Wiki Denial Help!-Amerigroup Medicaid

[TMB1965]

Amerigroup Medicaid denied procedure code 59160 stating it was part of the primary code 59410, but I didn't get a CCI edit, so not sure how to fix this. Patient had a SVD at 16 6/7 weeks for fetal demise. She had immediate post partum hemorrhage and retained placenta, so the provider did a curettage and suction with ultrasound guidance immediately after delivery of the fetus. These were the codes billed out 59410, 59160, 76998, so were these correct, and if so do I just need a modifier on 59160 even though I didn't see any edit for these 3 codes being billed together? Any suggestions would be greatly appreciated. Thank you.

 

[hopepg]

This reply probably won't be any help with coding but just an alternative suggestion. Maybe one of the other coders will reply with alternate code suggestions.

If there isn't a CCI edit with the codes billed AND the codes are documented in the records - I would go through the reconsideration or appeals process with Amerigroup.

In your reconsideration/appeal request I would specify that according to CMS CCI edits, there is not a bundle relationship with the reported codes. I would also explain where in the operative notes each of the procedures are described in detail.

I often will include that in my reconsideration/appeal requests. For example, I will say the procedure described as CPT xxxxx is documented by Dr. xxxx xxxxx in the attached operative note on page xx in the xx paragraph.

Good luck.