Wiki Multi Procedure Confusion

[javajunkie]

This is through UHC and I only have 2 cpt codes, who knew I would be so confused?!?!

1st claim I submit:
67904-50 (Procedure - Ptosis Repair; Dx - H02.413 Mechanical Ptosis bilateral upper eyelids)
67924-51; E4 (Procedure - Entropion Repair; Dx - H02.032 Senile Entropion right lower eyelid)

I thought since the first procedure was for upper eyelids and the 2nd procedure was for the lower eyelid, that's all I needed, even though the two codes are bundled, they weren't performed on the same eyelid.

However, UHC denied the claim stating procedure 67904 is not paid separately. We only received payment for 67924.

So, I tried again w/corrected claim and reconsideration request form:
67904-XS; 50
67924-51; E4

And again, the claim denied payment for 67904. I received a letter stating they processed the claim accurately. No further payment is due. Reimbursement policy CCI Editing Policy was used to process this claim. I called UHC for help, but was told they can't help me with this.

Any help would be greatly appreciated!

 

[miracle01]

appeal vs corrected claim

You should either appeal your claim and defend your coding or send in a corrected claim if you feel you billed the procedures incorrectly. You should never appeal a claim while sending in a corrected claim.

If you appeal the claim and they still deny it and you know you are correct then you should do a 2nd appeal. If you send in a corrected claim and they deny it then you should appeal it if you feel it should be allowed/paid.

Now do you have 2 claims out there? You will need to figure out which one UHC has and go from there. Do the research and defend your coding!

Good Luck!

 

[aruffolo]

I have found that UHC reconsiderations pretty much always get auto-denied with form letter responses. Check the date of your response letter, it was probably generated just days after you submitted the form.

Now that a reconsideration is in their system, you can escalate it to the formal appeal stage. Provide as much evidence as possible to defend your coding in your appeal letter, including full medical records and coding documentation.

Good luck

 

[javajunkie]

Thank you for your response. Do you think it is coded correctly? I honestly don't know if it is or not. Unsure which modifiers to use. I know they are separate eyelids and should be paid, just don't know the correct coding to make that happen. Do you have any advise on the proper modifiers? Thank you.