Wiki A little in sight please

[colleensso]

I have a question? If I am billing out a surgery in NY state does the CPT codes get paid according to RVU factor or what that insurance company finds to be there primary code? I thought in NY it is the RVU? I would love some help on this. Because I am billing surgeries according to RVU and major commercial insurance companies are changing my codes around. What should I do?

Colleen

 

[sbicknell]

Generally your RVU is an indicator of the more invasive or complex procedure and should be listed first on your claim as the primary procedure. The payer certainly should not be changing the codes you submitted. They can either pay or deny but they can not re-code.

As far as them changing the order and paying a different code as primary, do you have 1 or 2 examples. We could look at the specific codes, coding guidelines and general payment rules and suggest some answers

 

[colleensso]

Here are the codes they are changing

Thank you for responding
Here are the codes I submitted to Aetna for a surgery according to weight value

31255
31267
31288
61795
this is how they changed my codes
61795
31288
31267
31255
they reversed them and put them towards a pt deductible

Also GHI is not changing my codes but not paying 100% on the primary code then 50% on others for example
30520 highest rvu primary code they are paying only 261.50
31276 50 my second code they are paying as primary code which has a lower rvu
30140 50
31255 50
31267
they are paying all these codes out of order of their submitted sequence. Should that be or should I fight this?

Again your help is so appreciated
Colleen
61795