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Payers changing your coding

  1. #1
    Default Payers changing your coding
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    Has anyone been experiencing the above? I've noticed here lately, that "we" bill out one thing, and then the insurance company will change our CPT codes and pay on what they've changed. For example: the surgeon performed an injection at two separate tendon sites so, we billed: 20550 and 20550 -59. The insurance company involved denied those two codes and changed it to 20550 -50 (one claim line) and paid that at a extremely reduced rate. Not to mention the fact that they manipulated the fee amount! This is not the first time I've seen this, and I am seeing it more and more. I was always under the impression that the payers SHOULD NOT be changing CPT codes, specifically since they don't always have the operative report. I always thought that if the payer does not agree with our codes, they should deny those codes and it will be up to the provider to either appeal (at which point we will send the operative report) or send a corrected claim. Any thoughts????
    K-CPC

  2. #2
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    Quote Originally Posted by kandigrl79 View Post
    Has anyone been experiencing the above? I've noticed here lately, that "we" bill out one thing, and then the insurance company will change our CPT codes and pay on what they've changed. For example: the surgeon performed an injection at two separate tendon sites so, we billed: 20550 and 20550 -59. The insurance company involved denied those two codes and changed it to 20550 -50 (one claim line) and paid that at a extremely reduced rate. Not to mention the fact that they manipulated the fee amount! This is not the first time I've seen this, and I am seeing it more and more. I was always under the impression that the payers SHOULD NOT be changing CPT codes, specifically since they don't always have the operative report. I always thought that if the payer does not agree with our codes, they should deny those codes and it will be up to the provider to either appeal (at which point we will send the operative report) or send a corrected claim. Any thoughts????
    Did they pay you 150% of what they supposed to? with modifier 50 they suppose to pay 150% of alowed. Even if they would process this as two line items, they should have pay 100% first and 50% second procedure based on multiple procedure reduction.

  3. Default
    I agree that for bilateral they should be paying you at 150% of the allowed. If they are not paying this than I would file an appeal. In Pennsylvania they are allowed to change your codes as long as they notify you that they are doing it and you have a certain amount of time to appeal. Either way, if they are not paying you at the fee schedule I would appeal.

  4. #4
    Default
    In this case modifier 50 was just flat out incorrect, it wasn't a bilateral procedure. It was simply a procedure performed twice at separate incision sites, so the reimbursement is "moot." I actually did an appeal because what they changed the coding to was incorrect. I guess I should've been more clear, I apologize. The coding specifics wasn't what I was really inquiring about. That was merely an example. I was just wondering if any one else was having the issue of payers changing your coding to what they think it should be. I don't believe they should be doing that. For #1 they don't have access to the operative report unless they request it, which in most of these cases they are not. They are just changing the codes to what they assume they should be. What they are basing their changes on...I don't know and they are never able to explain that either when I call them. I believe that if they don't agree with our codes, they should deny those codes and give us the opportunity to explain ourselves via an appeal. I was just wondering if this was happening to any other practices out there and if so, how do you feel about it and how are you handling it?
    K-CPC

  5. Default Emg
    Having trouble getting paid by NF for 95886. If it is bilateral is it 95886 X 2 units? Previously for my office was billing for bilateral 95886 50. Then they tried 95886 lt, 95886 rt. What is correct billing NF. Specifically State Farm?

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