I am looking for clarification on the best method to pre authorize Cardiac Cath lab procedures involving coronary, peripheral angiograms with possible interventional procedures. Just would like to hear other peoples experiences. I work in the cath lab and billing has told us many of our procedures are being denied. I am looking for the best method to address this situation.
We have recently been receiving denials from many providers for procedures that were pre authorized for a diagnostic procedure that then required an interventional procedure. Because the interventional procedure was not pre authorized the whole claim is being denied. We are trying to determine what would be the best process to put in place for pre authorizing these procedure in order to provide the care to the patient that is needed. AS this procedure are dynamic it is difficult to determine all the possible procedures codes that may be required at time of service.
Scenario One: Patient has PAD with claudication (DX 173.9) and the physician orders an abdominal aorta gram(CPT 75625) and bilateral lower extremity angiogram (CPT 75716). This procedure is pre authorized for the diagnostic procedure. The physician performs the diagnostic exam and finds atherosclerotic disease in the left iliac artery with a severe 75% stenosis. The physician, based on patient symptoms and findings of the diagnostic procedure treats the stenosis with a stent in the left iliac. (CPT 37221). Diagnosis of atherosclerotic disease to native artery with claudication. The claim is processed and denied because the CPT 37221 was not preauthorized only the CPT codes for the diagnostic procedures CPT 75625 and CPT 75716. In this scenario how is it to be determined what Intervention procedure was going to be needed to be performed. This can only be determined at time of diagnostic procedure. Best practice is to treat the patient at the time of the diagnostic if patient is able to further go treatment and there are no contraindications. By treating vessel during the same session of the diagnostic procedure decreases further complications and cost that may be incurred if the patient was needed to be brought back for another invasive procedure.
Scenario Two: Patient scheduled for a Single chamber pacemaker. A pre authorization of single atrial pacemaker obtain (CPT 33206) The physician implants a single chamber ventricular pacemaker (CPT 33207) instead of the single chamber atrial pacemaker (CPT 33206). This claim is denied due to a non- pre authorized CPT Code. What is the best way to handle this situation. Should the patient procedure be delayed while the patient is on the procedure table so a pre authorization of the ventricular pacemaker can be processed. IS this another scenario when the patient needs to be brought back an incur another invasive procedure until an pre auth can be obtained.
Scenario Three: patient had previous peripheral angiogram and intervention three months prior to a scheduled plan peripheral intervention to the right lower leg. Physician found bilateral atherosclerotic disease in both superior femoral arteries. Three months ago physician performed procedures CPT 75625 75716 37224. Physician stated would bring patient back to perform peripheral intervention of the right femoral artery. Patient was pre authorized for an Abdominal Aorta gram with r/o( CPT 75630.) Because the patient already performed a diagnostic procedure (CPT 75630) was not billed and not on claim. However CPT 37224 was performed and claim was denied because CPT 37224 was not pre authorized.
Scenario Four: Patient had previous peripheral angiogram and intervention three months prior to a scheduled plan peripheral intervention to the right lower leg. Physician found bilateral atherosclerotic disease in both superior femoral arteries. Three months ago physician performed a 75625 75716 37224. Physician stated would bring patient back to perform peripheral intervention of the right femoral artery. Patient was pre authorized for a peripheral intervention procedure of the right femoral artery. Not knowing exactly what interventional procedure was going to be performed it was pre-authorized for angioplasty of the femoral artery (CPT 37224). However it was required to be treated with Atherectomy and stent (CPT 37227). Is this a scenario that the claim would be denied due to a non pre authorized CPT. ( since 37224 was the code pre authorized). This is a concerning scenario as it is not always known what form of treatment will be performed and sometimes exactly what vessels. When pre authorizing a peripheral interventional procedure should all possible procedure codes be preauthorized, diagnostic and interventional. ( For examples 75625, 75630,75716,75710, 37224 37225 37226 37227) this seems excessive. However this seems like what is being suggested to be done.
Scenario Five: patient had previous peripheral angiogram and intervention three months prior to a scheduled plan peripheral intervention to the right lower leg. Physician found bilateral atherosclerotic disease in both superior femoral arteries. Three months ago physician performed procedures CPT 75625 75716 37224. Physician stated would bring patient back to perform peripheral intervention of the right femoral artery. Patient was pre authorized for a peripheral intervention procedure of the right femoral artery. Not sure what interventional procedure would be performed the angioplasty code for femoral artery was used(37224). The physician preformed da angiogram to determine size of balloon and found the femoral artery no longer had a significant stenosis. The physician then preformed a diagnostic angiogram of the right lower extremity (36245, 75710). Based on this angiogram the physician determines that there was a change in status from previous diagnostic procedure and felt it was not necessary to do the intervention. Based on this information the procedure billed was CPT’s 36245 and 75710. Based on current experience we are concerned this will be denied due to non- pre authorized CPT codes, as the initial pre authorization was for CPT 37224.
Scenario Six: Patient schedule for a Dual chamber ICD initial implant meeting on indications for medical necessity per CMS guidelines and NCD. Patient is pre authorized for CPT code 33249. Claim is denied for not pre authorizing the C-codes related to the device and the leads. This is not a usual request pre authorizing c codes for devices.. Does Humana and Humana Medicare Replacement Gold Plus requires C-codes to be pre authorized at time of pre authorization. What if a different lead or device is needed that had a different c code at time of implantation.
We have recently been receiving denials from many providers for procedures that were pre authorized for a diagnostic procedure that then required an interventional procedure. Because the interventional procedure was not pre authorized the whole claim is being denied. We are trying to determine what would be the best process to put in place for pre authorizing these procedure in order to provide the care to the patient that is needed. AS this procedure are dynamic it is difficult to determine all the possible procedures codes that may be required at time of service.
Scenario One: Patient has PAD with claudication (DX 173.9) and the physician orders an abdominal aorta gram(CPT 75625) and bilateral lower extremity angiogram (CPT 75716). This procedure is pre authorized for the diagnostic procedure. The physician performs the diagnostic exam and finds atherosclerotic disease in the left iliac artery with a severe 75% stenosis. The physician, based on patient symptoms and findings of the diagnostic procedure treats the stenosis with a stent in the left iliac. (CPT 37221). Diagnosis of atherosclerotic disease to native artery with claudication. The claim is processed and denied because the CPT 37221 was not preauthorized only the CPT codes for the diagnostic procedures CPT 75625 and CPT 75716. In this scenario how is it to be determined what Intervention procedure was going to be needed to be performed. This can only be determined at time of diagnostic procedure. Best practice is to treat the patient at the time of the diagnostic if patient is able to further go treatment and there are no contraindications. By treating vessel during the same session of the diagnostic procedure decreases further complications and cost that may be incurred if the patient was needed to be brought back for another invasive procedure.
Scenario Two: Patient scheduled for a Single chamber pacemaker. A pre authorization of single atrial pacemaker obtain (CPT 33206) The physician implants a single chamber ventricular pacemaker (CPT 33207) instead of the single chamber atrial pacemaker (CPT 33206). This claim is denied due to a non- pre authorized CPT Code. What is the best way to handle this situation. Should the patient procedure be delayed while the patient is on the procedure table so a pre authorization of the ventricular pacemaker can be processed. IS this another scenario when the patient needs to be brought back an incur another invasive procedure until an pre auth can be obtained.
Scenario Three: patient had previous peripheral angiogram and intervention three months prior to a scheduled plan peripheral intervention to the right lower leg. Physician found bilateral atherosclerotic disease in both superior femoral arteries. Three months ago physician performed procedures CPT 75625 75716 37224. Physician stated would bring patient back to perform peripheral intervention of the right femoral artery. Patient was pre authorized for an Abdominal Aorta gram with r/o( CPT 75630.) Because the patient already performed a diagnostic procedure (CPT 75630) was not billed and not on claim. However CPT 37224 was performed and claim was denied because CPT 37224 was not pre authorized.
Scenario Four: Patient had previous peripheral angiogram and intervention three months prior to a scheduled plan peripheral intervention to the right lower leg. Physician found bilateral atherosclerotic disease in both superior femoral arteries. Three months ago physician performed a 75625 75716 37224. Physician stated would bring patient back to perform peripheral intervention of the right femoral artery. Patient was pre authorized for a peripheral intervention procedure of the right femoral artery. Not knowing exactly what interventional procedure was going to be performed it was pre-authorized for angioplasty of the femoral artery (CPT 37224). However it was required to be treated with Atherectomy and stent (CPT 37227). Is this a scenario that the claim would be denied due to a non pre authorized CPT. ( since 37224 was the code pre authorized). This is a concerning scenario as it is not always known what form of treatment will be performed and sometimes exactly what vessels. When pre authorizing a peripheral interventional procedure should all possible procedure codes be preauthorized, diagnostic and interventional. ( For examples 75625, 75630,75716,75710, 37224 37225 37226 37227) this seems excessive. However this seems like what is being suggested to be done.
Scenario Five: patient had previous peripheral angiogram and intervention three months prior to a scheduled plan peripheral intervention to the right lower leg. Physician found bilateral atherosclerotic disease in both superior femoral arteries. Three months ago physician performed procedures CPT 75625 75716 37224. Physician stated would bring patient back to perform peripheral intervention of the right femoral artery. Patient was pre authorized for a peripheral intervention procedure of the right femoral artery. Not sure what interventional procedure would be performed the angioplasty code for femoral artery was used(37224). The physician preformed da angiogram to determine size of balloon and found the femoral artery no longer had a significant stenosis. The physician then preformed a diagnostic angiogram of the right lower extremity (36245, 75710). Based on this angiogram the physician determines that there was a change in status from previous diagnostic procedure and felt it was not necessary to do the intervention. Based on this information the procedure billed was CPT’s 36245 and 75710. Based on current experience we are concerned this will be denied due to non- pre authorized CPT codes, as the initial pre authorization was for CPT 37224.
Scenario Six: Patient schedule for a Dual chamber ICD initial implant meeting on indications for medical necessity per CMS guidelines and NCD. Patient is pre authorized for CPT code 33249. Claim is denied for not pre authorizing the C-codes related to the device and the leads. This is not a usual request pre authorizing c codes for devices.. Does Humana and Humana Medicare Replacement Gold Plus requires C-codes to be pre authorized at time of pre authorization. What if a different lead or device is needed that had a different c code at time of implantation.