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Denial issues: No ROS and PEG tube placement

Good morning!

I have a claim I am struggling with.

This claim was initially billed to UHC as:
02/05/17 99223
02/06/17 99233 – 57
02/07/17 31600
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.

Medical Billing and Coding Forum

EGD w/BX and Pillcam Placement

Our provider delivered Pillcam with EGD scope but he also took biopsies from esophagus. I billed 91110/26 and 43239, this was done as outpt procedure
in hospital. BCBS Fl has denied 43239 stating it is bundled with 91110/26. I know that somewhere I have read that if biopsies are taken that the 43239 is
a separate procedure and is billable and is not bundled. I need to write an appeal letter but can’t find and specific guidelines stating that fact. Can any one one
direct me to a source that would clarify that is bx taken the 43239 is payable. I need to make copies so that I can attached to the appeal letter.
We have Super Coder, can find nothing there and I have also looked on AAPC coding forum. Please help me because the insurance can’t get away
with bundling and not paying the 43239. Thanks you

Medical Billing and Coding Forum

Turn to 0438T for SpaceOAR® System Supply and Placement

In July 2016, the American Medical Association (AMA) introduced CPT® Category III code 0438T Transperineal placement of biodegradable material, peri-prostatic (via needle), single or multiple, includes image guidance. The code subsequently was included in the 2017 CPT® codebook. Code 0438T describes the supply and placement of a temporary, biodegradable implant, marketed as the SpaceOAR® System […]
AAPC Knowledge Center

Bladder Tumor Resection and Ureteral Stent placement

Can someone please offer guidance?
My provider performed transurethral resection of bladder tumor that invaded the ureteric orifice. He inserted a stent to "facilitate drainage".
NCCI Edits bundle the two procedures together, is it appropriate to unbundle them in this scenario?

"The patient had a large, approximately 3-4 cm papillary bladder tumor on his right lateral wall, obscuring the identification of his right ureteral orifice. This was resected sequentially down to muscle. The right ureteral orifice was identified and it was not the source of the tumor, but did appear to have some involvement of papillary tumor at the orifice. The right ureteral orifice was resected and sent as a separate pathologic specimen. Given the resection, we placed a ureteral stent on this side to facilitate drainage and also assist future resections."


Thanks in advance…

Medical Billing and Coding Forum

ERCP-multiple stents exchanged with one new placement

Hello there,

We have a case where 5 stents were exchanged in the common bile duct along with one new stent. So, a total of 6 new stents were placed. How should this be coded since it was all in the common bile duct? 43276×5 or 43274×6?

Thanks for your help!

Medical Billing and Coding Forum

Aborted pacemaker placement

Hi, I could use some advice on this please. Would you bill this as a pacemaker placement 33207 with a 53 modifier along with a Venography? I appreciate the info.

PROCEDURE: Venogram was done on the right and left side-patent venous system was confirmed. The patient was prepped and draped in the usual sterile fashion. Access was gained into the left axillary vein after venography and fluoroscopy-first with a micropuncture wire and then with a regular wire. Right sided placement was confirmed after passing the wire below the diaphragm. The prior incision (made at the outside hospital was opened). The two wires were brought out of the incision.
The ventricular lead was advanced directly via a 7 Fr long sheath and positioned in the right ventricular mid septum under fluoroscopy. Lead characteristics were measured and were satisfactory. After I split the sheath there was copious bleeding seen. These occurred to have an arterial pulsation and were seen around the lead as well as in an area more lateral and inferior to the lead. I placed several purse-string sutures around the lead and cauterized other areas that appeared to be bleeding. Hemostasis could not be achieved.
I finally called the cardiac surgeons, who also placed purse string sutures around the lead with no effect.
After a long discussion about possible causes, that included damage to an arterial branch around the vein, or the main axillary artery itself, I decided to pull out the lead. Hemostasis was finally obtained by manual compression with gauze. Using a staged approach, compression was gradually released and hemostasis was confirmed. The wound was closed by the surgeon-please see his note for details.

Medical Billing and Coding Forum

Ureteroscopy with laser lithotripsy and stent placement question

I think I am correct on this, but I just want to double check.

Urologist did a cystoscopy with right ureteroscopy and laser lithotripsy, with bilateral stents placed. Am I correct to code this as 52356-RT and 52332-59LT? My reasoning is that only the stents are bilateral; the ureteroscopy and laser litho were right-sided only.


Medical Billing and Coding Forum