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CPT 43239 and CPT 45380- I need help please!

  1. #1
    Default CPT 43239 and CPT 45380- I need help please!
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    We can bill both of these CPT Codes togther as both procedures need to be done on the same day and have the insurance pay for both procedures fully.

    Right now some insurances are paying only 50% for the second one and some are not paying at all.

    Can you help me find out is there a modifier that needs to be used, is there another type of prior auth that needs to be obtained. What needs to be done to get paid for both CPT codes if done on the same day because it NEEDS to be done on the same.

    These 2 codes are frequently billed together and we need to figure out how to get them paid.

  2. #2
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    It is standard reimbursement policy throughout most insurance plans to pay multiple procedures at 100% for the first and 50% for each additional procedure done on the same day by the same provider. This is accepted practice because the work and cost involved in performing two procedures at the same session is naturally less than if the same two procedures were done at separate sessions. There is no modifier that will override this and allow both procedure to be paid at 100% and not something that you can change by billing differently.

    As for denials, insurance companies deny procedures for a multitude of different reasons and there is no single solution that will fit every situation. You'll need to look at the reasons the codes are being denied, speak with the insurance companies if those reasons are not clear, and become familiar with the different payers' policies. These two particular codes do not normally bundle or overlap, so if they are being denied for bundling, then it is likely an error on the payer's side. However, if they are being denied for medical necessity or authorization or other reasons, then your only recourse is to turn to those payers for guidance so that you understand their policies and requirements for billing, coverage and payment of the procedures that are denied.
    Thomas Field, CPC, CEMC

  3. #3
    Default Thank you
    Medical Billing
    Quote Originally Posted by thomas7331 View Post
    It is standard reimbursement policy throughout most insurance plans to pay multiple procedures at 100% for the first and 50% for each additional procedure done on the same day by the same provider. This is accepted practice because the work and cost involved in performing two procedures at the same session is naturally less than if the same two procedures were done at separate sessions. There is no modifier that will override this and allow both procedure to be paid at 100% and not something that you can change by billing differently.

    As for denials, insurance companies deny procedures for a multitude of different reasons and there is no single solution that will fit every situation. You'll need to look at the reasons the codes are being denied, speak with the insurance companies if those reasons are not clear, and become familiar with the different payers' policies. These two particular codes do not normally bundle or overlap, so if they are being denied for bundling, then it is likely an error on the payer's side. However, if they are being denied for medical necessity or authorization or other reasons, then your only recourse is to turn to those payers for guidance so that you understand their policies and requirements for billing, coverage and payment of the procedures that are denied.
    Thank you for taking the time to answer my question, so we cannot bill these two code differently unless they are conducted on two separate days, correct?
    Last edited by Jm6161; 10-15-2018 at 09:16 AM.

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