Wiki Surgical Laparoscopic procedure with diagnostic Sigmoidoscopy

[jewlz0879]

Gastro coding is not in my wheelhouse, so I'm reaching out for a bit of help.

A physician performed CPT 44208 and CPT45330.

CPT 45330 has been denied as inclusive to CPT 44208 as 'REIMBURSEMENT INCLUDED IN ANOTHER CODE PER CMS/AMA/MEDICAL GUIDELINES.'

Encoder shows no NCCI edits for these codes. My thought is that the surgical laparoscopy includes the diagnostic sigmoidoscopy, but I'm not sure.

Can these two CPT codes be reported together? If not, please provide feedback on why.

This was denied by Ambetter.

I appreciate any feedback.

 

[thomas7331]

Gastro coding is not in my wheelhouse, so I'm reaching out for a bit of help.

A physician performed CPT 44208 and CPT45330.

CPT 45330 has been denied as inclusive to CPT 44208 as 'REIMBURSEMENT INCLUDED IN ANOTHER CODE PER CMS/AMA/MEDICAL GUIDELINES.'

Encoder shows no NCCI edits for these codes. My thought is that the surgical laparoscopy includes the diagnostic sigmoidoscopy, but I'm not sure.

Can these two CPT codes be reported together? If not, please provide feedback on why.

This was denied by Ambetter.

I appreciate any feedback.

View attachment 5884

You're correct that there are no NCCI edits between these two codes, but then, not all payers follow NCCI and some use their own logic. Apparently Ambetter considers the sigmoidoscopy to be incidental. Without knowing their policies and the edit system, I don't know if they will allow a modifier or not (and without seeing the documentation, I can't say if a modifier would be supported). It's an unusual combination of procedures, but my thought is that if the physician is using the sigmoidoscopy as an integral part of the more extensive procedure, it's unlikely that this payer would accept your use of a modifier and/or allow a separate payment for this. On the other hand, if it was done in a separate operative session or for an unrelated reason, then if may be worth rebilling with a modifier and/or submitting and appeal with records.

 

[bethb]

Gastro coding is not in my wheelhouse, so I'm reaching out for a bit of help.

A physician performed CPT 44208 and CPT45330.

CPT 45330 has been denied as inclusive to CPT 44208 as 'REIMBURSEMENT INCLUDED IN ANOTHER CODE PER CMS/AMA/MEDICAL GUIDELINES.'

Encoder shows no NCCI edits for these codes. My thought is that the surgical laparoscopy includes the diagnostic sigmoidoscopy, but I'm not sure.

Can these two CPT codes be reported together? If not, please provide feedback on why.

This was denied by Ambetter.

I appreciate any feedback.

View attachment 5884

What was the reason for the sigmoidoscopy? If it was done to check the patency of the anastomosis, then it should not be reported separately.