AthensCoder
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Hello fellow coders,
I need some opinions from an auditors stand point regarding the below situation.
Patient presents for a screening colonoscopy. Last colonoscopy was in 2018 with the reccomendation to follow-up in 10 years. There is no family history of personal history of colon cancer or polyps. I notified the billing staff to alert the provider that the patient is not due for a colonoscopy until 2028 and query why the patient needed one sooner. The provider indicated that the patient is not having any signs or symptoms to prompt a diagnostic colonoscopy and he is doing it as a screening because "the patient has new insurance". I tried explaining to the provider from an auditors standpoint that there is no "medical necessity" to do the colonscopy earlier, and a change in insurance is not justification, as an auditor does not look at the insurance. They review the medical record. It's gotten pretty ugly between my biller and him.
Who's right in this situation.
I need some opinions from an auditors stand point regarding the below situation.
Patient presents for a screening colonoscopy. Last colonoscopy was in 2018 with the reccomendation to follow-up in 10 years. There is no family history of personal history of colon cancer or polyps. I notified the billing staff to alert the provider that the patient is not due for a colonoscopy until 2028 and query why the patient needed one sooner. The provider indicated that the patient is not having any signs or symptoms to prompt a diagnostic colonoscopy and he is doing it as a screening because "the patient has new insurance". I tried explaining to the provider from an auditors standpoint that there is no "medical necessity" to do the colonscopy earlier, and a change in insurance is not justification, as an auditor does not look at the insurance. They review the medical record. It's gotten pretty ugly between my biller and him.
Who's right in this situation.