Author Topic: Please help me. I am a cash patient. Was I upcoded? (99203 vs 99202 or 99201)  (Read 9672 times)

MedicalCodingHelp

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I went to an Orthopedic to get a simple second opinion about neck\back arthritis.  I brought him an MRI, the report for the MRI, and X-rays from a chiropractor.  I gave the nurse my MRI disc and report and the doctor was in to see in in five minutes.  I explained my symptoms and he said I was fine.  He put my XRAYS up and told me I was good.  He stated my arthritis is very mild and it is normal for about 20% of people my age.  He did a 2 minute examination of my reflexes and I pulled on his arms.  I asked him about the pain and he suggested exercise, physio, and said that I did not need surgery thank god.  He spent a total of 10, maybe 15 minutes (thats pushing it) face to face.  The examination was brief.  There was no "coordination of care" or "medical history analysis."  I would say the "medical complexity" was straightforward.  I was an "in and out" patient.  He billed me using code 99203.  I feel as if 99202 or 99201 would be more appropriate based on what I've been reading about CPT codes.  This was a "corporate doctor" and these codes were most likely generated by EMR software.  I am a cash patient that was told the bill would be about $80 but was hit with a $120 bill. 

Was I upcoded?  I would like to get the opinion of MBC experts before taking this up with the billing department.

Thanks in advance
« Last Edit: October 17, 2012, 11:23:25 AM by MedicalCodingHelp »

DMK

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99203 is appropriate for the appointment you described, particularly with an orthopedist (since they are a specialist) that includes looking at other radiological findings. They would RARELY have a new patient appointment less than a 99203 and usually it would be a 99204 or 99205.  Please bear in mind that these are NOT timed codes.

I'm sorry that the appointment was more expensive than you were expecting.  A specialist is usually costs more than an MD appt.  Unfortunately as a cash patient you get hit HARD!  Was there no discount offered for payment at time of service?

MedicalCodingHelp

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Thanks for the info.  It just didn't seem like there was any "work" done but I'm not a doctor heh.  That price was with a 50% discount.  I just thought I was up coded because I was told $80 on the phone.  I would assume that the person on the phone knew the doctor bills at either 99203,4,or 5 for a new patient and the price could never have been $80.

Are all office visits, regardless of the doctor, absent of other procedures, billed using the 99201-99205 (99211-99215 for established patients)?  Drs usually say on the phone "we don't know the price because there are many codes that can be billed".  Do you guys typically know the code that is most likely going to be billed for an "average visit"?

Also are office visits with other procedures "double coded"?  What I mean is do you pay a 992XX code each time you step in the office plus any other procedure, or does the procedure imply the office visit?

For example, let's say I broke my arm and had to get an X-ray elsewhere (just lets say).  I'de pay the 99205 for the diag, then X-ray facility.  When I come back to get my arm reset would I then pay on another office visit code (99213) on top of the procedure for resetting the arm?  Then I have to go back for a followup.  Do I pay once again on 99213?  Should I be paying that or just one 99205 for the diag, then a bundled "broken arm" code that includes the followup and cast removal. 
« Last Edit: October 17, 2012, 02:03:23 PM by MedicalCodingHelp »

rdmoore2003

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Thanks for the info.  It just didn't seem like there was any "work" done but I'm not a doctor heh.  That price was with a 50% discount.  I just thought I was up coded because I was told $80 on the phone.  I would assume that the person on the phone knew the doctor bills at either 99203,4,or 5 for a new patient and the price could never have been $80.

You say you took report, MRI, & Xrays to this appointment.  The information in your chart would have been looked at (report) before the dr came into the room.  How do you know that he hasnt had a call from your referring physician?  There are many veriables that a patient is not aware of and should never "assume" anything.   If you had questions, you should voice them at that time. As for the "assume" part, well, you cant assume anything in this field.  Usually, when completing first time paperwork, there should be a clinic policy that should have billing information listed.  Even with insurance companies, the have a clause that states, verbal benefits only and not a guarantee of payment.  When you called, there is no way the person can give you a "guarantee" of charges.    IMO, for an Ortho appt, I say you got a great deal even if you paid only 50%
Regina

DMK

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A new patient appointment at ANY doctor or chiropractor or PA or NP will be a 9920X.  That's the exam, and the doctor's diagnosing you.  If they do anything else, put on a cast, take an x-ray, adjust your spine, take a urine specimen for example, that's an additional service and would have a modifier added to the procedure code to indicate a separate service.

A follow up appointment will be a 9921X.  With additional services charged the same as above. 

SOME types of practices have the 9921X assumed with the service (chiropractic is one, we can NOT charge for an office visit every time you come in, only for the services, EXCEPT when a re-eval is done, and that's a full exam for a new injury or to finalize a case). 

Every office has a different fee for services and every insurance company has a different allowed amount for procedures.  Staff can usually give you some sort of estimate, but they have NO idea what the doctor will do, or what his findings will be, THEY ARE NOT THE DOCTOR.  EMR software does NOT determine the billing code, someone inputs that off the doctors superbill.  Every office is going to have a different policy for cash patients, a discount when paid at time of service is fairly standard, but IT'S NOT THE LAW! 

It's really important to understand, especially with all the changes come down the pipe, the insurance companies (Medicare first and foremost) have set the standard for how office must be run.  We don't just get to bill willy nilly, if Medicare even sniffs fraud they will come down hard.  Doctors are retiring from private practice and going to work at large clinics and hospitals because they simply can't keep up with good practice AND covering their butts constantly.  You can be accused of fraud and investigated to the point of putting you out of business when fraud made not even exist.  That's not even bringing up malpractice lawsuits.

Good care, at reasonable rates, in a timely fashion is going to be harder and harder to get in the future.