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Please help111

  1. #1
    Exclamation Please help111
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    I'm reading the LCD for debridements which inform me to code to the deepest tissue removed but notice that per they contract with a HMO ins. the company bills the codes that the ins agreed to pay. they justification is that in order to get to the deepest tissue, the clinican passed the other tissues. My judgement that this is undercoding. The right way would to get all codes associated with the practice on the contract. or contract to state "that regardless to what is performed you will only be reimburse for contractual procedures". The coders are being asked to code the procedures according to contract. I disagree with this method. I wonder if there any edvidence besides coding guidelines from the LCD.

  2. #2
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    Quote Originally Posted by coder1 View Post
    I'm reading the LCD for debridements which inform me to code to the deepest tissue removed but notice that per they contract with a HMO ins. the company bills the codes that the ins agreed to pay. they justification is that in order to get to the deepest tissue, the clinican passed the other tissues. My judgement that this is undercoding. The right way would to get all codes associated with the practice on the contract. or contract to state "that regardless to what is performed you will only be reimburse for contractual procedures". The coders are being asked to code the procedures according to contract. I disagree with this method. I wonder if there any edvidence besides coding guidelines from the LCD.
    I'm a little confused...are you trying to bill multiple debridements? And is this on Medicare or commercial? Could you post a link to the LCD?

  3. #3
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    The company is contracted with the HMO to provide just a level 307 for visit, and 42 for procedure. The clinican documents that the procedure perform was to the depth of 43. The company is billing 42 even if the clinican documents to a 43(which is the tissue removed). The company is coding 307 even if the notes reflect a different level for visit. The company rationale is that in order to reach 43, they had to reach 42.
    The florida medicare LCD coding guidelines states to code to the deepest level removed. Is is ok to bill a 42 even if the documentation states 43? I think this is grounds for undercoding.

  4. #4
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    It is very hard to follow your post but the jist is can you under coder for a payment decision? And the answer is no you cannot. You code what is documented, and nothing more or less. undercoding is not allowed.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
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    I agree with Debra - you can't undercode just to get paid. To make sure I understand you, though -

    Your doctor is performing 11043, but the HMO will only pay for 11042? Do they have something against subcutaneous tissues, or what? I understand what the billing company is telling you about billing 11042 when 11043 was done, and although their rationale makes MUCH more sense than the HMO's policy, it's still incorrect.

    Have you gotten disclosure on this payment policy in writing? It seems odd to only agree to pay for debridement in certain situations (eg, when there's no subcutaneous tissue involvement) - that would be like saying "We'll cover fracture repair, but only for closed fractures." I'd be willing to bet my paycheck that you've been misinformed (or someone at the billing company has), about this HMO's coverage criteria. I'd suggest calling them and asking them what their policies are for paying for debridements, and ask specifically about 11043. Play dumb, and keep asking questions until it makes perfect sense. (Seriously - the dumber, the better...don't worry about annoying them. It's their job to help you.)

    Hope that helps!

  6. #6
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    Columbia, MO
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    I am wondering, and only conjecture at this point... but is it possible they will only pay for debridement to the level of a 11042 when performed in the office setting, and a 11043 only in the oupatient OR setting? I know that some payers do dictate certain procedures for certain POS.

    Debra A. Mitchell, MSPH, CPC-H

  7. #7
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    Quote Originally Posted by mitchellde View Post
    I am wondering, and only conjecture at this point... but is it possible they will only pay for debridement to the level of a 11042 when performed in the office setting, and a 11043 only in the oupatient OR setting? I know that some payers do dictate certain procedures for certain POS.
    That would be a logical explanation...and one I never would have thought of! I'm curious about it, now...

  8. #8
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    The company contract with the HMO is ONLY for 11042 debridements and 99307 visit. If the company bill for anything else claims are denied. To cut down on denials, the company is downcoding the 11043 to 11042 to honor there contract with the HMO to get paid. The company logic: in order to perform a 11043 , you had to perform 11042 so you can bill for the 11042 even if you went all the way to perform a 11043. So the coders are coding only 11042 and 99307 even if the documentation states a 11043 was perform with a higher level visit.

  9. #9
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    Quote Originally Posted by coder1 View Post
    The company contract with the HMO is ONLY for 11042 debridements and 99307 visit. If the company bill for anything else claims are denied. To cut down on denials, the company is downcoding the 11043 to 11042 to honor there contract with the HMO to get paid. The company logic: in order to perform a 11043 , you had to perform 11042 so you can bill for the 11042 even if you went all the way to perform a 11043. So the coders are coding only 11042 and 99307 even if the documentation states a 11043 was perform with a higher level visit.
    In this situation, what the contract says isn't as important as why it says it. There's a reason that they won't cover debridements in a nursing facility - either they don't believe that the facility is adequate to perform extensive debridement, or there are state laws in your area that limit which providers may perform the procedure within their scope of practice. (See: http://www.sharpdebridement.com/file...te_Summary.pdf) You just have to find out what their reason is...

    What's the insurer's name?

  10. #10
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    I agree 100%, The insurer is Humana FL. The company provide services in mutliple states. I worked for another company who indeed had a contract with this HMO and their contract is based on a set fee for services. They are also performing the same services as this company.

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