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Blue Choice Carefirst denied a PTP edit CPT 11721-59 when billed with CPT 11056 with a denial reason code of “ccy”, I have never heard of this edit do you know what it is? I looked on their website and can’ find this anywhere! So, the we did some digging into this It turns out the EOB stated “ccy” and on the EOB=Provider must submit a valid modifier procedure code combination, really?

It turns out that CMS decided the LCA terminology was not appropriate. In addition to the LCD, CMS has the contractors now using either or both “LCD Reference Article” and “Billing and Coding Article” to outline payment and coding.

Did Medicare do away with the LCA’s?

ANSWER: When you look up ICD-10-CM code- I73.89, this is what you see: * I73.8 Other specified peripheral vascular diseases * Excludes1: diabetic (peripheral) angiopathy (E08-E13 with .51-.52) This means you must use E11.51 or E11.52 not I73.89 with E11.40

I just got back an EOB and the insurance denied my E&M when I used I73.89 with E11.40, why?

Yes, I agree that ICD-10 changes take affect on 10/1/24

Doesn’t it start on 10/1/2024 not 1/1/2025?

ICD-10-CM Coding gets updated when?

There has been significant pressure by all organized medical associations representing all stakeholders in this issue. This includes medical associations, wound care manufacturers and patient advocacy groups. It remains to be seen what action the CMS contractors will take. It is likley whatever action is taken it will be uniform as CMS is bent on cutting down on the abuse and escalating costs associated with CTPs. The recent OIG report certainly does not help. At this point the CMS contractors will either drop the entire issue as they have in the past, amend their initial draft policies or enforce their draft policies with no comment.My personal opinion is that they will take the signficant push back provided by medical providers seriously and either amend or drop the whole thing as they have before. They will then quickly adopt a new draft policy for comment. It would be a shame for any policy to throw the baby out with the bath water (as the proposed policy does) simply because of the inappropriate fraud and abuse of a select number of providers. CTP are here to stay and they most certainly have saved limbs.But perhaps the science behind it must be more strictly adhered to by the mfgs and the HCPCS Common Work Group needs to seriously consider revamping its approval of new HCPCS code for new CTP.

It is recommended that you reply to corresponding MAC by June 8th explaining why the policy does not have any evidence to support the number four! Please go to your MAC and look at the Proposed LCD’s. I have referenced them here:Noridian Healthcare Solutions, LLC - DL39764Noridian Healthcare Solutions, LLC - DL39760First Coast Service Options, Inc. - DL36377Novitas Solutions, Inc. - DL35041Palmetto GBA - DL39806National Government Services, Inc. - DL39828Wisconsin Physicians Service Insurance Corporation - DL39865CGS Administrators, LLC - DL39756 Billing Articles:Noridian Healthcare Solutions, LLC - A59628Noridian Healthcare Solutions, LLC - A59626First Coast Service Options, Inc. - A57680Novitas Solutions, Inc. A54117Palmetto GBA - A59691National Government Services, Inc. - A59712Wisconsin Physicians Service Insurance Corporation - A59740CGS Administrators, LLC - A59618

You cannot. Only DMEPOS providers can submit claims to Medicare for processing (be they paid or simply processed as Patient Responsibility). While you can provide a form for the patient to self-submit, Medicare will still not pay this claim and the patient will be forfeiting their opportunity to self-submit reimbursable claims in the future. If you are a non-participating provider under Medicare then you can elect to do the same and enroll as a non-participating DMEPOS provider and simply submit these types of claims with a GY modifier.

1. If the entity is a HIPAA covered entity it should deny using the typical codes we see that start with "CO’ or “N” or “PR” are some that common ones that come to mind right away. Looking on the Carefirst BCBS site and their billing requirements this is what was found: https://provider.carefirst.com/carefirst-resources/provider/pdf/provider-manual-chapter-5-claims-billing-and-payments.pdf 2. Can a private payer make up it’s own coding initiative, we have seen McKesson products over the years which incorporates NCCI but adds more is this that? Reaching out to this doctor, the representative stated they use NCCI to determine the denial! 3. Clearly, the code pair should be billed with a “59” on CPT 11721 as it is a column 2 code to CPT 11056 but are they looking for the “XS”? Hopefully, more information will be gleaned from this issue, stay tuned!