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Gastroenterology Coding Alert

Denial Management:

A 3-Step Strategy Could Get You Through Irrational Denials

Published on Tue Mar 08, 2011

The contract a patient signs with the insurance company holds true no matter what.Have you been in a situation where you wanted to contest a denial by an insurance company based on irrational payer guidelines? You may be right to think this is like trying to break down a stone wall, but you are not helpless to change to situation to your favor.Consider this gastroenterology situation:You want to fight an insurance company for payment for 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) with 45385 (... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). In denying your initial claim, the insurance company states in writing the following guidelines:"Exceptions to Modifier 59: The following endoscopic biopsy procedures will not be allowed with the associated endoscopic therapeutic procedures: 45380 with 45383-45385.Decision: The endoscopic biopsies with endoscopic therapeutic procedures in the same anatomical area will follow [...]
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