Part B Insider (Multispecialty) Coding Alert

Published on Fri May 12, 2006 PDF

One neurosurgery provider succeeds in convincing payor to cough up

Just because Medicare doesn't cover something, you shouldn't assume that other payors will deny it.

That's the lesson you can learn from the example of Georgia Neurosurgery in Athens, GA. The Centers for Medicare & Medicaid Services announced in May 2002 that it would no longer pay for operating microscope code 69990 with a laundry list of surgical codes, including laminectomy codes 63030 and 63047--but that didn't stop the Georgia practice from pulling out all the stops for payment. 

Since then, carriers, including non-Medicare payors, have denied claims for 69990 with 63030 and 63047 at least 80 percent of the time, according to Rena Hall, coder for the Kansas City Neurosurgery Group in Kansas City, MO.

Persistence pays: But when Georgia Neurosurgery demanded a refund on a claim for 69990 with 63030 from Blue Cross/Blue Shield of Georgia, the provider appealed the denial--twice. The second time, the Blues changed its tune, according to Insurance Coordinator Sarah Washington.

BCBS Georgia usually does pay for 69990 with laminectomy codes, but in this case they appeared to be acting as administrator for another carrier, says Washington. The payor claimed to believe that the surgeon had used magnifying loupes instead of a microscope. But Washington once again sent in the operating report, along with an explanation that the surgeon used a microscope to dissect fine structures in the spine.
"I don't know if they reversed their decision because they were just tired of dealing with it and I wasn't backing down, or if it was because they agreed with the use of the microscope," Washington says.
Note: Some payors, including Medicare carriers, will never pay for 69990 with those laminectomy codes, so appealing to them is a waste of time, she adds.
"I have no trouble proving the microscope was used, because my surgeon documents [that] very clearly.," says Hall. But many carriers have a "black hole edit" denying surgical microscope claims under any circumstances, she laments.