I have a claim I am struggling with.
This claim was initially billed to UHC as:
02/06/17 99233 – 57
02/07/17 43246 – 59
I have several issues with this claim/denial:
1. Line 02/05/17 99223 was denied for level of service. We sent the medical records, but they didn’t deem them sufficient for this level of service. I am having a hard time determining the level due to the information provided. Here is what I was given:
The HPI that was listed on the intake form is:
67F presented to X Facility on 01/28 after found down by husband at home. She was AO with left sided weakness on arrival but progressively worsened. She became less responsive, GCS 8 and was unable to protect her airway. She was remained intubated since that time. She was found to have a ICH due to a small AVM. No neurosurgical intervention is planned at this time. Off of all sedation she is only able to follow simple commands and oopens eyes to pain. General surgery has been consulted for trach and peg.
Med history: GERD, hyperlipidemia, hypertension, Osteoarthritis
Surg history: appendectomy, hysterectomy
Social history: lives with family, married
Family history: Father – Diabetes
ROS: Unable to obtain due to ventilator; ams
It also states under the Diagnosis, Assessment & Plan:
– Will plan for trach and PEG this week
– Procedure explained and all questions answered with husband and daughter
2. Line 02/06/17 99233 – 57 was denied for improper use of modifier.
The decision for surgery was made on 02/05/17 so this mod doesn’t apply. I think it needs to be removed, my co-worker disagrees.
3. Line 02/07/17 43246 – 59 was denied for Medical Record does not support code.
The lines from the Op Report that pertain to this are as follows:
The guidewire was passed. It was snared and brought out through the oropharynx with the EGD scope. A PEG was then placed through the guidewire and brought back down though the oropharynx into the stomach through the abdominal wall. It was secured at 3.5 at the skin incision and placed a 2-0 nylon the around bumper and to the skin.
Is that sufficient enough info to bill the 43246?
I know this is a lot to take in. I am new to this practice and not familiar with these types of surgeries just yet. I would appreciate any help and/or suggestions with the above listed three problems.