Wiki Help - i need some guidance!!!

[tori_ryan24]

Hi Everyone, I am a coder in Urology and I need advice on a scenario that was presented to me by another clinic.

Provider "A" wants to do a Transperineal Saturation Biopsy (55706) on a patient with BCBS of GA (private payer) insurance coverage. We go through all the motions of pre-cert. We ask specifically about 55706 - Template Guided Saturation Biopsy TransPERINEAL approach - and we get approval, not to mention that is part of our fee schedule with them for payment. The procedure is done and we bill it out. The claim comes back denied for CO55- this procedure is not payable bc it is deemed investigational or experimental. ????

Now, Provider "A" is speaking with Provider "B" in passing:

Provider "B" tells Provider "A" that he can still do the procedure and just bill it as a 55700 - TransRECTAL prostate biopsy - instead of the 55706 - TransPERINEAL Saturation Biopsy. That is just undercoding the procedure.

I DO NOT agree with this. I do not believe that it is "true" undercoding because you have a different approach, its less invasive, less risk of infection, multiple biopsies are taken and mapped to the direct location of the cancer, and the charges are actually less for a 55706 because you do not have the added cost if the two (2) separate ultrasounds you need to complete the 55700.

I am just looking for some feedback form other coders. I am standing my ground on this but sometimes, people can make you second guess your stance. I want to make sure I am not over thinking this too much.

I will post the same question on the Urology board - I was just hoping for multiple options on this. TIA -

Tori

 

[mitchellde]

You cannot use codes for procedures not performed. You can code only that which is documented. To intentionally code a procedure code that is not documented just to obtain payment is a false claim submission. If they approved it and then denied it, perhaps it is a problem with the diagnosis.

 

[tori_ryan24]

They are getting their pre-cert for the 55706 - with dx 790.93 which is correct. But once the claim is submitted, BCBS is denying it as investigational or experimental and no payment is made (the code denial is CO55). So it is not an issue of the wrong diagnosis - the insurance carrier just does not want to pay for the test.

I agree with you that is wrong to do what I presented in said scenario. I am just trying to get some other coders input as backup. I can not find specific documentation of what "under coding" means with examples to explain to the physician; so it is just making it harder. I was hoping for insight from here has my supporting documentation.

Thank you so much!

 

[JEYCPC]

Have you called the carrier? Or written an appeal? Perhaps the ins co made an error? Looks like 55706 has been around quite a while.