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Bone marrow biopsies

Jerilen Posted Fri 18th of March, 2016 15:04:38 PM

The hospital that sends us labs for bone marrow biopsies is getting denials for FISH and FLOW tests when the diagnosis is pancytopenia. Would you know why this diagnosis is not covered for these tests?

SuperCoder Answered Mon 21st of March, 2016 05:34:14 AM

Hi,

Medicare will consider the Urinary FISH test medically reasonable and necessary in the following circumstances:

* In the initial diagnosis of persons with hematuria suspected of having bladder carcinoma, in conjunction with, and NOT IN LIEU of current standard diagnostic procedures. Therefore it is expected that Initial urinary FISH studies are performed in conjunction with cystoscopic evaluation.
* In the monitoring for tumor recurrence in conjunction with cystoscopy in patients with previously diagnosed bladder cancer.
* Monitoring for additional recurrence after one or more recurrences have been treated.

The urinary FISH test for recurrent bladder is not considered medically reasonable or necessary under the following circumstance:

* When performed to provide additional confirmatory information after a diagnosis of bladder cancer recurrence has already been determined.

Medicare will consider Bladder Tumor Antigen Stat testing medically reasonable and necessary under the following circumstances:

* The patient must have a prior diagnosis of bladder cancer.
* The patient is being monitored for a status/recurrence/metastasis of bladder cancer in conjunction with cystoscopy.

Consistent with the above, Medicare expects that the urinary FISH study will be used no more frequently than cystoscopy, and may be used additively or substituted for conventional urine cytology depending on the grade of the tumor and potential diagnostic yield. The first FISH study as the diagnosis of urothelial cancer is being established will be coded with the appropriate morphometric analysis code 88120 or 88121, and with the appropriate neoplastic diagnosis required. Subsequent studies will be additionally coded with the V-code, V49.89 OTHER SPECIFIED CONDITIIONS INFLUENCING HEALTH STATUS, to indicate that repeat testing is believed to be medically reasonable and necessary.

Urinary cytogenetic studies will not be covered if the patient has signs or symptoms of hematuria or an active infectious/inflammatory condition at the time of the testing (e.g. cystitis, urethritis, or prostatitis).

Hope this helps!!

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