Wiki Medicare denial of 61697-AS

[tmarugg]

I received a denial from Medicare for procedure code 61697-AS. The assistant surgeon is our nurse practitioner. The denial states that this procedure is not within her 'scope of practice'. When I called Medicare, I was told they do not cover this procedure when billed by an NP. But we have been paid in the past with no issue.

I'm unsure of how to appeal this decision. She has been an NP for many years, and has been in our practice for the last 4. She has met all of her state issued regulations,etc.

Is this appealable?

Thanks in advance!

Tammy

 

[thomas7331]

This sounds like a processing error to me, especially if you have been paid for this in the past. It's possible that they may have missed the AS modifier on the claim. I would recommend calling your Medicare contractor again and ask that this be escalated (my MAC calls it escalating to a Tier 2 representative), and provide them with an example claim with the same code that was paid. They should be able to give you more concrete information about why this was denied which would help to be able to determine how and whether you can appeal. Medicare contractors cannot arbitrarily deny claims - there have to be regulations in writing that they are following and they need to be able to show you what those are.