Gastroenterology Coding Alert

If your claims have ever come up against irrational payer guidelines that significantly reduce your physician's reimbursement, you probably felt powerless to change the situation.

But in some cases, you're not powerless at all, according to Barbara Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

Tackle this gastroenterology situation, and learn two steps you can take to respond.

Example: 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).

However, they have in writing the following:

"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 standard coding logic, and no additional reimbursement will be made for these codes even when billed with modifier 59.

Rationale: The endoscopic biopsy is an integral part of the therapeutic endoscopic procedure. Generic ClaimCheck denies the endoscopic biopsy procedure when billed with a therapeutic endoscopic procedure in the same anatomical area."

Is there anyone who can help you get your denied claims paid? In addition, other insurances have started to deny 45380 with 45385, a combination your GI performs quite frequently. What can you do?

Fight This Decision in 3 Easy Steps

Unfortunately, the insurance company can set any rules it wants and you are forced to play by them when your physicians sign the contracts, Cobuzzi says.

Step 1: The first thing you have to do is get a copy of your contract and see what degree of latitude your payer can take relative to AMA and CMS coding rules. "If the insurer is violating what is set forth in the contract, use the contract in your appeal to fight this arbitrary policy and get it overturned," Cobuzzi says.

Step 2: If the contract is silent on this or allows such arbitrary use of rules in favor of the payer, you should prepare to "drop the payer as one of your participating payers. Don't have cold feet -- be truly ready to drop them in this stage," Cobuzzi says.

Step 3: Get a meeting between your physicians and the medical director. Ask the medical director to justify this policy in clinical terms as to why the insurer does not reimburse a physician for the diagnostic colonoscopy and the removal of polyps when you apply modifier 59 (Distinct procedural service) to indicate different sites. Explain that breaking the colonoscopy and the biopsy into multiple sessions will make the payer incur multiple facility fees, multiple anesthesia sessions as well as the physician professional fees.

If the medical director cannot explain the payer's rationale, follow through with your threats.