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Should this have been billed?

  1. #1
    Location
    Daytona Beach, FL
    Posts
    742
    Talking Should this have been billed?
    Medical Coding Books
    Not sure if I am posting this in the right forum, but I would appreciate all the help I can get!

    We have been requested to refund an overpayment for one of our docs from a RAC review for a visit from 2008 and the doc doesn't think that he billed incorrectly. Can someone explain why we should not have billed for the following scenario or if we were correct in billing?

    The patient presented on 05/6/08 for a consult to place a port-a-cath. The doctor decided at this visit that the patient would be a canidate for the surgery, however due to an exisiting open wound at her mastectomy site, it was decided that surgery would need to be postponed until the wound was completely healed to avoid an infection to the port site.

    The patient returned 05/12/08 for the doctor to see how the wound was healing. At this visit, he felt the wound was still not healed enough and had patient return on 05/16/08 again. The patient was asked again to return on 05/21/08 for further assessment. At this last visit, the doctor felt the wound had healed enough and scheduled the patient for surgery on 05/30/08. The procedure for the port-a-cath, 36561 was billed and has a 10 day global - which is a minor surgery.

    When I reviewed the Medicare website, it states that the global period starts the day of the procedure for a minor procedure. I could not find any statments about what is billable or not billable as far as E/M visits pre-op. I have tried to research this on this forum, but I am still confused as to why they are denying the 05/06 visit (when they have not denied the other visits).

    I appreciate any help in this issue - and also a source for documentation to support your thoughts as I could use this in the appeal the doctor wishes to pursue.

    Thanks,
    Jodi Dibble, CPC

  2. #2
    Default
    Hi Jodi,

    Just some thoughts:

    Did your doc perform the mastectomy?

    If so, was the 05/06/08 visit during the mastectomy global?

  3. #3
    Location
    Daytona Beach, FL
    Posts
    742
    Default
    Hi Mojo,

    No the patient had surgery done in Florida - we are in New Jersey. The patient is actually being followed by another doctor in this area for her mastectomy follow-up and treatments. My doc is a General Surgeon who was asked to evaluate the patient for the port-a-cath so the patient could start chemo. So, no this is not part of the global!

    Thanks,
    Jodi Dibble, CPC

  4. #4
    Location
    Evansville Indiana
    Posts
    451
    Default Rac
    How far into the RAC process are you? Was this an automated denial, or did they request records? What all was billed for that date of service? Had you ever seen the patient before? What was the reason for denial?
    Most of the automated denials that are going on for physicians now are for duplicate charges and global surgery. Did you make sure that this was not paid twice? Is the physician that did the original surgery a part of your practice or possibly employed by the same entity that your MD is?
    LeeAnn

  5. Default RAC Refund Request
    Quote Originally Posted by jdibble View Post
    Not sure if I am posting this in the right forum, but I would appreciate all the help I can get!

    We have been requested to refund an overpayment for one of our docs from a RAC review for a visit from 2008 and the doc doesn't think that he billed incorrectly. Can someone explain why we should not have billed for the following scenario or if we were correct in billing?

    The patient presented on 05/6/08 for a consult to place a port-a-cath. The doctor decided at this visit that the patient would be a canidate for the surgery, however due to an exisiting open wound at her mastectomy site, it was decided that surgery would need to be postponed until the wound was completely healed to avoid an infection to the port site.

    The patient returned 05/12/08 for the doctor to see how the wound was healing. At this visit, he felt the wound was still not healed enough and had patient return on 05/16/08 again. The patient was asked again to return on 05/21/08 for further assessment. At this last visit, the doctor felt the wound had healed enough and scheduled the patient for surgery on 05/30/08. The procedure for the port-a-cath, 36561 was billed and has a 10 day global - which is a minor surgery.

    When I reviewed the Medicare website, it states that the global period starts the day of the procedure for a minor procedure. I could not find any statments about what is billable or not billable as far as E/M visits pre-op. I have tried to research this on this forum, but I am still confused as to why they are denying the 05/06 visit (when they have not denied the other visits).

    I appreciate any help in this issue - and also a source for documentation to support your thoughts as I could use this in the appeal the doctor wishes to pursue.

    Thanks,
    This is the result of an automated audit, so the probability that it is incorrect is high. Immediately call your RAC customer number and talk to someone. It is possible it will be removed based on that. If not, appeal with your reasoning and request that it be reviewed manually. Let me know if you need any help. We've been through it. I don't know which contractor you have, but I wish you luck!

    Melanie

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