05/18/2022

Healthfirst-Appeal Denials for CPT 28296

I did an Austin Bunionectomy with screw fixation on Health first patient, Optum sent me a letter on an review and reconsideration response asking for op reports and records. I sent everything and got a denial that the "CPT code 28296 was not supported and there is a more appropriate CPT code that should have been used. I then uploaded an appeal stating that the op report justified the 28296, I just received a response letter from Optum stating that again the 28296 was denied that the documentation again does not support the 28296 because the documentation does not support that a sesmoidectomy was performed. My only option is to write another appeal within 60 days from the date of the letter. This is confusing because 28296 states sesamoidectomy when performed. Any help with my appeal would be appreciated.

Another person performed the procedure. He documented the procedure and you signed the note. What is your relationship? We think this has something to do with that relationship. Is he a resident? Why is one provider documented when another one is signing the note?

United has been denying a lot of claims for reasons that cannot be determined. It appears as though they are not reading the code with the "when performed" as the provider is.

We recommend that you ask for a further appeal based on the description of the code and would resubmit accordingly pointed to that fact specifically. Their shortened description does not account for the fact that the sesamoidectomy does not have to be performed. 

The only other option would be to use a 52 modifier but we don’t usually recommend this option as it is not the true service performed.