Wiki Is there a global period after making an interim obturator prosthesis 21079

[Barna226]

Insurance is denying the definitive obturator prosthesis 21080 stating that it is part of the surgical procedure as a whole. Anyone have any ideas regarding the appeal. The insurance paid for both the surgical obturator and the interim. Wondering if there is a global period.

 

[sls314]

Insurance is denying the definitive obturator prosthesis 21080 stating that it is part of the surgical procedure as a whole. Anyone have any ideas regarding the appeal. The insurance paid for both the surgical obturator and the interim. Wondering if there is a global period.

According to the Medicare physician fee schedule, both CPT codes have a 90-day global.

This type of procedure is not my area of expertise, so keep that in mind for what I type below...

From the description of the CPT codes, it sounds to me like these might be considered staged procedures. Here's an MLN article about global surgery - take a look at page 14, "Staged or Related Procedure or Service by Same Physician During Post-Operative Period" and see if it sounds accurate to you:

https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf

 

[CBLENNIE]

There is a coding tip in EncoderPro for Payers that actually references multiple surgical revisions during the healing phase which should not be billed separately. This appears to indicate you may have issues with receiving payment for revision surgeries after the standard 90-day global period.

So, you may run into some payers who will question additional surgical revisions beyond the 90-day global period. I am just pointing this out in case you have payers who refuse to pay for additional procedures after the 90-day global period which are performed during the typical 6-month healing phase.

Based on additional research per the National Library of Medicine (NLM) there are 3 phases to treatment with an obturator prothesis as you know and I'm wondering if the issue you are experiencing with getting payment for the definitive obturator has to do with the timeline for the 3 phases. How long after the interim obturator is placed is the definitive obturator being performed? From NLM's article it looks like the definitive phase should occur 3-4, months after the interim obturator is placed. So, if you are doing the definitive within the 90-day surgical period for the interim obturator 21079 then they are likely bundling the definitive obturator 21080 into the 21079.



Here is the NLM article Definitive maxillary obturator prosthesis: Timelines for fabrication and follow-up.