Wiki Help! Denials for using 00790 v 00840 during a hemicolectomy.

[TanyaJ]

We are getting a bunch of denials from a certain carrier because they state we should be using 00840 instead of 00790 for hemicolectomy/colectomy.

One specific case the mid transverse colon is where the tumor was and that is where the primary work was done. The only mention of the sigmoid is when "the white line of Toldt was taken all the way down into the sigmoid" to free the area up.

The ASA crosswalk points to 00790 and only use 00840 when work was exclusively done on sigmoid or rectum.

We have never had this issue before. Are we missing something? Has anyone else had this problem recently and how did you prove your case?

 

[LeslieJ]

Hi TanyaJ,

Sounds to me like your payer(s) has installed an edit in case physicians were over-coding their claims! They will place the burden of proof onto the physician, rather than simply paying on the claim. Ugh, right?

You're going to have to send appeals over, likely, until the people on the other end get educated. Although I believe payers are getting better at this sort of thing, please understand that those who are on the first level of adjudication aren't usually coders and they're certainly not usually educated in anatomy!

If you've got a lot of denials from a particular payer, it may be in your best interest to collect your notes, get your anatomy pictures out & show why 00790 is better than 00840 on those procedures. Make your case similar to the way you did in your post. Then, contact your payer representative & see if he/she can help you get this sorted out and work on a plan on how these arbitrary denials can be circumvented in the future. Y

It could be as simple as that & it might take a little while until things get sorted out, but it will be a relief when you can finally cut through this kind of stuff. You will see results when you work with your payer rep.

Leslie Johnson, CPC