Wiki Bundle code and Pre-Cert

[mentsa]

We are having a problem with pre-certs for bundle codes. An example is: Pre-cert request was put in for cpt codes 31267-maxillary sinus, 31255-ethmoidectomy, 31287-sphenoidotomy, 30140-resection inferior turbinate, 61782-guidance. When the physician got into the surgical procedure, he found that there was a necessity for a 31276-frontal sinus exploration w/removal of tissue. The 31255 and 31276 should be billed in the bundle code 31253 according to the information we have. The 31276 was not anticipated before the surgery so therefore a pre-cert was not done. One was not done for the bundle code 31253 either and the claim was denied. Is anyone else having any similar situations? If so, have you found a resolution to this?

 

[nickelclaw]

its best to get precert of all possible scenarios. I knew a ENT office that when sinus surgery was being done they pre-cert all sinuses
better to be overly cert'd and not need it then under

 

[mentsa]

its best to get precert of all possible scenarios. I knew a ENT office that when sinus surgery was being done they pre-cert all sinuses
better to be overly cert'd and not need it then under

We will try that and see if it works for us. Thanks for your help.

 

[csperoni]

I work in gynonc, and it would often be impossible to get pre-certs for ALL the possibles.
In the 17 years working in this specialty, I have rarely seen a denial for billing a related procedure. In those rare instances, I submit the op note and an appeal letter explaining why we didn't expect to do a debulking procedure based on pre-op imaging, but was absolutely medically necessary upon opening the patient. I can only recall 2 times that insurance just outright refused to pay for the more complex/additional procedure that was medically necessary regardless of the appeals. I would not have my staff spend their time pre-certing all the possibles unless that changed.

 

[freespririt0806]

i would appeal hopefully your Dr's documentation will support