Wiki Billing 29916 & 29914

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sandraclark5123@gmail.com

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Has anyone had issues with Anthem denying claim with CPT's 29916 & 29914 billed together? Anthem will pay 29916 but deny 29914 as bilateral.
 
Did you mean to say bundled? There is no NCCI edit with 29916/29914 but there may be another reason why, or Anthem may call these inclusive.

Questions would be:
Did the provider have authorization for all procedures?
What diagnoses were attached to each procedure? Was there FAI/Cam? Did the provider perform a femoroplasty?
Were there any other CPT codes that were billed with these (e.g.; 29862, 29863, 29915, or unlisted 29999) (which may or may not be considered inclusive?)
Was Availity used to check the codes for edits prior to submission?
What was the denial or rejection reason?
Was it coded correctly? Did someone accidentally attach the wrong side diagnosis to the CPT? Did someone accidentally append a Modifier 50 when it should have been RT/LT? This is one of the most common errors I have seen in ortho surgery coding. It gets denied and the A/R person is bending over backwards to try and figure it out and getting all worked up and all it was is that the RT should have been LT or vice versa. Sometimes it is the most basic of errors. This really should be caught by internal claim edits. :)

Hip scope coding can be complicated if there is not a a good understanding of the requirements such as documentation in the clinic visits, pre-auth, and all the way through coding and billing. The practice would also need a process to collect for what carriers may call "experimental" or non-covered procedures that may need to be performed but the patient would have to pay out of pocket for.

May not be the state you are billing in but you also have to check Anthem's Provider News, Carelon, AIM, etc.
Example: https://providernews.anthem.com/con...dical-benefits-management-inc-joint-s-1-14515 https://providernews.anthem.com/geo...dical-benefits-management-inc-joint-s-3-14517
  • Femoroacetabular impingement syndrome (FAIS) — Specified requirement for alpha angle greater than 55 degrees for femoroplasty
Really old and probably out of date, but you have to look for things like this too, as an example:
 
amyjph said:
What was the diagnosis code attached to it?
Click to expand...
This is the body of the op note:
PREOPERATIVE DIAGNOSIS: Right hip femoroacetabular impingement syndrome, with acetabular labral tear. POSTOPERATIVE DIAGNOSIS: Right hip femoroacetabular impingement syndrome, with acetabular labral tear. PROCEDURES PERFORMED: 1. Right hip arthroscopy with acetabular labral repair. 2. Acetabular osteoplasty for correction of pincer type lesion more than rim trimming. 3. Femoral osteoplasty to remove impingement cyst. ESTIMATED BLOOD LOSS: Minimal. TRACTION TIME: About an hour and 30 minutes. COMPLICATIONS: None. PERMIT AND INDICATIONS: The patient is an 18-year-old female with significant pain and dysfunction to her right hip. She was teaching some wrestling and injured the hip when performing some wrestling maneuvers and had pain and MRI, which revealed a labral tear. She was consented for surgery knowing full all risks, benefits and possible complications associated with the surgery as well as her nonoperative continued options. We proceeded at her request. DESCRIPTION OF PROCEDURE: The patient was seen and evaluated in the preop area, where she identified the right hip as the operative extremity, it was marked. She was then taken back to the OR suite, anesthetized and then placed on the Hana table with her legs in the protected boots, well padded. We checked C-arm fluoroscopy that we could adequately distract her and then her right hip was sterilely prepped and draped in the usual fashion, after which formal time-out indicated the correct site and antibiotics had been administered. At that point, we commenced our traction time and placed the hip under traction and created our anterolateral portal and then mid anterior portal was created under direct visualization. We then did an interportal capsulotomy with Samurai blade and once that was done, we had excellent visualization where we noted a superior labral tear. It was mostly superior from about 11 to 2 o'clock and there was a little bit of cartilage what appeared to be some labral cartilage separation, but we then dissected the capsule away from the labrum and identified quite a bit of bony irregularity and pincer type lesion on the acetabulum and once we did identify that and also a little bit of subspine impingement happening so we used the bur to clean off and eliminate the pincer lesion both under direct visualization and with C-arm fluoroscopy. Once we were satisfied with the resection of the acetabulum and had it down to good smooth margins and eliminated any significant pincer. We then placed more anterior curved Arthrex 1.8 mm awl suture anchor, as we did so the delivery device actually broke inside the acetabulum and we were unable to pull it out with any instrument and so we pulled the anchor out, which pulled out the delivery mechanism as well and it was caught in the soft tissues in between the hip and the skin, so we had to take some time and fish it out using C-arm fluoroscopy as our guide as well as the scope and we were able to successfully retrieve it. This took little extra time and then we were able to use four anchors into repair the acetabular labrum and restore and remove acetabular wave sign that was present underneath the labral tear. It tightened up the cartilage and the labrum and everything looked really good. Once we were done, and at that point, we were released traction, evaluated our suction seal, which was good and evaluated the femur and I felt like, as I took down the synovium and soft tissue over the proximal femur, there was some impingement cyst there noted, so I did a little bit of resection on the femur to smooth out those impingement cysts. Once that was done, we had finished our femoral osteoplasty and there was no dynamic impingement noted. We then reapproximated our capsule with three capsular stitches and then the skin portals were closed with simple interrupted nylon sutures and sterile dressings were applied. The patient was awakened and taken to PACU in stable condition.
 
I see the 29914:
"and evaluated the femur and I felt like, as I took down the synovium and soft tissue over the proximal femur, there was some impingement cyst there noted, so I did a little bit of resection on the femur to smooth out those impingement cysts. Once that was done, we had finished our femoral osteoplasty and there was no dynamic impingement noted."

What is the exact denial rationale and reason code? Are you sure it is not something such as the: "Multiple and Bilateral Surgery Processing – Professional" one? It has the word bilateral but it is also used for multiple.
Are they looking for a 51 modifier on the second code?

In addition to all the other questions above, I would also ask: when did this start and how many claims are impacted? Is it a one-off or all of them for hip scopes?
 
This is their denial reason:
The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
We have 2 claims that are denying for the same reason.
 
sandraclark5123@gmail.com said:
This is their denial reason:
The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
We have 2 claims that are denying for the same reason.
Click to expand...
This does not mean bilateral.
This means it is bundled. If that is on the 29914 line, they are telling you it is bundled with the 29916. You would need to check the payer policy for these services. Other than that, you would need to append a 59 modifier if/when appropriately documented.
 
amyjph said:
This does not mean bilateral.
This means it is bundled. If that is on the 29914 line, they are telling you it is bundled with the 29916. You would need to check the payer policy for these services. Other than that, you would need to append a 59 modifier if/when appropriately documented.
Click to expand...
Yes, I'm aware. This was their original denial decision. We have been working with our Anthem rep since May and they came back with the following: line 2 didn't pay because rev code 0490 is a global code unless there is a 50 modifier. If there was a modifier of 50, it would have paid 100% on line 1 and 50% on line 2 and 29914/29916 require 50 or 51 modifier because they are bilateral/unilateral and sent a policy for Professional claims, we bill Institutional claims.
 
It is very helpful when posting the initial question for help to specify if it is pro fee or facility/ASC.
What that sounds like to me is they are only going to pay the 0490 on the 29916 for the case, nothing additional for the 29914.
Other than that, not sure. Has anyone tried adding a 51 to the 29914?
 
amyjph said:
It is very helpful when posting the initial question for help to specify if it is pro fee or facility/ASC.
What that sounds like to me is they are only going to pay the 0490 on the 29916 for the case, nothing additional for the 29914.
Other than that, not sure. Has anyone tried adding a 51 to the 29914?
Click to expand...
Thanks for your help and I'll keep that in mine for future questions.
 
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