topic Re: Question for certified medical coder in Wellness

Question for certified medical coder

sgraham30 — Mon, 08 May 2017 12:49:11 GMT

Here's the situation: on 01/08/16, I had an angiogram, which was done outpatient at a local hospital. The billing code used was CPT 93458, global days for the procedure are 000.

The doctor who did the procedure is not the one who ordered it, that was my cardiologist. I never saw the doctor who did the procedure until the day of the procedure itself. I met him before the procedure, while I was in the holding area at the facility. He went over what he'd be doing, told me the risks, & had me sign forms. After completion of the procedure, he came to the room I'd been put in, gave me the results of what he'd found (nothing, thank goodness) & discharge instructions. I haven't seen him since.

Earlier this week, I received a bill for CPT code 99214-25, with the same date of service as the angiogram, which was 01/08/2016. From the research that I've been doing the past 2 days, the rendering physician should not be billing for evaluation & management services done the same day as the surgery since pre-procedure, intra- procedure, & post-procedure work is considered inherent in the procedure.

I requested a copy of the CMS-1500 form that was submitted because I plan on fighting this. Is my rationale correct or am I way off on this?

Thanks to anyone who might respond to this.

Re: Question for certified medical coder

Carmie — Sun, 07 May 2017 20:35:41 GMT

Procedure codes in the 99214 to 99225 are codes used by a physician in a hospital setting for evaluation services.

Procedure code 93458 is the procedure billed by the hospital for the facility services they provided ( I won't mention the service to protect your privacy) It is not the code for an angiogram, but another related proceduredo in done in addition.

Usually doctors who work in the hospital are self employed and their bill is not included in the hospital facility fee.

You will always get doctor bills separate and many times there is more than one doctor involved,

easy example... you fall and break a bone. You go to the ER for treatment.

your bill will include the ER/ op room Hospital fee, your ER doctor's fee and the doctor who looked at the x- ray and gave the results to the ER doctor.

In addition, you will get a bill for the surgeon who repaired the break and an anesthesiologist. All of these providers will bill

All of the services done today are billed by computer. If the biller were to put something that is not allowed, it will be kicked out. If it is reentered with a modifier that can be used, it will go through to the insurance company.

if it is an integral services that should be included and not billed seperately, it will be denied saying so.

i am not sure why you are so involved with this. Did you receive a bill for a claim that that was denied? If so, let me know. I can offer suggestions for getting the insurance to pay it.

Re: Question for certified medical coder

chrystaltree — Sun, 07 May 2017 20:43:21 GMT

First, I'm happy to hear that you are ok. 93458 is the technical part, it's what the hospital charged for your procedure. 93458 is not a surgical procedure, it does not fall into the surgical part of the CPT code book, it is in the Cardiovascular medicine part and you would not apply the surgical "rules" to this code. 99214 or 99215 reimburses the physician who did the angiogram for that pre-procedure visit and the post-procedure visit. He saw you twice on that day but he could only bill for one visit. The bill is correct. If you had a surgical procedure, like a tenotomy on your toe 28010, then you would have been correct. It would have been incorrect to bill for a visit on the same day as the surgical procedure. Yes, I am a certified coder and I have over 20 years experience in healthcare reimbursment.

Re: Question for certified medical coder

sgraham30 — Sun, 07 May 2017 21:31:02 GMT

@chrystaltree, thank you for your response & the clarification. I don't doubt your qualifications, I've seen posts by you before.

What is code CPT code 93458-26? That was billed on the same form that the CPT 99214-25 was billed on.

Re: Question for certified medical coder

sgraham30 — Sun, 07 May 2017 21:33:53 GMT

@Carmie, except for CPT code 99214-25, all the charges for date of service 01/08/2016 were paid.(as far as I know) The facility has my correct insurance info but the people in the billing department keep submitting my bills to an insurance I have nothing to do with. I've given them the correct insurance & mailing address multiple times now. I've e-mailed them the correct info twice now yet bills keep getting sent to the wrong insurance.

I finally got fed up & messaged them via the Contact Us option on the website where you can pay the balance due. I gave them the correct insurance info/address & told them that since they seem to be having so much difficulty submitting the bills where I'm telling them they need to be sent to, make copies of the CMS-1500 forms, send them to me, & I'll submit them where they need to go myself.

The bills were finally sent to the correct insurance after that. My insurance denied the charges for timely filing since there is a 12 month timely filing limit (date of service was 01/08/16, my correct insurance finally got the bills April 2017)

The timely filing denial can be appealed but proof of timely filing has to be sent. The bill was submitted to the wrong carrier & denied by them THREE TIMES before I received a balance due statement. There is proof of timely filing but it's not to my correct insurance.

Any suggestions you have would be much appreciated. Thank you.

Re: Question for certified medical coder

Carmie — Sun, 07 May 2017 21:34:06 GMT

@sgraham30 If the provider of service is in network with your insurance company, and they submitted the bill to the correct insurance company late, they cannot bill you. They must eat the charges or they must appeal to the insurance company.

if they are out of network or not participating, you should appeal the claim with your insurance company. It must be done in writing and don't forget to enclose a copy of the. E-mail or EOB's from the incorrect insurance company that you received. You will need proof that you tried to get the claims submitted promptly and the provider dropped the ball. Send them everything you have and and what you did.

if you have a copy of the EOB from your correct insurance company denying the claim for timely filing, it probably has a comment letting you know if you are responsible for payment or you could call and ask.

Re: Question for certified medical coder

chrystaltree — Sun, 07 May 2017 21:36:12 GMT

@sgraham30 wrote:
@Carmie, except for CPT code 99214-25, all the charges for date of service 01/08/2016 were paid.(as far as I know) The facility has my correct insurance info but the people in the billing department keep submitting my bills to an insurance I have nothing to do with. I've given them the correct insurance & mailing address multiple times now. I've e-mailed them the correct info twice now yet bills keep getting sent to the wrong insurance.

I finally got fed up & messaged them via the Contact Us option on the website where you can pay the balance due. I gave them the correct insurance info/address & told them that since they seem to be having so much difficulty submitting the bills where I'm telling them they need to be sent to, make copies of the CMS-1500 forms, send them to me, & I'll submit them where they need to go myself.

The bills were finally sent to the correct insurance after that. My insurance denied the charges for timely filing since there is a 12 month timely filing limit (date of service was 01/08/16, my insurance finally got the bills in March or April 2017)

The timely filing denial can be appealed but proof of timely filing has to be sent. The bill was submitted to the wrong carrier & denied by them THREE TIMES before I received a balance due statement. There is proof of timely filing but it's not to my correct insurance.

Ok, you should have received an EOB with the denial every time the bills were sent to the wrong insurance company. Those EOB's are your proof that the bills were sent to the wrong insurer. If you do not have any of the EOB's, call the doctor's office or go there and ask them for an account summary that shows the number of times they bill to the wrong insurer and the dates and the denials. They have it, all they have to do is print off a copy and mail it to you. Don't let them tell you otherwise. That's your proof. However, this might not suffice as proof of timely filing for some insurers because it was submitted three times and you should have received the 3 denial letters or EOB's from that wrong insurance company, so you could have resolved the matter within the filing period. Some insurers are more lenient than others. They are all different when it comes to things like this. If you don't get what you want, go through all the steps of the appeal. If I got it right, the facility has the right information but the phycians's office does not. My advice to you and everyone else is that whenever you are scheduled for a surgery or admission or expensive procedure; call the doctor's office and facility and verify that they have all the correct information. Don't assume that they do.

Re: Question for certified medical coder

sgraham30 — Sun, 07 May 2017 21:49:13 GMT

@Carmie, the insurance that I have doesn't have in or out of network providers, it's an indemnity plan. I never received any denials from the wrong insurance company, I found out that the claim had been submitted/denied 3 times by the wrong carrier when I called to see why the balance due statement was showing that I "Have no insurance on file."

The person that I spoke to advised me that the claim had been submitted/denied by my insurance 3 times. I asked for the insurance info & she gave me the name/address for the wrong insurance. For the third (maybe 4th time) I gave her the name/address for the insurance where the bills should be sent. I know they have the correct insurance info on file because I was on my patient portal earlier today & the insurance info that's on file for me is the correct info.

I need to get copies of the EOB's indicating that the charges had been denied & once I have those, I can call my actual insurance & see how to proceed from there.

Thank you so much for your help.

Re: Question for certified medical coder

sgraham30 — Mon, 08 May 2017 12:52:15 GMT

@chrystaltree, thank you for your input, it's much appreciated. I'm not sure what the doctor's office is getting when a charge is denied but I'm getting absolutely nothing.

There was another instance where a date of service had been denied because it was sent to the wrong carrier. The date of service was 01/21/16, I got a form letter denying the charge from the wrong carrier dated 03/20/17 stating that they have no record of me, which is correct, I'm not in their system. In this instance I got a a balance due statement after the first denial so I called billing to see what was going on. They managed to get the bill to the correct insurance & the bill was paid based on the fee schedule allowed amount.

Re: Question for certified medical coder

drizzellla — Mon, 08 May 2017 02:10:52 GMT

I hope you get it resolved.

I am currently fighting a bill for services that occurred almost a year ago. I got an EOB from my Insurance Company stated I owed nothing, But the Hospital is now billing me for an additional Surgeon. The Insurance Company already paid a surgeon and a plastic surgeon for a mastectomy.

The hospital billed me previously for a lymphodema consult - that was to be free (coupon) from my Doctor. My husband said it was easier to just pay because I was getting no where with my Doctor or the hospital. So I paid for that. Now all the sudden I am getting a bill from another surgeon. I only talked and met two surgeons. I know nothng about a 3rd.

I sent a note and copies of the EOB to the hospital billing department and called my Insurance Company. The Insurance Company assured me I did not owe the hospital anything additonal. But the hospital keeps billing me. Guess they just throw out the EOB and notes.

Re: Question for certified medical coder

Moonchilde — Mon, 08 May 2017 02:27:38 GMT

@drizzellla wrote:
I hope you get it resolved.

I am currently fighting a bill for services that occurred almost a year ago. I got an EOB from my Insurance Company stated I owed nothing, But the Hospital is now billing me for an additional Surgeon. The Insurance Company already paid a surgeon and a plastic surgeon for a mastectomy.

The hospital billed me previously for a lymphodema consult - that was to be free (coupon) from my Doctor. My husband said it was easier to just pay because I was getting no where with my Doctor or the hospital. So I paid for that. Now all the sudden I am getting a bill from another surgeon. I only talked and met two surgeons. I know nothng about a 3rd.

I sent a note and copies of the EOB to the hospital billing department and called my Insurance Company. The Insurance Company assured me I did not owe the hospital anything additonal. But the hospital keeps billing me. Guess they just throw out the EOB and notes.

Many types of surgery pretty much require an assistant surgeon. He (or she) is in the OR assisting your primary surgeon during surgery. S/He fills a definite purpose and the surgeon needs/wants him there. You would not have necessarily ever seen the asst surgeon. I had a total hysterectomy and never saw mine, although I knew ahead of time there would be one. But yes, they bill for their services. Not every surgery requires one and not every surgeon wants one in every surgery. I'm not positive, but I believe the surgeon has to justify the reason he asked for an assistant; at least, that used to be the case.

Re: Question for certified medical coder

CatLoverDogsToo — Mon, 08 May 2017 03:39:38 GMT

The .25 modifier on the evaluation code indicates that it is a separate evaluation from the procedure. The .25 modifier allows the evaluation to be billed and paid on the same date a procedure is performed as it indicates there was "more than" the surgeon walking in and doing the procedure. He evaluated you and explained things, and while he evaluated you he could have seen something (or not) that would change his opinions.

You seem bent on complaining and looking for "fraud" where I doubt seriously there is any.

Modifiers attached to many CPT codes indicate different things and allow for payments for procedures perfomed the same day as an evaluation.

There is no "law" or "regulation" stating that the evaluation code can never be billed with a procedure.

I ran a practice for many years, so I do know why modifiers are used. .

Re: Question for certified medical coder

sgraham30 — Mon, 08 May 2017 12:46:40 GMT

@CatLoverDogsToo, if this is directed to me, I'm not looking for fraud, I'm looking for an explanation, which I got from @chrystaltree & @Carmie. Since it's a valid bill, I have no problem paying my co-pay, once specific insurance issues have been resolved.

Re: Question for certified medical coder

sgraham30 — Mon, 08 May 2017 12:53:10 GMT

@drizzellla, I hope you get your situation resolved as well.

Re: Question for certified medical coder

drizzellla — Tue, 09 May 2017 00:08:55 GMT

@Moonchilde wrote:
@drizzellla wrote:
I hope you get it resolved.

I am currently fighting a bill for services that occurred almost a year ago. I got an EOB from my Insurance Company stated I owed nothing, But the Hospital is now billing me for an additional Surgeon. The Insurance Company already paid a surgeon and a plastic surgeon for a mastectomy.

The hospital billed me previously for a lymphodema consult - that was to be free (coupon) from my Doctor. My husband said it was easier to just pay because I was getting no where with my Doctor or the hospital. So I paid for that. Now all the sudden I am getting a bill from another surgeon. I only talked and met two surgeons. I know nothng about a 3rd.

I sent a note and copies of the EOB to the hospital billing department and called my Insurance Company. The Insurance Company assured me I did not owe the hospital anything additonal. But the hospital keeps billing me. Guess they just throw out the EOB and notes.

Many types of surgery pretty much require an assistant surgeon. He (or she) is in the OR assisting your primary surgeon during surgery. S/He fills a definite purpose and the surgeon needs/wants him there. You would not have necessarily ever seen the asst surgeon. I had a total hysterectomy and never saw mine, although I knew ahead of time there would be one. But yes, they bill for their services. Not every surgery requires one and not every surgeon wants one in every surgery. I'm not positive, but I believe the surgeon has to justify the reason he asked for an assistant; at least, that used to be the case.

Thanks for your input. My cancer was .2 cm and was a completely contained dot. It had not spread. That is why I think Cigna paid for 2 surgeons. Since it was a routine mastectomy, there was no need for an assistant. In fact my surgeon never mentioned anyone but herself and the plastic surgeon doing the surgery. Or the need for any additional people working on me. And there were a few people that were paid by my insurance company I had no idea who they were. I assumed anesthesiologist and their assistants. In fact I am going to go back to all my EOBs (I have a 2 page spreadsheet of all the charges) and count all the people who particpated and were paid, the day of my surgery.

Clearly they have ignored the copies of the EOBs and notes I have sent. I think they are just going to continue to bill me and then send me to collections.

Re: Question for certified medical coder

drizzellla — Tue, 09 May 2017 10:54:48 GMT

@Moonchilde wrote:
@drizzellla wrote:
I hope you get it resolved.

I am currently fighting a bill for services that occurred almost a year ago. I got an EOB from my Insurance Company stated I owed nothing, But the Hospital is now billing me for an additional Surgeon. The Insurance Company already paid a surgeon and a plastic surgeon for a mastectomy.

The hospital billed me previously for a lymphodema consult - that was to be free (coupon) from my Doctor. My husband said it was easier to just pay because I was getting no where with my Doctor or the hospital. So I paid for that. Now all the sudden I am getting a bill from another surgeon. I only talked and met two surgeons. I know nothng about a 3rd.

I sent a note and copies of the EOB to the hospital billing department and called my Insurance Company. The Insurance Company assured me I did not owe the hospital anything additonal. But the hospital keeps billing me. Guess they just throw out the EOB and notes.

Many types of surgery pretty much require an assistant surgeon. He (or she) is in the OR assisting your primary surgeon during surgery. S/He fills a definite purpose and the surgeon needs/wants him there. You would not have necessarily ever seen the asst surgeon. I had a total hysterectomy and never saw mine, although I knew ahead of time there would be one. But yes, they bill for their services. Not every surgery requires one and not every surgeon wants one in every surgery. I'm not positive, but I believe the surgeon has to justify the reason he asked for an assistant; at least, that used to be the case.

Well, I looked up my charges for the surgery the insurance paid

Doctor #1 - lab Insurance also paid the Lab

Doctor #2 - diagnostic

Doctor #3 - lab

Doctor #4 - diagnostic

Doctor #5 - radiology Insurance also paid Radiology Group

Doctor #6 - anestesia Insurance also paid Anesthesia Group

plus my Surgeon and Plastic Surgeon

and I just started getting billed for another Doctor for surgery from June 2016?!?!