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Trusted Contributor
Posts: 1,408
Registered: ‎05-22-2010

Re: Who Do I File Complaint for Medical Coding Issue?

 They do not handle anything  promptly and professionally.   It took, and I am not exaggerating, 18 phone calls to their office in 1 year to get the claim filed to my insurance.

 

They filed the claim originally to a insurance company I never had. I sent a letter with the correct insurance information, they never updated my file with that information. Then once they had acknowledged they filed the claim to my insurance and my insurance had no record of it being received, they would never resubmit it.  They always said "too soon - we have to wait 90 days"! Also, they never could provide an actual date as to when they sent the claim to insurance. 

 

I told them that I have a 1 year filing submission clause, the claim must get to the insurance before that time or it will be denied for timely filing.  I spoke to supervisors and they told me not to worry, if they don't get the claim to my insurance in time, they'll write it off.

 

Sure does not sound too prompt and professional that they may not be able to get a claim filed IN ONE YEAR, so they rather just write it off????   How efficient / professional is that?  I consider their practices unacceptable. 

 

I could go on and on about the experiences I had with them and, therefore, as they say "considering the source" I know I'm dealing with a billing service that is very inadequate.

 

Thank you to those of you that provided some assistance with who I can contact to file a complaint - I appreicate your help.

 

Oh yes, and when I called today.  The first thing that the rep. said to me is 'I see you have a balance on your account and WE HAVE NO RECORD OF YOU HAVING INSURANCE".  Really,  I only called 18 times previously with that information!!!   No - this is NOT a professional company.

Trusted Contributor
Posts: 1,402
Registered: ‎07-25-2010

Re: Who Do I File Complaint for Medical Coding Issue?

I do coding for a living and how do you think a pathologist can code something other than a polyp?  That is what was found, that is what has to be coded or it is fraud, plain and simple.  Call The Office of the Inspector General if you do not agree.  I used to work at a multi-specialty clinic and patients always wanted their claims recoded so their insurance would pay.  You can only code what is found, in this case a polyp.  

Trusted Contributor
Posts: 1,408
Registered: ‎05-22-2010

Re: Who Do I File Complaint for Medical Coding Issue?

The PRIMARY diagnosis should be the same as the ordering physician's and the facility bill -  screening.   The patient had no symptoms or complaints when the procedure was ordered/performed.

 

The pathologist should list as the SECONDARY diagnosis the results of the screening - polyps. 

Trusted Contributor
Posts: 1,402
Registered: ‎07-25-2010

Re: Who Do I File Complaint for Medical Coding Issue?

Hutchill-You are absolutely correct.

Honored Contributor
Posts: 61,630
Registered: ‎03-10-2010

Re: Who Do I File Complaint for Medical Coding Issue?


@HerRoyaLioness wrote:

The pathologist has to bill what they found, what he is examining. In this case it was a polyp.  It was coded correctly. Your insurance should know that. 


@HerRoyaLioness   @BunSnoop.  If the pathologist just removed a polyp, he doesnt know whether or not its diseased.  Removing it is part of the diagnostic process.

 

I'd call your state's insurance regulatory agency and ask who would oversee such a situation.

New Mexico☀️Land Of Enchantment
Honored Contributor
Posts: 27,473
Registered: ‎05-10-2010

Re: Who Do I File Complaint for Medical Coding Issue?


@BunSnoop wrote:

The PRIMARY diagnosis should be the same as the ordering physician's and the facility bill -  screening.   The patient had no symptoms or complaints when the procedure was ordered/performed.

 

The pathologist should list as the SECONDARY diagnosis the results of the screening - polyps. 

 

Wrong!!!!!    


 

Honored Contributor
Posts: 8,505
Registered: ‎03-09-2010

Re: Who Do I File Complaint for Medical Coding Issue?


@Gracies Mom wrote:

I agree with you HerRoyalLioness---the polyp was coded correctly.

 

What if a person had a screening mammogram and a mass was found---the coded diagnosis would be what was found. The fact that the reason for the mammogram (or colonoscopy) was a screening--could be coded as a secondary diagnosis.

It's true that insurance companies should know that. They look for excuses not to pay.

 

Hope this issue works out.


I could be wrong but in the case of a preventative mammogram a biopsy isn't done on the spot.

Valued Contributor
Posts: 831
Registered: ‎04-25-2011

Re: Who Do I File Complaint for Medical Coding Issue?

Of course a breast biopsy is not done on the spot if anything suspicious is found on a mammogram--but the fact an abnormality--a mass--was found--that can be coded as such.It's the same issue as the polyp found on a colonoscopy--a biopsy is not done on the spot--but just the fact it was there is codable.

Valued Contributor
Posts: 517
Registered: ‎08-28-2018

Re: Who Do I File Complaint for Medical Coding Issue?

Thanks for posting this thread.

Esteemed Contributor
Posts: 6,096
Registered: ‎03-30-2014

Re: Who Do I File Complaint for Medical Coding Issue?

The pathologist can not use a ICD-10 code for a colonoscopy.  His primary diagnosis would be something like K63.5.

 

The bill itself would be the PC of the CPT from the physician fee schedule on a 1500.  Perhaps 88304?

 

If the facts are as stated, the bill would require modifier 33 to remove the patient responsibility.  That should be true for the TC too.

 

It has been a while and I seem to recall some trap about the CPT?