Assistant Surgeon claim not paid due to CCI edit with CPT codes

574coding

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Hello, Our provider performed an arthroscopy of the knee and we billed 29873 and 29875-59. The claim was process and paid. Our provider had an assistant surgeon and the charges were billed and both denied. How can you get a code paid that does support an assistant surgeon (29875) , if you have a CCI edit with the primary CPT code (29873)? CPT code 29873 is not payable to assistant but 29875 is payable. Thank you for your help with this!
 

Orthocoderpgu

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Short answer is you don't unless there is something very unusual that would require an assistant. Per the NCCI Surgical Policy Manual 29875 cannot be billed with any other knee procedure on the same knee. This is a "Separate Procedure" and should not be reported when performed in the same area as another procedure. 29873 does not allow an assist and should not be billed.
 

574coding

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Do you only bill out the codes for the assistant that are allowed?
Do you omit the other codes that do not support an assistant on the claim?
 

fwnewbie

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My question is why would a surgeon need an assistant for an arthroscopy? There's only so much room in there and when I see "assistant", to me it means you need an extra set of hands for medical reasons and I can't see a knee case needing an assistant. It just doesn't make sense.
 

Orthocoderpgu

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Do you only bill out the codes for the assistant that are allowed?
Do you omit the other codes that do not support an assistant on the claim?
The answer is yes, you can't be billing cpt codes to insurance knowing that they are not supported. 29873 & 29875 don't allow an assist. If a code does not allow an assist, don't bill it. Additionally your billing company billed 29873 & 29875. These codes can't be billed on the same day unless they were performed on opposite knees. The question then becomes, if your with the billing company, who is doing the actual coding?
You need to understand the surgeon's mind set. After surgery they write down the CPT codes of the procedures that were performed. Those codes can't just be submitted to a billing company to have them billed. They need to be "coded". The coder needs to look at the documentation and make sure that the documentation supports every code being billed. Not every procedure performed in the OR is billable. That's where coding comes in. If the op notes are not being coded, there are legal issues which have fines attached to them.
 
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