F E B R U A R Y 2 0 1 6 • O U T PA T I E N TS U R G E R Y. N E T • 1 3 7
battling for acceptance, says Ms. Mueller. The procedure uses
radiofrequency energy to remodel and improve muscle tissue between
the stomach and esophagus, resulting, in most cases, in improved bar-
rier function.
Stretta has a CPT code (43257), but "a lot of payers still aren't cover-
ing it," says Ms. Mueller. Instead, she says, payers tend to look more
favorably on "traditional" open approaches, such as fundoplasty with a
fundic patch (43325), laparotomy (43327) and thoracotomy (43328). The
laparoscopic Nissen approach (43280) has also been widely accepted by
payers and is now the most common procedure overall, she says.
Trust but verify
The bottom line is that while physicians might be extremely enthusi-
astic about a given new procedure, neither they nor the facilities they
work in can afford to do it if they're not going to get paid.
"Verification eligibility is essential," says Ms. Mueller. "And it's
important to remember that obtaining pre-authorization is just 1 step
in a 2-step process. Pre-authorization is when we find out whether we
need to get a procedure approved. For outpatient procedures, most of
the time pre-authorization isn't a requirement, but you still have to call
and tell them it's being done. But at the end of the conversation,
they'll always say, this is not a guarantee of payment, did you verify
the patient's eligibility? That's where you find out if this is considered
an experimental procedure by this payer."
OSM
