Rebundling

jira85

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Can anyone tell me if an insurance company is able to change to codes
(22845 and 22855) into one code (22849) that we didn't have on our HCFA?

I don't think that they can, but the insurance representative is fighting me on this one.

Please help!
 

dmaec

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need to see the op report/procedure & to know what was coded - to try to figure out why it's being bundled, especially since 22845 is an add-on code, and 22849(reinsertion) & 22855 (removal) are so different.

more info needed...
 

jira85

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Well, we billed codes:

63075
63076
22554
22585
22851
22845
22855


The insurance company then changed 22855 & 22845 into 22849 on our claim form. I am having trouble finding literature stating that this practice is illegal.
 
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I suspect the carrier is accepting the coding as submitted, but is basing the reimbursement on a different code. I am the compliance analyst for a carrier and do not recommend this practice however, it is a standard edit option within editing systems. Although I believe this is technically HIPAA compliant, I personally don't like this practice because I think it is confusing, but it seems to be common practice. I'm interested in hearing from others about this type of situation.
 

RebeccaWoodward*

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Question:

Our surgeon submitted the following CPT codes to the commercial insurance company:

22554

22845
63075

22855
The insurance company denied CPT codes 22845 and 22855. They re-coded this to 22849 and paid. Why would they re-code these to this CPT?

Answer:

While we never like to see a payor change CPT codes, based on how this was submitted, the payor may be right. There are no modifiers on the CPT codes, thus the payor assumed removal and reinsertion at the same level. If this is correct, then 22849 is the correct CPT code. If instrumentation was removed at one level and new instrumentation was placed at a new level, the submitted codes are correct, but modifier 59 would be appended to CPT code 22845 to indicate new instrumentation at a new level.

Also, review the fee scheduled for these procedures. CPT code 63075 has higher

http://www.karenzupko.com/resources/codingcoach/cc_orthoarchive_2007.html
 

jira85

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Okay, so just to make sure that I'm understanding what everyone is saying, the insurance company is actually allowed to change the codes that we billed to something else, and it is legal? I've never seem a carrier do this, and I've been billing for quite sometime. Does anyone know where I can find literature on whether or not this is a legal practice??


Thanks.
 

RebeccaWoodward*

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I have had similar situations occur in our practice. For example...physician coded the patient as a new patient and the carrier changed the CPT code to an established level they felt was equivalent. UHC is one of those carriers that try this method. Is it right, per se...no...but I have seen carriers get by with it. I have seen this practice with some of our surgical procedures. Some were justified and some were not...those were appealed. In your scenerio this can be costly especially if the removal and insertion were performed at two different levels. I applaud you for catching and addressing the issue. Many carriers are crossing their fingers with the hopes it will "slip by" the eyes of the coder.
 
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Working as a bill review for work comp here is our take. Never never change a code that is billed. We may recommend payment based on appropriate coding using override methods but never change what has been issued on the bill. Or, if nothing else can be done call the provider or pend for corrected billing. I too am not sure what the actual rule is regarding changing a code. But, I certainly dont approve of it. Just my 2 cents!
 

bhaskins1

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Speaking as a former Senior Customer Service Professional for one of the large commercial carriers... I can't speak to the legality of it except to say that I don't believe there is a law against it... but I can tell you that if there are two services that should be bundled together into a third code the carrier I worked for would change it. Their take on the situation was that they could either rebundle and pay the claim (1 and done) or they could pay the portion of the claim that was coded correctly, deny payment on the other codes and leave it for the Dr.s office to figure out how to code it correctly. Then when the Dr.s office would call us in customer service, we were not allowed to advise the caller how it should have been coded. Now I'm coding for a pediatrics practice and generally our coding situations are not so complicated here but if I were in your position I would verify if the rebundling is correct, if not I would appeal.

Just my opinion... hope it helps.
 

kevbshields

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To my knowledge it is usually "allowable" practice to rebundle based upon contract language. Because they are the payer, they have not only a right to review documentation, make assessments on the accuracy of a submitted claim, but also to render payment in accordance with those findings.

One can only hope that the reviewers are at least as knowledgeable as the coder who coded the claim. Hence, the importance of having the CPC-P!
 

bhaskins1

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To my knowledge it is usually "allowable" practice to rebundle based upon contract language. Because they are the payer, they have not only a right to review documentation, make assessments on the accuracy of a submitted claim, but also to render payment in accordance with those findings.

One can only hope that the reviewers are at least as knowledgeable as the coder who coded the claim. Hence, the importance of having the CPC-P!
I agree with you completely... unfortunately commercial carriers don't usually require their first line of processors to be credentialed.... that's why it is always key for us to question their decisions when they use this practice. I have seen where a corrected claim with a modifier changed the coding edits they get when processing... so I would always review when the insurance company takes it upon themselves to "re-code" your claim for you. Usually they do this without requesting medical records and the coder may have access to information they didn't have when making the decision to change the codes.

And WOW... look at all of your credentials...You are one busy guy... I don't know when you have time to code... just a question... does test taking get easier as you go along... I'm truly impressed.
 
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I gotta jump back in here. I can't speak for all carriers, but most carriers retain the submitted codes, but listing the code in which they base their reimbursement on the EOB. It is a "standard" reimbursement function on many commercial editting products. I may be splitting hairs on what they are actually doing, but as a payer/provider consultant, I wanted to share my perspective. :)
 

RebeccaWoodward*

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Claudia,

Do you work for a payer? I'm intrigued by your statement "but as a payer/provider consultant". Providing both services, in my opinion, can be a conflict of interest. How do you provide a non-bias opinion? I've been in this business for many years and I have, yet, not found a middle ground between the provider and the "payer". I do not mean for this comment to sound disrespectful...only inquisitive.
 
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Rebecca, I appreciate your question. I'm not sure how to respond because I love what I do and when I start talking about it, I can get a little long winded. If anyone is interested in specific details, just send me a private message. I don't want to bore others if they aren't interested.

Fortuately for me and my clients, we work hand in hand to understand the similarities and differences in provider and payers. We all are pretty familiar with the differences, but you'd be suprised how similar they are.

My main focus is correct coding and reimbursement regardless if it's a payer or provider. I present sessions on payer/provider relationships. Most of it is understanding the other's perspective and talking the same language when it comes to coding issues. Very few payers have coders on staff so they are happy to have someone explain coding compliance. You'd probably be surprised at what happens when payers and provider speak the same language and stop butting heads. I know it sounds like I'm wearing rose colored glasses, but I see this regularly. Don't get me wrong, there is still a lot of politics in both areas. But I enjoy making it just a little easier.

OK, enough from me. I hope this sheds some light on one of things I do as a payer/provider consultants do. :D
 
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