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coding help - United Healthcare

  1. #1
    Default coding help - United Healthcare
    Medical Coding Books
    I have a pt who has United Healthcare and had an inpt consult (99253) for a hand abscess on 11-4-07. This is the first time the patient was ever seen by Dr. at Cornerstone Surgical. Dr was able to express some pus from his hand at this visit, however he decided that further drainage of the abscess was needed. He did that on 11-5-07 (proc 10061). The consult was denied as included in global/pre-op. I can't use a 25 modifier because the surgery wasn't on the same day as the consult (the pt had eaten breakfast so he had to wait til next day). I can't use a 57 modifier because this is a 10 day global and 57 modifiers can only be used on 90 day global surgeries. So, is there anything I can do to get the consult paid? The doctor tried expressing pus from his hand at the consult but it still needing addl draining, thus the decision for surgery.



    Since I can't attach a modifier, can I appeal w/ the consult notes which indicate the dr expressing pus from his hand at the consult, and the notes also indicate that the pt's hand needs further draining and surgery would be done next day because he at breakfast; or does this consult have to be written off as global since the diagnosis for the consult and surgery are both the same.

  2. #2
    Location
    St. Louis, Missouri
    Posts
    262
    Default
    I would appeal this because you billed it correctly. It does not need a modifier and both should be paid. Just send in your notes.

    Melissa Blow, CPC

  3. #3
    Location
    North Carolina
    Posts
    3,126
    Default
    Just my opinion~

    I would review UHC guidelines on their website. There is an area for reimbursement policies and then it directs you to "global days Policy". They tend to have gray area for these type of issues.


  4. #4
    Default
    All I can say is good luck with United Healthcare, for a lack of better terms...

    They suck!!!!!!!!!!!

    I think they make up policies by each phone call or appeal they get, I have never been able to get the same answer from any of the reps who answer the phone.

    Anything that has to do with that company is always a "tragedy"....

    Roxanne Thames, CPC





    Quote Originally Posted by lcomfort View Post
    I have a pt who has United Healthcare and had an inpt consult (99253) for a hand abscess on 11-4-07. This is the first time the patient was ever seen by Dr. at Cornerstone Surgical. Dr was able to express some pus from his hand at this visit, however he decided that further drainage of the abscess was needed. He did that on 11-5-07 (proc 10061). The consult was denied as included in global/pre-op. I can't use a 25 modifier because the surgery wasn't on the same day as the consult (the pt had eaten breakfast so he had to wait til next day). I can't use a 57 modifier because this is a 10 day global and 57 modifiers can only be used on 90 day global surgeries. So, is there anything I can do to get the consult paid? The doctor tried expressing pus from his hand at the consult but it still needing addl draining, thus the decision for surgery.



    Since I can't attach a modifier, can I appeal w/ the consult notes which indicate the dr expressing pus from his hand at the consult, and the notes also indicate that the pt's hand needs further draining and surgery would be done next day because he at breakfast; or does this consult have to be written off as global since the diagnosis for the consult and surgery are both the same.

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