Forum - Questions & Answers

Apr 17th, 2014 - lbares83

Anesthesia and Essure Elective Sterilization.

Can someone please help me with anesthesia coding for the Essure system 58565 that will result in better reimbursement for our group?
The scenario is as follows:
If a patient would like to receive an elective sterilization (ESSURE). It is my understanding that under the Affordable Care Act that the elective sterilization CPT® 58565 is a preventative service and should be covered at 100% of the allowed amount, deductible does not apply, coinsurance does not apply.
Associated services should also be covered at the same rate, specifically the anesthesiologist. The anesthesiologist are rarely in network, but should be pulled in to the in network benefit level due to the RAPL or OLOGIST rule. It is my understanding that because the surgeon performing the procedure is an in network preferred provider, and the services will be rendered in an in network preferred provider office, the anesthesiologist of choice will be covered as well.
If the anesthesiologist is billing with CPT® 00952 and includes the preventative service modifier 33 and appropriate ICD-9 V25.2, my anesthesiologist should be paid at the in network level at 100% of the allowed amount excluding deductibles and coinsurance.
There has been a lot of back and forth with my doctors offices on what policy is correct.
Please advise! Any help or direction from more experienced coders would be a blessing!



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