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Core Needle Vacuum Assisted biopsy

Pam Posted Tue 30th of August, 2016 16:43:44 PM
I used 19083, with DX N60.21 and N60.11. Medicare denied stating 1. These are non-covered services because this is not deemed a 'medical necessity' by the payer. 2 "The information furnished does not substantiate the need for this level of service" This decision was based on a National Coverage Determination (NCD)
Pam Posted Wed 31st of August, 2016 14:08:34 PM
I need to appeal this non payment but Is there something new that I did not include? Did I code this incorrectly?
SuperCoder Answered Thu 01st of September, 2016 04:40:41 AM

Hi,

As per the guidelines CPT 19083 is billed correctly with  ICD 10 N60.21 and N60.11. The new update effective 01-01-2014 is that CPT 19083 has been added to conditional bilateral list.

https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r2838cp.pdf

But, here are few points which will help you in the appeal:

The first reason of denial, i.e., CO50, the sixth most frequent reason for Medicare claim denials, is defined as: “non-covered services because this is not deemed a ‘medical necessity’ by the payer.” When this denial is received, it means Medicare does not consider the item that was billed as medically necessary for the patient.A CO50 denial cannot be resubmitted. It must be sent to redetermination. If you do not send the claim to redetermination within 120 days of the date of the denial, you have missed the timely filing deadline and will need to write off the claim. If a claim is billed to Medicare without a KX modifier, it will be denied with the CO50 denial. When you add the KX modifier, that states to Medicare that the specified medical necessity documentation is on file within the patient's medical record and that the patient meets the specified coverage criteria as outlined by the Local Coverage Determination.

Hope This Helps.

Thanks.

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