My doctor claim the insurance CPT 99204 (new patient visit) + CPT
46600 (anonscopy procedure). I have 2 insurances, one is spouse's but
I am on it, I did not tell my doctor I have 2 insurance. My own
insurance that the doctor claim return the money for CPT 99204, but
nothing for CPT 46600 ( deductible not met)., so I got a bill for CPT
46600. So I am trying to claim it on my spouse's insurance manually.
Hers has no deductible. Now, can I just claim procedure CPT 46600 just
by itself?? Or does all procedures need to be bundled with with either
a new/exisiting patient office claim such as 99204, etc for it to be
valid?? But the first insurance already pays for 99204, how can I
enter CPT 99204 if it's already been paid for partially and the
provider accepted it as in full? Would that be fraud if I put CPT
99204 in too in the 2nd claim withi my spouse's insurance? Should I
just claim the 2nd insurance manually with the procedure CPT 46600
itself only and exclude CPT 99204? or it will get rejected because it
doesn't have a patient office claim bundled with it?
More information:
so the first insurance comes back wiih this:
CPT 99204 Amt charged by provider: $225 Discount Amount $116.93
Deductible: 0 copay: $40 Payable by insurance: $68.07
CPT 46600 Amt charged by provider: $350 Discount Amount: $278.18
Deductible: $71.82 Copay: $0 Payable by insurance: $0 (deductible
not met)
It states I am responsible for $71.82 for the deductible, and also I
paid $40 copay.
Now I am going to claim this manually with my spouse's insurance, how
would i go about putting the amount and CPT code?? Should I leave CPT
99204 out and just claim CPT 46600? Since she has no deductible, her
insurance will cover CPT 46600, and her copay is $20 instead of $40,
is there a way to get the other $20 copay back ? How do I go about
claiming this so there won't be any fraud?
Or maybe since my first insuance already paid for CPT 99204 of $68.07 + I paid out of my pocket $40 copay for that CPT 99204 visit, and my provider accepts that payment for CPT 99204 as payment in full (doctor in network), in my new manual claim can I simply put $40 (since I paid $40 copay) or maybe $20 (since in my spouse's insurance it is $20 copay) for office visit CPT 99204 in additional to the $350 for CPT 46600, so whatever they pay me will not be overpaid?
Or would putting so little amount for such a CPT seem suspicious to them? What does office usually charge for CPT 99204 ? Or that method would be considered medicial fraud? But is there anyway they would find out? Would they call provider office to verify?
Also, when I file a this 2nd claim manually, are they going to verify with my provider office all the information? Or just based on what I put in on the form? I asked because if I reduce the amount for CPT 99204 from $225 to $40 or $20, and they called to verity, the claim would get denied? But the thing is, if I put $40 or $20 for CPT 99204, would the insurance gets suspcisous of why the charge is so low and go ahead and perform an audit?
Thanks!