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Follow these steps when appealing a Medicare claim
Written by Ray Painter   
Monday, 01 May 2006

 

 

Q How does one go about the process of appealing a denied Medicare claim?

 

A If the payer has a standard appeal form, fill out the Medicare appeal form and resubmit it with a copy of the original claims form, Medicare EOB, correct coding edits, and any other supporting documentation that proves the codes should be paid.

 

If the payer does not have a form, draft a letter stating all the reasons why the claim should be paid according to guidelines and provide proper contact information. All supporting documentation should also be attached.

 

Certain states have a phone appeal line where all appeals need to originate. Many Medicare appeal departments have a specific address that all appeals must be processed through.

 

If the claim is denied by the Medicare appeals department, and the intent is to continue the process of getting the claim paid, state- and payer-specific guidelines must be followed to elevate the appeal to a higher level.

 

Q How should I be billing when performing a potassium sensitivity test?

 

A There is no specific code for the potassium sensitivity test. However, since the test includes the instillation of a drug, then 51700 (bladder irrigation, simple, lavage, and/or instillation) should be used. In addition, you would use the appropriate J code for potassium chloride solution (J3480).

 

You would also charge an E&M code if there was a significant and separate E&M service provided, for example, a consult or a discussion on the disease process and the treatment of the disease process following the test. Of course, if an E&M visit is charged, the –25 modifier should be attached.

 

Q We have confirmed with hospitals that they are billing each component of a urodynamics study (CPTs 51726, 51784, 51795, 51797 and 51741) with modifier TC (technical component). In turn, after one of our physicians interprets the urodynamics results and documents such in our patient's medical record, we bill each component with modifier –26. Do you recommend reducing the standard fee for each CPT code billed with modifier –26? Or should we bill full fee for each and let the insurance company determine the reduction?

 

A If you have a contract with the insurance company that pays you a set fee for each service performed, such as Medicare, I would continue to bill the full fee for the service and let the payer reduce your fee. However, if this is a patient who's paying his or her own fees, or if this is an insurance company with which you do not have a contract, then you should reduce your fee to the amount that you should expect to be appropriately paid for your services. That would also prevent patients with their own medical savings account from having to pay the full fee out of their pocket. They do not have the edits to monitor the charges; therefore, you should be fair in your charges to those people.

 

Q Does code 52352 cover the retrograde pyelogram and ureteral catheter placement?

 

A The CPT book definition for Code 52352 is: "Cystoscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catherization is included)."

 

This procedure includes the insertion of a ureteral catheter, insertion of stent, or installation of contrast media if it is used to facilitate the procedure. In that case, all would be covered with the same code.

 

However, if you were to have scheduled the patient for a diagnostic retrograde, and the diagnostic retrograde led to the diagnosis of the calculus and you proceeded with the 52352, then you should be paid separately for the diagnostic retrograde, 52005.

 

Unfortunately, it is bundled, and it can never be unbundled. Therefore, you will be denied. However, some payers, upon appeal, will pay, as they appropriately should.

 

In addition, if you insert an indwelling stent following the procedure, to be left in for removal at a separate setting (52332), then charge 52332 in addition to the 52352. This is bundled, but can be removed with a modifier, and if charged, the –59 modifier should be attached.

 

This is completely appropriate since the AMA and AUA have determined that an indwelling stent is not a component or an integral part of the ureteroscopy procedure, and if inserted, should be charged separately.

 

Send coding and reimbursement questions to Ray Painter, MD, c/o Urology Times, at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it
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Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

 

Urologist Ray Painter, MD, is president and CEO of Physician Reimbursement Systems, Inc. in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook.

 

 

 

 


 
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