Vitrectomy Battle Still Underway
The Centers for Medicare & Medicaid Services revised its Vitrectomy National Coverage Determination (NCD) policy 80.11 in October 2017 to update applicable ICD-10 codes. Instead of removing redundant diagnoses, as they stated was the goal, they deleted approximately 25 percent of the codes.
Practices nationwide started receiving denials from Medicare Part B and other payers for services that were medically necessary. The Academy reached out to CMS, which rescinded the coverage policy changes in January 2018, indicating that the policy would be reviewed. In the interim, CMS advised all Medicare Administrative Contractors (MACs) and Medicare Advantage Plans to process vitrectomy surgeries. CMS continues to review the policy and has not provided a date as to when it will be updated. As soon as CMS releases their final determination, we will alert practices of appropriate billing.
Practices are still reporting some Medicare Advantage plans and commercial payers continue to deny vitrectomy surgeries. While most plans have received direction from CMS, they are not following their guidelines.
What practices can do:
CMS has asked to be notified if practices continue to see denials during the interim.
- For Medicare Part B:
- If you had claims on hold, submit as they will be processed.
- If claims were previously denied, your MAC should reprocess them.
- Currently no complaints of denials are coming from Medicare claims.
- Notify your MAC representative, or contact CMS at 1-800-Medicare.
- For Medicare Advantage plans:
- Contact CMS at 1-800-Medicare. The agency is monitoring issues closely and forwarding the information to regional offices.
- Notify the Academy at email@example.com and firstname.lastname@example.org when you receive denials. We are working with CMS to address these issues.