Is the diagnosis payable? Only the carrier knows for sure

August 3, 2010

It seems that not all Medicare was created the same. Since Medicare is a national government-issued insurance program created in 1965, one would think that every state would have to follow the same rules and coverage policies. But that is not so.

It seems that not all Medicare was created the same. Since Medicare is a national government-issued insurance program created in 1965, one would think that every state would have to follow the same rules and coverage policies. But that is not so. Every region contracts out with a private company (Medicare carrier) to operate as the intermediary between the government and medical providers.

These private companies have the authority to create local coverage determinations that spell out coverage criteria and diagnoses for certain CPT codes. If you deal with multiple practices in different states, you are most likely going to have to deal with different carriers, which can be a headache.

For example, if you have a lot of patients with memory loss, you may want to have your practice in snowy Indiana where a diagnosis of 780.93 is on the local coverage determination for an MRI of the brain. However, stay away from warm Texas because memory loss is not the local coverage determination for MRI of the brain. Why is it that a certain diagnosis justifies an exam in one state but not another?

Recently, New Jersey came out with a bulletin stating the physicians must justify the use of ultrasound on a knee injection by meeting certain conditions, such as the patient being morbidly obese. So far, I can find no other carrier with such a specification.

Coding across states can be challenging. It is important for your coders to be diverse in their knowledge of each carrier’s local coverage policies; it can mean the difference between payment and denial.


Ms. Snyder is corporate director of coding for Zotec Partners.