Wiki Joint Replacement Assistant Surgeon Billing question

[pjenack@gmail.com]

Good Morning,

Was wondering if anyone else has run into this issue and can assist me. MC recently retracted a payment for the charges for joint replacement surgery due to " the service on the original claim was not considered medically necessary. This decision is based on either the documentation that was submitted or the failure by the physician /supplier to furnish information that was requested to support the claim.

I bill a claim for the surgeon fee and I also bill a separate claim for the assist charge with the AS modifier. I've not had this problem in the past. I'm wondering if something has changed that I need to bill both services on the same claim or if the issue is that the Surgeon is not documenting enough information that MC feels the assist was not medically necessary. The operative report as well as conservative treatment progress notes were submitted for review.

Thank you for your thoughts on this issue
Paula J

 

[kkalani]

Good Morning,

Was wondering if anyone else has run into this issue and can assist me. MC recently retracted a payment for the charges for joint replacement surgery due to " the service on the original claim was not considered medically necessary. This decision is based on either the documentation that was submitted or the failure by the physician /supplier to furnish information that was requested to support the claim.

I bill a claim for the surgeon fee and I also bill a separate claim for the assist charge with the AS modifier. I've not had this problem in the past. I'm wondering if something has changed that I need to bill both services on the same claim or if the issue is that the Surgeon is not documenting enough information that MC feels the assist was not medically necessary. The operative report as well as conservative treatment progress notes were submitted for review.

Thank you for your thoughts on this issue
Paula J

Check if there is an LCD for the denied CPT code. There may be specific diagnosis that support medical necessity or it’ll indicate what is needed in the documentation to support medical necessity. Medicare should also send out a letter that gives additional info on why it was recouped.

 

[pjenack@gmail.com]

Check if there is an LCD for the denied CPT code. There may be specific diagnosis that support medical necessity or it’ll indicate what is needed in the documentation to support medical necessity. Medicare should also send out a letter that gives additional info on why it was recouped.

MC had paid both claims, Surgeon claim and Assist claim - Surgery was Hip replacement w/ dx code meeting medical necessity on LCD list. MC retracted Surgeon payment after reviewing all documentation. We did receive a letter with the denial reason documented in my question.
As a coder, I'm reading as that the surgeon needs to document better on what the assist performed, but I reviewed the operative report and it is very detailed what the assistant did and why he was needed for the procedure. As a biller I question how the services are billed out on the claim. The assist in this case is a Physician's Assistant.
I'm wondering if I should code for both Provider's on the same claim rather than on two separate claims.
The assist in this case is a Physician's Assistant.
Thanks for your thoughts
Paula J

 

[amyjph]

You should not bill them both on the same claim. But, there are too many variables as to why they could have taken it back. I always start with the basic questions: correct modifiers (RT/LT), does the laterality of the modifier match the laterality of the diagnosis code, does the diagnosis code match the op note and is it the correct joint? (I have seen coders accidentally code hip for knee, or wrong laterality, etc.), You would want to go through and double check all the info on the claim versus the op note to make sure. 8/10 times it's just a typo or basic error. Like M17.11 but they put 27130 by accident or vice versa. Or let's say the patient had a primary TKA 27447 on the RT but someone accidentally coded the LT modifier.

If the payer took back the surgeon's payment, that's where you would start because of course they are not going to pay for the assistant if the primary surgeon was denied.

Another error I have seen is someone accidentally appends an AS modifier to the surgeon's claim or they don't cut the fee in half or at least reduce it for the assistant and both claims have the same exact dollar amount. I have seen denials for this too.