CMS Announces NCD 80.11 Diagnosis Code Fix

Date: August 17, 2018

Many of our clients encountered denials or received rejections from their claims intermediaries when trying to file claims for a variety of vitrectomy services; these began shortly after the first of the year, due to the deletion of some ICD-10-CM codes from the list of approved diagnoses for National Coverage Determination (NCD) 80.11, Vitrectomy.

Some of the denials frankly did not make sense; the proper medical indication for the surgery in many cases was deleted from the ICD-10 list for NCD 80.11.  A prime example of this problem is a patient who needed their epiretinal membrane fixed via a pars plana vitrectomy due to intolerable distortion and blur.  All the epiretinal membrane diagnosis options, H35.37-, were inappropriately deleted from coverage, causing a denial or rejection when coded with CPT 67041, Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg macular pucker).  Although CMS did eventually instruct MACs to process the claims in the interim with the deleted codes while they worked on the issue in the background, the actual CMS Transmittal was not available until August 10, 2018.

The Change Request (CR 10859) to move the deleted codes back into proper claims processors was published in Transmittal 2122.  It notes, in the Summary of Changes:   “These NCD coding changes are the result of newly available codes, coding revisions to NCDs released separately, or coding feedback received.”  In this case, we believe the “coding feedback” was the mechanism for reinstatement.  The effective date for Transmittal 2122 is shown as January 1, 2019 but, in the meantime, offices can feel safe that the already-in-place interim instructions to MACs to process the deleted codes remains.  In addition to the Transmittal, CMS actually makes the list of proper diagnoses available for view.  You can view the actual CMS file (an EXCEL spreadsheet) showing the reinstated ICD-10 codes at the below link:

Some private payers also rejected or denied claims for the same issue since, in most cases, they use the CMS lists as guidance.

This new Transmittal and the interim “patch” until then should allow claims to process and pay correctly when medical necessity exists.  CMS also published an MLN Matters provider education article through the MLN Connects weekly newsletter.

We are happy to assist providers and groups in any way with other topics including proper code selection, impacts of regulation on the practice, periodic chart reviews of a variety of types, and questions on payer actions.  We can also provide training on these or other subjects.  Please contact us via phone or email, or on our “App”, Corcoran 24/7, which can be accessed via one of the links below.

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