Author Topic: Is my bill coded correctly?  (Read 1460 times)

cbvarnell

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Is my bill coded correctly?
« on: February 10, 2015, 05:42:56 PM »
I don't know if this is the right place to ask this question, but Google supplied me with this link so...
I got new insurance last year, and had to find a new in network doctor.  I scheduled my first appointment with them as a well check. I even wrote it on the forms I filled out. The forms also had places to check if you had any of the following conditions.  I checked obesity (because I obviously know I am fat).  The doctor was very thorough.  Besides taking weight and blood pressure, I brought up that I would like to lose weight and that it had been hard for me after I had my child. I specifically said that I could gain 10lbs in a month without trying and lose only 5lbs a month on calorie restictive diet. I told her that I felt something had changed after I had my baby with my body, and she suggested a blood panel to check my thyroid and hormones.  I told her that I had already had one about 6 months ago (that was never filed on insurance) that she was supposed to request from the other doctor, and everything came back normal.  She replied that we could check again to make sure everything was still normal, and told me that my insurance would pay for it anyways.  I agreed, and they took blood. She wrote me a prescription for birth control, gave me a pamplet about salt intake, and I left.  Everything came back normal including the diabetes and cholesterol screening that I wasn't aware she was doing.  I never follow up for anything or was giving a diagnosis. Now I have a bill of $420, of which $100 isn't covered because the cholesterol screening wasn't covered and because of my coinsurance.  I call the insurance company to find out everything was sent in as diagnostic including the office visit and all of the panels. It won't pay for the cholesterol panel at all because it was coded as diagnostic.  My questions are how do you determine if things are diagnostic or preventative? I was under the assumption that obesesity management, diabetic screenings and the cholesterol are preventative per healthcare reform.  I also understand that she did look for an underlying cause, but I don't see how if I had diabetes or high cholesterol that that would be the cause of my obesity, but rather a symptom of.  So are these coded correctly, or could part of my bill not be coded as diagnostic and the other part (cholesterol and diabetes panels) coded as preventative? Everything I find is kind of murky. And to be clear I have no other health problems besides that I am just overweight.

PMRNC

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Re: Is my bill coded correctly?
« Reply #1 on: February 11, 2015, 11:34:09 AM »
Do you happen to have the itemized bill with CPT (procedure) codes and diagnosis codes?
Preventative care is covered to a point under ACA, however if your plan is grandfathered you may not have those provisions of the ACA.
Grandfathered plans under ACA don't have to meet the ACA provisions unless there is a change in status of grandfather clause.
Linda Walker
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cbvarnell

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Re: Is my bill coded correctly?
« Reply #2 on: February 12, 2015, 01:06:32 AM »
No I don't. I haven't even gotten a bill yet just my EOB. I don't know what grandfathered in means, but we actually went through the HCMP to enroll with BCBS, and it says that the cholesterol and diabetes screening were convered. Evidently though, the cholesterol is only covered if it is preventative. The insurance supposedly called the doctors office and said everything was coded as new patient visit and that they didn't do check ups until you were an established patient which I have never heard of. When I called the doctor's office however the nurse just kept saying that it looked like I came in for other stuff but couldn't tell me anything different than what we talked about me feeling off since baby, irregular period (which was part of the form and She suggested hormonal birth control) tired and my weight. I was reluctant to even do the panels because I had already done them and wasn't sure what they would pay, but the doctor said "You've got insurance, they'll cover them." I'm currently waiting to hear back from nurse that was supposed to talk to the doctor. I can see the thyroid and hormones panel being diagnostic, but I just don't really see how it is for everything else when the only concern I brought up was my weight. Anything else discussed or done was responses to her questions about history or at her suggestion like the panels. I'm not opposed to paying my coinsurance for those, but they act like it is all or nothing on how it is all coded.

kristin

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Re: Is my bill coded correctly?
« Reply #3 on: February 14, 2015, 09:08:56 PM »
Sounds like the doctor chose an ICD-9 code(diagnosis code) for the cholesterol panel that was considered diagnostic, and not preventative/screening. Therefore your insurance is not paying. Please, don't believe doctors/office staff when they tell you: "You've got insurance, they'll cover them."  "Them" being tests, blood work, etc,.

Because what happens next is you get the bill for "them", and the response from the office is "You are the insured, you should know what is covered under your policy, not us". See how that works?

I don't know that that is what happened here, but it sure sounds like it.

shanbull

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Re: Is my bill coded correctly?
« Reply #4 on: March 09, 2015, 11:02:55 AM »
Sounds like the doctor chose an ICD-9 code(diagnosis code) for the cholesterol panel that was considered diagnostic, and not preventative/screening. Therefore your insurance is not paying. Please, don't believe doctors/office staff when they tell you: "You've got insurance, they'll cover them."  "Them" being tests, blood work, etc,.

Agreed on all points. You can call the doctor's office and ask them to send you a copy of the bill they sent in to your insurance company. Just ask them to print the HCFA form and they can mail/email/fax it to you. It may not make a lot of sense to you, but if you show it to us (after removing anything that shows your personal info) we can tell you a bit more about what happened, and how you can ask them to code it for a re-submission that will cover the cholesterol screening. I have never heard that screenings can't be preventative for a new patient, we do it that way a lot, especially if the patient already has records from a previous doctor. There is some discretion involved when deciding how to code an annual well visit, and what goes above and beyond to become what is called a "problem-focused exam," but you can always ask them to consider changing the coding, especially because they apparently didn't code for an additional office visit.

PMRNC

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Re: Is my bill coded correctly?
« Reply #5 on: March 09, 2015, 08:01:05 PM »
Quote
how you can ask them to code it for a re-submission that will cover the cholesterol screening.

I completely DISAGREE. I can't name how many times a patient or parent of a patient has called me and told me to tell the doctor to "code it so the insurance will pay".   That's not going to fly.. or at least it should NOT fly.
I suggest asking the doctor for the actual records and notes from YOUR visit.. tell them you wish to review their notes from that date. Take it from there. The answer is not to tell the doctor how they should bill it and code it. That is fraud.  It's YOUR record so you call and make apt and tell them you are coming in to review the medical report and notes from that visit. Get a copy and then file an appeal with your insurance company. It's your claim, so you should actually do the appeal and send in the medical notes from that visit.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com