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Mcare "accepted descriptions for unlisted procedures" for box 19

Kathy Posted Thu 01st of October, 2015 13:08:35 PM

I've been advised this list exists, but have been unable to obtain from Medicare. Do you have anything like this. Specifically & most immediately, I'm looking for an acceptable description for cpt 49999, for a "wound exploration, injection of bladder & wound I&D & culture" for non-healing wound from rectal CA. Thank you.

SuperCoder Answered Mon 05th of October, 2015 02:33:58 AM

There is no Medicare accepted list as such for unlisted codes. However, to improve and better your reimbursement chances, please ensure you follow the below steps:

Determine an appropriate comparable procedure and identify differences between it and the new procedure you have performed. Include these differences in your cover letter.

Gather RVUs and/or charges for the similar procedure. While providing this information, it is likely most payers will make the payment determination based on their fee schedule for that procedure.

Be prepared to submit supporting documentation, which may include:
1. Clinic notes to support medical necessity of the procedure
2. Operative note providing the nature and extent of the patient condition and detailing the work involved in the procedure
3. Published articles and clinical information supporting the efficacy of the procedure
4. Cover letter that is concise and outlines the procedure, medical necessity, and fee with supporting justification.

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