# Coding question? 42820 & 42825



## ivonneatanacio (Oct 16, 2015)

I do facility billing , there is an ENT group that provides services from our ASC. Here is the case:

ENT group received pre authorization for tonsillectomy 42825, the surgeon preformed tonsillectomy and adenoidectomy 42820 (fairly common to happen) it was billed 42820 and denied for no auth, I sent an appeal for medical necessity and my appeal was denied (for no preauthorization for the code billed)  the surgeon billed 42820 but auth code is 42825.
Now my manager wants to change the code for the ASC side to the approved code 42825, I advised that the surgeons code must match to the facility and she disagrees and states that it does not have to. I understand the want to get paid , but I don?t believe we can do that unless the surgeon also changes his. In my years of experience I always known that the physician and ASC codes should match. 

My question is : is my though correct and if so, where can I find  it in writing to back up my thought?


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## jackjones62 (Oct 20, 2015)

OK, did you contact the ENT surgeon's office with regards to this?  Realistically, it's their responsibility to send in the appeal and make sure you receive a copy for your reference; this situation happens all the time and it is an appealable situation; keep on the surgeons office, I am sure they want to get paid as well....Also, find out if they got paid?, if they did and you did not, again, another argument in your favor...

As far as billing the 42825, technically you are only billing for half the procedure, is it wrong? by coding standards, it's not correct,  you are undercoding intentionally just to get paid.

If the surgeons office is unwilling to help, get the surgeons medical records and operative report, exhaust all appeal options, if that fails, file a complaint with the State's Insurance Commissioner....
Jennifer
CTENT


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