Wiki Pre-auth and related codes

[Jessim929]

Hi All -

This question was posed to me today and I'm curious to any school of thought (especially official ones) on it.

When a specific surgery is pre-auth'ed but a lesser of the same surgery is billed, do insurance companies connect the dots on related codes?

For example, one of my docs wants to do a lap hysterectomy on a patient. Because we don't know the size of the uterus beforehand, and the decision on taking tubes and ovaries is usually decided when they get in there, would it be more prudent to authorize the 58554, which is the lap hysterectomy, uterus over 250 gm with removal of tubes and/or ovaries even if once the dictation is coded it ends up being 58550 - lap hysterectomy under 250 gm uterus, no tubes/ovaries removed? Would a claims processor draw the conclusion that the codes are related - one is the "bare bones" of the other? I mean, if you authorize a lap procedure and it ends up being open, it's easy to fight on appeal based on "doctor planned to do ... but when the patient was on the table, they found .... and the decision was made to go open", would the same recourse be had billing a lesser but related code than what was authorized?

If anyone knows any documentation pointing one direction or another, that link would be appreciated as well.

Thank you!!

 

[csperoni]

Let me start by saying I have no documentation. The documentation would POSSIBLY be part of your provider contract with each insurance company, part of your provider handbook with each insurance company, or may not address it at all.

From a ton of personal experience, whether you authorize 58550 and perform/bill a 58554, or authorize 58554 and perform/bill 58550, you will have zero issue 99.99% of the time. And the .01% of the time you do have a problem, you will have it in either scenario. The insurance will simply state that the code you billed does not match the code you authorized. You will then have to appeal and hopefully someone with some common sense will read your appeal.

As a note: the lap hyst codes are all deemed outpatient and most insurances don't even require authorization for it. Offhand, I can only recall United Healthcare Community Plan ever denying as the auth does not match what was billed.

 

[Jessim929]

Awesome! Thank you!!