Saturday, June 26, 2004

Jacob tells a tale of spending 90 minutes on his day off on the phone attempting to get $59 worth of reimbursement. All because he used a "mental health" ICD-9 code. The ICD/CPT coding system is complex and difficult to use, especially in the evaluation and management arena. What separates a high-complexity initial inpatient visit versus a moderate one? Even the experts have difficulty reaching agreement. As surgeon, however, I have many problems with the procedural codes (10021-75996). That is about 250 pages in the 2004 CPT guide. There are many procedures that have been performed for several years (laparoscopic ventral herniorraphy and laparoscopic colectomies) that have no specific CPT codes. If, for example, I perform a laparoscopic ventral hernia, and use CPT 49659 (Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy,herniotomy), the claim will be denied. So the open repair code (49560) and mesh implantation (49568)is used, and this usually insures payment. Payment for supervision of conscious sedation (99141), used when attempting to reduce a hernia, is frequently denied. The basis is that I am not an anesthesiologist. The use of ultrasound in the evaluation of the trauma patient is widely accepted. Yet my submission of the code for a FAST exam (76705) is routinely denied. I guess they would rather pay thousands for a CT scan.
My partner attends coding conferences where he is told that insurance companies will not open their mail on Thursday or Friday on the oft chance that a claim will lapse. Medicare and Medicaid a often no better, as the last two examples above were Medicare/Medicaid denials. Much like Jacob, my practice writes off thousands of dollars. Payers deny claims because they know that not every physician is going to take the time, or go through the effort, to collect that fifty-nine dollars.
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