Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on June 17, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied procedures codes remain not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of the denied codes is: CPT 27487: revision of a total knee arthroplasty, with or without allograft; of the femoral and entire tibial component CPT 27335: arthrotomy of the knee with synovectomy, anterior and posterior including popliteal area CPT 27430: quadricepsplasty (Bennett or Thompson type) CPT 27425: open lateral retinacular release CPT 27324: deep (subfascial or intramscular) biopsy of the soft tissue of thigh or knee area CPT 12036: Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm CPT 15273: Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children CPT 11981: Insertion, non-biodegradable drug delivery implant CPT 15274: Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this were not coded correctly. Our coding reviewer found the medical records provided do not include documentation in the operative report of a revision of a total knee arthroplasty, with or without allograft; of the femoral and entire tibial component; therefore 27487-58-59 cannot be verified. CPT 27335 has a bundled relationship with the primary procedure code 27487 that was submitted by the provider. According to edits, a modifier is allowed to unbundle the procedure providing the medical records can validate the appropriate use of the modifier. The provider used modifier 59 to indicate Procedure code 27335 was was distinct or independent from other non-E/M services performed on the same day. The medical records do not include documentation to support that 27335 was a was distinct or independent from other non-E/M services performed on the same day, therefore it is inappropriate to append a 59 modifier thus CPT 27335 is ineligible for reimbursement consideration. Although a quadricepsplasty is documented in the operative note, CPT 27430 would be inclusive to a more comprehensive code that was performed on the same day by the same physician, therefore it is not eligible for separate reimbursement. Although open lateral retinacular release is documented in the operative note, CPT 27425 would be inclusive to a more comprehensive code that was performed on the same day by the same physician, therefore it is not eligible for separate reimbursement. Although a deep (subfascial or intramuscular) biopsy of the soft tissue of thigh or knee area is documented in the operative note, CPT27324 would be inclusive to a more comprehensive code that was performed on the same day by the same physician, therefore it is not eligible for separate reimbursement. Although Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm is documented in the operative note, CPT 12306 would be inclusive to a more comprehensive code that was performed on the same day by the same physician, therefore it is not eligible for separate reimbursement. Although Current Procedural Terminology (CPT) code 15273 58 - Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children is documented in the operative note, CPT 15273 would be inclusive to a more comprehensive code that was performed on the same day by the same physician, therefore it is not eligible for separate reimbursement. The medical records provided do not include documentation of an Insertion, non-biodegradable drug delivery implant being performed on June 17, 2019 therefore this service cannot be validated. CPT code 15274 is an add-on code and requires the primary service code to be eligible for reimbursement before it can be eligible for reimbursement. CPT 15273 was denied, therefore, 15274 cannot be reimbursed separately. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on June 17, 2019.