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Payors changing your coding

  1. #1
    Default Payors changing your coding
    Medical Coding Books
    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
    Default
    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????
    They'll rebundle things for you, or in this case, change them to their preferred method of billing, but they shouldn't be adding or taking away anything that you didn't bill. Yes, they could deny the claim, and make you go through the hassle of getting the EOB, calling to find out what denied, making the correction, then waiting another 3-4 weeks for that claim to process...or, they could just change it, pay it, and be done with it.
    The reduced payment you're seeing is likely due to a multiple surgical procedure payment policy, in which they pay 1 unit @ 100% of the allowable, and the additional units @ 50% of the allowable. If you weren't paid at least 1.5 times your allowed amount for one unit, then you've got a problem. Otherwise, they probably saved you money in the long run by doing it that way (from costs of following up).
    Watch out for rebundling of labs to a panel, if you don't have all of the parts to the panels billed, or for strange allowable payments (I've seen payors try to bundle 80061 & 83721/59, and pay them as a single service, for example. Tsk, tsk...). Also, check your payor's website for their MSP policy, so you can know how much to expect when you bill out multiple procedures in the same day, in the future. Hope that helps!

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