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Medicare coding/reimbursement ?

  1. Default Medicare coding/reimbursement ?
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    I came from a hospital billing and coding and am now with a Clinic. I am kind of lost as to why the difference between the two for coding and billing and am wondering if anyone can help.

    First of all, we do scopes in the clinic under MAC anesthesia. Medicare is denying a colonoscopy against an egd as being "allowed in another procedure" - but why would this be if the two scopes are in different parts of the body and are through different enterances?

    Also I have been billing for Versed and Propofol under the CRNA that is performing our anesthia but Medicare states that they do not pay for those for a CRNA - any way to get around that or any advice as to what my next step would be?

    And my third question is when we would bill colonoscopies for the hospital we would bill for everything together, like biopsy, polypectomy, removal w/snare, etc depending on what was performed. When I tried to code everything like a biopsy and polypectomy together Medicare denied the one against the other, why would this be even though they were reimbursed together under a hospital form.

    Any insight would be greatly appreciated, there are no other surgery clinics around that are the same set up as us to bounce ideas/questions off of. Also another thing to keep in mind is we are not certified by medicare as an ASC yet - i am working on getting the paperwork and survey done.

    Thank you!

  2. #2
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    Quote Originally Posted by AmandaM2153 View Post
    First of all, we do scopes in the clinic under MAC anesthesia. Medicare is denying a colonoscopy against an egd as being "allowed in another procedure" - but why would this be if the two scopes are in different parts of the body and are through different enterances?!
    Amanda, what does the NCCI have to say about your CPT codes for the various scope procedures? I've never coded these for real (I'm a medical coder/biller student), however, I had three scope procedures recently: an EGD, a flexsig, and a scope up the small intestine entering through my temporary ileostomy. Medicare paid on the first two but refused the third on the basis that it's included in the first. Using the CPT codes from my bill from the GI and looking at the NCCI tables, I confirmed that the third procedure is excluded because it's included in the first.

    Quote Originally Posted by AmandaM2153 View Post
    Also I have been billing for Versed and Propofol under the CRNA that is performing our anesthia but Medicare states that they do not pay for those for a CRNA - any way to get around that or any advice as to what my next step would be?!
    Hmmmm? Chapter 12 (Physicians/Nonphysician Practitioners) of the Medicare Claims Processing Manual (http://www.cms.gov/manuals/downloads/clm104c12.pdf) at Section 140 talks about when a CRNA or AA can bill and be paid. From my own procedure, I know that Medicare and I paid for both a CRNA and an Anesthesiologist. What about the procedures you're coding caused the denial? Does the NCCI help explain the denial? Are you using the appropriate modifier from among QX, QZ, & QS?

    Quote Originally Posted by AmandaM2153 View Post
    And my third question is when we would bill colonoscopies for the hospital we would bill for everything together, like biopsy, polypectomy, removal w/snare, etc depending on what was performed. When I tried to code everything like a biopsy and polypectomy together Medicare denied the one against the other, why would this be even though they were reimbursed together under a hospital form.!
    I'm completely out of my depth on this part of your questions.

    Thanks,

    Ron McKenzie
    Windermere, FL

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