Question: One of our payers is denying 57240, saying this code is bundled against 58260. Is there a modifier we can use to get the 57240 paid?
Tennessee Subscriber
Answer: You should receive reimbursement for both 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele) and 58260 (Vaginal hysterectomy, for uterus 250 grams or less).
The National Correct Coding Initiative does not bundle these codes, nor should payers. An ob-gyn would not perform both these procedures for the same reason, and the operative sites are different.
But just in case, check your diagnostic coding to be sure you have linked the cystocele repair to 618.01 (or 618.2-618.3 if the patient had both uterine and vaginal prolapse).
Good advice: If this coding is in order, you should definitely appeal. This may include your physician writing a letter to the insurance company's medical director regarding the medical necessity for both procedures, as well as letting the American College of Obstetricians and Gynecologists (ACOG) know about this denial.
By accessing ACOG's Web site at
www.acog.org/departments/dept_notice.cfm?recno=19&bulletin=1932, you will get some solid advice about challenging inappropriate payment denials. You can also access a form to outline your particular payer problem to ACOG staff.
