Forum - Questions & Answers

Aug 23rd, 2010 - cobgyn

Insurance rule on paying multiple procedures

I recently filed a surgical claim where 58260 was the main procedure and then filed
49204 and 49205.

The insurance company paid 49205 because it was the highest allowable code then paid the other two at half of the allowable.

Does this rule apply to every insurance company? I did not find it in the coding book.

My largest amount was on the 58260 and the 2nd & 3rd code amounts were less than half of the insurance's allowable.

The insurance paid the first code half of their allowable then the 2nd and 3rd code 60.00 less than I billed.

So we got paid very little.

I know I can appeal this but do I have any law or rules to go on?

Help and thank you in advance!!


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Aug 23rd, 2010 - jschmutz   323 

49204 and 49205

I'm wondering if you appropriately reported 49204 and 49205 together? These two codes aren't usually reported during the same encounter.

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Aug 24th, 2010 - Codapedia Editor 1,399 

58260, 49204, 49205

Did you check the RVUs and NCCI edits?

49205 has the highest RVUs: 46.32 You should have been paid in full for that.

jschmutz pointed out that 49204 is a component code of 49205. Did it meet the requirements of a separate and distinct service?

58260 is not bundled,and has an RVU value of 22.43.

Payers pay based on RVUs, not your fees.

Does this help?

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