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Thread: Payers tell the patients we should change the diagnosis

  1. #11
    Join Date
    Apr 2007
    Columbus GA

    Red face

    AAPC: Back to School
    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
    Join Date
    Apr 2007
    Dover Seacoast New Hampshire


    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, CPC, PCS, COC
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

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

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