Wiki 2nd Opinion, fracture, can we bill Office Visit?

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JMichelle

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If someone could PLEASE shed some light on this because there are differing opinions in the office.

A child was seen by a different practice, he has a broken arm, I am ASSUMING they billed a fracture code.
Mom wants him to come see us for a second opinion because they are removing the cast while the break is still visible and she has concerns.

Our front desk said they would need to be selfpay due to them being in a global at a different office.
This doesn't seem fair to the patient, does anyone else have experience with this and using modifiers or how they have dealt with this situation in their practice?
 
The front desk is correct. The other provider has been paid to perform all associated visit s for 90 days assuming they billed as fracture care. The patient has made the decision to seek other care for the same fracture and that is all patient responsibility, and yes it is fair.
 
Gotcha, what about if it was a transfer of care? Same thing?
Also, assuming we need them to sign an ABN?
There insurance would I assume pay for Xrays so only collect for OV? Or, file ins and if they pay, refund the pt? But then they could come back and audit.
 
If the provider transfers the care during the global you do need this in writing and keep it in the chart, then you bill the same fax care code he/she used and attach the 55 modifier for post op care. In box 19 you put a really short note stating care transferred from .... I would not assume that they will pay the xrays , I am not sure. Without a transfer of care I would charge the patient for everything. With the transfer of care I would probably communicate with the payer first to indicate the care is being assume by your provider with a transfer and get your ducks in row before you bill
 
I'm not certain I agree that a 2nd opinion E&M would not be payable by insurance. IF you were taking over care of the fracture, then definitely as mentioned, there should be a transfer of care with the appropriate billing for such. However, the situation you describe sounds like the patient/parent simply wants a 2nd opinion about whether or not the cast should be removed, not to actually manage the fracture.
I work in gyn oncology. I'm certain over the years, we must have had a patient who had a surgery by another physician, who then came to us during their global period for a second opinion, or even for additional care. For example - primary ob/gyn removed a cyst that turned out to be cancer, and then referred to us for management of the cancer. I cannot recall ever getting a denial of an E&M stating the global period belonged to another physician.
 
Your example of the GYN surgery is completely different. The patient in that had surgery for removal of a cyst. The subsequent diagnosis of cancer warrants additional visits and discussions as that is not the diagnosis the patient had prior to the surgery. In the fracture scenario. The patient is unhappy with Dr A and while under treatment with Dr, A decided to go to Dr B for the exact same treatment to see if they like it better. The payer will not pay two providers of the same specialty for the same problem in the same treatment time frame one of the providers must yield. If the patient had a non healing fracture and the treating provider needed another provider to evaluate then that is different.
 
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