Re: Gobo/BC Codes

[Guest guest]

Hi Gobo,

When I was calling the DS surgeons in the country to find out what

codes they used 99% used the usual and customary CPT codes 43847 and

43633. This is what Dr is now using. I didn't call Dr

Maguire's office but he's an established Ds Dr so he probably uses

the above codes. I sent Dr a copy of the Regence Policy

Manual that I had found online and the May 1998 issue of the CPT

Assistant publication. They devoted 4-5 pgs to the billing of

bariatric surgeries.

Dr didn't have a hard time taking my suggestions she just

wanted to make sure it was legal. The biller Vicki was the one who

didn't want change from her unlisted code.

I think Becki and I were the only ones submitted and denied with

with the old codes.

I found out that Dr Heap does not do LAP surgeries only open. His

nurse said he still feels the complication rates are too high.

P.S. There is also a code that the Drs use for cholesectomy(sp) but

this doesn't apply to Dr since she leaves the gallbladder.

> Hi Angel;

> 's sister went away for the weekend to take a much

> needed break. She was stressing out really badly. I tried to see

> when I was in Portland on Thursday but she was off the

> unit having tests. I've called her every day since then. Friday I

> tried calling 3 times but she was out of her room each time.

> Saturday, when I finally reached her, her husband had just

> arrived so she was distracted. Whenever I would ask how she

> was doing, she would just say, " I don't know " . So, I feel stymied

> in trying to support her right now. I think her spirits may be

> dipping again. ;- {

> Hopefully, once her sister's back in the saddle, we'll get back on

> track in following the progress of our dear .

>

> In the meantime, I'm feeling fine again, thanks for your concern.

It

> must have been something I ate.

>

> Now, on to insurance concerns:

> > I have Cigna HMO

> > and now I have one denial, but at least they've okayed

> > a consult with Dr. Maguire! Tammy (referral person? at

> > Cigna) said to go to Dr. Maguire and if I want, have

> > him write up a treatment plan for the DS and have him

> > submit it and we'd go from there.

>

> I'm not absolutely positive (since I've not dealt with Cigna/HMO)

> but with other HMO's this would definitely be a good thing!

>

> > Do you think his

> > chances will be better at getting it approved (since

> > they all ready denied the DS surgery once?) Can the

> > way he " codes " it, make a difference?

>

> ABSOLUTELY!!!!!

> Dr. in Portland USED to code the DS in such a way

> that ALL insurance companies were denying benefits. Patients

> were desperately trying to get her to change the way she coded.

> Initially, she wasn't interested in being 'told' how to run her

> office

> by patients until she started seeing that ALL insurance

> companies were denying benefits.

>

> Some patients took the trouble to learn how other surgeons

> were sucessfully coding. She now codes in a more consistant

> way.

>

> In addition, Regence Blue Shield (part of Blue Cross) has their

> acceptable CPT codes posted on their web site for WLS. I think it

> would be useful to find out what Dr. 's 'new and rivised'

> coding is and compare it to Regence's. Are they they same? If

> so, that's the coding that would probably meet Cigna's criteria.

>

> However, I want to warn you that surgeon's do not like being told

> what to do. I would present the CPT coding issue as a problem

> you are aware of with insurance companies and how others

> have solved it. Dr. Maguire will be smart enough to fill in the

> blanks and take it from there.

>

>

> I have also been

> > collecting letters from (of course), my PCP,

> > cardiologist, sleep clinic and nephrologist. All are

> > willing to recommend the DS specifically to the

> > insurance co..

>

> BE SURE to tell Dr. Maguire what the status currently is; that

> Cigna has initially denied but has requested that you get a

> treatment plan from Dr. Maguire. Also, before that, I would call

> the person at Cigna who told you to go ahead and get the

> treatment plan. Tell her that you need that in writing to give Dr.

> Maguire. Explain that because this is a request/suggestion from

> the insurance company is following a denial, the surgeon is

> going to want to see that this 'treatment plan' is per Cigna.

>

> If she balks at putting anything in writing (which she undoubtably

> will) ASSURE her that you are not trying to trap her or Cigna into

> anything; you just want to provide Dr. Maguire that it is

legitimate

> for him to do a treatment plan and not a waste of his time. At that

> point, she might deny that the treatment plan is going to result in

> approval. I would ask her then, what the purpose of her

> suggestion was? She'll tell you whatever she's going to admit to;

> such as, we need to review the procecdure, etc.

>

> Well, whatever she says, you reply that " that's EXACTLY what I

> have to provide the surgeon with. We BOTH understand what

> Cigna's position is but I need to give the surgeon a reason for

> doing this. Surgeon's sit up and take notice of requests made by

> insurance companies more that they do patients they may never

> see again. "

>

> The point of all this is that insurance companies are notorious

> for later denying anything that is not in writing. I hate to say

this

> but I can visualize you going through the treatment plan with Dr.

> Maguire and then having some supervisor later claim that they

> never suggested you do it. I've even seen situations where the

> person DID get something in writing and then a manager or

> supervisor later claims that the person who put it in writing had

> no authority to do so, and the agreement is null and void.

> Insurance companies can be totally devoid of integrity and ethics

> (at their worst).

>

> I'm not trying to depress you, because as a consumer you DO

> have rights and CAN make it work for you. I'm just trying to

> impress upon you the importance of being an informed

> consumer and protecting yourself by having EVERYTHING in

> writing. You probably want to have a separate file on 'insurance'

> stuff pertaining to WLS.

>

> What's your BMI? If it's close to or over 50 that should be a big

> reason for having the DS. Also, the fact that many r-n-y's need to

> be revised.

>

> I hope this doesn't discourage you. Fighting an insurance

> company CAN be a downer. But! it CAN be done with

> perserverance and conviction. The encouraging thing about

> HMO's is that they really do treat each patient on a case-by-case

> basis. I've sucessfully appealed many denials. The one thing

> they won't budge on is approving 'out of network'.

>

> Let me know if I can offer any more assistance.

>

> Hugs,

> gobo