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clarkin15

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Im getting a denial from Tricare, stating 21196 is only for inpatient, but this was an outpatient surgery. Is there any other code I could use to get it paid?

Our facility did receive an authorization for the code, and we are capable of providing inpatient care; however the patient did not meet criteria and did not need to stay longer than outpatient. Any comments would be appreciated!
 
I would call Tricare and find out why they are denying the procedure since you had an authorization for it. They can change the place of service to outpatient on the authorization. Sometimes if a place of service changes, it can cause the claim to deny if the auth isn't changed to reflect that.
 
Are you sure that this code accurately describes what the physician did? I actually had this procedure done and personally, there is no way I would have been an outpatient. Beyond that, there are some codes that are designated inpatient only, so even if the code was authorized if it was done in the incorrect pos it will not get paid (why do you think they always tell you that authorization is not a guarantee of payment?).
 
OP procedure:
1. Internal vertical ramus osteotomies bilaterally with placement of maxilla mandibular fixation.
2. Implant reconstruction, left maxilla with bone graft and pericardia freeflap graft.

She was only in the hospital 4 hours. Code 21196 is designated for inpatient only, that's why I was wondering if it was coded wrong, and another could be used. Thanks!
 
A copy of the op note would be needed to see if a different code is needed. But if it is designated as inpatient only then you must have an inpatient POS. That is a heck of a procedure for only 4 hours total!
 
21194 comes up with the description of vertical rami osteotomies with bone graft. I have never run across a code that is designated as inpatient only. Both of these codes have RVUs for facility and non-facility. Some codes are deemed to not ever be done in the office setting, but they can be done either in-patient or out-patient at a hospital.

If the intent was for the patient to remain in-patient and that is how you authorized the procedure, you can still bill the procedure with place of service code for in-patient. If she chose to leave before she had reached that status for the facility, that is for the hospital billing, not the procedure billing.
 
Thanks so much for your help guys! I'm used to only doing E&M and OB visits, so this is a whole different area for me.

OP procedure:
1. Internal vertical ramus osteotomies bilaterally with placement of maxilla mandibular fixation.
2. Implant reconstruction, left maxilla with bone graft and pericardial freeflap graft.

Description of operation:
Attention was first directed to the edentulous left maxilla. A full-thickness mucoperiosteal flap was elevated. There was some irritation to the gingival tissues. The area of the endentulous maxilla was approached with a round bur, then a 3.4 taper drill to a depth of 13 mm, then a 5.0 taper drill to a depth of 13 mm, then a 6.0 taper drill to a depth of 13 mm.

A 6.0 x 13 mm implant was placed into the area. There was some overexposure of the threads of the implant. OraGraft was placed over this area, and then a pericardia graft was placed over the area. The pericardium was sutured into place, with horizontal mattress sutures of 301 Vicryl suture.

The area was stabilized, then attention was directed to the left mandible. An arch bar was adapted to the left mandible and secured to each tooth with interdental wires from the left side to the right side into position. An arch bar was then adapted to the maxillary dentition with itnerdental wires in that area as well.

Attention was directed to the left mandible retromolar area. An incision was made in the left retromolar area, halfway up the ramus, of about a 2 cm incision. The ramus was exposed on the left side. The area of the left ramus was approached first with an oscillating saw. Initially this was sued superiorly. When it came down to inferiorly a significant amount of bleeding was approached. This portion was terminated.

The right side was approached in a similar manner. A right angle drill with a #8 round bur was utilized up throught the area to the mandible from between the condylar neckand the coronoid process and the notch. This was taken downard and posteriorly through the inferior angle of the mandible. A curved chisel was utilized in the area, an dthe caudal area was seperated from the distal area.

The left side was approached the same. Drill was used in the posterior aspect of themandible here. Directed in an upward to a downard position, the osteotomy was finished there with the curved chisel. This allowed for the condyles to be disarticulated from the rest of the mandible.

The patient was placed into maxilla mandibular fixation with 4 wire loops.
 
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I'm with Debra, a copy of the op note would be needed to see if a different code can be used. sometimes the procedure the surgeon lists is different fthan the description in the body of the note.

With regards to ajs response, it does not matter what the intent was, TriCare pays based on the hospital charges. If the hospital bills outpatient and the physician bills inpatient the physician charges will be denied because there is no corresponding admission. The physician charges will aslo be denied if there is no inpateint authorization on file for the hospital. As far as RVUs, if you look at the Medicare fee schedule all non-facility charges have N/A listed under them. Tricare does not publish its fee schedule, but it is a government program, so it would be fairly safe to say that if CMS doesn't have a fee for non-facility then neither does TriCare.

3:40 pm You must have been posting the note as I was writing this, thanks.
 
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I would speak with the doctor, have him look at codes 21193 and 21198, the note does not say anything about internal fixation, the arch bars are considered external and so are the wire loops. There technically is no graft to code because the graft codes are for autologous (taken from the patient) and the grafts used were purchased biological grafts. The implant reconstruction sounds like a dental procedure and I could not find a CPT code it, you might want to check the CDT manual. You also might want to check if this is considered cosmetic.

Hope this is a little helpful, at least maybe you're headed in the right direction.
 
Yes, thank you very much. I am going to suggest the 21193 since it specifically states reconstruction of vertical osteotomy, with a placement of mandibular fixation (arch bar and wire loops). Thanks again!
 
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