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two OV on the same day w/different specialist

  1. Default two OV on the same day w/different specialist
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    two office visits on the same date by different specilist within the same group is paid by all carrier but Blus Shield California. We explained many many times; but no luck.
    Would anyone know any aritcle to show them to get paid
    thank you for your help.

  2. #2
    Default
    What is their reasoning for not paying? Is this denying because of a policy they have and have they shown you the policy? Or are they sure it's not denying in error?
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I, AAPC Fellow
    AHIMA Approved ICD-10-CM/PCS Trainer
    AAPC National ICD-10-CM Trainer

  3. #3
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    North Carolina
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    30.6.5 - Physicians in Group Practice
    (Rev. 1, 10-01-03)
    Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.
    Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group.

    http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

  4. Default
    Thank you rebecca.
    Blue Shield CA moved claim center to overseas. Then many problem started. Blue Shield CA used be the one of the most professional people working. I missed so much.

  5. #5
    Location
    North Carolina
    Posts
    3,126
    Thumbs down
    You may want to contact you insurance commissioner. Personally, I'm tired of insurance carriers creating policies to suit their own needs. Whether or not the patient saw two different specialist on the same day or on different days, the patient needed to be seen (assuming the documentation supports this). The patient's health should be priority not the pockets of the insurance carriers. As insured individuals, we pay our premiums and our co-insurances. The least the carriers can do is pay their portion of the service when they are medically necessary. It's pretty sad when the carriers can't even adopt Medicare's standards.

  6. Default
    Where the dx's different? If not, then why should an insurance company double pay for same service and same specialty on same day?

  7. #7
    Location
    North Carolina
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    Difference specialist within the same practice? Occasionally, this happens to us. Patient has an appt with our orthopedic physician for back pain. During the visit, the physician takes an xray and determines that the patient has a severe, bulging disc. Due to the nature of the problem, he will send the patient to our neurosurgeons, same day. Whether it happened the same day or next day... two different specialties, medical necessity met.

  8. #8
    Default
    The dx could be the issue. I've had times where the internist sees the patient, then refers to specialist in same group, same day, same dx - the insurance denies first go around, but on appeal it gets paid. (most of the time) I think some of the insurance's claims processing edits automatically denies if same dx, multiple docs without regard to specialty. In hopes you write it off and forget about it i'm sure! LOL. In a multispecialty group though, you should have less issues getting paid- as long as too though, the credentialing & specialties are set up correctly! If different dx's it shouldn't be a problem, should be paid first time. And also- you could have two doc's with the same specialty see the patient, same day, but one has an area of expertise in the field...these will be paid on an appeal basis.

    Good luck

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