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Question on Appealing PA surgeries to Medicare

  1. #1
    Unhappy Question on Appealing PA surgeries to Medicare
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    We have a standing protocol in our practice that when Medicare denies any PA assisted surgery as CO-54 "physicians assistants/cosurgeons not allowed in this case" that we are to appeal this denial. The reason they say to appeal it is that according to the latest Global Surgery Indicator depending on the code says we can bill it with a 59. The most recent Global Surgery Indicator we have is from 2003. I feel we should not be appealing these, they are not bundled or denied global, but denied as PA not covered for this code, and when we do appeal them they are denied as CO-54 again anyway. I also would like to know if anyone has access to a more recent Global Surgery Indicator besides the one from 2003.
    Thanks for your help,

  2. #2
    I'm a little confused, what does the 59 have to do with that rejection?

    Assist at Sugery is not allowed for all procedures, that is what that rejection is saying, not that it is bundled.

    I use and they tell whether or not an assist is allowed based on CMS guidelines but I'm not sure how often CMS updates that.

    Example from encoderpro

    Mediastinoscopy, with or without biopsy

    Medicare Rules

    Physician Service
    Multiple Surgery Reduction
    Assist-at-Surgery Not Allowed

    Removal of lung, other than total pneumonectomy; single lobe (lobectomy)

    Medicare Rules

    Physician Service
    Multiple Surgery Reduction
    Assist-at-Surgery Allowed
    Cosurgery w/Documentation

    Laura, CPC, CPMA, CEMC

  3. #3
    One of the codes in question was 29881, which according to the 2003 global surgery indicator can be billed for a PA, but it was billed with another code that was paid. I guess my issue is more than anything, is proving in writing that when Medicare denies using CO-54- we can not appeal. I have tried to explain this to the biller that in turn will reverse the write off and appeal it. Which every time they come back denied as CO-54. She bases her determination on the 2003 Global Surgery Indicator- which I feel is outdated and not a good resource to base appealing something that Medicare clearly states is not payable in this circumstance. This particular biller feels we should add a 59 and appeal, which she did and it denied again. I guess I am just looking for documentation.
    Thanks for your help.

  4. #4
    On that particular code it shows the following on encoder

    Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving)

    Medicare Rules

    Physician Service
    Special Rules for Multiple Endoscopic Procedures
    Bilateral Procedure Allowed
    Assist-at-Surgery w/Documentation

    So it is allowed, maybe your documentation is the problem, not the coding. If the documentation doesn't support active involvement by the assistant they will deny it as well. Or maybe the medical necessity of an assistant was not demonstrated. Something to look into.

    Laura, CPC, CPMA, CEMC

  5. #5
    North Carolina
    The Physician Fee Schedule is current with the assistant surgery allowed codes.

    -Click on Payment Policy Indicators -->next
    -click next again
    -Enter your CPT code and select "all modifiers" on your drop down key and submit

    0=paid w/ documentation
    1=can not be paid
    2=can be paid
    9=concept does not apply

  6. #6
    I did read the op note for this case and all it did was list the assistant was in the OR- it did not say anything about what the assistant did.

  7. #7
    Thanks for the website directions, Laura thank you for your input.

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