Billing > Billing

Re-submitting as routine?

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Michele:
If the dr is ok with it being considered a routine exam, then you aren't doing anything fraudulent.  As long as the patient's chart also shows it was a routine exam.  I find that the dr walked into the room intending for it to be a routine exam, found a medical problem, and then it really could go either way.  That is why the dr has to OK the change from medical to routine.  And the notes must also reflect it.  They can show that the dr addressed the medical concern, but the main reason for the visit was routine.

Michele

Pay_My_Claims:

--- Quote from: wildcat1842 on December 07, 2009, 04:48:14 PM ---Thank you guys! The patient did come in for a routine exam, but the dr found medical diagnoses. If we changed the diagnosis and re-submitted it, would that be breaking any rules/laws?

--- End quote ---

If the routine eye exam turned into a medical exam the MD did the right thing and billed as such, however, the patient had the right to know prior to, and changing it to suit the needs of the patient IMO is fraud. The MD documented a medical exam, therefore that is what we bill. The MD could have told the patient. Sir/Madam, your preliminary test are showing some medical issues that we need to address, so therefore I need to reschedule your routine eye exam to address these issues and see you under our medical services to futher assist you.

Michele:
Charlene is right.  If the exam distinctly became medical then it should not be changed.  However, that is why I said that the Dr is the only one who can make that call as he was in the room and provided the service.  Did he perform a routine exam, but note a medical problem and make the patient aware of it?  Or did the visit turn from routine to medical.  We bill for several eye drs and run across this regularly.  The dr always has to make the call.  Also, we never change them based on the patients needs or requests.  However, as Charlene also stated, it is imperative that the Dr inform the patient during the visit so they are not surprised!  :)

Michele

Anand:
I agree with Michele&Charlene. They are right. As a matter of fact codes cannot be changed just to get payments or the way patient wants to be. We have instances in my office too.. We get a lot of Pt calls on this issue. As Steve pointed out sometimes it will be cumbersome process to make the pt understand. I would go ahead and check with the Dr and confirm if the service were rendered as a routine or it was changed based on the medical necessity of the ailment.

Thanks,
Anand.

Steve Verno CMBS, CEMCS:
I went to my personal physician the other day.  He was trying to come to the room I was in.  An angry senior citizen was blocking his way, yelling and screaming at the top of his lungs.  he ws accusing the doctor of fraud.  He said his insurance company told him if the doctor changed his diagnosis, his insurance company would pay the bill.  He must have said he would sue about 10 times. My doctor was excellent, he kept his cool.  He took the patient into a private room, asked me if I could help.  He asked the patient if I could see his chart.  He explained to the patient about my credentials.  I looked and explained that the doctor used the right code.  I showed the patient what the code was. I showed the code tat the insurance company wanted  The patient calmed down, admitted he used the internet to do some investigation.  He said he went to an internet site and someone responded saying the doctor was committing fraud.  I asked, was this person a coder?  Nope!  Just someone who was anonymous.  I explained that we cannot change what is documented just because an insurance company wants something change.  I also explained if we changed the code, we might be committing fraud.  The patient apologized and left saying he would give the insurance company a call.  The doctor thanked me.  I was impressed.  He said he was used to it when he did his intership and residency in Brooklyn.   

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