Wiki Hernia Denial

[tng141@aol.com]

Hello Everyone! I am needing some advice on a denial I received for CPT code 49596. This procedure was done in an outpatient setting (22) and Anthem Medicare is stating they are denying this claim because this CPT code is only
allowed in an inpatient setting (21). Has anyone ever received this denial before? If so will Anthem Medicare pay once disputed? I cant seem to find any articles explaining if this is an inpatient code only. Thank You all in advance.

 

[JDACPC]

49596 is an inpatient only code, a few of the hernia codes are but not all. We use EncoderPro and there is a designation for inpatient-only procedures, check your encoder. Here is the CY2025list (they usually make a couple changes every year, published in the Final Rule): https://www.summacare.com/-/media/project/summacare/website/medicare/inpatient-only-list-2025.pdf

We have not had much luck getting these paid on appeal so we developed a whole workflow for the provider, OR nurses, UM, and the Auth team to be notified if there are any deviations to what was scheduled once the surgery is completed. It is imperative the inpatient order is put in prior to discharge. We did an information blitz, created an easy look-up tool in Excel with the current list so schedulers could quickly check and get the IP order rolling. The Surgeons freak out sometimes about unnecessary admissions but one key to educate on is that the 2-midnight rule does NOT apply for IPO surgeries. We expect the patient to stay at least 8 hours for monitoring but if the surgeon feels the patient is well enough to go home - they can discharge. The IP status is they key, not the 2-midnight stay.

There are some insurance carriers that do not follow the IPO rules so we created a list so we don't have to go through the whole process unnecessarily.