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Payers tell the patients we should change the diagnosis

  1. #11
    Red face
    Medical Coding Books
    I recently had to appeal my own colonoscopy because the provider DID NOT use the screening code that was on the order. The colonoscopy was normal and should have had the V-code given. I would have gladly paid towards co-insurance or dedutible if the provider was correct but they did not code it correctly. The insurance company did tell me it was coded incorrectly but would not give me what was used so it took me going all the way to the physician himself that performed the colonoscopy to straighten it out. He was sincerely upset that his office did not code what he had read to me off of the report. The new healthcare reform has to be looked at closely and your policy itself to get things in the right perspective.

  2. #12
    Location
    Dover Seacoast New Hampshire
    Posts
    2,030
    Default
    Jackie, I do agree that errors are made on the physician side, but what we're experiencing is that payers are telling the patients that if services were 'coded differently', they would be paid.

    In your case, you knew the difference, and understood that it was an error. For most patients, the coding rules aren't common knowledge, and they don't seem to understand why it would be wrong to code for a screening lab, when they already have the disease. And the payers, rather than telling our patients that they simply have different coverage for disease management vs. preventive care, insist that we made a coding error.

    To me, that is very, very wrong, and I plan to elevate this at my next state MGMA meeting.
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  3. #13
    Location
    New Windsor, New York
    Posts
    1,185
    Default Things haven't changed...
    Hi - while I see this is quite an old thread (it was in my list of "similar" ones from something else I posted) I can say that this is still the same. I have been getting more requests like this - not only in the type of scenario that Pam described in the opening message, but also when a patient complains about their ER bill. Either the payer or our patient liaison will tell the patient that they will see if the ER level is correct and maybe that would lower the bill. So while not directly being told the code was wrong, the patients are calling asking for it to be reviewed - and that still doesn't make them happy. Even if we can reduce from say 99284 to 99283, they are still going to be billed for a significant amount - not what they want to hear, they believe that all we have to do is change the code and they won't be responsible for anything. *sigh*

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

  4. #14
    Location
    New Windsor, New York
    Posts
    1,185
    Default Patient Portas
    Something else that may fall under this category - watch what diagnoses go into the patient portal as those that the patient says they have will end up there if coded. I had one patient tell me I HAD to remove his DM because he insisted he didn't have it - it was documented on the physician's notes, it was the dx for which the outpatient tests were ordered and the results had "borderline". But because his insurance didn't cover it AND he was concerned about the implications of that appearing on the portal, he insisted we take that off because "the doctor said I didn't have it." Well, we spoke to the doctor, offered him a chance to amend the record properly - but the MD said he was sticking with his original documentation. Just wanted to add that now this has patient portal implications as well to increase the fun.

    Lance

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

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