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denials for CPT 31240

Marilyn Posted Fri 26th of February, 2010 17:44:55 PM

insurance co. are denying payment for CPT 31240 when billed w/cpt 31256, 31254. Appeals denied, not following NCCI edits. Any suggestions to assist in getting this service approved for pymt

SuperCoder Answered Tue 02nd of March, 2010 06:17:50 AM

Even though the Correct Coding Initiative doesn’t bundle 31240 with 31254 31255, 31256 31267 many commercial payers do, anyway. They consider the concha bullosa resection integral to opening the ethmoid sinus. They argue that the ENT has to go through the concha bullosa to get to the ethmoid anyway.

Include the vignettes for both procedure codes which show they are separate, Point out that CCI does not bundle the procedures, Include operative notes that distinguish the two procedures, members of AAO-HNS can contact the organization if the insurer does not overturn their coverage determination after submitting appeals.
One more possibility is to call on modifier 59. If you have a history with a payer that denies 31240 when reported with ethmoid or maxillary surgery before you appeal, send the initial claim out with modifier 59 instead of modifier 51. Also, tell your otolaryngologist that solid documentation can make the difference between 31240 payment on appeal and nonpayment.
Hope this helps

Marla Answered Tue 20th of April, 2010 18:45:38 PM

Has anyone ever been able to get a total thyroidectomy and a parathyroid exploration paid for at same operative session? Especially when the patient has two separate diagnoses - multinodular goiter and a parathyroid adenoma?? Have tried different modifiers but have not had any luck.

SuperCoder Answered Wed 21st of April, 2010 07:15:40 AM

Please/always start a new thread for a new query. I have posted this as a new query named as "Pay for total thyroidectomy and a parathyroid exploration"

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