I had a patient with 606.8 from CBAVD (congenital bilateral absence of the vas deferens) who needed to undergo a 55899. 55899, according to the CPT book is: genital procedure NOS. In this particular case, it was an epididymal and testicular sperm aspiration and extraction, done in conjunction with an IVF procedure. Though the patient had coverage for 606.8, the carrier could not say whether or not the patient had coverage for 55899, because it was a 55899--an unlisted code. They would only make that determination after the fact. In other words, they expected me to do the procedure on faith.
Since I can't pay my bills on faith, I asked for $750 up front from the patient, which is comparable to what I had been paid in the past for this exact procedure. The patient paid and I performed the procedure and his wife is now expecting.
Today I received a check in the mail for $219 for the 55899, 95 days after I performed it. Apparently, the insurer felt that $219 is the usual and customary for this procedure. A medical director may--or may not--have looked at the operative note that we supplied and said, "Well, I think it is basically a 54505 (biopsy). Let's pay'em for a biopsy." Hence $219. Therefore, I owe the patient ~$500.
My problem is--and I'll send back the money--is that ~$200 is the usual and customary for a testis biopsy, but certainly not for a testis sperm extraction, which requires significantly more expertise and time and has much more complex administerial and scheduling issues.
So now what do I do; appeal their usual and customary decision.