Hi everyone - We've been having a lot of issues with doc offices/insurance companies calling us to want us to change our routine code to a wellness or preventive so the patient's pap will get paid - after some research we found we could if we get specific written permission from the patient's insurance but it doesn't say anything about a doctors office being able to do the same - some say we can (if the doc office gives us specific written permission) and some say we can't - any thoughts? (I have included the Paget's rule below - we've also discussed add the 33 modifier but we don't have a lot luck with those). Thanks!!
The act of knowingly and willfully presenting a CPT procedure or ICD diagnosis code on a
claim in a manner that’s contrary to generally accepted standards for the express purpose of
altering the amount that’s payable by the insurer or patient creates a false claim situation. So,
no, you shouldn’t unilaterally manipulate your ICD coding to appease a patient. However,
there are at least three things you can do to potentially help the patient without putting your
practice or laboratory into jeopardy: (1) append preventive service modifier 33 to the CPT
code; (2) get specific, written permission from the patient’s insurer to alter the otherwise
prescribed ICD coding; or (3) support the patient’s efforts to seek relief from his/her insurer.
Preventive service modifier 33 is more fully described at Appendix 2, although little is
known about how insurers are actually reacting to this modifier.
The act of knowingly and willfully presenting a CPT procedure or ICD diagnosis code on a
claim in a manner that’s contrary to generally accepted standards for the express purpose of
altering the amount that’s payable by the insurer or patient creates a false claim situation. So,
no, you shouldn’t unilaterally manipulate your ICD coding to appease a patient. However,
there are at least three things you can do to potentially help the patient without putting your
practice or laboratory into jeopardy: (1) append preventive service modifier 33 to the CPT
code; (2) get specific, written permission from the patient’s insurer to alter the otherwise
prescribed ICD coding; or (3) support the patient’s efforts to seek relief from his/her insurer.
Preventive service modifier 33 is more fully described at Appendix 2, although little is
known about how insurers are actually reacting to this modifier.