HOME » Coding Review Overturns Denial Case Study

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A Georgia hospital placed an account with Convergent that had been denied for no authorization. Prior to the procedure, the hospital had checked authorization and was told one was not required for the services contemplated. However, when doing the surgery, the surgeon determined that the underlying hernia was different than anticipated and a different procedure needed to be performed. The procedure performed did require prior authorization.

Convergent conducted an internal coding review which advised that the code billed by the hospital would not be reimbursable due to the surgeon billing a different procedure. Undaunted, Convergent submitted an appeal to battle not only the lack of authorization but also the conflict with the paid surgeon’s claim (the surgeon had billed for an open surgical procedure while the hospital billed an unlisted laparoscopic procedure), arguing that the coding on the claim was proper, as the records clearly showed the procedure was done laparoscopically, and the facility should not be bound to use a different code when the records supported the hospital coding of the claim. The service was medically necessary and should be retro authorized under these circumstances

The insurance carrier reversed their denial and released payment of $3941.40.