Wiki changing 76805 to 76815

Create Wiki
R

rachelhall05@yahoo.com

New
Messages
7
Best answers
0
Debating Question and concern about changed a OB ultrasound code from a Full to limited for INS to pay.

example only:
Provider sees an OB patient at 22 weeks and he is doing a FULL (76805) ultrasound for basic anatomy screening with no problems. The ins will only pay for one FULL OB ultrasound when no problems are noted and patient already had one done and it was paid. but the INS will pay for a limited 76815 with no problems. My question is, can you change the code from 76805 to 76815 to get INS to pay for the lesser part? to get some type of reimbursement?

I was under them impression, we code what the provider did and if the INS does not cover it, we have to write it off instead of changing the code to get paid. I hope my question makes since.

Any advice would be greatly appreciated.

Thank you.
 
rachelhall05@yahoo.com said:
Debating Question and concern about changed a OB ultrasound code from a Full to limited for INS to pay.

example only:
Provider sees an OB patient at 22 weeks and he is doing a FULL (76805) ultrasound for basic anatomy screening with no problems. The ins will only pay for one FULL OB ultrasound when no problems are noted and patient already had one done and it was paid. but the INS will pay for a limited 76815 with no problems. My question is, can you change the code from 76805 to 76815 to get INS to pay for the lesser part? to get some type of reimbursement?

I was under them impression, we code what the provider did and if the INS does not cover it, we have to write it off instead of changing the code to get paid. I hope my question makes since.

Any advice would be greatly appreciated.

Thank you.
Click to expand...
So are you saying that you have already billed and been paid for 76805 a few weeks earlier? If so, and there was no issue with the first one, what is the medical indication for the second one? You should never bill for something that was not documented and undercoding is as bad as overcoding. Medical necessity is the real issue here and insurance will only pay when a test is medically indicated. If you had previously billed 76801 and now are billing 76805, I can see that you have grounds for appeal should you get a denial. But if there were no problems at all, then a limited ultrasound would not be medically indicated. If this is happening in your practice a lot, a frank discussion with the providers and a review of protocols set for ordering/performing screening ultrasound might be in order.
 
Thank you for responding back. I might not have used a good example but I was really concerned about changing the ultrasound codes. The ultrasounds are really getting denied because of it not being medical necessity. But the provider stills orders them regardless.

But for another example, it was mentioned to change the 76805 to 76815 if we knew 76805 were not covered. But without it being medical necessity it would still have to be wrote off but the write off would be the 76815 instead of 76805.

Or INS might pay for three limited ultrasounds (w/o being medical necessity) but the provider is still doing the full 76805, to change it to 76815?

I wanted someone to verify that we could not change the codes like that, as you mentioned the under coding. This has not happened but it was mentioned and I wanted to make sure I had a clear answer as I felt that was not right.

Thank you.
 
I don't like to use the F word, but CMS definition:
“Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.”
So, intentionally changing any code to a service that is different than what was provided is extremely highly discouraged.
I agree with @nielynco about discussing this with your providers. Now, there may very well be cases where the patient is extra nervous, or the provider has an unfounded suspicion about something and may simply want to provide the service, regardless of payment. I can tell you there are times I have had a provider say something like "there was nothing wrong with the previous scan, but I didn't like the way it looked." If the subsequent scan actually finds something, then you can bill the service with the appropriate diagnosis.
 
You must log in or register to reply here.
Top