Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to pay for 36556 and 76937. We decided that the Plan does not have to pay for 93010. 

You asked the Plan to pay for procedure codes 36556, 76937, and 93010 rendered on March 23, 2023.. You say that this should be paid for. The Plan says that the records do not support the services billed.

We decided that the Plan has to pay for 36556 and 76937. 

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The definition of the overturned codes are:

CPT 36556:

Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older

CPT 76937:

Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure)

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request for these codes. Our reviewer says that that there is satisfactory documentation that a central line (CPT 36556) was placed in internal jugular vein. There is satisfactory documentation that the line was placed centrally. As most central lines placed in the emergency room/intensive care unit are not placed under fluoroscopic guidance, the exact location of the tip cannot be documented. Therefore, it is not reasonable to require this information to justify billing. Additionally, the x-ray report that was provided confirms that the tip of the catheter was central, specifically at the caval-atrial junction.

In terms of CPT 76937, this codes for ultrasound guidance for vascular access. There is satisfactory documentation that ultrasound guidance was used to access the jugular vein.  While there is a stipulation that the images must be archived, it is not reasonable to require documentation of this in the operative note.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 36556 and 76937. 

We also decided that the Plan does not have to pay for 93010.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The definition of CPT 93010 is "Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only."

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request for CPT 93010. Our reviewer says that this codes interpretation and report of an electrocardiogram. A complete interpretation and formal report does not appear to have been rendered to the level of this code.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 93010 have not been met. Therefore, we decided that the Plan does not have to pay for 93010