Dear Coding Experts,
Kern Health System in CA does not pay for secondary procedure 45380 billed with modifier 59 along with 45385 (with modifier SG) on the same day. We tried to appeal secondary procedure 45380 along with medical records and with copy of CCI edits however we are not getting reimbursed still stating denied as inclusive. Do other Gastroenterology practice face the same and I would like to get help how this needs to be properly handled so that we get paid for CPT 45380.
Do we need to follow any other coding guidelines on billing secondary procedure 45380 to Kern Health Sytem.
Thanks in advance
I do get paid for 45380 using a 59 modifier. SG modifier is no longer required.
Look to see if the code is a benefit the patient is entitled to receive.
I can assume that your doctor is non-par or not contracted.
If the service is a benefit, and you are not contracted, I would write to the CEO:
Dear name (CEO)
On (date) your member, presented themselves to our practice for (medical condition). As you can see from the medical record, CPT Codes XXXXX and YYYYY, both are covered services under your member's health benefit contract, as defined from Page X of your member's health benefit manual. Per nationally recognized and accepted coding guidelines, also known as National Correct Coding Initiative (NCCI), we submitted the claim with the correct CPT codes and modifers, as defined by the American Medical Association.
I am sure you are aware, that as a non-participating or non-contracted provider, we are not required to accept your company's internal coding policies, however, we make every effort to provide medically necessary medical care that is a benefit your member is entitled to receive and is entitled to be reimbursed. Using your company's internal coding guidelines, which does not conform to Nationally Accepted Coding Guidelines, and using this to deny your member the payment of their contracted health benefit, may be a possible breach of the agreement you have with the member and it could also be possible it might be a vioilation of applicable State and/or Federal law. Your denial of the payment of the member's health benefit might imply that the payment for the medical care is transferred to your member.
If the healthvcare benefit is under the jurisdiction of Federal laws and regulations, specifically 29 USC 18, 1003(a) and 1144(a) and 29 CFR 2560-503-1 may be defined as an adverse benefit determination, requiring your member to exercise their Federally protected appeal rights or to file a lawsuit in Federal Court.
The denial may be an error which I am sure your company can cure through the payment of the contracted healthcare benefit. We are willing to assist your member with the appeal of their denied health benefit, in addition to filing grievances with the applicable State and Federal regulatory agencies, to and including asking the Internal Revenue Service to investigate possible fraud or possible wrongful financial gain.
We expect to receive your positive reply, in the form of the health benefit payment, fourteen (14) calendar days from the date of receipt of this letter.
Name of Provider
(1) EOB, dated (date)
(2) NCCI Edits
(3) Medical Record Copy
(4) Page X of (name of patient) health benefit manual or Summary Plan Description.
(1) Office of (State) insurance regulation.
(2) Secretary of labor, Washington D.C.
(3) Employee Benefits Security Administration
(4) Legal Department, Federal Trade Commission
(5) Internal Revenue Service
Do your additional homework to support your letter.
(Disclaimer) I am not a lawyer. This post contains no legal advice.
This post is for training purposes only.