Wednesday, June 30, 2010

EMPIRE MEDICARE'S covered diagnosis for anesthesia


ICD-9 CM Diagnosis Codes that Support Medical Necessity

It is not enough to link the procedure code to a correct, payable ICD-9-CM diagnosis code. The diagnosis or clinical suspicion must be present for the procedure to be paid. Below are diagnosis codes that support medical necessity.

ICD-9 Code           ICD-9 Description  

 290.11-290.13  Presenile dementia
 290.20-290.21  Senile dementia with delusional or depressive features
 290.3  Senile dementia with delirium
 290.40-290.43   Arteriosclerotic dementia
 290.8  Other specified senile psychotic conditions
 290.9   Unspecified senile psychotic condition
 291.0-291.5   Alcoholic psychoses
 291.81-291.89   Other specified alcoholic psychosis
 291.9  Unspecified alcoholic psychosis
 292.0  Drug withdrawal syndrome
 292.11-292.12   Paranoid and/or hallucinatory states induced by drugs
 292.2  Pathological drug intoxication
 292.81-292.89   Other specified drug-induced mental disorders
 292.9  Unspecified drug-induced mental disorder
 293.0  Acute delirium
 293.1  Subacute delirium 
 293.81-293.89   Other specified transient organic mental disorders
 293.9   Unspecified transient organic mental disorder
 294.0-294.9   Other organic psychotic conditions (chronic)
 303.00-303.02   Acute alcoholic intoxication
 303.90-303.92   Other and unspecified alcohol dependence
 304.00-304.05   Opiod type dependence
 304.10-304.12   Barbiturate and similarly acting sedative or hypnotic dependence
 304.20-304.22   Cocaine dependence
 304.30-304.32   Cannabis dependence
 304.40-304.42   Amphetamine and other psychostimulant dependence
 304.50-304.52   Hallucinogen dependence
 304.60-304.62   Other specified drug dependence
 304.70-304.72   Combinations of Opoid type drug with any other
 304.80-304.82   Combinations of drug dependence excluding Opoid type drug
 304.90-304.92   Unspecified drug dependence
 305.00-305.02   Alcohol abuse
 305.20-305.22   Cannabis abuse
 305.70-305.72   Amphetamine or related acting sympathomimetic abuse
 410.00-410.92   Acute myocardial infarction
 411.1  Unstable angina
 427.1  Paroxysmal ventricular tachycardia
 427.41  Ventricular fibrillation
 427.42  Ventricular flutter
 428.1  Uncompensated congestive heart failure
 456.0  Esphageal varices with bleeding
 456.20  Esophageal varices with bleeding in diseases classified elsewhere
 518.4  Acute edema of lung, unspecified
 518.5  Pulmonary insufficiency following trauma and surgery
 518.81  Respiratory failure
 518.82  Other pulmonary insufficiency, not elsewhere classified
 530.7  Gastroesophageal laceration-hemorrhage syndrome
 530.82  Esophageal hemorrhage
 531.00-531.01   Acute gastric ulcer with hemorrhage
 531.20-531.21   Acute gastric ulcer with hemorrhage and perforation
 531.40-531.41   Chronic or unspecified gastric ulcer with hemorrhage
 532.00-532.01   Acute duodenal ulcer with hemorrhage
 532.20-532.21   Acute duodenal ulcer with hemorrhage and perforation
 532.40-532.41   Chronic duodenal ulcer with hemorrhage
 532.60-532.61   Chronic or unspecified duodenal ulcer with hemorrhage and perforation
 533.00-533.01   Acute peptic ulcer with hemorrhage, site unspecified
 533.20-533.21   Acute peptic ulcer with hemorrhage and perforation, site unspecified
 533.40-533.41   Chronic peptic ulcer with hemorrhage, site unspecified
 533.60-533.61  Chronic or unspecified peptic ulcer with hemorrhage and perforation, site unspecified

Reasons for Denial

Services with diagnoses other than those listed above and services where the submitted diagnosis is not an active medical problem which would impede the safe performance of the procedure will be considered not medically necessary or reasonable.

Non-Covered ICD-9-CM Codes

Use of any ICD-9-CM diagnosis code not included in the "ICD-9-CM Diagnosis Codes that Support Medical Necessity" section of this policy will be cause for denial of claims.

Coding Guidelines

  1. The diagnosis code (ICD-9-CM) should indicate the co-existing medical condition requiring the presence of the anesthesiologist/anesthetist, rather than the gastrointestinal condition for which the endoscopy was done.

  2. For those requiring the presence of an anesthesiologist/anesthetist because of massive upper gastrointestinal bleeding, use the appropriate ICD-9-CM diagnosis code for gastrointestinal hemorrhage.

  3. When upper and lower endoscopy procedures are performed at the same setting, and a physician other than the performing surgeon administers anesthesia for both procedures, he/she should bill the base charge only once plus the time for both procedures

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