ChristinaMoore1968
Guest
I work for a physician who does his own coding. I audit each claim before submission and make corrections to his CPT and ICD-9 codes if necessary before submission. Most of the time he does a wonderful job but in the past there were issues because the woman who did my job was not as informed as she should have been about coding and reimbursement. She had no idea about even basic things such as NCCI edits and proper use of modifiers. I spent the first year here correcting claims that were submitted with incorrect coding. Now with this background in mind, I need some help.
I just received a letter today from a Medicare HMO asking to be repaid for overpayment due to incorrect coding on a claim from January 2011. When I pulled the chart, the medical documentation supports the CPT codes that were billed, however there were mistakes made. The same primary diagnosis code was used on the entire claim for all the CPT codes billed. The Op Note and discharge summary document the proper diagnosis for the procedures my physician performed.
This is how it was coded:
Line 1 63047 DX 724.03
Line 2 63047 22 DX 724.03
Line 3 63709 DX 724.03
Line 4 63048 DX 724.03
Line 5 69990 DX 724.03
When the surgeon (my physician) opened this patient, he discovered an anomalous adhesion that needed to be removed in addition to the spinal stenosis. He reported the repair even though it was an NCCI edit. The 22 modifier was used because the fairly large dural adhesion (approximately 1 cm)between ossified ligamentum flavum and the dural sac caused the laminectomy be extended in order to reach the adhesion and remove it in effect making it a more difficult procedure than it would have been under normal circumstances. Also, I would have added a 59 modifier to the 63709 code and linked it to the diagnosis code 349.2 for the pseudomeningocele caused by necessity to remove the adhesion.
My question is this; Should I/can I proceed with the appeal of this Overpayment Notification using the documentation or do I have to let the practice eat the repayment because the claim was improperly coded? Any help with this would be greatly appreciated!!
I just received a letter today from a Medicare HMO asking to be repaid for overpayment due to incorrect coding on a claim from January 2011. When I pulled the chart, the medical documentation supports the CPT codes that were billed, however there were mistakes made. The same primary diagnosis code was used on the entire claim for all the CPT codes billed. The Op Note and discharge summary document the proper diagnosis for the procedures my physician performed.
This is how it was coded:
Line 1 63047 DX 724.03
Line 2 63047 22 DX 724.03
Line 3 63709 DX 724.03
Line 4 63048 DX 724.03
Line 5 69990 DX 724.03
When the surgeon (my physician) opened this patient, he discovered an anomalous adhesion that needed to be removed in addition to the spinal stenosis. He reported the repair even though it was an NCCI edit. The 22 modifier was used because the fairly large dural adhesion (approximately 1 cm)between ossified ligamentum flavum and the dural sac caused the laminectomy be extended in order to reach the adhesion and remove it in effect making it a more difficult procedure than it would have been under normal circumstances. Also, I would have added a 59 modifier to the 63709 code and linked it to the diagnosis code 349.2 for the pseudomeningocele caused by necessity to remove the adhesion.
My question is this; Should I/can I proceed with the appeal of this Overpayment Notification using the documentation or do I have to let the practice eat the repayment because the claim was improperly coded? Any help with this would be greatly appreciated!!
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