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You're working as a Professional Fee Coder or a Reimbursement Specialist. One of your job requirements is to review charges as they process through the revenue cycle. The attached pdf. has 5 questions. Questions 1-4 will require you to review the LCD -Local Coverage Determination policy on the Medicare website.

Useful FYI---- CGS Administrators, LCC currently processes & pays Medicare Parts A & B claims for Ohio Medicare beneficiaries. Commercial payers will often mirror Medicare with some slight differences. For this assignment, we'll just be looking at Medicare.

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Solution Preview

The following questions were answered using the LCD for Ohio state (see attached).

1. Virtual Colonoscopy (CT Colonography) 74261 or 74262 Verify which diagnosis, which (if any), are considered a medical necessity & would be consider payable by Medicare. (We will assume conditions have been met). The LCD ID# L30300

a. 626.4 b. 557.1 c. 562.13 d. V67.1

Virtual Colonoscopy review was found with LCD ID #31833. (See Attached)
Code 557.1 for chronic vascular insufficiency of intestine, 562.13 for diverticulitis of colon with hemorrhage, and V67.1 for follow-up examination following radiotherapy are considered medical necessity. However, code 626.4 for irregular menses is not covered, as it is not related to a colon procedure.

2. Neuromuscular Electro-diagnostic Testing, CPT codes 95907. Verify which (if any) diagnosis is considered a medical necessity & would be "considered" payable by Medicare. (We will assume all conditions have been met) (LCD ID# L33249)

a. 354.0 b. 354.1 c. 340 d. 723.0

LCD ID # 33249 specifies that Electromyography studies (CPT 95907) are medically necessary under the following conditions: a) to ...

Solution Summary

The solution involves analysis of the medical necesity fro the LCDs L31833, L33249, and L31855 according to ICD9 codes given and the NPI numbers for Dr. Vivek Hallegere Murthy and Dr. Conrad Robert Murray.

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