Wiki TOPS procedure

[hnfbernard@gmail.com]

We've had a denial for a TOPS procedure stating "procedure not proven to be effective" despite it having been pre-approved by the carrier for this patient. The carrier is now suggesting we need to submit a different code. Has anyone had experience with this specifically regarding the TOPS procedure? Have you submitted a different code? If so, what code(s) and how did that go? We billed (and had pre auth for) 0202T per CPT guidance for TOPS

 

[NRaizman]

That is the correct code.
It's a Cat III code, as you know, and most carriers will consider it experimental and are not under obligation to pay it. Same with Medicare and MA - I believe it is contractor priced.

But if it was preauthorized, you may have some legal remedy. Or at least you could file a grievance with your state insurance board.

It would not generally be appropriate to submit with a different code.

 

[hnfbernard@gmail.com]

That's helpful in confirming our understanding - thanks for getting back me!