Surgery Not Paid-Can we bill for subsequent visits?

Hello! We have a surgery that denied because our physician chose to perform a procedure in the Outpatient place of service instead of Inpatient. Therefore, the insurance is not paying for ANY part of the global surgery package.

Because of this, are will able to bill the e/m codes for the subsequent visits following the surgery since we did not receive any payment?

Comments

  • edited May 2017
    I don't have an answer for your specific question but have a question for you. I have been successful in appealing cases done at our ASC which were not on our contract/fee schedule. However, some payers will not pay, no matter what the situation. Dependent upon your contracts and the payer, you may be able to appeal for medical necessity. Have you tried to appeal?



    Tami Lucarelli, CPC/PAR
    Certified Professional Coder
    Patient Accounts Representative
    Department Lead
    Overlake Surgery Center, LLC
    1135 116th Avenue NE
    Suite 300
    Bellevue, WA 98004
    Phone (425) 709-7522
    Fax (425) 709-2323
  • Thank you! As far as I know, we have not tried to appeal this denial as the CPT 63051 is on the Inpatient only list for CMS, although the payer is not CMS but Aetna/UHC.
  • edited May 2017
    That might be a tough one but I personally think an appeal is worth a try. If it was disallowed as provider write off, I would absolutely appeal. You might want to compare it to a similar CPT code that you do have a contracted rate and approach it from an angle that doing this procedure as an outpatient saved the payer considerable money at no additional risk to the patient. You may want to ask the surgeon to dictate a letter of medical necessity and rationale for his choice of POS. Summarize in a final paragraph the reimbursement you seek.

    If it was denied as patient responsibility, you may need to get an authorization from the patient to appeal on their behalf.
    I ALWAYS bill the patient immediately. If the claim was denied as provider write off, I send an “info only” statement letting them know that nothing is due from them “at this time” and that we are appealing the denial. If it was denied as patient responsibility they need to know ASAP. Many payers have different timely filing guidelines between patient and provider appeals.

    No matter which denial we receive I typically always contact the payer to find out what their guidelines are for appeal (i.e. do they require a special form, can we fax our appeal, if the claim was denied as patient resp. can we appeal on the patient’s behalf and, if so, does the patient need to sign an auth, what are their timely filing, etc.). After I call the payer I also follow-up with a phone call to the patient.

    Good luck!!




    Tami Lucarelli, CPC/PAR
    Certified Professional Coder
    Patient Accounts Representative
    Department Lead
    Overlake Surgery Center, LLC
    1135 116th Avenue NE
    Suite 300
    Bellevue, WA 98004
    Phone (425) 709-7522
    Fax (425) 709-2323
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