This question was posed to me today and I’m curious to any school of thought (especially official ones) on it. I posted it in Billing/Reimbursement as well, but I’ll welcome any of point of view.

When a specific surgery is pre-auth’ed but a lesser of the same surgery is billed, do insurance companies connect the dots on related codes?

For example, one of my docs wants to do a lap hysterectomy on a patient. Because we don’t know the size of the uterus beforehand, and the decision on taking tubes and ovaries is usually decided when they get in there, would it be more prudent to authorize the 58554, which is the lap hysterectomy, uterus over 250 gm with removal of tubes and/or ovaries even if once the dictation is coded it ends up being 58550 – lap hysterectomy under 250 gm uterus, no tubes/ovaries removed? Would a claims processor draw the conclusion that the codes are related – one is the "bare bones" of the other? I mean, if you authorize a lap procedure and it ends up being open, it’s easy to fight on appeal based on "doctor planned to do … but when the patient was on the table, they found …. and the decision was made to go open", would the same recourse be had billing a lesser but related code than what was authorized?

If anyone knows any documentation pointing one direction or another, that link would be appreciated as well.

Thank you!!