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Thread: Payment for failed gyn procedure

  1. #1
    Join Date
    Apr 2007
    Atlanta Perimeter

    Default Payment for failed gyn procedure

    AAPC: Back to School
    Hello all
    I am billing for an ASC and we recently had a procedure where the doctor attempted to do a HTA ablation and that attempt was failed so the doctor attempted a Novasure ablation which also failed. The doctor resected uterine submucosal myomas. The insurance has paid us for one of the ablations and for the resection, does anyone know how we can get paid for the other failed ablation? Since we are the facility and our device cost is added into our reimbursement, we are out the cost of that device if they do not pay for the second ablation. Thanks in advance for any feedback!

  2. #2

    Smile Use Modifiers for the failed Procedures


    I presume the failed procedures, and the successful procedure was done by the same physician ...

    That would lead us to the usage of modifers.

    Here, you will have a choice. Depending on how you want this to be ... looking on the front cover of the CPT book ... you will find the modifiers.

    You can use Modifier 22 or Modifier 51.

    Modifier 22 is used for "Increased Procedural Services," and Modifier 51 is "Multiple Procedures.

    Try rebilling the unpaid procedures, and modifying them both with 22. If appropriate, give each procedure a different diagnosis code.

    If the insurance companies still deny payment ... rebill the procedures with the other Modifer.

    By law, you are allowed to rebill (even "Doctor-approved" changing codes) ... until procedures get paid.

    Also, if you're not already billing for a separate office visit, in addition to your procedures ... speak with the Doctor about doing the appropriate tasks related to an office visit (History, Time, Medical Decision Making) ... and as the Doctor will give you the appropriate level of an office visit, have him also give you a separate, more generalized diagnosis for the office visit. Link the 2nd procedure to a different diagnosis. This will ensure both procedures get paid at fee schedule rates. (A total of 2 diagnoses, with 1 DX linked to each procedure).

  3. #3
    Join Date
    Apr 2007
    Atlanta Perimeter


    Hi Searchtheweb
    We did bill with the modifier 51, so I was just wondering about whether or not it is typical to expect payment for a failed procedure. Modifier 22 on one of my failures was the next move, just wasn't sure if insurance companies typically pay in these cases.

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