Question coding a secondary claim different than you coded/billed the primary claim

aslover

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Bonne Terre, MO
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I am performing auditing for a FQHC. They are changing coding (even if by only adding a modifier) and are billing the secondary on a HCFA when they billed the primary on a UB. They are modifying billing in their EDI system, which then does not match their revenue management system. When I share that they should make their corrections in their revenue management system to match the billing sent to the payer, bill on the same claim form for the secondary as they did for the primary - AND not change coding on just the secondary to bill different codes/modifiers than on the primary they push back that they have been doing this for some time and they're confident it's correct. Has anyone else ever experienced a state system that allows these nuances within the billing of healthcare claims?
 

lexvcarter

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Atlanta, GA
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First and foremost, why aren’t they billing the primary and secondary for both the professional (HCFA form) and the facility (UB) form..?! For example, if the patient has Medicare as primary and a supplemental plan as secondary you’d bill both insurances for both claims (HCFA & UB). Because whatever Medicare doesn’t pay the supplemental insurance will.
 

TThivierge

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Lithonia, GA
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Hi Aslover,
Years ago I was reimbursing manager billing mental health claims. In this state each indigent patient had 2 payers ; Medicaid and commercial payer. The indigent patient used state Medicaid for case management or psych inpatient services. Whereas when the same patient if treated by a doctor or psychiatrist used another preselected commercial payer assigned to this patient. The dx codes were kept the same if related but the billing payers was on differ formats CMS1500 vs UB92. Some commercial payers did want certain modifiers defining the provider type. Also if the primary paid, the copy of the EOB had to be faxed or scanned to the secondary payer in some cases. Medicare and Medicaid have ongoing contract to automatically pay their portions when it is electronical filed.
I hope this data helped you
Lady T
 
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