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20610 Denied, Need Help

  1. Post 20610 Denied, Need Help
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    Insurance is United Healthcare and 20610 is getting denied due to "The benefit for this service is included in the payment/allowance for another srvice that has already been adjudicated".
    Patient had knee arthroscopy and about 4 days after surgery, the patient came in the office because of pain and swelling and the physician did aspiration of her knee for a knee effussion. It was my understanding that the 20610 would be billable.
    Any suggestions if insurance is correct or how to appeal this denial?

  2. Default
    Was anything else billed w/ 20610?

  3. Default
    Since patient is in a post op period, the injection will need to have a modifier added on.

    Which one depends on what the dictation states?

    Hope this helps!

  4. #4
    Default
    An increasing number of payors are following medicare guidelines for global surgery package. Medicare states it will not pay for complications of a surgery unless it requires a return trip to the OR. I don't know if your patient had a new injury that caused the effusion, if not, it is a complication from the surgery.

    A lot of commercial payors follow this policy now, however, some do not and you would need to append modifier "58" to get the injection paid. You can get reimbursed for the meds that were injected though.

  5. Default
    Quote Originally Posted by PLAIDMAN View Post
    An increasing number of payors are following medicare guidelines for global surgery package. Medicare states it will not pay for complications of a surgery unless it requires a return trip to the OR. I don't know if your patient had a new injury that caused the effusion, if not, it is a complication from the surgery.

    A lot of commercial payors follow this policy now, however, some do not and you would need to append modifier "58" to get the injection paid. You can get reimbursed for the meds that were injected though.
    I disagree. If it's truly a complication, you'd use the modifier 78 if the patient was brought back to the OR.

    ~L
    CPC, CGSC, COSC

  6. Default
    Quote Originally Posted by Treetoad View Post
    I disagree. If it's truly a complication, you'd use the modifier 78 if the patient was brought back to the OR.
    Please read through the above posts. A 78 modifier is NOT correct in this situation as the patient WAS NOT taken back to the OR, but had the procedure in the OFFICE, so the 58 modifier is absolutely correct.

  7. Default
    I would check with your carrier and your local Medicare office regarding the post op complication policy. I just attended a Medicare seminar yesterday and they stated that they do not cover post op complications unless it necessitated a return to the OR.

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