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If you have ever been in a situation where you wanted to contest a denial by an insurance company based on irrational payer guidelines, you may be right in thinking this is like trying to break down a stone wall; however you are not helpless to change the situation in your favor. Here's a gastroenterology coding scenario: Say you want to fight an insurance company for payment for 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) with 45385 (… with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). While denying your initial claim, the insurance company states the following guidelines in writing: Exceptions to modifier 59: The following endoscopic biopsy procedures will not be allowed with the associated endoscopic therapeutic procedures: 45380 with 45383-45385. Decision: The endoscopic biopsies with endoscopic therapeutic procedures in the same anatomical area will follow standard coding logic, and no added payments will be made for these codes even when billed with modifier 59. Rationale: The endoscopic biopsy is a vital cog of the therapeutic endoscopic procedure. Generic Claim Check rejects the endoscopic biopsy procedure when billed with a therapeutic endoscopic procedure in the same anatomical area. As such what do you do in such a situation? Your steps in fighting for your claim could make or mar your practice's chance for a proper reimbursement. But then, the insurance company can set any rules it wants and you're forced to play by them when your doctors sign the contracts. However you can break through the barriers by learning this three-step approach: The first thing you need to do is to get a copy of your contract and see what degree of latitude your payer can take relative to AMA add CMS coding rules. If the insurer is violating what's set forth in the contract, use the contract in your appeal to fight this arbitrary policy and get it overturned. If the contract is quiet on this or allows such arbitrary use of rules in the payer's favor, you should get ready to drop the payer as one of your participating payers. Do not have cold feet; be all geared up to drop them in this stage.
Fix a meeting between your doctors and the medical director. Enquire the medical director to justify this policy in clinical terms as to why the insurer doesn't reimburse a doctor for the diagnostic colonoscopy and the removal of polyps when you add modifier 59 (Distinct procedural service) to point to different sites. Make clear that breaking the colonoscopy and the biopsy into multiple sessions will make the payer incur multiple facility fees, multiple anesthesia sessions as well as the doctor professional fees. For more on this and for other articles to assist your gastroenterology coding, sign up for a good medicalcoding resource like Coding Institute.
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