Wiki Billing 27043 in an office setting

[Slraheb]

Hi I'm hoping someone can assist me with this. The provider I work with billed a 27043 with 13101 and 13102 and it was denied by Tufts US Family. It is billed with a place of service code 11. Their denial reason is; (lines for 13101 and 13102). 7R Denied. This procedure is mutually exclusive of another procedure billed for the same date of service or payment for this service is included in the primary procedure. The member is not responsible for payment. (line for 27043) Q1 THIS CHARGE HAS BEEN DENIED. THE PLACE OF SERVICE INDICATED IS NOT APPROPRIATE FOR THIS PROCEDURE.THE MEMBER IS NOT RESPONSIBLE FOR PAYMENT. They are also stating when I called this policy is per CMS guidelines, yet when I called Medicare the representative looked also and there isn't anywhere on the CMS website saying that about this code, that it can't be billed in an office setting as an outpatient.
How would someone appeal this? I sent a claim review form explaining this over a month ago and when I called a couple of weeks ago I was told it was still in review, I did not receive an EOP saying it was denied yet when I called again they said it's denied and the representative told me I only have 90 days from the date of service to appeal. When I look online in the provider manual from US Family it states I have 90 days from the denial. So the other question is what am I suppose to be going by what is said in the provider manual or what the representative said?

 

[sls314]

Hi I'm hoping someone can assist me with this. The provider I work with billed a 27043 with 13101 and 13102 and it was denied by Tufts US Family. It is billed with a place of service code 11. Their denial reason is; (lines for 13101 and 13102). 7R Denied. This procedure is mutually exclusive of another procedure billed for the same date of service or payment for this service is included in the primary procedure. The member is not responsible for payment. (line for 27043) Q1 THIS CHARGE HAS BEEN DENIED. THE PLACE OF SERVICE INDICATED IS NOT APPROPRIATE FOR THIS PROCEDURE.THE MEMBER IS NOT RESPONSIBLE FOR PAYMENT. They are also stating when I called this policy is per CMS guidelines, yet when I called Medicare the representative looked also and there isn't anywhere on the CMS website saying that about this code, that it can't be billed in an office setting as an outpatient.
How would someone appeal this? I sent a claim review form explaining this over a month ago and when I called a couple of weeks ago I was told it was still in review, I did not receive an EOP saying it was denied yet when I called again they said it's denied and the representative told me I only have 90 days from the date of service to appeal. When I look online in the provider manual from US Family it states I have 90 days from the denial. So the other question is what am I suppose to be going by what is said in the provider manual or what the representative said?

CPT 27043 has a payment indicator "G2: Non office-based surgical procedure added in CY 2008 or later"

That is likely what the health plan references when they say it is denied according to CMS guidelines.

I tried researching for any circumstances where a CPT with a G2 could be billed for POS 11, but I didn't find anything conclusive at a quick glance. I'd suggest you research that further, and see if you can find anything that might assist you in an appeal.

Also, there are NCCI edits between 27043 and 13101/13102.

 

[ahotlokn1]

Hi I'm hoping someone can assist me with this. The provider I work with billed a 27043 with 13101 and 13102 and it was denied by Tufts US Family. It is billed with a place of service code 11. Their denial reason is; (lines for 13101 and 13102). 7R Denied. This procedure is mutually exclusive of another procedure billed for the same date of service or payment for this service is included in the primary procedure. The member is not responsible for payment. (line for 27043) Q1 THIS CHARGE HAS BEEN DENIED. THE PLACE OF SERVICE INDICATED IS NOT APPROPRIATE FOR THIS PROCEDURE.THE MEMBER IS NOT RESPONSIBLE FOR PAYMENT. They are also stating when I called this policy is per CMS guidelines, yet when I called Medicare the representative looked also and there isn't anywhere on the CMS website saying that about this code, that it can't be billed in an office setting as an outpatient.
How would someone appeal this? I sent a claim review form explaining this over a month ago and when I called a couple of weeks ago I was told it was still in review, I did not receive an EOP saying it was denied yet when I called again they said it's denied and the representative told me I only have 90 days from the date of service to appeal. When I look online in the provider manual from US Family it states I have 90 days from the denial. So the other question is what am I suppose to be going by what is said in the provider manual or what the representative said?

To appeal this regardless of whom the insurance is that denied it , you must break it down to whomever is going to read it by saying something like the 27043 is for the incision etc , then include the guidelines on say blue cross or Aetna, Cigna web of the inclusives say that this procedure is not included with the cpt 13101/13102. Then also pull the guidelines under those cpt. Then if you also have the book I think it was called the exclusive? (I used to appeal for orthopedics years ago) which it said what was included and then there was a small article why is or isn’t (books were the best) also that book explain the minor procedure of 10? Days vs 90 global period . Which then in my appeal I summed up say this cpt not included because had to make a new incision the repair the prior ? . And including supporting information reports and guidelines book. And maybe ask md to write a small paragraph stating why medically necessary such as .. patient had previous minor therefore repair also warranted due to. Hope this idea helps anyone needs to appeal. You can use other insurance guidelines in your favor since they approve it.

 

[thomas7331]

Hi I'm hoping someone can assist me with this. The provider I work with billed a 27043 with 13101 and 13102 and it was denied by Tufts US Family. It is billed with a place of service code 11. Their denial reason is; (lines for 13101 and 13102). 7R Denied. This procedure is mutually exclusive of another procedure billed for the same date of service or payment for this service is included in the primary procedure. The member is not responsible for payment. (line for 27043) Q1 THIS CHARGE HAS BEEN DENIED. THE PLACE OF SERVICE INDICATED IS NOT APPROPRIATE FOR THIS PROCEDURE.THE MEMBER IS NOT RESPONSIBLE FOR PAYMENT. They are also stating when I called this policy is per CMS guidelines, yet when I called Medicare the representative looked also and there isn't anywhere on the CMS website saying that about this code, that it can't be billed in an office setting as an outpatient.
How would someone appeal this? I sent a claim review form explaining this over a month ago and when I called a couple of weeks ago I was told it was still in review, I did not receive an EOP saying it was denied yet when I called again they said it's denied and the representative told me I only have 90 days from the date of service to appeal. When I look online in the provider manual from US Family it states I have 90 days from the denial. So the other question is what am I suppose to be going by what is said in the provider manual or what the representative said?

The status code G2 is for ASCs, that doesn't apply to physician claims, so I don't think that's the issue. But if you look at the Medicare fee schedule, the office and facility reimbursement for this code is the same for both locations, which indicates to me that CMS considers this a facility procedure since they're not paying any additional differential for the office setting. I don't know TRICARE's policy regarding this, but the rep you spoke with should have been able to direct you to something in writing if they are quoting that as the reason for the denial.

But before you can consider appealing, you really need to look and see if this claim was coded correctly in the first place - if it wasn't, then an appeal isn't going to do any good because you may need to submit a corrected claim instead. As mentioned in the posts above, the closures are considered inclusive to this procedure (unless they are completely unrelated to the excision of the lesion, in which case a modifier would be required). Those codes most likely should not have been billed. As for CPT 27043, that is in fact a procedure that is usually done in a facility because it for excision of deep soft tissue tumors not involving the skin. If in fact that is what the provider did, and if they are not able to provide you with a written policy stating that this makes the procedure non-payable, then you might be successful in appeal.

As for time limit on the appeal, if you have it in writing that it is from date of denial, and your information is current, then the rep probably gave you incorrect information. That is a common thing because many insurance phone reps have limited training and minimal experience with coding. Any time you doubt what they say or question the information you're getting, you should challenge them for a better explanation or a policy in writing and if they aren't able to give you that, ask to speak with a supervisor instead. In my experience, I've found that physician office billers and coders more often than not have a better understanding of coding and claims than do the phone reps at insurance companies.

 

[Slraheb]

Thank you so much for your help! I confirmed that the claim is coded correctly and so I will included notes and other important information and will send an appeal. I also spoke to a supervisor who did confirm what I said about the timely filing.