Wiki 49594 IP ONLY CPT Denial and documented size denial

[arkassabaum]

We are receiving a high volume of DNB requests from our billing dept asking us to review hernia coding, in addition to formal denials from payors.

We have two main concerns 1) Addressing the IP ONLY review request and 2) The sizing is often noted in the "findings." However, the provider does not specifically indicate the size was taken prior to opening the defect.

Humana denial verbiage: Records do not support coding criteria for CPT 49594. As per guidelines, hernia defect size can be measured prior to opening the hernia defect. After review, given medical records does not specify the pre-operative hernia defect size to validate the billed procedure. Therefore, CPT 49594 will not be reimbursed on the date of service XX/XX/XXXX. Reference: AMA 2023, CPT Professional Edition.

Findings example verbiage: Three separate ventral hernias - 2 cm umbilical, 2 cm supraumbilical, 2 cm subxiphoid, all incarcerated with preperitoneal fat. The furthest distance between the most inferior and most superior hernia was 18 cm.

We have been unsuccessful in appealing. Is anyone receiving similar denials?

 

[iowagirl77]

There is a great article in Healthcare Business Monthly July 2023 on hernia repair coding, if you haven't already read it. It states that pre-op measurements should be documented because the fascia can retract during the repair and the measurement would be falsely elevated, so I can see Humana's point. Humana might pay for the lowest level without having the pre-op measurements, so you may need to submit a corrected claim with a lower level to get reimbursed at all since appeals have been unsuccessful. Hopefully the provider(s) can be educated to document it pre-op in the future.

 

[arkassabaum]

There is a great article in Healthcare Business Monthly July 2023 on hernia repair coding, if you haven't already read it. It states that pre-op measurements should be documented because the fascia can retract during the repair and the measurement would be falsely elevated, so I can see Humana's point. Humana might pay for the lowest level without having the pre-op measurements, so you may need to submit a corrected claim with a lower level to get reimbursed at all since appeals have been unsuccessful. Hopefully the provider(s) can be educated to document it pre-op in the future.

We've been dropping to the lowest level if denied. Our concern is the majority of providers are not specifically stating the measurement was taken prior to opening the defect, but rather just the defect size itself which is often noted in his/her "findings" Coders are pushing back stating only the defect size is required for coding and they assume when a provider gives them the defect size that it is sufficient. We are working with providers for documentation improvement, but it is slow going.