Question:

We are adjusting off quite a few computed tomography (CT) scans that are performed to follow up a cancer diagnosis after treatment is complete. Our state’s local coverage determination (LCD) covers the cancer diagnosis code but does not cover the “history of” the specific cancer nor does it cover Z08 for completion of treatment. Is there any compliant way around this denial? For instance, can we bill the cancer diagnosis that is covered even though the report states no evidence of recurrence or metastasis?

Answer:

Medicare doesn’t cover “watchful waiting”– just checking to see if there has been recurrence without some kind of medical necessity. Other payers may or may not allow that. For Medicare, you must have medical necessity – a problem, not just routine yearly checking. You should not report a current cancer diagnosis code when the patient is no longer being treated for the cancer.

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