Reader Question:
Tonsillectomy
Published on Sat Apr 01, 2000
Question: Recently, one of our insurance carriers denied claims for gross examination only [CPT 88300 ] of tonsils and adenoids. The denials state that the procedure is not medically necessary. What could be the source of this denial? Have other offices encountered this also, and if so, how have they approached the problem?
Tamala Green
Sierra Pathology Associates, Reno, Nev.
Answer: As a first step to solve this dilemma, check with the physician office responsible for the tonsillectomy to ensure that the diagnosis code you are reporting is correct. Also, request an explanation of the denial from the carrier, to see if ICD-9 coding is the issue.
We have heard reports, however, that other practices, particularly in Wisconsin and Georgia, have experienced similar claim denials from a particular insurance carrier. Evidently, this carrier has characterized the gross examination of tonsils and adenoids as a hospital-mandated exam, for quality assurance.
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