Medicare denial on debridement

Patient had a hernia operation 11 months ago and continues to have spells of infection and /or serous drainage from the wound. Medicare has denied all debridements during and after global period, because of using Dx like 998.83, 998.59 or 998.32. Another clinic was reimbursed (same patient) by using Dx 879.3. Please explain if 879.3 is appropriate when the wound is not caused by a trauma but surgery.

re: Medicare denial on debridement

I would recommend reviewing the Medicare LCD for debridement.

re: Medicare denial on debridement

I know LCDs for debridements: dx 998.59, 998.32, 998.83 and 682.X are not covered. My question was: is 879.3 correct coding for a wound cause by surgery 11 months prior?

re: Medicare denial on debridement

It is difficult to explain if a code is appropiate without reviewing documentation as you know the age old saying...If it's not documented it did not happen" Furthermore, Im sure you understand that just because one gets paid does not mean the claim was billed correctly. You will need to code what is supported in your provider's documentation. Just with the information provided, I would not code 879.3 you most likely know this code lives in the injury and poisoning section based on your brief decscription, I would likely code 958.3 which happens to be listed as a covered dx on the LCD. Can you advise as to the reason Medicare denied your claims during and after the global period? What procedure code are you using have you appended modifiers or submitted an appeal? Trying to help but I need a bit more information.

re: Medicare denial on debridement

Thank you so much for your attention to this issue. All of the denials are for "not medically necessary" because of using the earlier mentioned Dx that are not covered under LCD. We have not sent an appeal; that is the next step. I just wanted to be reassured that I was choosing the Dx correctly by staying out of the injury section, even though those codes get paid. (the Dx you suggested, 958.3, is also caused by an injury). Thanks!