Tuesday, April 23, 2019

Quality to the Next Level


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Coding Issues

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1-991166855 - Friday, May 10, 2013
Rationale for the Referral: The physician fee schedule payment for 23472 constitutes payment in full for each procedure and that amount is not subject to review. The ALJ erred in allowing additional payment on the basis that a particular technique described by 23472 may be more difficult than another technique.

Referral Document

Appeals Council Decision

 
1-761503536 - Tuesday, June 5, 2012
Rationale for the Referral: Payment for one unit of CPT code 95874 (needle electromyography) is considered payment in full for the entire series of needle electromyography procedures performed on a beneficiary on a single date of service under the National Correct Coding Initiative and Medically Unlikely Edit programs.

Referral Document

Appeals Council Decision


 
1-776529312 - Tuesday, June 5, 2012
Rationale for the Referral: Payment for one unit of CPT code 67820 (removal of eyelashes to correct trichiasis) per date of service constitutes Medicare’s full payment for the procedure. American Medical Association coding guidance states codes 67820 and 67825 are intended to be reported per procedure, not per eyelash or eyelid. Additionally, CMS has assigned a Medically Unlikely Edit of one to code 67820, meaning it is medically unlikely the procedure would be completed on a single beneficiary more than once on a single date of service.

Referral Document

Appeals Council Decision


 
1-765778336 - Thursday, October 13, 2011
Rationale for the Referral: NCCI edits in effect for the dates of service at issue denote that CPT codes 73564 (x-ray exam, knee; complete, 4 or more views ) and 73565 (x-ray exam of knees, standing, anteroposterior) are not separately billable and use of a modifier is not appropriate to override the payment restriction. CPT code 73565 is a component code of the comprehensive code 73564 and may not paid for the same beneficiary and same date of service, even if the modifier “59” is added to the component code.

Referral Document

Appeals Council Decision 
  
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