Update: AAO announces that CMS will fix NCD 80.11 Vitrectomy coverage denials
In October 2017, the Centers for Medicare & Medicaid Services (CMS) eliminated a large number of diagnoses from the coverage related to vitrectomy under National Coverage Determination 80.11 for Vitrectomy (NCD 80.11). The CMS noted the reason in Transmittal 1975, which you can link to here. In the Transmittal, CMS noted that as ICD-10 changes are implemented through updates, covered diagnoses naturally need to be adjusted; they stated:
“Coding (as well as payment) is a separate and distinct area of the Medicare Program from coverage policy/criteria. Revisions to codes within an NCD are carefully and thoroughly reviewed and vetted by the Centers for Medicare & Medicaid Services and are not intended to change the original intent of the NCD …”
Unfortunately, quite a few of the over 300 deleted ICD-10 diagnosis codes (which made up nearly 25% of the total) used to properly process claims are commonly needed. To illustrate only one example of the problem denials, the ICD-codes for macular hole (H35.34-) were eliminated and, after October 1, 2017, can’t be used for CPT code 67042 (pars plana vitrectomy for this purpose). This makes no sense as it is one of the most common indications for medically appropriate macular hole surgery.
This week, the American Academy of Ophthalmology (AAO) announced that they had met with, and were assured by, CMS representatives that this improper and inaccurate set of diagnosis-related denials would be fixed. CMS also stated that they would direct the Medicare Administrative Contractors (MAC) to correct their systems. No actual date for the fix by CMS or the MACs has been given at this point, but when it does claims will once again process correctly.
In the meantime, we see no reason not to continue to file claims since if there is a retroactive fix, those denied should be among the first to be corrected.
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