Diagnosis (ICD-9) Codes which do not support Medical Necessity

CMS and local Medicare/Medicaid Carriers have specific diagnosis codes that support medical necessity for particular procedures.

If a diagnosis is used and is not in their list, the procedure will be denied as being not medically necessary. (For example: CPT codes 64493, 64494, 64495, 64622, 64623, 64626, and 64627 are not considered medically necessary when billed with diagnosis 724.8.) The provider is responsible for obtaining a signed ABN the day of and prior to the procedure from the patient stating the patient is aware they may be responsible for the charges for diagnoses not medically necessary.

If an ABN is not obtained and the procedure is denied, you will not be paid for your services. Be aware of what diagnosis codes are not covered and obtain the ABN signed by the patient. Please submit those signed ABN’s to our office with your charge tickets. It is necessary to bill the procedure with a –GA modifier in order to later bill the patient in case of denial. If you are unsure of what diagnosis codes are not covered, and cannot locate those on the CMS or local Carrier websites, please feel free to contact our office.

BCBS of Kansas has issued a Policy Change

Injection into the sacroiliac joint has historically been considered experimental/investigational without any exceptions; however, BCBS of KS has now made an exception for the following conditions. All conditions must be met for the test to be considered medically necessary:

  1. Pain originates from the sacroiliac joint; and
  2. Duration of pain of at least 3 months; and
  3. Average pain level of ≥ 6 on a scale of 1 to 10; and
  4. Failure to respond to more conservative management including physical therapy and non-steroidal anti-inflammatory agents; and
  5. Lack of obvious evidence for disc related or facet joint pain

Repeat Injections are to be no more frequent that every 2 months. Repeat injections extending beyond 12 months may be reviewed for continued medical necessity. Sacroiliac injections are considered experimental/investigations for all other indications. Arthrography of sacroiliac joint is considered experimental/investigational.

If someone shows up in an ER or is scheduled through a treatment room or surgery and the above conditions are not met – the patient must sign the BCBS patient waiver or ABN in order for the charges to become the patient’s responsibility.