Coding > Coding

help with code

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PMRNC:
The insurance carrier is NOT there to tell you how to code, how could they tell you how to code without the medical record? They are not allowed to even suggest codes to you, that's actually to safeguard any fraud.   

If the provider is seeing the couple for marriage counseling ONLY the diagnosis will be the V-code.. that's not exactly accurate that the carrier won't pay v Codes.  There are still MANY carriers who flat out don't cover marriage counseling, to put any other diagnosis to a claim where marriage counseling services are being rendered to preclude payment from the carrier would constitute fraud. When I verify benefits I flat out ask if there is a benefit for marriage counseling, it's going to be yes or no and most times you still need the authorization anyway and that's another added protection.

Sophrosyne:
It makes sense that the insurance company can't suggest codes. I just wish they could accurately tell me if a particular code is covered or not (although I suppose that also could be to safeguard against fraud--not that we would alter our coding if the code we used wasn't covered, we just like to be able to tell patients what they can expect to pay for each visit). We've had a few cases in which an insurance company says that marriage counseling is covered, but then denies the claim because of the V-code. But then we've also had one instance in which the insurance company said marriage counseling is not covered, but then paid the claims. This made me wonder if maybe we were missing something.

Michele:
Unfortunately there is lots of error in this field.  Call the same company 3 times and you probably will get 3 different answers.  It certainly can get frustrating.  Also, even with technology, claims are often processed incorrectly.  I've seen Medicare go back 5 years and say "we shouldn't have paid that" and demand the money back.  I'm wondering why didn't they notice when the claim was paid? 

PMRNC:

--- Quote ---It makes sense that the insurance company can't suggest codes. I just wish they could accurately tell me if a particular code is covered or not (although I suppose that also could be to safeguard against fraud--not that we would alter our coding if the code we used wasn't covered, we just like to be able to tell patients what they can expect to pay for each visit). We've had a few cases in which an insurance company says that marriage counseling is covered, but then denies the claim because of the V-code. But then we've also had one instance in which the insurance company said marriage counseling is not covered, but then paid the claims. This made me wonder if maybe we were missing something.
--- End quote ---

It's actually not that you are being misled. As someone who's worked quite a few years on the carrier side it goes like this.. always remember "medical necessity" so if you have a couple seeing a therapist for routine marital problems it's not going to be covered, if you however have a carrier that pays for marriage counseling and the couple presents with one or both problems that relate to the marriage, then it's covered.   Again, this is why an insurance carrier will never tell you that the following services are covered for the following diagnosis.. it's to prevent fraud/abuse. Coding is done based on the couple/patient's presented, not what the carrier will or will not pay for.     A good example is that most therapists will see a couple but they will also be seeing one or both individually, and that also determines under which patient the claim is processed as well so it stands to reason there needs to be an underlying presented illness for it to be covered.  I know.. but ya gotta dot the i's and cross the t's. :)

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