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Help with ethical question

  1. Question Help with ethical question
    Medical Coding Books
    I am a student in the cpc course but have been a biller for several years. The clinic that I do billing for has told me to bill to a patients insurance a procedure that was performed at another facility (a lab to be specific-codes 83001,36415 DX V26.21). The pt was not seen at our clinic on this dos. Am I wrong to not want to bill this out? Wouldn't the lab that performed the service bill out the procedure? Is there any documentation that I can give to them if this is not valid.

  2. #2
    Philadelphia, PA
    Why would someone want to do this? Do they have a rationale, because it seems to me this is fraud. bottomline. If it is not at your clinic, and another place did the service? This is kinda frightening..: I would maybe take a look on the medicare website. Does your clinic have any business ties to the other lab?
    Last edited by SS62; 02-04-2010 at 09:45 AM.

  3. Default
    Frightening is exactly what I thought too. They told me that because the procedure was performed out of state and the lab would not bill out to an out of state ins. company, that we could bill it out and reimburse the lab?????? Wow that sounds even I on the wrong track, is this something that is done with labs??

  4. #4
    Hold up, don't freak out just yet.

    Did they pay the lab for doing the service instead of the lab billing the insurance directly? If so, then it would be correct for the office to bill the insurance for the service. Now whether or not they are billing it correctly is a different story, that needs to be looked into further.

    It has been years since I had an office do this and I don't remember the ins and outs but more research needs to go into this before the fraud word gets thrown in the mix.

    Just my opinion,

    Laura, CPC, CPMA, CEMC

  5. #5
    Columbia, MO
    Yes Laura is correct. The is a place on the 1500 to indicate outside lab and the amount paid. This is field 20 and here is the instruction:
    Complete this field when billing for purchased services. Enter an X in "YES" if the reported
    service(s) was performed by an entity other than the billing provider. If "YES", enter the purchased price under charges. A "YES" mark indicates that an entity other than the entity billing for the service performed
    the purchased services. A "NO" mark indicates that no purchased services are included on the claim. When "YES" is annotated, Item Number 32 must be completed. When billing for multiple purchased services, each service should be submitted on a separate claim form. Only one box can be marked. When entering the charge amount, enter the amount in the field to the left of the vertical line. Enter the number right justified to the left of the vertical line. Do not use commas or a decimal point when reporting amounts. Negative dollar amounts are not allowed. Dollar signs should not be entered. Use 00 for the cents if the amount is a whole number. Leave the right-hand field blank.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
    Philadelphia, PA

    i suppose when i said "does the clinic have any business ties to them" is what i meant, in reference to the above posts. These posters are correct, if they have an agreement in place, then yes they can bill and reimburse back to the lab. I also remember a long time ago, this scenario. I guess i just needed a good memory jog...So yes, dont freak out just yet..LOL Thanks for clarifying the situation guys..

  7. Default
    Thanks so much!!! What a load off my mind. Great info, I was not sure where to go for help.....Thanks again

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