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When McKesson edits contradict commercial insurance AND CMS guidelines

  1. #21
    Location
    Milwaukee WI
    Posts
    4,466
    Default An anecdote re peer-to-peer
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    Many years ago I worked on a claim where the physician performed and billed 21138 (along with other codes) for a baby with severe congenital skull deformity.

    Insurance denied as "cosmetic surgery" (despite a pre-authorization). I appealed with op note.

    Insurance denied again - "cosmetic." I asked for second level appeal, again sending op note, photos and another letter explaining why this was hardly "cosmetic" in nature given the several congenital deformity.

    Insurance denied again - "cosmetic." I told doc he needed to request peer-to-peer review.
    He wrote a succinct note requesting a peer-to-peer review, appending the op note yet another time. His note read, "repairing a defect in the skull to protect the brain is NOT cosmetic surgery."

    He finally got paid (about 18 months AFTER the surgery).

    Never give up!

    F Tessa Bartels, CPC, CEMC

  2. #22
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by FTessaBartels View Post
    Many years ago I worked on a claim where the physician performed and billed 21138 (along with other codes) for a baby with severe congenital skull deformity.

    Insurance denied as "cosmetic surgery" (despite a pre-authorization). I appealed with op note.

    Insurance denied again - "cosmetic." I asked for second level appeal, again sending op note, photos and another letter explaining why this was hardly "cosmetic" in nature given the several congenital deformity.

    Insurance denied again - "cosmetic." I told doc he needed to request peer-to-peer review.
    He wrote a succinct note requesting a peer-to-peer review, appending the op note yet another time. His note read, "repairing a defect in the skull to protect the brain is NOT cosmetic surgery."

    He finally got paid (about 18 months AFTER the surgery).

    Never give up!

    F Tessa Bartels, CPC, CEMC
    Just makes you go...hmmmmmmm...........lol! Good story!
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. #23
    Location
    Everett, WA
    Posts
    886
    Default
    Just in case anyone is still interested. FINALLY found a rep (after requesting the services of others and getting no where), who is taking this issue farther up the food chain to McKesson itself, and hopefully will get an answer soon. Debra, if you're still 'out there" am still anxiously awaiting your response and this is my attempt to keep the thread open. Has anyone ever fought the McKesson edits and won?
    ---Suzanne E. Byrum CPC

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