Appeal type: Surgery
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided on November 10, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for a lack of medical records in the file. The Plan requested a reopen and provided the required medical records.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for the drainage of an abdominal abscess or infection (Procedure code 49020-51) provided on November 10, 2021. The medical records show the enrollee had a diagnosis of Peripancreatic abscess and necrosis. The Plan approved procedure code 48105 (Under Excision Procedures on the Pancreas). Procedure code 49020-51 was denied as "Inclusive to another Billed Code." The Operative Note states, "The planned procedure was drainage of pancreatic abscess." The Operative Note includes, "The drain been placed in the left upper quadrant. I slowly worked my way over to the area of the drain. This required mobilization of the colon, stomach, and some small bowel. The greater omentum was also mobilized. All the tissue was very inflammatory. Serosal injuries during mobilization were imbricated with interrupted 3-0 silk sutures. Eventually I was able to reach the percutaneous drain. I cut out onto this with the cautery. I then followed this tract down into the retroperitoneum between the transverse colon and the stomach. I entered the abscess cavity. Cultures were obtained.
The percutaneous drain was removed. I then utilized the Babcock clamps to extract the significant amount of necrosis in the retroperitoneum this came out in large pieces. There was no significant liquid portion to the collection at this point. All of the necrotic tissue was debrided. There was no obvious remaining necrosis in the left retroperitoneum. The wound cavity was irrigated copiously with warm saline. There was good hemostasis. A 19 French Blake drain was placed in the left upper quadrant and placed into the necrosis cavity. The abdominal cavity was irrigated with warm saline. There was good hemostasis." Procedure code 48105, in a patient with acute necrotizing pancreatitis, the provider removes pancreatic tissue via resection and debridement. Procedure code 49020, in this procedure, the provider incises the abdomen and drains an area of infection or abscess in the membrane lining of the abdominal contents, not involving the appendix. These codes include all services usually performed as part of the procedure as a standard of medical/surgical practice. A physician shall not separately report these services simply because codes exist for them. Procedure code 49020, drainage of an area of infection or abscess in the membrane lining of the abdominal contents, is not usually performed as part of the procedure 48105, removal of pancreatic tissue via resection and debridement as a standard of surgical practice. Consequently, the Plan's denial of procedure code 49020 is not justified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on November 10, 2021.