MAR 02, 2022
Advise on Medicare denial 67036 Vitrectomy, mechanical, pars plana approach for a Medicare patient with diagnosis of Cataract (lens) fragments in eye following cataract surgery, left eye
My retinal doctor has charged 67036 Vitrectomy, mechanical, pars plana approach for a Medicare patient with diagnosis of Cataract (lens) fragments in eye following cataract surgery, left eye. Medicare is denying as: 67036 SMARTEDIT LBI PER LCD OR NCD GUIDELINES PROCEDURE CODE 67036 HAS NOT MET THE ASSOCIATED DIAGNOSIS CODE RELATIONSHIP CRITERIA FOR CMS ID(S) L37863. (67036). Can you advise on this?
Medicare has a national coverage determination (NCD) for vitrectomy. Links to current NCDs can be found on aao.org/lcds.
ICD-10 code, H59.02- cataract fragments in the eye following cataract surgery, is not a covered diagnosis per the Vitrectomy NCD 80.11.
Here are a few that would be covered. There is an expanded list in the policy, link below.
H27.01 Aphakia, right eye
H27.02 Aphakia, left eye
H27.03 Aphakia, bilateral
H27.10 Unspecified dislocation of lens
H27.111 Subluxation of lens, right eye
H27.112 Subluxation of lens, left eye
H27.112 Subluxation of lens, bilateral
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R2202OTN.pdf