Insurance and DS coding

[Guest guest]

I have a consult with Dr. Hess on October 15. Since he is out-of

network for me (and everyone else) I got the procedure codes and

approximate dollar amount he bills from his nurse. I sent these to

my insurance co to find if they fall in the range of usual and

customary. Here is there response (abbreviated)

You requested the Maximum Allowable Fee for the following CPT

(Current Procedural terminology) Codes:

43847 Gastric procdure with gastric bypass for morbid obesity: with

small bowel reconstruction to limit absorption

43633 Gastrectomy, partial, distal: with Roux-on Y construction

44130 Enteroenterostomy, anastomosis of intestine, with or without

cutaneous enterostomy (separate procedure)

Based on the current data available, all pre-treatment estimates are

within the Maximum Allowable Fee.

(a bunch of info about my deductibles, co-pays using doctors in-

network)

Please not, the CPT Manual lists under Surgery Guidelines a heading

of Separate Procedures that states:

" Some of the listed procedures are commonly carried out as an

integral part of a total service, and as such, do no warrant separate

identification. When, however suc a procedure is performed

independently of, and is not immediately related to other services,

it may be listed as a 'separate procedure'. Thus, when a procedure

that is ordinarily a component of a larger procedure is performed

alone for a specific purpose, it may e considered to be a separate

procedure. "

As CPT code 44130 will be performed in conjunction with CPT code

43633, no benefits are available, as it is an integral part of CPT

code 43633.

( and then some more stuff about medically neccesity and performing

treatment in the cheapest manner possible even if incovenient for you

blah blah blah)

I know the DS usually gets coding in several parts since no one code

exisits to cover the whole procedure. Since I really don't know what

part of the procedure each code is covering, I'm trying to figure out

if their not covering procdure code 44130 will be a problem for me to

get approval for a DS surgery. Does anyone have opinions on this?

Thanks