DIEP Flap 19364 vs S2068

generic808

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So my phys has negotiated with some insurance companies using S2068 for a higher payout vs 19364. My question is on a recent DIEP procedure, a certain ins company paid out $3700 for the entire procedure plus the assistant surgeon ($3300 and $400). I find this absolutely shocking! It is a 12 hour procedure with 4 days of post-operative follow up in hospital. For those familiar with a DIEP, what is the average payout that y'all are seeing? I'm appealing this at the moment and wanted to know if there is anything in particular that you guys are doing to get an appeal turned.
 

CodingKing

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In Massachusetts the Medicare rate is $2,832.32. My negotiated rates may be different from your negotiated rate so I'm not sure how sharing of rates would make a difference. If your contract says a rate and that's what it paid, there's nothing to appeal. Looking at the RVU the total time is an average of about 13 hours so it would probably be hard to argue that its modifier 20 eligible. Now if the reimbursement was not according to your negotiated rate then you would have a good case.
 
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