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  1. #1
    Chicopee, MA
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    I am currently studying for my CPC exam, which I am taking next month. Meanwhile, I currently work for a small billing company and one of the accounts I work on is a Plastic Surgeon. I took over his billing almost a year ago. The Dr I bill for does several reconstruction surgeries for breast cancer patients. When I first began billing his surgeries he always gave me Brst CA, 174.9 as the primary diagnosis. During my studies I have learned that Brst CA should not be our primary diagnosis as this is not what the Dr is treating. He should be using other diags, ie V45.71, 611.89 and so this is what I advised the Dr.

    So, we have started billing with other diagnoses primary. I have recently come into a situation where a hand full of patients who have had complications with their reconstruction needed additional surgeries. I coded all cases for the complication first, ie 996.54, 996.7, 996.69 with 174.9 or V10.3 (pr hx of brst ca) as my 3rd or 4th diag.

    The payers are saying they are not medically necessary or are considered cosmetic and have denied all of them. The payers are telling me that because I am not listing the Brst Ca diags as my primary there is no way for them to know that it is related to the breast reconstruction and not cosmetic. One payer went as far as telling me it was because I did not use 174.9 as my primary diagnosis, and I told them that was ridiculous because the patient was treated for her cancer over a year ago so why would I list that as her primary diagnosis. I have had to do written appeals for all cases in order to get them paid, and most are still pending.

    Have I given the Dr bad advice? Am I doing something wrong?!?!

  2. Default
    I have coded plastic/reconstructive surgery for over 5 years. The primary diagnosis I use was always the breast cancer for the primary diagnosis for initial, staged, and/or complications in breast reconstruction. Have all other diagnosis follow the primary. This leaves no question on the claim that it is medical. This will save you the headache from denials and appeals. There is a book that only plastic surgeons can get called the CPT Corner this book helps with diagnosis and coding of reconstructions, flaps, etc. It is a very useful tool and help with alot of questions in the reconstructive field.

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