Author Topic: 25600 for one time vist??  (Read 1047 times)

japerf1

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25600 for one time vist??
« on: May 12, 2016, 02:20:26 PM »
I think I'm being charged for services not received.  I got billed for codes 25600, 99203 and 73100 plus a few small charges for meds and splint supplies for a closed fractured wrist that did not require any manipulation/setting in Vermont on vacation.  I believe 25600 is a global charge for care of the fracture.  I made it clear that I would not be returning follow up care.  I only went to that facility once and did not receive any further care from that doctor or facility. I went home to Pennsylvania where I received the rest of my care. Is 25600 appropriate or is there another way to bill this for a one time visit?   Thoughts?

kristin

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Re: 25600 for one time vist??
« Reply #1 on: May 12, 2016, 09:03:50 PM »
I agree with you, the doctor in Vermont should not have billed the 25600. This article from CGS Medicare nicely lays out when a fracture care code like a 25600 should be billed, and when it should not:

http://www.cgsmedicare.com/partb/pubs/news/2013/0513/cope22035.html

If the doctor in Vermont knew you would never be returning for further care, they should have just billed the 99203, the 73100, and any splinting charges/supplies. By billing the 25600, they were implying that they would handle all your follow-up visits for 90 days(global period). In addition, just splinting the arm with no "restorative" treatment, doesn't meet the requirements of the code.

To make things worse, any doctor you see for this injury where you live should get their claim denied as being within that 90 day global period, unless the doctor in Vermont put a 54 modifier on the claim(which I doubt), then officially on paper transferred care to your hometown doctor, so they can put a 55 modifier on their charges, which will result in some payment, but reduced payment.

I don't know if the doctor in Vermont(or their coder, if they have one) just didn't understand the situation, or if they did, and didn't care, because they wanted the higher reimbursement for billing the fracture care code. Regardless, I would fight this. If the doctor's office isn't willing to submit a corrected claim, and refund your insurance for a code they shouldn't have been paid for, then take it to your insurance company, and have them review everything, so that they can pursue the doctor for a refund.

japerf1

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Re: 25600 for one time vist??
« Reply #2 on: May 13, 2016, 12:36:50 PM »
I was going to suggest they add the 54 modifier or should I ask to have the 25600 removed completely since I was charged for the 73100 as well?
Thank you so much for your info.
Patrick
« Last Edit: May 13, 2016, 12:46:41 PM by japerf1 »

kristin

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Re: 25600 for one time vist??
« Reply #3 on: May 13, 2016, 02:45:21 PM »
I would ask them to remove the 25600 completely, if it were me.