Wiki Correct Coding of Breast Reconstruction Revision

[stefishel32]

I am needing some help or direction to some additional resources to ensure this procedure is coded and billed correctly.

The back story: my preauth rep received a request from the surgical dept to get a preauthorization for a revision of left breast reconstruction. She contacted the patient's insurance and had code 19380 (revision of reconstructed breast) preapproved. Fast forward to surgery day and when it comes time to enter the charges and our coding team reads the op report there is documentation of creation of a pocket in the chest wall and placement of a tissue expander. Due to these details, we code the procedure as 19357. The claim is sent and insurance denies because this code was not preauthorized.

Now the A/R manager wants us to do a corrected claim with the original code (19380). Her argument is that we did do a revision of a breast reconstruction so why can't we use this code? My hesitation lies in the fact that it is my understanding that we always code to the highest accuracy and code 19357 MORE accurately represents what was actually done. Is it considered downcoding to use the preauthorized code to bill this procedure? I am against it. It doesn't feel right to me, but I need more than my gut to take back to her as a reason to take the substantial financial loss. Any help would be greatly appreciated. Thanks!

 

[Hockeyjo]

Go to the fee schedule for the insurance carrier (or CMS.gov) to plug in each code to see what the carrier (or Medicare) allows for each code. Print them off for the provider. The provider's office can also call the insurance company to update the preauth code since this is not an uncommon occurrence with surgeons. Also on CMS.gov there are guidelines on how to use their online tools, it does require some digging sometimes, but worth it, especially the NCCI edit tool. I hope this helps!