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Does a medical procedure claim have to be bundled with a office visit claim ?

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lendbz:
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!

RichardP:
You should have received an Explanation of Benefits from the primary insurance.  Make a copy of this and attach it to whatever you send to the secondary insurance.  If your doctor gave you a fee slip listing the diagnosis and procedures / charges, attach a copy of this as well.  That will tell the secondary all they need to know.

We bill all insurances - primary, secondary, third if there is one.  Next time, give your doctor all of your insurances and you can avoid all of thism (unless he maybe only bills the primary). :)

This is the simplified response.  Others may want to elaborate.

Merry:
You need to let both insurance companies know that there are two insurance policies. You are asked so I assume that you said no. I am not comfortable with this.

PMRNC:
I have to agree with the others, you really need to correct your insurance process with the provider, it will save you a lot of headaches.

--- Quote ---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?
--- End quote ---

If you change that bill in any way, shape or form that will be fraud. You will be billing the secondary with the original billing form or an itemized superbill and you will attach the primary carriers Explanation of Benefits to the original bill.


--- Quote ---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?
--- End quote ---

Your skating a fine line, I'll just be blunt.  You are NOT going to create your own manual bill as you'll be asking for trouble. You will again, attach the proper billing from the provider's office and enclose the primary carrier's EOB.  You are trying to avoid the provider and in doing so you put yourself at more risk of being caught. You may not change any codes, services or even create your own manual bill at all. This MUST come from the provider. You can file ONLY what they give you (procedures/amounts as listed and done) and YOU MUST have a copy of the Primary EOB with the claim. Now if your secondary does not know about your primary, you have another incident of fraud on your hands.


--- Quote ---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?
--- End quote ---

Again and I repeat again... YOU WILL NOT PUT CPT CODES AND AMOUNTS anywhere unless you do want to be investigated for fraud. Get an ITEMIZED bill from the provider and make sure you have the Primary carriers EOB.   I know I sound like a broken record but in multiple places you stated you wanted to "create a manual bill"   NO NO NO.

RichardP:
Question:  In some instances, doctors will bill primary but not secondary.  Does anyone know of situations where the doctor's office will give patient a copy of the fee slip containing codes the doctor's office will use to bill primary, plus a blank CMS 1500 Form for the patient to fill out and attach to the appropriate paperwork when the patient bills the secondary?

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