The Art of AppealsPresented by Lori Dafoe, CPC

Agenda•Review what to look for in an appeal, while reviewing an actual example.

•Review different appeal process for various insurance carriers.

•Review additional examples.•Questions

Understand:•Understand the denial.•Understand what your provider is billing and why.

•Understand basic coding principles.

•Understand the carrier’s requirements.

•Understand your rights.

APPEAL•Ask•Probe•Provide Evidence•Explore•Affirm•Link

Ask•Why is the claim being denied?

•NEVER assume.

Date Proc MD Chg Allow Pymt Adj GRP REM

12/23/2013

92928 RC $1,000 $0 $0 $1,000 CO 45

12/23/2013

92928 LC $1,000 $0 $0 $1,000 CO 203

12/23/2013

93458 59 $625 $625 $625 $0 CO 203

ASK

Reason Code(s):

45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.

203 Discontinued or reduced service.

CO Contractual Obligations

ASK

ASK•Actual reason for non-payment: Prior authorization required.

Probe•Research to make sure it was billed correctly.

Probe•Review documentation for appropriate

coding.

•Check for authorization.

•Review medical policy

Provide Evidence•Use Medical Policy to refute denial.

•Provide evidence to support your stance (clinical studies, CPT Assistant Articles, etc.)

Provide Evidence

•Knowledge of procedure.

•Policy allows payment for drug eluting stents under certain conditions.

Explore•Know the specific carrier’s appeal process.

Explore

•Complaint can be made verbally or in writing. If submitting in writing, specific cover sheet/form must be completed.

•Level 1 Appeal may be submitted verbally or in writing.

•Complaint and Level 1 must be submitted within 365 calendar days from the initial process date.

Appeal Letter•Patient X underwent an angiography with left heart catheterization and subsequent stenting of the right coronary and left circumflex (obtuse marginal branch). Your company has denied payment for the stenting based on a policy that indicates prior authorization is required. The purpose of this letter is to request a review of the claim based on medical necessity, and to ask that this policy for prior authorization be assessed and revised.

Appeal Letter•First, please note that although prior

authorization was not obtained, this service was medically necessary. The patient has a prior history of quadruple coronary bypass grafting and stenting to the right coronary artery. He presented to follow up from a hospitalization where he had experienced new onset symptoms of unstable angina. Due to his history, symptoms, and the fact that he lives 133 miles away from adequate treatment (Forks, WA), it was determined that stress testing would not be prudent, and the heart catheterization was scheduled.

Appeal Letter•Secondly, the policy indicates that drug-eluting stents are considered medically necessary when stents the length of 15mm or longer are placed in a single vessel, or for treatment of left main coronary disease. The patient met both of these criteria. The operative and prior office notes are included for your review.

Appeal Letter•Finally, we would like to request a Medical

Review of the policy in question (also attached for your review). Prior authorization for this service is not feasible. The provider does not know if stenting will be required until after the angiography/heart catheterization is performed, nor can he tell where a possible blockage may be or what percentage the vessel is occluded. To either stop the procedure to obtain prior authorization when needed, or stop the procedure, obtain prior authorization, and reschedule the stenting would put the patient at greater risk for complications.

Appeal Letter•For these reasons, we ask that you reconsider

payment for our claim, and revise the policy to allow adequate care for our patients, your beneficiaries. After careful consideration of the medical record and supporting documentation we anticipate the reversal of your initial decision and issuance of payment in full for our claim. If you have any questions or require further information, please contact me. Should you choose to deny this request, I ask that you send written documentation including the criteria and/or guidelines used to make your determination.

Affirm•Follow up! •Take next step as needed.

Affirm•Level 2 Appeal MUST be submitted in writing

and received within 15 calendar days from the receipt of the Level 1 appeal denial

•Level 3 Mediation. Non-binding mediation may be requested if there is a disagreement with the second level of appeal. Mediation request must be submitted in writing and received within 30 calendar days from the Level 2 appeal notification. Mediator fees are shared equally between both parties.

Link•Document in the patient’s account what you have done to resolve the claim.

Link

•01/14/14 Spoke to insurance rep. She could not explain reason for denial. Will send back for reprocessing. Biller A

•01/18/14 Rec’d voice mail from insurance. States denial was for no authorization. To coder for review. Biller A

•01/25/14 Biller reviewed, coding accurate, planned procedure, no auth obtained. To compliance for review. Coder A

Link

•01/25/14 Compliance reviewed, coding correct, auth not obtained but service was medically necessary. Disagree with prior auth policy. Letter of appeal drafted and given to Biller A to submit. Compliance Analyst A.

•02/27/14 Appeal 1 denied. To Compliance for review. Biller A.

•02/28/14 Advised Biller A to submit Level 2. Compliance Analyst A.

Link

•03/21/14 Level 2 appeal denied. To Compliance for review. Biller A.

•03/21/14 Spoke with provider representative regarding Mediation. Would like peer-to-peer review between our cardiologist and insurance medical director. Rep will call back to schedule. Compliance Analyst A.

•03/27/14 Rep called back, peer review scheduled for 04/09/14 @8am. Compliance Analyst A.

Link

•04/09/14 Peer-to-peer review completed. Medical Director agreed. Will overturn denial and allow payment. Will also take this to higher level to make sure prior authorization policy for cardiac services is reviewed and modified. Reference number for call #1234 given to help with any other denials we may receive until policy is updated. Compliance Analyst A.

APPEAL•Ask•Probe•Provide Evidence•Explore•Affirm•Link

Appeal Process by Carrier•Aetna•Cigna•KPS•Medicare•Premera •Regence•United Healthcare

Aetna, cont.•Timeframes for reconsiderations and

appeals:

AetnaHealth care providers can use the Aetna dispute and appeal process if they do not agree with a claim or utilization review decision.The process includes:• Reconsiderations: Formal reviews of claims

reimbursements or coding decisions, or claims that require reprocessing.

• Level 1 appeals: Requests to change a reconsideration decision, an initial utilization review decision, or an initial claim decision based on medical necessity or experimental/investigational coverage criteria.

• Level 2 appeals: Requests to change a Level 1 appeal decision.

Aetna, cont.To help us resolve the dispute, we'll need:•The reasons why you disagree with our decision

•A copy of the denial letter or Explanation of Benefits letter

•The original claim•Documents that support your position (for example, medical records and office notes)

Aetna, cont.•Must have

member complete a form if filing an appeal on behalf of the member.

• http://www.aetna.com/faqs-health-insurance/documents/Authorized-Representative-Request-Form.pdf

Aetna, cont.•Mailing address for reconsiderations for WA:

Aetna Provider Resolution TeamPO Box 14079

Lexington, KY 40512-4079

http://www.aetna.com/health-care-professionals/disputes-appeals/disputes-appeals-overview.html

Cigna•Time frame: 180 days

Cigna•Requests for Claim Processing Error/Missing Information vs. Payment Appeal Process

Type of Claim Address/Fax/PID Guidelines

Corrected Claim Paper: Address on back of card.Electronic: Submit to Payer ID original claim was submitted to

Paper: Claim form with remarks .Electronic: Update Claim Frequency code.

Timely Filing Denial Submit to claim address on back of card.

Valid proof of timely filing, such as the EDI Acceptance Report for electronic claim(s), etc.

Duplicate Submission

Submit to claim address on back of card.

EOB or Claim Control # of claim being disputed.Reason for disputing claim.

Incomplete Submission

Submit to claim address on back of card.

EOB or letter requesting additional info.Additional info, such as op report, test results, etc.

http://www.cigna.com/assets/docs/health-care-professionals/MM_002_appeal_request_for_provider_payment_review.pdf

Type of Claim Address/Fax/PID Guidelines

No Authorization Cigna ID: National Appeals Unit (NAO) PO Box 188011, Chattanooga, TN 37422

Great-West ID: Great West Healthcare PO Box 188062, Chattanooga, TN 37422-8062

Send EOB, Supporting documentation, Reason preventing prior-auth from being obtained, Completed Health Care Professional Payment Form (medical necessity)

Medical Necessity Cigna ID: National Appeals Unit (NAO) PO Box 188011, Chattanooga, TN 37422

Great-West ID: Great West Healthcare PO Box 188062, Chattanooga, TN 37422-8062

Send EOB, Supporting documentation as to why decision should be overturned, such as op reports, medical records, etc, Completed Health Care Professional Payment Form (medical necessity)

Type of Claim Address/Fax/PID Guidelines

Mutually Exclusive, Incidental, Bundling Denials and Modifier Reimbursements

Cigna ID: National Appeals Unit (NAO) PO Box 188011, Chattanooga, TN 37422

Great-West ID: Great West Healthcare PO Box 188062, Chattanooga, TN 37422-8062

Sent documentation that supports by the decision should be overturned, such as operative reports, medical records, etc, Complete Health Care Professional Payment Appeal form

Contract/Fee Schedule Dispute

Cigna ID: National Appeals Unit (NAO) PO Box 188011, Chattanooga, TN 37422

Great-West ID: Great West Healthcare PO Box 188062, Chattanooga, TN 37422-8062

Sent specific contract element you disagree with and a copy of the contract page, Complete Health Care Professional Payment Appeal form

Type of Claim Address/Fax/PID Guidelines

Benefit Exclusion, Limitation, Administration (i.e., copay, deductible, etc)

Cigna ID: National Appeals Unit (NAO) PO Box 188011, Chattanooga, TN 37422

Great-West ID: Great West Healthcare PO Box 188062, Chattanooga, TN 37422-8062

Sent documentation supporting why decision should be overturned, such as operative reports, medical records, Complete Health Care Professional Payment Appeal form.

High Tech Radiology (HTR) and Nuclear Cardiac Services

MedSolutions730 Cool Springs Blvd, Ste 800Franklin, TN 37067

Sent documentation supporting why the decision should be overturned, such as op reports, medical records, and reason preventing you from obtaining prior authorization.

Cigna/MedSolutions

•Access to Imaging Guidelines requires login.

•https://www.medsolutionsonline.com/portal/server.pt/community/medsolutions_online/223

Chest CT Denied (71260)•PSR called Cigna, was told no authorization needed. Given reference number for call.

•Claim denied for no authorization.•Two-fold appeal:1.) Cigna Rep said no auth required.2.) Service was medically necessary.

Chest CT Denied (71260), cont.

•Med Solutions denied as service would not have been authorized based on their clinical guidelines.

•Cigna denied because service was not authorized.

Chest CT Denied (71260), cont.•We are in receipt of a letter denying our appeal for a CT of the thorax with contrast.  The letter admits that there were extenuating circumstances that prevented pre-certification in a timely manner, but continues to deny based on medical necessity.  This letter indicates that this is the final internal level of appeal.  We disagree with the manner in which this claim has been handled and are requesting special dispensations regarding this unique claim situation.

Chest CT Denied (71260), cont.• Please note that our scheduler contacted Cigna’s provider

customer service team to request prior-authorization information.  The representative mis-quoted the patient’s benefits.  We were told that no prior authorization was required as the customer service representative sees this group in your Medical module as PHS, which does not require an authorization.  However, upon further investigation it has been determined that this group is actually PHS plus, which does require an authorization.  We were told to request an authorization from Med-Solutions, which we did.  This was denied as Med-Solutions does not allow retro-authorizations.  We then appealed the service with Cigna, and the denial indicates the service was considered not medically necessary.  It further states that claim payment policies do not allow for consideration of medical necessity once the procedure has been completed except for cases considered urgent with supporting documentation presented for review by the Medical Director. 

Chest CT Denied (71260), cont.•First of all, I understand that Cigna requires prior authorization from MedSolutions, and we have done our best to educate all staff members of this.  However, in this instance the employee was covering in the department and was not aware of this protocol specific to Cigna.  As such, she called the telephone number on the back of the patient’s insurance card and was subsequently given erroneous information.

Chest CT Denied (71260), cont.•Secondly, please note the patient, who had

already been evaluated in the Emergency Department, presented with complaints of shortness of breath, and chest pain.  Due to the patient’s symptoms and family history of pectus excavatum, Dr. Dawson ordered a CT of the thorax with contrast.  Attached, please find a medical journal supporting the testing for this condition.  I have also attached a copy of the patient’s office visit and subsequent CT results.  I have also included a copy of the front and back of the insurance card, which you can see does not specify MedSolutions must be contacted for prior authorization of services.

Chest CT Denied (71260), cont.

• I understand that MedSolutions does not consider this test to be medically necessary, but our physician did.  Additionally, I have provided a clinical case study in which CT is considered the best diagnostic tool for symptomatic patients at rick of PE to estimate the deformity and whether there are associated anomalies.

• In this instance, to not allow a peer-to-peer review because the service was already performed is unfair.  The service was performed in good faith, based on the information given by the staff at Cigna. 

• For these reasons, we are asking that the Medical Director review this and after careful review of the medical record and supporting documentation, we anticipate the reversal of your initial decision and issuance of payment in full for our claim.  Should you choose to deny our request, I would like for you to send documentation outlining our right to an independent review organization (IRO). If you have any questions, or need additional information, please do not hesitate to contact me.

Cigna, cont.•Additional Appeal Options: Arbitration

KPS•Information can be found on the paper remits, or on the KPS website in the provider portal, under the 2014 KPS Practitioner Manual

•Timeframe: 30 days

•Good Faith Discussions

KPS, cont.•Formal Appeal•Address:

KPS Health PlansAttn: Provider Complaints c/o Provider RelationsPO Box 34262Seattle, WA 98124-1262

KPS, cont.•Mediation •Address:

KPS Health PlansAttn: Mediation c/o Provider RelationsPO Box 34262Seattle, WA 98124-1262

Layered Closure, CPT 12051 & 12031

•KPS denied claim for intermediate repair of the cheek (12051) as being included in the intermediate repair of the scalp (12031-59).

•Although the codes themselves ARE bundled, a modifier is allowed and was used appropriately.

Layered Closure, CPT 12051 & 12031

•We are in receipt of a letter from your company denying the charge for the intermediate cheek repair. The remittance indicates that the claim for the intermediate repair of the cheek (12051) was denied as being included in the charge for the intermediate repair of the scalp (12031). The purpose of this letter is to request an appeal of that determination.

Layered Closure, CPT 12051 & 12031• As documented in the operative note, the patient had

two cysts removed from the scalp requiring intermediate repair; and one cyst removed from the face requiring intermediate repair. Per coding guidelines, a code for each excision was billed, with the intermediate closures reported separately. Also in accordance with coding guidelines, the sum lengths of the repairs from the same anatomic site and same classification (intermediate repairs of the scalp) were added together to report the correct wound repair code (12031). However, although the other repair was also intermediate in complexity, the repair on the face is listed under a different grouping of anatomic site and was therefore reported with CPT 12051. Since these repairs were of two separate anatomic sites, requiring additional work, they should be reimbursed separately.

Layered Closure, CPT 12051 & 12031

•Attached, please find a copy of the medical record. After careful review of the medical record and supporting documentation we anticipate the reversal of your initial decision and issuance of payment in full for our claim. If you have any questions or require further information, please contact me. Should you choose to deny this request, I ask that you send written documentation including the criteria and/or guidelines used to make your determination.

Medicare - Reopening

Medicare - Redetermination

Medicare - Reconsideration

Medicare – Administrative Law Judge (ALJ)

Medicare – Appeals Council (Departmental Appeals Board (DAB))

Medicare – Federal Court Review

Medicare•Https://www.noridianmedicare.com/partb/•Appeals•Forms

Medicare•CPT 97597: Debridement, open wound,

first 20 sq cm or less

•ICD-9: 873.1: Complicated head/scalp wound

920: Contusion scalp

•Denied: CO-50 - Contractual Obligation. These are non-covered services because this is not deemed a “medical necessity” by the payer.

Medicare•Diagnoses listed is NOT on the LCD;

however, the LCD specifically states, “CPT 97597 and 97598 may be used for medically reasonable and necessary debridement when utilized consistent with this LCD and within the scope of the performing provider”.

Medicare1. The service was medically necessary2. The procedure performed was consistent

with the guidelines of the LCD, even if the specific diagnosis was not listed.

3. The procedure performed was within the scope of the physician’s practice.

Medicare

•Patient on blood thinners for a heart condition, fell and hit her head resulting in devitalized tissue from a complicated open scalp wound requiring debridement down to the bone using sharp scissors.

Medicare

•Medical necessity cited as non-viable tissue can produce a noxious odor and frequently unacceptable discharge. Devitalized tissue also provides a culture medium for bacterial growth and wounds containing necrotic tissue are therefore at risk of becoming clinically infected.

Medicare• Q2 Response: The service was denied because the

facts do not support a payable condition or diagnosis based on LCD.

• You billed 873.1 for open wound of the scalp is not a covered condition for this treatment according to LCD L24374. Your records did support debridement of an open wound an apparent devitalized tissue. Although the diagnosis was not listed in the LCD, the records support the services were reasonable and necessary for the care and treatment of the beneficiary. Therefore, the service can be allowed for payment as billed. The documentation supports the service was reasonable and necessary in accordance with Medicare guidelines.

PremeraResolution Level Date Requirements Response Timelines

Complaint 365 days 30 days

Level I Appeal 365 days Billing related - 30 daysNon-billing related – 60 days

Level II Appeal 15 Days from Level I decision.

15 Days

Mediation 30 Days

PremeraInformation can be

found by logging onto OneHealthPort.

Premera•CPT 92083, Extended Visual Field Test•ICD-9: 374.87 Dermatochalasis

•Denied as not medically necessary

Premera• Your company has denied our request for reimbursement

of a visual field test (CPT 92083) and external ocular photo (CPT 99285) for derrmatochalasis (ICD-9 374.87) stating the service is not medically necessary. The purpose of this letter is to request an appeal of that determination.

 • Dermatochalasis is redundant and lax eyelid skin and

muscle. Dermatochalasis can be either a functional or a cosmetic problem for patients. As in Mrs. X’s case, functional dermatochalasis obstructs the superior visual field. Because of the drooping upper eyelids, Mrs. X has complained of having lift up her eyebrows in order to see better. As the condition worsens, blepharoplasty may be required to correct this.

•  

Premera• The Premera medical policy for a blepharoplasty surgery to

correct this condition requires that the patient have documented visual defects to specific degrees. In order for us to determine the severity of Mrs. X’s visual function, we had to perform the extended visual field test (CPT 92083) and the external ocular photo (CPT 92285). Because this service was provided in relation to a functional problem and not a cosmetic service, we must ask that you reconsider payment for this claim.

• Attached, please find a copy of the medical record documenting the service provided and the subsequent findings. After careful review of the record and supporting documentation we anticipate the reversal of your initial decision and issuance of payment in full for our claim. Should you choose to deny this claim again, I would ask that you send written documentation listing the criteria used to make your decision.

Premera•Denials of medical necessity based on

“Milliman Care Guidelines”

•CPT: 58550 - Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less;

•ICD-9: 627.0 - Premenopausal menorrhagiaExcessive bleeding associated with onset of menopause

Regence•http://www.wa.regence.com/provider/clai

ms-and-billing/appeals/

•Timeframe: Within 12 months after payment of the claim or notice that the claim was denied.

Regence•Reconsideration requests for Medical and

Reimbursement policies (not related to a claim) may be submitted using the

1.) Medical Policy Review Request process

2.) Reimbursement Policy Request for Review process

•Administrative Denial Appeals

Regence

http://www.wa.regence.com/provider/library/form/docs/provider-billing-dispute-appeal-form-washington.pdf

Regence – Audit Appeal Process•Appeal form for Provider Billing Disputes

and Medical Necessity denials may be submitted via facimile to (866) 273-1820. Large documents or information sent certified should be mailed to:

RegenceAttention: Provider AppealsPO Box 1239Portland, Oregon 97207

Regence – Audit Appeal Process•Information to submit: 1.) A detailed description of the disputed

issue(s); 2.) the basis for disagreement with the decision; and 3.) All evidence and clinical documentation supporting your position.

Regence – Audit Appeal Process•A written decision on an Internal Review

of an Adverse Determination appeal will be sent within thirty (30) calendar days of receipt of all documentation reasonable needed to make the determination. A description of the External Review option will be supplied with the written decision, including the time limit for requesting External Review.

Regence – Audit Appeal Process•If initial determination is upheld, you have

the option to seek External review or one of the other dispute resolution processes. The time limit for requesting External Review is ninety (90) calendar days after the written Internal Review determination.

Regence •Voluntary binding external review•Amount in dispute must exceed $500.•Adverse Determination Appeal must be

submitted in writing.•Provider pays $50.00 filing fee for each

Adverse Determination Appeal•Fee must be submitted within sixty (60)

calendar days of notice that fee is due.•External Review Organization will process

and notify of recommendation within thirty (30) calendar days of the filing fee.

•Decision is binding on both parties.

Regence

Regence• Went through Internal Review/Appeal, requested

External Review.• Received Approval of Procedure Codes as

Submitted by Provider• Rationale for approval of code: “29822 is an

Arthroscopy, shoulder, surgical debridement, limited. 23430 is a Tenodesis of long tendon of biceps. These two procedures do not have an NCCI edict indicating that they are bundled; also they are two entirely separate procedures, one done with an arthroscope, and one with an open incision. 29822 is separately reimbursable.”

Regence AIM Clinical Guidelines•http://www.aimspecialtyhealth.com/clinical-guidelines/agreementAccess

CPT 74175: CTA, abdomen with contrast

•Claim denied as authorization number obtained was for regular CT scan, not CTA. AIM refused to retro-auth procedure.

•Regence representative said that since AIM did not make an error they would not entertain any other reason for appeal.

•Scheduler thought CT venogram was just a regular CT angiogram. As such, service was pre-authorized as a regular CT scan (CPT 74176-74178), instead of CPT 74175. Education provided to staff member, but payment should still be made for this medically necessary service.

•AIM Clinical Appropriateness Guidelines state CTA of abdomen is allowed for suspected renovascular hypertension from renal artery stenosis for patients on therapeutic doses of 3 or more anti-hypertensive medication.

• Patient presented to vascular surgeon with chronic massive lower extremity edema. Also has very difficult to treat hypertension and is currently on 5 medications.

• Exam revealed bilateral 4+ lymphadema. Right and left leg Doppler exams indicated biphasic flow. Venous ultrasound was performed and deep venous reflux was identified in the right common femoral vein. Reflux could not be noted in the right or left great saphenous vein due to obesity and edema. However, reflux was suspected because of multiple enlarged tributatries, and increased diameter of the saphenous vein and the patient’s symptoms of swelling.

•Multiple possibilities considered in the differential diagnosis of peripheral edema, including lymphadema praecox, venous obstruction, venous reflux, lymphatic obstruction. The CTA of the abdomen was ordered to determine the cause of the edema.

•No venous or lymphatic obstruction noted on CTA performed; however there was a lesion noted in the pancreatic tail, inflammatory changes in the superior mesentery and a large 3.2 cm mass in the superior mesentery that could represent an enlarged and necrotic lymph note, mesenteric metastasis, or even aneurysm.

•Because the patient had a previous pancreatic biopsy, the enlarged lymph notes were present on the CTA were worrisome for metastatic disease, the patient was referred to hematology oncology as a possibility of a retroperitoneal malignancy could manifest as lymphadenopathy.

•Although prior authorization was not obtained for the correct study, the service was medically necessary and would have been approved according to AIM’s guidelines.

UHC

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Claims%20&%20Payments/Combined_Claims_reconsideration_paper_form_and_guide.pdf

UHC, cont.•Paper Claim Reconsideration requests:

United Healthcare and United Heathcare West: Address on EOB, PRA or claim address on

back of member’s ID Card

UnitedHealthcare Empire Plan: PO Box 1600

Kingston, NY 12402-1600

UHC, cont.

•Online Claim Reconsideration – Quick Reference

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Help/ClaimReconsiderationQRC.pdf

UHC, cont.•CPT 99203-57 – New Patient, Level 3,

Outpatient•CPT 46060 – I&D of ischiorectal abscess

or intramural abscess, with fistulectomy, fistulotomy, submuscular, with or without placement of seton.

•Claim denied, and 1st Level Appeal Denied, stating services described by CPT code 99203-57 are included in the global service package for CPT code 46060.

UHC, cont.•We are in receipt of your letter denying our

Level I Appeal for an E&M service on the same day as a major procedure. The purpose of this letter is to request a second level appeal. We further ask that a board certified physician of like specialty review this claim.

•Attached, please find the documentation for the physician’s office visit. Dr. Y had to do a full work up on this patient to determine the appropriate treatment for this patient, which resulted in a major procedure.

UHC, cont.• Your letter states, “UHC considers the Current

Procedural Terminology (CPT) manual to be the industry standard reporting convention including when a physician submits multiple CPT codes for services to the same patient. However, UHC does not believe this reporting convention determines what physicians should be reimbursed in all situations… Our clinical staff has reviewed your appeal and determined that the services described by CPT code(s) 99244-57 are included in the global service package for CPT code 46060.”

UHC, cont.

•An E&M service provided the day before or the day of a major surgery that results in the initial decision to perform that surgery, should be eligible for reimbursement when modifier -57 is appended to the E&M code. A major surgery is defined as having a 90 day global period as assigned by Centers for Medicaid and Medicare Services (CMS).

UHC, cont.• It is a fact that the relative values for surgeries do not

include the initial E&M service, where the decision for surgery is made, and is therefore not included in the global service package. Additionally, according to both CPT and Medicare, the decision for surgery is not part of the surgical package and should be separately coded using an E/M code. Because the –57 modifier indicates more involved medical decision making on the physician’s part, the carrier should not take exception to paying for the separate encounter on the same date that the procedure or surgery was performed. Your letter also indicated that “UHC’s policies seek to fairly and appropriately reimburse physicians for services performed”. We ask that you follow industry standards with regard to the -57 modifier and the appropriate usage of this as identified by both CPT and CMS guidelines by paying us “fairly and appropriately”.

UHC, cont.• In our previous appeal we requested that you

provide documentation to support your decision. Your letter states, “…UHC seeks to take into account many relevant factors including, where appropriate, the views of specialty societies, consultants and the Centers for Medicare and Medicaid Services…”. Should you choose to deny this request for payment, I again ask that you send written documentation supporting your decision; specifically your policy/criteria used to determine when your company will allow payment for an initial evaluation and management service where the decision for surgery is made.

ExamplesDOS CPT Charge Payment Remarks

03/18/2014 26123 2,000.00 0.00 CO4

Adjust Codes

CO4 – Contractual Obligation. The procedure code is inconsistent with the modifier used, or a required modifier is missing.

CPT 26123 - Palmar fasciectomy and release small finger contracture.

Review of documentation revealed patient underwent same procedure on the LEFT hand January 7, 2014. Still under global period from that surgery. Procedure on 03/18/2014 was for RIGHT hand.

Examples

Examples•Denial stated office used CPT Assistant

article from January 2005 to substantiate personal bundling edits.

•Coder located article and did not believe carrier was applying it correctly.

•Also found an article by AAOS to support

coding.

Examples• The CPT assistant article being referenced describes two

different paragraphs on the same type of procedures which are done with different techniques.

• The section you are referencing to validate your denial is discussing a base procedure (CPT 26447) not the suspension arthroplasty (CPT 25447) which our provider performed.

• The article titled “Variation: Suspension Arthroplasty” clearly states that when billing CPT 25447 it is appropriate to bill either CPT 25310 or CPT 26480 in addition as the transfer of the FCR to the base of the first metacarpal is not part of the basic first CMC arthroplasty procedure and must be coded in addition to the 25447. In addition to the above, our office has located a bulletin from the American Academy of Orthopedic Surgeons dated August 2005 which reinforces the above determination stating that the tendon transfer is not bundled into the arthroplasty procedure and should be allowed and reimbursed separately.

Examples•Unable to locate any documentation to

support this inappropriate McKesson bundling edit. I have carefully reviewed the NCCI (National Correct Coding Initiative) edits and this tool does not bundle these services together. Because of this, the addition of the modifier 59 would be inappropriate as well as unnecessary and both lines of this claim should be paid.

QUESTIONS?