Wiki Insurance question

Create Wiki
J

Jinx75

Networker
Messages
25
Location
Summerville, SC
Best answers
0
I have a patient that saw their PCP for anxiety and the PCP coded 99213 with a dx of 300.00. The insurance co is telling the patient they are responsible for a specialist co-pay of $50 versus the PCP co-pay of $25 because the patient was dx'd with anxiety?! Is that accurate?
 
Yes, Mental Health DX are paid at a reduced rate if the performing physician is not a mental health provider. It is that way for all insurances that I have billed for. Try using another DX as primary and the mental health code as secondary and that should get a larger payment
 
mallorymartinelli said:
Yes, Mental Health DX are paid at a reduced rate if the performing physician is not a mental health provider. It is that way for all insurances that I have billed for. Try using another DX as primary and the mental health code as secondary and that should get a larger payment
Click to expand...

I cannot agree with this advice. You cannot disguise a visit that is non covered or payable at a reduced rate as a visit for something else just to obtain payment. If anxiety is documented as the reason for the encounter then that is the dx code that must be first listed
 
:rolleyes:
Jinx75 said:
I have a patient that saw their PCP for anxiety and the PCP coded 99213 with a dx of 300.00. The insurance co is telling the patient they are responsible for a specialist co-pay of $50 versus the PCP co-pay of $25 because the patient was dx'd with anxiety?! Is that accurate?
Click to expand...

That just doesn't sound right. The co-pay for specialist should depend on the provider's specialty not the patient's diagnosis.:confused:
 
Jinx75 said:
I have a patient that saw their PCP for anxiety and the PCP coded 99213 with a dx of 300.00. The insurance co is telling the patient they are responsible for a specialist co-pay of $50 versus the PCP co-pay of $25 because the patient was dx'd with anxiety?! Is that accurate?
Click to expand...

It could possibly be the third party (Behavioral health Insurance Company) is charging a $50 copay.

As for the appeal question; I don't know it is in your area but here on my mountain the sole behavioral health doc does not script medications, he send all patients to the PCP so they can have proper monitoring.

Hope this helps.
 
I would contact your provider relations rep to verify how the contract reads for these svcs. Many times the plans have a benefit specific carved out and that is how the svcs are done per the benefits, period. My carrier treats PCP rendered svcs regardless of the MH dx as regular medical benefits for a copay. Its likely benefit/contract driven.

Try that. Hope it helps.
 
You must log in or register to reply here.
Top