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Thread: Need coding help

  1. #1

    Unhappy Need coding help

    AAPC: Back to School
    can anyone please help with a coding sitation? I have a physician was treated his wife in the office, then the performed surgery on her the following week. Dr wants these office/surgery charges billed to her(their) insurance. Insurance is a private carrier and I have reviewed the company guidelines but cannot locate a specified immediate family member scenario. I have located the Medicare regs, but Dr says this situation is not Medicare. What to do??

  2. #2


    I would check with your state medical board. It will have restrictions there, if any.

  3. #3
    Join Date
    Apr 2007


    Most insurances won't allow these procedures to be billed, since they were performed by her husband. Check the policy. When I worked in office, our Blue cross policy specificially prohibited billing services performed by your employer. In Michigan, Blue Cross's official policy states that they follow Medicare guidelines regarding the family scenario. You may find many others say the same thing, even though doctor says "It's not Medicare".


  4. #4


    I say listen to your physician. If you have reviewed his personal insurance regulations and see no stipulation then I would bill the carrier as appropriate. It really is however a Medicare rule and this is not Medicare. I know it would seem more compliant to do what we do for Medicare we do for everyone, but sometimes it is just not feasible.

  5. #5
    Join Date
    Apr 2007


    I was always taught that was not appropriate. I have always been told this is un-ethical.

  6. #6
    Join Date
    Apr 2007
    Greeley, Colorado

    Thumbs down

    My question is why did he not have someone else do the surgery? Imagine the consequences had something gone wrong! Sorry, I know this doesn't help answer your question, but it seems very unwise on his part. As far as billing the insurance, it has always been my understanding that a doctor cannot treat an immediate family member and bill for it. Is there anything in the Stark Law that addresses this issue?

  7. #7


    Check with the specific insurance carrier first. - I think the services should be billed for informational purposes. Everyone must be kept up to speed with patient (no matter who they are) records, including the insurance carriers.

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