Wiki Negotiated Rate vs CPT Order of Coding

[Gkowal]

Does anyone have any opinion or factual information on an issue we are having with some payers?
Normally payers pick up a higher RVU CPT as primary when it is billed with another CPT.
When a provider has a negotiated fee with a specific CPT code which happens to be the primary surgical procedure, shouldn't that CPT be paid primary even if a higher RVU code is billed on the same claim?

My situation is, we have a negotiated fee for a Sleeve Gastrectomy (43775). It is sometimes billed with a Hiatal Hernia Repair (43281,59). Even though 43775 is our primary procedure, the payers are paying the 43281 primary and discounting our 43775 which is resulting in an underpayment.

We are trying to figure out if a negotiated fee takes precedent over a higher RVU code on a multiple billing scenario.

Any thoughts would be appreciated. Thank you

 

[vimenchaca]

Hi, Gkowal.

It seems that the possible reason that the 43281 is getting paid as primary is because there actually IS an assigned RVU indicated for it while the 43775 has no such value assigned. Many payers are guided by the RVU number in deciding which code is primary. This is usually an automated process and they may not realize how it's actually paying out. Arrange for your provider and the medical director of the payer to meet to discuss this, it may result in a change in their approach.

Unfortunately, you are already living the underpayments and without a previously agreed upon arrangement you may have little recourse if they don't go along with the suggestion in the previous paragraph.

Aside from that, you now have payment experience that can be applied to future negotiations. Prepare your presentation package for the next round of negotiations (usually done annually).

Good luck!