Wiki Billing units for C1776

[Lois Helms]

Hello,

I wanted to pose a question related to facility billing of C1776 for Total Knees and Total Hips. How many units of the C1776 is appropriate/allowed to be billed for a knee and how many for a hip?

Thank you !!

 

[coderfromtexas]

I came on to the AAPC website to pose a similar question. We are getting a post payment review refund request when we are billing more than two units of C1776. This denial really doesn't make any sense to me as there are more than one components that are used together to make each side of the joint. This is a new denial we have been getting from Humana, but only after post payment record review. They are stating that the medical record doesn't support 4 units of C1776, even when we send the implant log and explain there are components that are used together. I appealed and their decision was upheld. Anybody have any additional advice? Thank you!

 

[thomas7331]

I came on to the AAPC website to pose a similar question. We are getting a post payment review refund request when we are billing more than two units of C1776. This denial really doesn't make any sense to me as there are more than one components that are used together to make each side of the joint. This is a new denial we have been getting from Humana, but only after post payment record review. They are stating that the medical record doesn't support 4 units of C1776, even when we send the implant log and explain there are components that are used together. I appealed and their decision was upheld. Anybody have any additional advice? Thank you!

Medicare list a MUE value of 10 for this code. If Humana has its own policy or contractual requirements for this code that would justify denying it for the number of units, they should be able to point you to that and not be arbitrarily denying your claim.

Even so, I know of very few reimbursement methodologies where the number of units on a facility claim line item has an impact on the calculation of payment for an outpatient facility claim. Unless you have a carve-out in your contract for separate payment for implants where this denial would cause an underpayment, it's unlikely this is making a difference in your reimbursement.

 

[coderfromtexas]

Thank you for your response! Humana is citing Coding Clinic for HCPCS Q1 2020 and Q4 2021 that C1776 is a joint device that functions as its natural counterpart. As such, other hardware and accessories placed at the time of a joint replacement are not applicable under C1776 and will not be reimbursed.

They would pay more than two if there was more than one joint replaced, so I don't think the MUE value being 10 will change their response to the denial. I read the Coding Clinic referenced above, and I don't interpret it the way Humana is. We have had other post payment reviews of these same surgeries with no denials, so I'm not sure if this is something new and was wondering if others are experiencing the same.

We are CAH and paid on a percentage of charges, so they are expecting us to send the money back. I can take two of the units and add them to the 270 revenue code with no HCPCS, and they would have to pay a percentage of that too. If we decide to let them recoup the money, can I send a corrected claim after that? Or should a corrected claim be part of my appeal?

 

[thomas7331]

Thank you for your response! Humana is citing Coding Clinic for HCPCS Q1 2020 and Q4 2021 that C1776 is a joint device that functions as its natural counterpart. As such, other hardware and accessories placed at the time of a joint replacement are not applicable under C1776 and will not be reimbursed.

They would pay more than two if there was more than one joint replaced, so I don't think the MUE value being 10 will change their response to the denial. I read the Coding Clinic referenced above, and I don't interpret it the way Humana is. We have had other post payment reviews of these same surgeries with no denials, so I'm not sure if this is something new and was wondering if others are experiencing the same.

We are CAH and paid on a percentage of charges, so they are expecting us to send the money back. I can take two of the units and add them to the 270 revenue code with no HCPCS, and they would have to pay a percentage of that too. If we decide to let them recoup the money, can I send a corrected claim after that? Or should a corrected claim be part of my appeal?

I'd agree with you and payers can sometimes be knuckleheads. They aren't disputing that you charged for the devices, only that you used this particular HCPCS code for devices that shouldn't have been coded this way, if I'm understanding correctly. So yes, you could roll those charges into any of your supply or surgical charge codes, or use a different code such as L8699. Good luck.