Wiki 29876 and 10140

[pchamp25]

I'm looking for help regarding a denial we received for 10140 which was billed with 29876. This is the reason for denial we have received from the insurance, Anthem, -Code 10140 do not require a precertification. And I have checked that it was denied as bundled to 29876. - Multiple surgical procedures can be performed on a single member on a single date of service by the same provider. Per CMS, for these surgical procedures which are performed during the same operative session, separate payment may be allowed. These surgical procedures are not representative of components of the major surgical procedure. When two or more eligible, surgical procedures are performed on the same member on the same date of service by the same provider, the procedures are ranked. The procedure ranked at one should be reimbursed at 100%, while subsequent procedures should be reimbursed at 50%. The allowance was reduced for this/these procedure(s) because two or more eligible, surgical procedures were performed and a multiple procedure cutback was deemed appropriate. Therefore, this procedure code was adjusted.
From what I can find, there is no bundling edit for 10140 and 29876. Is the 10140 considered to be part of synovectomy? The I&D was performed on the lateral part of the thigh & not part of the arthroscopic procedure. Any help understanding the reason for this denial would be greatly appreciated! TIA

 

[amyjph]

We would need more information such as the op note.
There may not be an NCCI edit, however did you check Clear Claim Connection or McKesson or make sure Anthem doesn't have a different edit for these codes?
Were there any other procedures done on the same date/operative session?
I am not understanding what you stated is the denial, was it fullu denied? What was the reason/remark code for the denial associated with it? Was it denied or just the multiple procedure reduction applied to 10140 since it would be the second listed/lower RVU code? What was the reason 10140 was done at the same time as 29876 on a different part of the same leg, post op infection/sinus tract from a knee infection?

 

[pchamp25]

We would need more information such as the op note.
There may not be an NCCI edit, however did you check Clear Claim Connection or McKesson or make sure Anthem doesn't have a different edit for these codes?
Were there any other procedures done on the same date/operative session?
I am not understanding what you stated is the denial, was it fullu denied? What was the reason/remark code for the denial associated with it? Was it denied or just the multiple procedure reduction applied to 10140 since it would be the second listed/lower RVU code? What was the reason 10140 was done at the same time as 29876 on a different part of the same leg, post op infection/sinus tract from a knee infection?

All great questions and ones I am still learning to ask so let me see if I can do my best to answer them! First I don't know of Clear Claim Connection or McKesson when it comes to checking for edits. For Anthem, it is a different story as I am billing for an ASC, this denial was for the facility claim. I reached out to ask about the professional claim and was advised they billed the same CPT codes but Anthem denied 29876 as not medically necessary and paid 10140 on the professional claim. The actual denial reason on the claim was due to no authorization obtained. The excerpt from above was when we were following up with Anthem because no authorization was required which they confirmed but now mentioned a multiple procedure reduction and about being bundled with 29876. Here is the OP note:
....A meticulous search for the loose body was then performed. All the compartments were visualized multiple times. There is no loose body visualized in the medial gutter, lateral gutter, intercondylar notch, posterior medial, posterior later, and suprapatellar pouch regions. A synovectomy of the suprapatellar pouch, medial gutter, lateral gutter was performed. An anterior synovectomy was performed. Loose body was still not visualized. We went through all the major compartments multiple times and a discrete loose body wasn't seen. After an exhaustive search, decision was made to stop searching. The patient had been warned that there is a possibility loose body would not be found. The knee was irrigated with copious amounts of normal saline. Incisions were closed with 4-0 Monocryl.
Attention was then directed towards the lateral thigh seroma. The seroma area had been localized by palpation and ultrasound visualization in the peroperative holding area. This area been marked. A longitudinal incision was made over the central region of this area. Incision was carried down to skin and subcutaneous tissues. The was some thickening of the subcutaneous tissues. There is no frank fluid collection encountered. The subcutaneous tissues was elevated off the iliotibial band using a key elevator in the area previously marked with ultrasound. Wide decompression was obtained. There is associated thickening of the iliotibial band. The tibial band was split for approx. 3cm. This was then elevated off the vastus lateralis to make sure there is no fluid or adhesions underneath contributing to the patient's symptoms. The deep subcutaneous tissues were irrigated copious amounts of normal saline. The iliotibial band was closed with 0 Vicryl. It was then closed with 0 Vicryl 2-0 Vicryl and a 3-0 Monocryl. Steri-strips and xeoform gauze were applied....

 

[amyjph]

Sounds like multiple issues going on here. You also have two separate claim issues the pro-fee was processed one way and the facility was done differently? Is that what I am reading there?

It also depends on what the intent of the procedure was in the first place, it sounds like they went in for a suspected loose body/removal. If the synovectomy was incidental ("clean-up") I can see why it was not covered. Also, depends on the diagnoses attached, among other things. Plus, if they needed auth in the first place and didn't obtain it... 29876 would not necessarily be covered if there was no diagnosis or reason for performing it other than, "they were already in there". There would have to be a reason why the major synovectomy was done other than just to "clean up while in there looking for a loose body". This sounds more like the plan was 29870 or 29874. It may be more appropriate, just looking at the brief info here, to report 29874-52 since it seems like they went in looking for a LB but did not find one. What were the stated diagnoses? What did the provider actually order on the surgery order?

Side note for questions here - it is always helpful to indicate if you are talking about a facility or a pro-fee claim. Most of us would assume it is the pro-fee/surgeon unless otherwise noted.

1. A patient can have multiple procedures on the same date by the same provider.
2. If that was the case and both were payable and not considered components of the same procedure (bundled, separate procedure designation, more extensive procedure, etc.). They would be ranked by RVU and the lower RVU one would be paid at 50% (multiple procedure reduction) if it was not an add-on code.
3. However, since it looks like what you are stating is, they denied in full the 29876, they should have paid 10140 at 100%.
5. Facility and pro fee may have different rules when it comes to these procedures also.
6. Both the pro-fee claim and the facility claim and coding may need to be reviewed for both to make sure they are actually coded correctly in the first place and so both can be on board with the correct coding. You may be trying to work a denial/get paid for something that was coded incorrectly from the start.

This paragraph is confusing, is it taken word for word from the remarks or did you paraphrase? "-Code 10140 do not require a precertification. And I have checked that it was denied as bundled to 29876. - Multiple surgical procedures can be performed on a single member on a single date of service by the same provider. Per CMS, for these surgical procedures which are performed during the same operative session, separate payment may be allowed. These surgical procedures are not representative of components of the major surgical procedure. When two or more eligible, surgical procedures are performed on the same member on the same date of service by the same provider, the procedures are ranked. The procedure ranked at one should be reimbursed at 100%, while subsequent procedures should be reimbursed at 50%. The allowance was reduced for this/these procedure(s) because two or more eligible, surgical procedures were performed and a multiple procedure cutback was deemed appropriate. Therefore, this procedure code was adjusted."

 

[pchamp25]

Sounds like multiple issues going on here. You also have two separate claim issues the pro-fee was processed one way and the facility was done differently? Is that what I am reading there?

It also depends on what the intent of the procedure was in the first place, it sounds like they went in for a suspected loose body/removal. If the synovectomy was incidental ("clean-up") I can see why it was not covered. Also, depends on the diagnoses attached, among other things. Plus, if they needed auth in the first place and didn't obtain it... 29876 would not necessarily be covered if there was no diagnosis or reason for performing it other than, "they were already in there". There would have to be a reason why the major synovectomy was done other than just to "clean up while in there looking for a loose body". This sounds more like the plan was 29870 or 29874. It may be more appropriate, just looking at the brief info here, to report 29874-52 since it seems like they went in looking for a LB but did not find one. What were the stated diagnoses? What did the provider actually order on the surgery order?

Side note for questions here - it is always helpful to indicate if you are talking about a facility or a pro-fee claim. Most of us would assume it is the pro-fee/surgeon unless otherwise noted.

1. A patient can have multiple procedures on the same date by the same provider.
2. If that was the case and both were payable and not considered components of the same procedure (bundled, separate procedure designation, more extensive procedure, etc.). They would be ranked by RVU and the lower RVU one would be paid at 50% (multiple procedure reduction) if it was not an add-on code.
3. However, since it looks like what you are stating is, they denied in full the 29876, they should have paid 10140 at 100%.
5. Facility and pro fee may have different rules when it comes to these procedures also.
6. Both the pro-fee claim and the facility claim and coding may need to be reviewed for both to make sure they are actually coded correctly in the first place and so both can be on board with the correct coding. You may be trying to work a denial/get paid for something that was coded incorrectly from the start.

This paragraph is confusing, is it taken word for word from the remarks or did you paraphrase? "-Code 10140 do not require a precertification. And I have checked that it was denied as bundled to 29876. - Multiple surgical procedures can be performed on a single member on a single date of service by the same provider. Per CMS, for these surgical procedures which are performed during the same operative session, separate payment may be allowed. These surgical procedures are not representative of components of the major surgical procedure. When two or more eligible, surgical procedures are performed on the same member on the same date of service by the same provider, the procedures are ranked. The procedure ranked at one should be reimbursed at 100%, while subsequent procedures should be reimbursed at 50%. The allowance was reduced for this/these procedure(s) because two or more eligible, surgical procedures were performed and a multiple procedure cutback was deemed appropriate. Therefore, this procedure code was adjusted."

I thought that paragraph was very confusing as well, which made me reach out as I'm not sure what the Anthem rep is trying to say. It is taken word for word from the response received via Anthem chat. But are reading my response correctly, pro-fee claim processed with payment for 10140 and denial of 29876 and facility claim processed with payment for 29876 and denial of 10140. Diagnosis codes used on facility claim were M76.31, M25.561, & M70.951
An auth was obtained for 29870 and approved and a retro auth for 29876 has been submitted, still waiting on the decision.
This whole case is confusing honestly which is why I'm not sure how to move forward regarding follow up.
Per H&P, pt had surgery because she injured her knee in the fall of 2021 where she was advised she had a hematoma over her distal vastus lateralis. Over the past 3 years, pt was seen for follow ups due to still having pain in her knee and she also felt a loose body in her knee. Last MRI obtained prior to her surgery showed "decreased size of small fluid collection overlying the vastus lateralis muscle, compatible with resolving hematoma. Partially imaged edema-like signal interposed between the R iliotibial band and greater trochanter may reflect fluid within the greater trochanteric bursa or sequela of iliotibial bands syndrome."

 

[amyjph]

If you have a senior coder or someone experienced in ortho, have them re-look at the op report. There may be a more appropriate way to code it. But again, it sounds like there are multiple issues going on. Especially between a surgery center and the surgeon's coding, starting from the original surgery order, attempt at authorization. If it were me I would start over with the op note, even checking the dictation is correct and makes sense and go from there. I personally don't do facility coding and if this was an ASC, there could be reasons why something was processed a certain way too. But, if the two claims don't match, that could be a reason.
Taking chat dictation and trying to understand CSR reps for claims is not always the best. They don't even know what the heck they are talking about half the time. I would go by the EOB/ERA and start over from the beginning.
Hopefully your surgery center has a good relationship with the provider side/office.

 

[pchamp25]

If you have a senior coder or someone experienced in ortho, have them re-look at the op report. There may be a more appropriate way to code it. But again, it sounds like there are multiple issues going on. Especially between a surgery center and the surgeon's coding, starting from the original surgery order, attempt at authorization. If it were me I would start over with the op note, even checking the dictation is correct and makes sense and go from there. I personally don't do facility coding and if this was an ASC, there could be reasons why something was processed a certain way too. But, if the two claims don't match, that could be a reason.
Taking chat dictation and trying to understand CSR reps for claims is not always the best. They don't even know what the heck they are talking about half the time. I would go by the EOB/ERA and start over from the beginning.
Hopefully your surgery center has a good relationship with the provider side/office.

Thank you for the insight! We do have a good relationship so I will follow up with the coder that does the professional side.