Wiki Wrong procedure code was precerted

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ericksonj325

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Can someone please clarify this for me. Our front desk employee precerted a pts sx with code 58570...hysterectomy without BSO. After I got the op note in the billing dept I didn't realize the wrong code was precerted so I coded it correctly with 58571 with BSO. So we got the denial from the ins company. I explained to my admin that the wrong code was precerted even though it is written in the pts H&P that she was having a hysterectomy with BSO. She told me to go ahead and rebill it with the precerted code. Is this ok to do even though the op note states "with BSO" and so does her notes in her chart. I understand this would be down coding and we would have to take the loss from the tubes and ovaries. I would rather do that instead of take a loss for the whole sx.
 
Did anyone call the insurance company and try to get the correct code added? Depending on the insurance company they may change to correct code.
 
Sorry to be the bearer of bad news, but you must code the procedure the way it was performed. Changing a procedure code just to get payment is not allowed. The solution to this is more training for the staff so this doesn't happen again. Misrepresenting what was done is considered fraud, no matter whether it is upcoding or downcoding.
 
midnightsun1369 said:
Did anyone call the insurance company and try to get the correct code added? Depending on the insurance company they may change to correct code.
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Yes, I agree. Try to get the precerted code changed before you submit the bill. Sometimes they will do this for you. I should have thought of that when I posted my comment above.
 
Sometimes our hospital will update the precertification if the surgery is different. I would try to contact them just in case and see if they have another precert more accurate to the surgery.
 
Thanks for the response...I just checked the hospital. They are billing the right code with the wrong auth # as well. I have already billed it and tried to appeal it but the ins co will not budge. I am not billing the wrong code just for payment...it's wrong. Thanks again Walker!!
 
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