Wiki split maternity billing dilemma

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jebond123

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My doc followed a patient for her entire pregnancy, including 11 prenatal visits, c-sect delivery, and postpartum follow-up. Global billing (59510) was submitted and paid with date of service 6/28/22. During her pregnancy, a covering doc saw the patient once while my doc was on vacation. His biller submitted 59425 in error & insurance paid him. Subsequently, Anthem has requested a full refund of our claim. I submitted a provider dispute form with a copy of her flow sheet showing visits as well as a detailed explanation of what happened. Also, other doc's biller sent a "letter requesting claim be voided" but that is as far as she will take this. Anthem states they never received void request & review of our records was found to be insufficient. They have retracted our claim's payment. I am left now with the only option of submitting corrected claim to get some portion of this back. My question is this: how do I send a claim for the antepartum visits as a corrected claim if we never submitted one to begin with? I am sending 59515 to replace 59510 for the delivery portion on the original claim (as corrected) but the antepartum visits(59426) have never been billed out so won't they deny this as beyond the billing deadline? I am not sure if it is possible to include the antepartum visits on the same claim as the in-patient delivery claim. Please help me - Any input is very much appreciated.
 
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I disagree with changing your coding, as it was correct. What was "insufficient" in your records? Maybe you accidentally missed sending something. Maybe they didn't properly review what you did send. I would appeal the denial rather than coding incorrectly.
 
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csperoni said:
I disagree with changing your coding, as it was correct. What was "insufficient" in your records? Maybe you accidentally missed sending something. Maybe they didn't properly review what you did send. I would appeal the denial rather than coding incorrectly.
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I'd also wonder whether the other doctor should have sent any claim at all. They were covering one visit while the patient's doctor was on vacation.

When one of my physicians is on vacation, we have a locum doctor and they are compensated by the practice for the days they work. That physician does not submit claims to payers. They get paid a fair daily rate for the days they cover.

Maybe it works different in OB/GYN? However, even if the physician was correct in sending a claim, they were still incorrect billing 59425 for one visit.
 
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jebond123 said:
My doc followed a patient for her entire pregnancy, including 11 prenatal visits, c-sect delivery, and postpartum follow-up. Global billing (59510) was submitted and paid with date of service 6/28/22. During her pregnancy, a covering doc saw the patient once while my doc was on vacation. His biller submitted 59425 in error & insurance paid him. Subsequently, Anthem has requested a full refund of our claim. I submitted a provider dispute form with a copy of her flow sheet showing visits as well as a detailed explanation of what happened. Also, other doc's biller sent a "letter requesting claim be voided" but that is as far as she will take this. Anthem states they never received void request & review of our records was found to be insufficient. They have retracted our claim's payment. I am left now with the only option of submitting corrected claim to get some portion of this back. My question is this: how do I send a claim for the antepartum visits as a corrected claim if we never submitted one to begin with? I am sending 59515 to replace 59510 for the delivery portion on the original claim (as corrected) but the antepartum visits(59426) have never been billed out so won't they deny this as beyond the billing deadline? I am not sure if it is possible to include the antepartum visits on the same claim as the in-patient delivery claim. Please help me - Any input is very much appreciated
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Did the other biller refund the insurance company since they were paid? If not, that is part of the issue. I would not change your codes as you are billing correctly. If the other biller is not willing to resend the request to void the claim and the refund, I suggest going up the chain of command.
 
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The other biller sent a letter (twice) asking them to void the claim. She did not, however. submit an electronic corrected claim to void it. I am going to appeal.
Thanks for the input.
 
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