you are correct, you will have to do an appeal (I had to every time) below is the type of appeal letter i would send. good luck
Policy #:
Name:
DOB:
Claim #:
DOS:
This letter is in reference to a denial of payment on the above patient.
We feel you have denied this claim in error. The coding department at ____________________billed CPT code 59855 and ICD-9 code 632 per CPT and American College of Obstetricians (ACOG) guidelines.
The patient had fetal death/demise/anomalies and delivered at ___weeks ___days gestation. The labor was induced with use of Cytotex, not surgically treated, delivered vaginally and prior to 20 weeks 0 days gestation it supports the billing of 59855. Since delivery was before 20 weeks gestation the coding department cannot code a delivery code (59400-59410) per CPT and ACOG guidelines.
Although 59855 states abortion, there is a difference between therapeutic and elective. As supported with the attached documentation.
This was a therapeutic abortion.
Attached is the hospital documentation to support the procedure billed. Please review the attached documentation/guidelines that supports the billing of 59855.
59855 CPT Definition states:
Induced abortion, by one or more vaginal suppositories (e.g. prostaglandin) with or without cervical dilation (e.g. laminaria), including hospital admission and visits, delivery of fetus and secundines.
59855 Coders Desk Reference Description:
The physician terminates a pregnancy by inducing labor with vaginal suppositories. Before using the suppositories, a laminaria, which is an applicator made of kelp or synthetic material, may be inserted in the cervix to soften and expand the cervical canal. Once the cervix is ready, the physician inserts the vaginal suppositories and labor usually results. The fetus and placenta are delivered through the vagina.
CPT Assistant Definition of Induced Abortion:
Both Therapeutic and Elective abortions may be classified as induced abortions. Therapeutic abortion is the termination of pregnancy before the time of fetal viability for medical indications. Elective abortion is the interruption of pregnancy before viability at the request of the woman.
632 Missed Abortion definition:
Early fetal death before completion of 22 weeks? gestation with retention of dead fetus.
Retained products of conception, not following spontaneous or induced abortion or delivery.
According to the above stated information and supporting documentation attached this claim does need to be re-processed and paid according to the fee schedule.
Thank you for your time.