The C1769 prior authorization puzzle: A billing challenge

Could you clear up a discussion we had with our coding department? They say we must obtain a prior authorization (PA) for C1769 (Guide wire) when billing 52356 or 52332. Every insurance carrier that we have tried to obtain PA from states that no PA is required, but the claims for C1769 are being denied for no PA. I can’t find documentation to submit to our coders showing that C1769 is included in 52356 and 52332. Can you help with this? I do see where cardiology has several codes that you can bill C1769 separately, and it does require PA. Any help with this is appreciated.

Jonathan Rubenstein, MD

As you know, billing for supplies with C codes is typically reserved for facility billing based on the types of service provided. As the request surrounds the PA, we assume you are struggling with this code concerning private payers for Medicare Advantage and standard commercial plans, as Medicare has not added any 5XXXX codes to the limited PA list for outpatient services. We should also add that some C codes are inappropriate for all procedures. As we are focusing on your question relative to PA denials, we will address the C code issue as if it were not a bundled service. You should also be aware that in the case of C1769 (Guide wire), the supply may be considered as a packaged supply with the facility fee for 5XXXX codes; again, your contract and payer guidelines, as available, should be reviewed.

Unfortunately, we can only provide some general guidance in this area as contracts for ambulatory surgical centers and hospital outpatient departments with commercial payers vary significantly. We have noted that attempting to obtain a PA for services that do not have a specific policy matching the CPT code with a CXXXX device code will typically receive a “no PA required” response. As you have noted, the codes, when billed, are frequently rejected with a response indicating that a PA was required. Note: This also occurs with unlisted codes. We can recommend some extra steps; however, the final solution is based on your contract with that payer. Contracts can be negotiated to provide guidance and certainty for payments that will or will not be made for devices reported with CXXXX codes. Carve-outs are another option as contract addendums to cover specific situations such as the one you are encountering.

Mark Painter

Extra steps you can take if you lack contractual guidance require more work and must be performed for each encounter affected. Use the predetermination process to test the encounter for payment. This process, if available, allows you to submit the claim as intended with CPT, Healthcare Common Procedure Coding System, and ICD-10 code against the patient’s actual benefit plan and according to the contract. The process is essentially a test of the claim against the payer’s programmed rules for that patient and your tax ID. Unfortunately, this service is not always available and is time-consuming. You must determine as a team whether the expense is worth the result. If the determination is positive, it can be used in the appeal process if the payer denies the claim when submitted. If the determination is negative or inconclusive, the team will have decide the next steps. Is the physician willing to forgo the use of the glide wire if the C1769 is not paid with the service to be provided for that patient? Is the entity willing to forgo the reimbursement for the device if the predetermination is negative, or inclusive if the physician is required to use the device based on medical necessity? Balancing the work required, the resources available for the entity, and the number of times the process is successful must be considered in setting your protocols for using the predetermination process when available.

If the predetermination process is unavailable, you should attempt to obtain a PA. Note your attempt to obtain the PA and the response provided. Record phone calls if allowed or capture screenshots if attempted via the portal. Document in the patient record the details of any phone call, whether recorded or not, including identification of the office staff and the insurance representative and the request and the response. This information can also be used in an appeal for a “no PA” denial. As you know, a PA does not guarantee payment. Unfortunately, this could mean you may successfully overturn the denial for no PA but ultimately receive a denial for a bundled device or another reason.

We have received numerous complaints about the PA and predetermination process. We all wish we could answer this differently and definitively. Unfortunately, this administrative hassle continues to haunt both facilities and physician groups. We should also mention that if anything changes in the operating room requiring a different coding than that included on the PA, a new PA will need to be obtained before billing. Addressing this problem in the long run will require better contracts or, on a broader scale, state and federal government rules forcing the process to be regulated.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.