Results 1 to 6 of 6

Acute fracture while in hospice

  1. #1
    Question Acute fracture while in hospice
    Medical Coding Books
    Happy Friday fellow coders! This is a new one for me so I wanted to put it out there for input.....thanks in advance!

    Patient is covered under secure horizons-recently went into hospice (which means anything hospice related will be paid by Medicare direct and not sec horizons). Patient fell out of bed while in hospice went to the hospital and had surgery. Now since this falls out of the hospice treatment secure horizons would need to pay for the consult and surgery performed right? The claim is denied by sec horizons stating that this is hospice related and should be billed as such.....but medicare will deny since this is an acute injury.....or am I way off base

  2. #2
    North Carolina
    Was the GW modifier submitted?.... “service not related to the hospice patient's terminal condition.”

  3. #3
    It was and the strange thing is my AR rep appealed the claim and with the help of our provider rep (I know...provider rep help...can you believe it???) the denial was overturned and paid. Now johnson and roundtree wants a refund and my rep has talked to customer service at the insurance co.....they are saying too bad should have been paid under hospice. I mean no disrespect but sometimes those employed at the insurance companies are not always the brightest bulbs in the pack....know what I mean? Any ideas on how to "help" them see the error of their ways?

  4. #4
    North Carolina
    I completely understand your frustration. Many times I find myself speaking in very elementary terms when in a conversation with the insurance reps. How do they justify this injury in relations to the hospice condition?

    Often, I submit CMS citations to overturn denials. Do you think it would help if you referred them to section 50 of Chapter 11?

  5. #5
    That is perfect....thanks for the link! I'm gonna add to our ammo and maybe draw some pictures too! Thanks again and have a wonderful weekend!

  6. #6
    North Carolina
    Good luck and same to you!

Similar Threads

  1. Replies: 1
    Last Post: 12-23-2015, 01:51 PM
  2. ORIF only for acute fracture?
    By Sephardic in forum Orthopaedics
    Replies: 1
    Last Post: 04-05-2013, 07:35 AM
  3. Acute Fracture VS Aftercare
    By jbrightw in forum Diagnosis Coding
    Replies: 2
    Last Post: 08-20-2012, 11:05 AM
  4. Fracture Aftercare vs Acute
    By troupe327 in forum Orthopaedics
    Replies: 0
    Last Post: 04-05-2012, 12:33 PM
  5. Acute Fracture Care
    By rryder1963 in forum Orthopaedics
    Replies: 1
    Last Post: 03-24-2009, 09:28 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.