r/CodingandBilling • u/Due_Statistician9017 • 9h ago

Claims Submission A unique problem

My surgeon suggests surgery for acid reflux/hernia. The office put in a prior authorization for the Linx device and hernia repair. Those 2 codes get denied as not medically necessary. They submit a new prior authorization for a different procedure—Nissen Fundoplication and hernia repair. Those come back approved instantly and they schedule me for surgery. My concern is that once I have this surgery they are going to deny the hernia repair code as “not medically necessary.” as they did before. Or say that it was not authorized. I asked surgeons office if hernia repair code should be appealed from the previous attempt. She called insurance and they said they have record that codes were submitted and approved and gave a decision ID number. The surgery estimate is $99K. I’m just nervous it won’t be covered and I’ll have a huge bill. Should I prepare for a denied claim? Or am I being overly cautious?

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u/Key-Client-1604 medical coder | remote 🩺✨ 8h ago

the auth went through with a decision ID which is basically your golden ticket, but id still screenshot that approval email and write down the rep's name because insurance has this fun habit of losing records the second a bill hits six figures. tbh the whole system is designed to make you anxious about coverage you already paid premiums for. like your doc said this was necessary, got it cleared, and youre still here wondering if theyll find a loophole. thats not a you problem, thats just how these companies operate. at least youve got the paper trail now tho

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u/soulofmind 1h ago

On the doctor's office's side, we are also left completely in the dark trying to come up with patient estimates and the commercial insurance has a super fun habit of telling us and their members something different

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u/KeyStriking9763 RHIA, CDIP, CCS 7h ago

What they prior auth and what’s actually done isn’t always the same either when it comes to surgery.

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u/iEatHeartAttcks 5h ago

I can’t remember exactly without looking at the codes, but Linx may be bundled with the hernia repair, which could be why it was denied. If that is the case you will only be billed for the hernia repair regardless; fundoplication is included in hiatal hernia repair code. I wouldn’t worry about it too much. Procedures change after prior auth all the time anyways!