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Category III codes-I am having much

  1. #1
    Question Category III codes-I am having much
    Medical Coding Books
    I am having much difficulty regarding the Category III codes. My physician really, really wants to perform 0275T - Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; Lumbar. He did perform it once, on a patient who has Medicare. It was denied, billing company sent an appeal and we are still waiting for their answer. But now my physician wants to try getting a pre-authorization from a commercial payor so he can start performing this procedure. I really don't know what else to do. I have had responses from coders in other states indicating that this code comes back denied and I have relayed that information to my physician, but he just seems determined to perform the service.

  2. Default
    Most Cat III codes are not paid by medicare and are paid on a per insurance basis most will deny though

  3. #3
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    Quote Originally Posted by barbara45 View Post
    I am having much difficulty regarding the Category III codes. My physician really, erally wants to perform 0275T - Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; Lumbar. He did perform it once, on a patient who has Medicare. It was denied, billing company sent an appeal and we are still waiting for their answer. But now my physician wants to try getting a pre-authorization from a commercial payor so he can start performing this procedure. I really don't know what else to do. I have had responses from coders in other states indicating that this code comes back denied and I have relayed that information to my physician, but he just seems determined to perform the service.
    This is exactly why Category III codes are established. They are temporary codes and frequently are testing new technology or new procedures to see how often they are performed. I would definitely attempt to get pre-auth from a commercial payer for the procedure. The doctor may need to write a letter explaining why this procedure is better than any other alternative treatment for the patient and include any literature available on the pros and cons for the procedure. Some payers will authorize payment if a case can be effectively made that this is the best treatment. The more this is done, then it will show the need to this procedure to "graduate" to a regular CPT code. There have been instances where Medicare has allowed a procedure which has a temporary code.

    The problem is when folks just bill the code without doing some work ahead of time to see what it takes to get the procedure authorized. Research the procedure and get more information from the physician who wants to perform it.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  4. #4
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    Try checking with that patients' insurance company to see if they accept Category III codes. If you have online access then usually their medical policies and/or guidelines, coding and requirements to support medical necessity for use of these codes are readily available. Most insurance carriers have these policies.

  5. Default
    One of our dr's wanted to do this same procedure as well and I found that the majority of insurance companies do not pay for this because they consider it experimental. Go on the health insurance companies website and you should be able to find a medical policy that says it is experimental. Most insurance companies do have their medical policy's online. I then explained to the dr that even though he feels that the procedure is in the patient's best interest, it does not mean that the insurance company would pay for it. What the dr. feels is medically necessary and what the insurance company says is medically necessary and a covered procedure are two very different things.

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