Wiki Surgery Auths

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LaurenBrooke

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11
Location
Rocky Mount, NC
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Curious-

Has anyone had surgery auth denials for final coding not being what was anticipated and auth'd prior to surgery that they've appealed successfully?

Example:
Surgery paperwork may states "Knee arthroscopy, diagnostic, meniscectomy"
CPTs: 29870, 29881 called on/submitted for surgery authorization by surgery schedulers.

DOS provider gets in the knee and a meniscal repair is done rather than a meniscectomy.
CPT: 29882 billed

Denies no auth on file and *will not retro auth*. Does not drop PR.
Office is requesting an appeal stating the auth we had on file was the anticipated surgery and it changed once surgery started. -Fair, but has this approach worked for payers who do not retro?

(will also post in billing forum)
 
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I have had some success appealing, explaining that the changes could not be anticipated because is was decided during surgery based on the doctors findings during that surgery. I don't always have success, but there have been times where sending a letter explaining what was planned, and why it changed has gotten the surgery reimbursed.
 
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Same has happened at our ASC, authorization for a certain CPT code, actuallly coded a CPT not included in auth. Unless you catch it a day or 2 later, I have had no luck in getting these claims paid, appeals upheld their denials.
 
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For the pro fee side, this happens to us all the time. Maybe laparoscopic converted to open, or frozen section comes back malignant so more extensive procedure is done. I would say at least 90% of the time, it gets paid with no intervention from us. For the 10% of the time it is denied, an appeal letter along with the op note is all that was needed. In 16 years of billing for surgeries, maybe 10 times we were not able to get payment.
It might be different for ASCs.
 
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We had the same issue with meniscus surgery denials. If there is a meniscus tear, we ask the scheduling team to preauthorize a repair and also the meniscectomy in case the repair can't be performed. If they get flack from whoever they are talking to and both with not be authorized, we ask they push the issue and at least get it documented that they tried. Seems to be working.
 
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For my type of surgeons (gyn onc), there's too many possible things that could take place it would be impossible to auth every possible.
FYI - Here's an appeal letter that did get paid on appeal.
Please be advised this is a letter of appeal for the above claim. Services were rendered by Dr. XXXX for Ms. ZZZZ that were not processed or paid correctly. Our office billed CPT 58561 (hysteroscopy, surgical, with removal of myoma) which denied with remark PSX,, "Service denied for no authorization or does not match the authorization obtained." Our office did request authorization for CPT 58558 (hysteroscopy, surgical, with sampling of endometrium and/or polypectomy, with or without D&C) at which time we were informed no authorization was required. During the initial procedure (CPT 58558) the entire uterine cavity was inspected and the surgeon determined the need to proceed with removal of a mass. Therefore, it was necessary to bill CPT 58561. The decision to remove the myoma was during the initial procedure, and therefore should be payable.
I have included a copy of the operative report. I am certain after review that you will agree the claim should be reconsidered for payment. If you have any further questions or issues, please reach out to me at ###-###-#### or email: email@email.com. Thank you in advance to your prompt resolution of this matter."
 
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LaurenBrooke said:
Curious-

Has anyone had surgery auth denials for final coding not being what was anticipated and auth'd prior to surgery that they've appealed successfully?

Example:
Surgery paperwork may states "Knee arthroscopy, diagnostic, meniscectomy"
CPTs: 29870, 29881 called on/submitted for surgery authorization by surgery schedulers.

DOS provider gets in the knee and a meniscal repair is done rather than a meniscectomy.
CPT: 29882 billed

Denies no auth on file and *will not retro auth*. Does not drop PR.
Office is requesting an appeal stating the auth we had on file was the anticipated surgery and it changed once surgery started. -Fair, but has this approach worked for payers who do not retro?

(will also post in billing forum)
Click to expand...
This just frustrates me. There is NO WAY that a doctor can know beforehand that the patient will have a meniscus repair. It's just not possible. Google an MRI of a torn meniscus. See if you can identify a meniscus tear that will need debridement vs repair. I would ask the insurance company if they have someone there who is capable of looking at an MRI and can accurately identify if a repair is the correct treatment or just debridement (29881). Over the years I have seen surgical plans change once the surgeon was able to get in and see the entire joint. Most of the time changes are minor, but I have seen others have changed drastically, but it's all based on what the surgeon finds when they get in there.
 
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We ask the doctors to provide all possible surgery codes on authorization requests so that if they have to perform one or the other, they are covered. It's very common, for example to anticipate a medial meniscus tear, and when they perform the surgery they also see a lateral meniscus tear. We have the doctors request 29881 and 29880.
 
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TPeniston61 said:
We ask the doctors to provide all possible surgery codes on authorization requests so that if they have to perform one or the other, they are covered. It's very common, for example to anticipate a medial meniscus tear, and when they perform the surgery they also see a lateral meniscus tear. We have the doctors request 29881 and 29880.
Click to expand...
Do you routinely pre-auth 29882 for the repair as well?
 
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