by Gail Robinson, Fotheringill & Wade, LLC
Our fifth and final article in honor of Breast Cancer Awareness Month addresses the current trend among commercial payers to limit pre-authorizations to specific Common Procedure Technology (CPT) or Healthcare Common Procedure Code System (HCPCS) codes. This practice has led to an increase in technical denials for no-authorization, when the CPT/HCPCS code billed on a claim varies even slightly from the CPT/HCPCS code authorized.
Issue: With some exceptions (outlined in our prior articles), most surgical procedures and other treatments for breast cancer are covered benefits under standard commercial health plans. However, most covered surgeries and treatments also require prior authorization. If authorization is not obtained for the exact services rendered, increasingly identified by CPT/HCPCS code, payment may be denied for no-authorization.
Takeaway: Be aware of payer timeframes to revise an authorization, which can vary from two days to two weeks, post-service. If the exact procedure code cannot be determined in advance, establish procedures to request a range, or alternative codes. Keep records of these requests. Use these records to establish that the payer’s protocols were followed; therefore, a post-service clinical review for medical necessity of the procedure (code) performed is required on appeal.
Healthcare providers utilize CPT/HCPCS codes to report services performed on patients. Some procedure codes are very specific. Others are more general with the potential for overlap or confusion “[b]ecause many procedures can be performed by different approaches, different methods, or in combination with other procedures, there are often multiple HCPCS/CPT codes defining similar or related procedures.”
Commercial payers are progressively linking prior authorizations to specific CPT/HCPCS codes. This is problematic in cases where a particular surgery or treatment is anticipated, but a slightly different procedure is performed. A physician may use his or her best professional judgment in planning, but the claim is coded based on the medical record after-the-fact, when any slight clinical variance can cause a different code to be billed. Payer timeframes for requesting revision of a prior authorization can vary from two days to two weeks, post-service. Unfortunately, it can take that long for the medical record to be finalized, the claim coded, and the variance identified.
Case Study 1: A payer issued an authorization for HCPCS code J9355 for the chemotherapy agent Trastuzumab (brand name: Herceptin) for a 45 year-old woman with HER2 positive breast cancer. The patient was given J9354, Trastuzumab-Emtansine (brand name: Kadcyla) and the claim denied for no-authorization. The provider could not locate the authorization request to prove that the wrong drug had been authorized.
To state the obvious, J9355 and J9354 which are 1 digit apart, and the generic names “Traxtuzumab” and “Trastuzumab-Emtansine,” can be easily confused. Despite the lack of an authorization request, Fotheringill & Wade successfully demonstrated the high likelihood of confusion by citing a 2013 Safety Alert published by the FDA which cited potential medication errors due to the similarity in name, and mandating the use of the prefix “Ado” before “Trastuzumab-Emtansine” for Kadcyla, to distinguish it from Herceptin.
Case Study 2: Consider the case of a 36 year-old woman who presented for a right-sided symmetry reduction after a left-sided mastectomy and reconstruction. For the symmetry procedure, the provider obtained prior authorization for CPT code 19318 “reduction mammaplasty,” which includes removal of excess breast tissue. Unfortunately, the provider billed CPT code 19316 “mastopexy,” which is a skin reduction breast lift, with removal of underlying breast muscle. The difference was an unanticipated and very slight reduction of muscle to reorient the breast, as identified in the operative report. The timeframe for revising the authorization had passed, and the claim denied for no authorization.
To again state the obvious, 19316 and 19318, as well as “mammaplasty” and “mastopexy,” could be easily transposed. Both codes describe breast reduction and involve removal of excess tissue; mastopexy is only more specific in that it addresses removal of muscle.
Confused? Maybe the payer was too, and authorized a different code than you requested. Check your authorization request, the authorization granted, and your coding of the claim. Evidence that you requested authorization for the service performed is a strong indicator of payer error. Even if you performed a service that is different than the authorization requested, similarities of codes can be effectively argued.
One of the most important elements in disputing a technical denial is evidence that the payer’s authorization protocols were met. In this case, prior authorization was properly requested and granted, but for a slightly different code. Prior authorization is the payer’s confirmation that a procedure is approved as medically necessary, and it would follow that a slight variance was medically necessary too. A clinical comparison of the similarities in the procedures may be your best administrative argument.
Finally, address the unpredictability of the variance. A clinician using their best professional judgment may know what services are necessary but cannot predict how the claim will be coded. From a clinical standpoint, explain why the procedure performed was unanticipated but medically necessary as opposed to the procedure that was authorized. If possible, explain why a different code was used on the claim.
Technical denials for no-authorization are not limited to breast cancer treatments, and the strategies discussed herein can be used for any denial when a different CPT code than is authorized is performed. We expect that these technical denials will continue to increase as payers progressively define service authorizations more narrowly.
 National Correct Coding initiative Policy Manual for Medicare Services, Chapter I, General Correct Coding Policies (01/01/2014)
 U.S. Food and Drug Administration, “Kadcyla (ado-trastuzumab emtansine): Drug Safety Communication – Potential Medication Errors Resulting from Name Confusion” (05/06/2013) at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm350817.htm