Insurance coverage of septal perforation repair for out of network surgeon - best CPT and ICD-10 codes to result in coverage?

Question

I have a consultation with a nationally renowned surgeon who specializes in septal perforation repair. He does not accept insurance and is out of network, and he charges up to $30,000 for the surgery. I want to convince my insurance company (United Healthcare) to cover part of the cost. Does anyone know which CPT and ICD-10 codes are most likely to result in insurance coverage? I am in Texas. Any advice would be much appreciated. Thank you!

Sandy Sule, MD · Answer

The codes (icd 10 and cpt) depend upon what procedure is being done. You should be able to ask your surgeon this information. Being out of network only implies that your surgeon is not contracted with your insurance carrier to take pre negotiated rate of reimbursement for a procedure. It does not mean the surgeon can not give you codes that may be covered by your insurance carrier--especially the anesthesia and surgery center fees.

Bradford A. Bader, MD · Answer

There is no magic formula of CPT and ICD-10 codes to get a septal perforation repair covered by insurance. All insurance plans will cover this kind of functional nasal surgery. When a surgeon is out-of-network it means that your insurance carrier does not have a contract with a set fee for a particular CPT code. Your insurance carrier will pay for your surgery but your surgeon might not think that amount is acceptable and will bill you for the remainder. In short, you are essentially negotiating with the surgeon and not the insurance company. Be sure you check your benefits because many insurance plans provide greatly reduced or zero benefit for out-of-network services. The alternative is to consult with surgeons within your network to take advantage of the insurance benefits that your premiums give you access to and pay a fraction of the cost.

Richard Ellenbogen, MD (retired) · Answer

I wish you a lot of luck and sucess. The doctor I know charges much less and has operated on tons of them. Out of network is always a fight that shouldnt happen.

Michael Elam, MD (retired) · Answer

Dear bindallastx, Your surgeons office should have an insurance billing company that will bill the insurance for you. The ICD and CPT codes are based on the diagnosis codes and are billed accordingly. I am personally "out of network" since I do not have contracts with insurance companies however when functional issues need correcting through surgery I bill the insurance through an outside contractor who is an expert in insurance billing and coding. Best regards, Michael V. Elam, M.D.

Insurance coverage of septal perforation repair for out of network surgeon - best CPT and ICD-10 codes to result in coverage?

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