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The 2001 Correct Coding Initiative permits payment for 61795 when performed simultaneously with endoscopic sinus surgery. HCFA adopted this on a national level; however, a number of states, each of which has an independent review process, have not followed these guidelines. An example is New York. However, after writing to the medical director of Blue Cross New York and providing documentation of the Correct Coding Initiative as well as the information contained in the 2001 CPT manual, the policy was reversed to permit reimbursement. (Blue Cross is the administrator of Medicare in New York State.)
The HCFA letter is included in our site and can be downloaded. However, many commercial/local/managed care carriers are not accepting the HCFA guidelines. For instance, Blue Cross is refusing to follow the HCFA guidelines. We continue to pursue these issues in order to obtain a broad-based policy consistent with the HCFA guidelines.
The ARS continues to work on this problem. We strongly suggest that ARS members inform the ARS Board and the ARS Patient Advocacy Committee of their successes and problems with CPT 61795.
If you choose to appeal inappropriate reimbursement decisions with local carriers and payers, please consider using these documents:
ARS Letter to HCFA
HCFA response
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