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A little in sight please

  1. Default A little in sight please
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    I have a question? If I am billing out a surgery in NY state does the CPT codes get paid according to RVU factor or what that insurance company finds to be there primary code? I thought in NY it is the RVU? I would love some help on this. Because I am billing surgeries according to RVU and major commercial insurance companies are changing my codes around. What should I do?

    Colleen

  2. Default
    Generally your RVU is an indicator of the more invasive or complex procedure and should be listed first on your claim as the primary procedure. The payer certainly should not be changing the codes you submitted. They can either pay or deny but they can not re-code.

    As far as them changing the order and paying a different code as primary, do you have 1 or 2 examples. We could look at the specific codes, coding guidelines and general payment rules and suggest some answers

  3. Default Here are the codes they are changing
    Thank you for responding
    Here are the codes I submitted to Aetna for a surgery according to weight value

    31255
    31267
    31288
    61795
    this is how they changed my codes
    61795
    31288
    31267
    31255
    they reversed them and put them towards a pt deductible

    Also GHI is not changing my codes but not paying 100% on the primary code then 50% on others for example
    30520 highest rvu primary code they are paying only 261.50
    31276 50 my second code they are paying as primary code which has a lower rvu
    30140 50
    31255 50
    31267
    they are paying all these codes out of order of their submitted sequence. Should that be or should I fight this?

    Again your help is so appreciated
    Colleen
    61795

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