Forum - Questions & Answers

Jul 15th, 2016 - cd.wilkins

Code Help

i was submitted to an in-network hospital for an emergency, the surgeon they provided was out-of-network i was not informed. have appealed the insurance(anthem BCBS) lack of payment once, they did not send me documentation of appeal decision. when i called they claimed to have paid 100% of what they would have for an in-network provider. my plan is an 80/20 they have not paid 80%. when i called anthem customer service i was told they do not go by MUE standards and that their payment is based off of my areas average cost of procedure. I’ve looked on the fair health, bluebook and physician fee schedule for prices. anthems payment is much lower than anything I’ve found.

i have researched the codes submitted by the provider, his office billed one code 20103X3. the insurance is only paying X1 MUE value is 4. i also think there is a bundling issue, the procedures were done on the same day, time and hand.

codes list as:

64721 modifier LT (was told by provider that one out of four 20103 codes was bundled but have no documentation of the bundle)

20103X3 modifier LT (insurance only paying for 1 unit despite MUE max value 4)

11043 modifier 59 (not sure why this code/modifier is billed separate and not bundled)

99221 modifier 57 (I did not meet the surgeon before or after procedure)

after the procedure i was told that the provider did not see any justification for the surgery in the first place. that what he saw on the X-Ray i should have check again by another doctor?! would this be an indication for malpractice? carpal tunnel release can cause future problems.

any advice would be much appreciated!!

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