. I initiated a redetermination online and attached scanned documentation showing that R97.2 has been updated to R97.20. I have not received denials from any other payers - yet. Hopefully I don't!

 

[MeriAnn]

Our office has received denials from Medicare. We found out that Medicare's lab system is not accepting the new DX codes until January 3, 2017. See their National Coverage Determination ID# 190.28.

 

[KMCFADYEN]

This is a post from a previous thread by:
holloman@msaphy.com

Looks like the update to the NCD file will not occur until January or April 2017 per the CMS website. The new ICDs will be backdated to their effective date, 10/1/16, but they sure make it a pain in the mean time.

"Please note that due to this being the first regular ICD-10 code update since the partial code freeze October 1, 2011, (there were limited new codes introduced in fiscal years 2012, 2013, 2014, and 2015), and the voluminous number of new codes involved, the Medicare shared systems will split implementation of the new codes over the January 2017 and April 2017 quarterly updates. While the implementation dates will be in January and April, the effective dates of the new codes will still be October 1, 2016. All deleted codes will not be valid for payment after September 30, 2016. Contractors will be instructed to adjust claims brought to their attention."

https://www.cms.gov/Medicare/Coverag...NCDsICD10.html

 

[michelleaapc2012]

Do we hold our PSA claims until after January 3 2017?

 

[TammyHF]

I spoke with a rep for WPS she said that they have to 12/5/2016 to update their system but CMS would publish the new lab NCD till January 2017. She said they are not planning on doing a mass readjustment at this time and suggested a test claim be submitted after 12/5/2016 per the MLN MM9806.
https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/LabNCDsICD10.html

 

[Coder2468]

I had initiated a redetermination for the denied PSA charge, and I just received an answer today. Medicare is stating that their appeal decision is unfavorable, and they are maintaining that they denied it correctly. I just wanted to post this update so others don't waste their time doing appeals. Looks like we'll just have to wait until they do their update. It's very frustrating having these PSAs clogging up my AR!

 

[TammyHF]

I got my first payment with R97.20 as the only diagnosis for PSA for WPS Medicare contractor.

 

[karenlucas]

This is the posting from CMS...
2017 ICD-10 CM diagnosis codes are required on claims for services performed on or after 10/1/2016. Changes to the claims processing systems to implement the ICD-10 updates for CMS NCDs for laboratory services have been implemented as of 12/5/2016. Laboratory claims for dates of service on or after 10/1/2016 with ICD-10 diagnoses and ICD-10 procedure codes associated with NCD edits should now be processing normally. 12/16/2016: For laboratory based claims, a system resolution was installed on Monday, 12/5/2016. Providers are advised to resubmit all associated claims denied on or after 10/1/2016 for reprocessing. Providers are also advised to continue to monitor this Production Issue Alert and NGS listserv releases for any additional details or instructions.

 

[misstigris]

Anyone have any more updates? We are getting our claims for Medicare paid now, but BlueCross Medadvantage and Healthnet Medadvantage are still denying and referring back to the NCD 190.31