Noridian Issuing Claims Denials for Eye Surgery MAC Anesthesia

Recently, some of our Corcoran Consulting Group clients have received denials for large numbers of eye surgery anesthesia services with code series 0014x. The denials are for services on or after December 10, 2012. While the information is early, we are posting what we have as of this date and will update as we know more.

Noridian Administrative Services, LLC, the Medicare Administrative Carrier (MAC) for several states (AK, AZ, ID, MT, ND, OR, SD, UT, WA, and WY), has begun issuing denials for Monitored Anesthesia Care associated with eye surgery for claims entered to Part B Medicare.

Clients are seeing denial code CO-50 (These are noncovered services because this is not deemed a “medical necessity” by the payer).

The affected policy originated on December 1,2006, but appears not to have been implemented for eye surgery codes until December 10, 2012. A sample LCD policy (this one is for Oregon) can be found at this link here. Other policies are nearly identical within Noridian’s coverage area.

Noridian notes in the above LCD:

“The presence of an underlying condition alone, as reported by an ICD-9-CM code, may not be sufficient evidence that MAC is necessary. The medical condition must be significant enough to impact the need to provide MAC, such as the patient being on medication or being symptomatic, etc. The presence of a stable, treated condition of itself is not necessarily sufficient.”

Based on the above, anesthesia services may need to support the need for this type of anesthesia in additional ways, such as with documentation of the systemic disease and other co-morbidities of the patient.

Corcoran Consulting Group has additional information which may help. For more information, contact us via phone or web.