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Q: We are receiving regular denials when coding for the aqueous shunt procedure. What might be the cause of this?
Cristina Bentin, principal, Coding Compliance Management: While there are a few potential codes utilized for the reporting of aqueous shunts and devices, Category III code 0192T (Insertion of anterior segment aqueous drainage device, without extraocular reservoir; external approach) is at the top of the list when it comes to denials due to lack of medical necessity. According to CMS and many commercial carriers, 0192T is considered medically necessary as a method to reduce intraocular pressure in patients with glaucoma where conservative methods/medical therapy has failed to control the intraocular pressure.
Medicare denials are being seen due to the lack of documentation that the procedure is being performed to reduce intraocular pressure in patients with glaucoma. The facility may be coding the procedure and conditions correctly according to the operative documentation but the documentation is lacking in medical necessity for the condition of glaucoma. ASC facilities must verify with individual commercial carriers and/or MAC/LCD policies for medical necessity requirements/conditions when reporting 0192T. For example, currently, CMS considers ICD-9-CM series 365.10-365.15, open-angle glaucoma as medically necessary to perform Category III code 0192T. Operative documentation must support all conditions for which the procedure is being performed to include the condition of glaucoma when warranted and that the intraocular pressure is not currently being controlled by medications/medical therapy.
Cristina Bentin can be reached at cristina@ccmpro.com. Learn more about Coding Compliance Management.
The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
Q: We are receiving regular denials when coding for the aqueous shunt procedure. What might be the cause of this?
Cristina Bentin, principal, Coding Compliance Management: While there are a few potential codes utilized for the reporting of aqueous shunts and devices, Category III code 0192T (Insertion of anterior segment aqueous drainage device, without extraocular reservoir; external approach) is at the top of the list when it comes to denials due to lack of medical necessity. According to CMS and many commercial carriers, 0192T is considered medically necessary as a method to reduce intraocular pressure in patients with glaucoma where conservative methods/medical therapy has failed to control the intraocular pressure.
Medicare denials are being seen due to the lack of documentation that the procedure is being performed to reduce intraocular pressure in patients with glaucoma. The facility may be coding the procedure and conditions correctly according to the operative documentation but the documentation is lacking in medical necessity for the condition of glaucoma. ASC facilities must verify with individual commercial carriers and/or MAC/LCD policies for medical necessity requirements/conditions when reporting 0192T. For example, currently, CMS considers ICD-9-CM series 365.10-365.15, open-angle glaucoma as medically necessary to perform Category III code 0192T. Operative documentation must support all conditions for which the procedure is being performed to include the condition of glaucoma when warranted and that the intraocular pressure is not currently being controlled by medications/medical therapy.
Cristina Bentin can be reached at cristina@ccmpro.com. Learn more about Coding Compliance Management.
The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.