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Our client, a healthcare investor requested that Sinaiko Healthcare Consulting, Inc. assist them by offering a professional opinion regarding the use of specific CPT codes for a procedure that uses a specific implantable device and by conducting an assessment of a small number of patient records on whom this procedure was performed. We were requested to conduct an assessment of the appropriateness/correctness of the use of several CPT codes as they relate to this procedure. Our client wanted to understand the opportunity to get reimbursed from the various payors for this procedure.
Further, Sinaiko assessed a sample set of patient records including the surgical operative report, corresponding UB-04 billing form, detail billing form and the Explanation of Benefits (EOB) for cases in which the patient underwent the procedure using this specific implantable device.
Sinaiko reviewed the materials received and conducted an interview with the CEO of the company that creates the device.
Our conclusion was that these operative cases are complex, intricate procedures that are not only difficult for the surgeon to perform but also a challenge to code. We advised that the use of accurate medical and coding terminology by the surgeon in the operative note dictation is essential to obtaining the most appropriate reimbursement for that service. This coupled with the medical necessity of the procedure will ultimately decide payor reimbursement. There are many types of these surgeries and many, related CPT codes. Given the information we received, we agreed that the CPT codes in question were appropriate codes to represent the procedure performed using this specific device. |
