Wiki Changing sx in the OR

[flmoore]

The surgeon I work for does Bariatric surgeries, normally he does not do the sleeve, however he went in the O.R. today to do a Roux-en-Y on a pt, and had to do a sleeve instead after he already started the sx. I don't know why yet but the nurse said it was medically nessessary. Does anyone know how to get the insurance company to give an auth # for the sleeve? All opinions are welcome. Thanks

 

[FTessaBartels]

Depends

This is not my area of expertise, but I do work for surgeons ...

If the surgeon lets us know immediately that s/he did something other than what was planned, we call the insurance company immediately and ask to amend the auth because of medical necessity and intraoperative findings.

Most of the time, however, the physician doesn't let us know ...

If I get a denial for "no auth," I appeal with a letter of explanation and the operative report that shows what happened and the medical necessity of doing an additional procedure as a result of intraoperative findings.

Hope that helps you.

F Tessa Bartels, CPC, CEMC

 

[flmoore]

Thanks for the input.
So far the only insurance that has ever pre-approved the sleeve procedure has been Anthem Michigan, so I think I'm going to have to add a modifier of 53 to the original sx, and take a loss on the sleeve. Our surgeon calls from the O.R. to let us know of changes, and the Nurse manager called the insurance co. I think it's more a matter of the sleeve being an experimental procedure.