Author Topic: Billing provisional and/or rule out diagnoses  (Read 3462 times)

Sophrosyne

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Billing provisional and/or rule out diagnoses
« on: November 07, 2013, 04:57:56 PM »
One of my therapists is wondering if she can bill provisional and/or rule out diagnoses. We don't want to wait until testing is done and a final diagnosis given to bill insurance. Is there a particular format for this on the claim form? I've seen doctors write out "PROV314.01" or "R/O314.01"; is this how you'd enter it on the claim?
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PMRNC

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Re: Billing provisional and/or rule out diagnoses
« Reply #1 on: November 07, 2013, 05:18:38 PM »
I'd say NO. Many carriers won't even cover ADD. The tests are not even conclusive really just yet. What exactly are you looking to bill that is outside the testing services??
Linda Walker
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Sophrosyne

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Re: Billing provisional and/or rule out diagnoses
« Reply #2 on: November 08, 2013, 10:30:05 AM »
The ADD diagnosis was just an example. I don't have an actual provisional diagnosis as of yet. I was just wondering if it was even possible to bill a provisional or rule out diagnosis to an insurance company. And if so, if there is a particular format for it?
The basic issue is this. The therapist wants to try to file with insurance after each testing session to see if it will be covered by the insurance company. She doesn't want to risk waiting until the testing is done only to find that insurance doesn't cover and the patient is stuck with a huge bill (which may or may not get paid). I'm not sure if this is even possible--maybe there's nothing to be done to mitigate the risk, except call in/go online and try to see if there are any limitations or exclusions on the policy.

RichardP

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Re: Billing provisional and/or rule out diagnoses
« Reply #3 on: November 08, 2013, 02:05:53 PM »
The first line of responsibility is the patient.  They should be the ones checking with their insurance to see if a desired procedure is covered.

As a service to their patients, the staff of some doctor offices will check with the patient's insurance to see if the procedure is covered.  But, ultimately, it is the patient's responsibility to know what their insurance will pay for.

As for your billing question - do you understand how many kinds of illegal it is to bill for services that have not been provided?  That, in essence, is what you are wanting to do.

Unfortunately, many insurance carriers won't give you a straight answer about whether something is covered.  You may have to just do, bill for it, and see what gets paid.  And what gets paid will vary, depending on the insurance carrier, and any given plan within an insurance carrier.

PMRNC

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Re: Billing provisional and/or rule out diagnoses
« Reply #4 on: November 08, 2013, 02:42:04 PM »
Quote
As for your billing question - do you understand how many kinds of illegal it is to bill for services that have not been provided?  That, in essence, is what you are wanting to do.

I have to agree, basically the therapist is wanting to submit testing and "see if insurance will pay". If the psych testing codes are authorized you can check with carrier when you verify benefits. There's not too many "rule out" diagnosis codes you can use in Mental health.. no such thing as "rule out depression", "rule out bipolar disorder etc."  The tests should be medically necessary and documentation in the patient's chart needs to reflect services rendered and diagnosis presenting. It is NOT usual for a therapist to go testing w/out seeing the patient to make initial assessment.   
Linda Walker
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Sophrosyne

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Re: Billing provisional and/or rule out diagnoses
« Reply #5 on: November 11, 2013, 04:56:32 PM »
I think I didn't explain myself very well. The doctor DID do an initial assessment and has documented a few provisional diagnoses for the patient. However, she intends to do some psychological testing as well to determine a final diagnosis. She was just wondering if we could file these visits as the patient is seen (certainly NOT before the services are provided!) with the provisional diagnosis. This diagnosis MAY change after she has completed the testing. What she is looking to avoid is waiting until all testing is done and some $2000+ dollars billed to file and see if the insurance is going to pay. She is concerned with 1. Sticking the patient with a huge bill that they weren't prepared for and 2. Not getting paid if the insurance doesn't cover for some reason. I wouldn't be surprised if that's just the risk she has to take, but she wanted me to look into this.
At this point I'm thinking that perhaps the thing to do is file with the provisional diagnosis as the patient is seen. And if/when the doctor finds a more fitting diagnosis during/after testing, use that diagnosis from that point forward. Does this seem appropriate? We certainly aren't trying to do anything illegal here!

PMRNC

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Re: Billing provisional and/or rule out diagnoses
« Reply #6 on: November 12, 2013, 08:28:46 AM »
MUCH of what your asking really is clinical decision making which none of us are really qualified to do. For most part there are DOZENS of mental health diagnosis's that exist that CANNOT be established by way of psychological testing. Yes, the testing is expensive but from a clinical stand point only she is qualified to ascertain the condition that is suspect. I can't tell you that if she is doing a lot of testing that carriers won't flag it if she's doing a lot of it. Clinically she only should be making clinical decisions for testing based on suspect diagnosis, MUCH of the testing is not mean to rule out MOST diagnosis's in mental health.  Like you mentioned this is a cost of doing business and she has to make clinical decisions this is not really a "billing issue" because performing medical tests based on the patient's insurance is definitely a NO NO.  Carriers also usually require a separate authorization for testing and they have a means of establishing medical necessity for psych testing. For example Value options requires their own form to authorize testing, the authorization is then given for a certain amount of testing hours (8 for value options, for my plan example) 

With that in mind I would recommend looking into what the patient's carrier's requirements are, submit the clinical info they require and let the carrier authorize. If the carrier does not authorize the testing you still need to refer to the contract if one exists with the carrier to see if it's billable to the patient. Some plans won't let you, some will.
Linda Walker
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Merry

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Re: Billing provisional and/or rule out diagnoses
« Reply #7 on: November 12, 2013, 06:27:49 PM »
I must add..please do not bill until you have a definite diagnosis. This information is frequently stored at a large clearinghouse, MIB in MA. An incorrect diagnosis can really hurt someone trying to get life insurance or disability insurance.
I had a derm who insisted on coding for a malignant lesion that he had removed before the path report came back. I caught the claim and held it. The lab report was benign but had this been reported initially in the days of pre-existing conditions and health insurance or even getting life or disability insurance, the patient would have been screwed.

Merry