Wiki coding

[fcctn-2008@yahoo.com]

A patient is having an EGD 43235 and the procedure was precerted by the INS , when the provider went to do the procedure it changed to 43239, how do I bill this , should I use any modifier or leave the 43235 and use a modifier , and which modifier, we tried to call the Ins to use the same Prior Auth and they refused , please advice

thank you

 

[thomas7331]

A patient is having an EGD 43235 and the procedure was precerted by the INS , when the provider went to do the procedure it changed to 43239, how do I bill this , should I use any modifier or leave the 43235 and use a modifier , and which modifier, we tried to call the Ins to use the same Prior Auth and they refused , please advice

thank you

My answer wouldn't change from the previous answer I gave to your question - you have to bill the procedure that was actually performed, and there is no modifier available to let you do otherwise. You cannot bill an incorrect code just to get payment - that could be considered fraudulent.

If they have refused to update the auth, then I would escalate it with a supervisor or with your network provider representative. It is a very common situation for providers to need to perform additional procedures or to do procedures that were different in some way from what they had originally planned in advance. Providers often need to make these changes while they are in the operating room, and it's not possible to contact the insurance company to get authorization first before doing what's necessary for the patient. Payers should have some sort of process in place to allow for these situations. A phone rep may not recognize this as they are often not well trained, but a network surely will understand this and be able to give you guidance on how this situation is to be handled. You will need to know this because it's likely it will occur again.

Hopefully some other users might share how they've handled this situation and give you some pointers, but I don't think that any are going to say you can bill a code that isn't correct or that you there's any modifier you can use for this.