Page 1 of 2 12 LastLast
Results 1 to 10 of 12

Payers tell the patients we should change the diagnosis

  1. #1
    Location
    Dover Seacoast New Hampshire
    Posts
    1,970
    Default Payers tell the patients we should change the diagnosis
    Medical Coding Books
    Is anyone else having this problem?

    Here's the scenario: Our patients (primary care) are given a lab slip in preparation for their upcoming annual physical. The patient has a pre-existing condition. The provider (correctly) puts the diagnosis on the lab slip relative to the patient's condition, because these labs are for surveillance. For example, if the patient is diabetic, and the doc is ordering a HgA1C to be reviewed when the patient comes in for the pe, then the doc would code 250.XX.

    Of course, because the patient has a previous diagnosis, and it doesn't fall under routine care, the payer is processing the lab charge against a deductible and co-insurance, and the labs are not being paid at 100% for 'preventive care'. The payers are telling our patients that we coded these wrong, and should use the V72.62...lab work ordered as part of a routine general medical examination. I say, that since the labs are drawn for surveillance of the DM, we should not use the V code, but should code for the reason for the lab....diabetes. Unless things have changed, we can't prevent a condition that is already established, which is the whole point of preventive care! But the payers are telling patients that we are coding incorrectly, and we look like the bad guys. We all know that "they didn't code it right" is secret insurance language for "we don't like you because you're sick, and you have our cut-rate policy".

    Is anyone else having this problem? Should I code the V72.62 first, and then the 250.xx? That just goes against the ICD-9 rules, which state you should code the symptom or condition, if it exists, so I'm reluctant to code in order to satisfy coverage requirements.

    I would really appreciate feedback! Thanks!
    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

  2. #2
    Location
    Charleston, WV
    Posts
    245
    Default
    I've worked on both sides, for payers and for doctors. I would be curious to know who the payer is. Actually, I would like to know if it was a small payer or a TPA. I have found that small payers, TPA's especially do not provide adequate, if any training on coding to their employees. Most likely, if you bring this to the attention of someone a little higher up in the payer's heirarchy, you can get this stopped, at least until the next new rep is hired. However, I have dealt with a few TPAs that had NO ONE who understood coding. Good luck.

    Oh, and before anyone gets too upset, I have dealt with many more payers who DO understand coding and provide quality training to their employees. I have also dealt with MANY providers who were lost when it came to billing and coding and have had some suggest the same thing Pam just mentioned. For the record, I work for a payer. I try to be an equal opportunity offender.
    J G Stanley, MHA, CPC

  3. #3
    Location
    Lauderdale Lakes
    Posts
    203
    Default
    I have had problems with patients calling and saying that there insurance said if you change the code then it would get paid. These are from the big insurance companies, BC, United Health and Humana. The problem that I am finding out is that the people who are answering the phone dont know anything about coding. I had BC tell a patient that if we change the code, instead of telling him to fill out the preexisting form that they were waiting for him to send back before paying our claim, then the claim would be paid. They didnt have my office notes to even see what was done. I had called BC and made a complaint. I have also had United Health call me and tell me that I put the modifier on the wrong procedure and that is why the claim was denied. When I told her that the modifier was on the correct procedure and that the modifier goes on the procedure with lesser RVU she had no idea what I was talking about. I then asked her to speak with someone who knew about coding, She said there was no one else to talk to. I was also on three way with a patient whose insurance (BC) said that we billed a procedure (EGD) as an emergency. I had told the rep that we did not bill it as an emergency and that there was no way on the HCFA to put it as an emergency. Then he tells me that he made a mistake and didnt look at the claim properly. I can keep going on. The insurance companies are just hiring anyone to answer the phones and are just saying anything to get that patient off of the phone and unfortunately they are making the doctors office look like the bad guy.

    I will agree with Gost that alot of doctors office's employ people who dont know anything about coding, I have worked for plenty. I have not worked for an insurance company, so I cant say that the people that we are not allowed to talk to have coding knowlege.

  4. #4
    Location
    Dover Seacoast New Hampshire
    Posts
    1,970
    Default
    Thanks....I was beginning to second-guess myself!

    I'm asking our customer service people to track these complaints and let me know which payers are doing this. I know that Anthem is a big offender. Then I'm going to our state MGMA, where we have a third-party-payer forum, and I'm going to make a ruckus.
    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

  5. #5
    Default Sounds like fraud to me...
    ... the payors should know that they can't do that. That sounds like fraud. I wonder if they realize that? Does that sound like fraud to anyone?

  6. #6
    Default Found this info, hope it helps...
    I just found this information:

    Down-coding or changing of codes
    Payers must pay for the services as billed or deny the
    codes/modifiers not supported by the presented
    documentation and/or Relative Values for
    Physicians/DOWC rules. Payers are required to be
    very clear and specific on why they are denying the
    billed codes. Payers cannot change billed codes,
    unless the provider agrees. The provider has 60 days
    to resubmit the denied codes and modifiers with

    additional information.

    http://www.coworkforce.com/dwc/physa...ent_issues.pdf

  7. #7
    Location
    Columbia, MO
    Posts
    12,531
    Default
    Quote Originally Posted by tpontillo View Post
    I have had problems with patients calling and saying that there insurance said if you change the code then it would get paid. These are from the big insurance companies, BC, United Health and Humana. The problem that I am finding out is that the people who are answering the phone dont know anything about coding. I had BC tell a patient that if we change the code, instead of telling him to fill out the preexisting form that they were waiting for him to send back before paying our claim, then the claim would be paid. They didnt have my office notes to even see what was done. I had called BC and made a complaint. I have also had United Health call me and tell me that I put the modifier on the wrong procedure and that is why the claim was denied. When I told her that the modifier was on the correct procedure and that the modifier goes on the procedure with lesser RVU she had no idea what I was talking about. I then asked her to speak with someone who knew about coding, She said there was no one else to talk to. I was also on three way with a patient whose insurance (BC) said that we billed a procedure (EGD) as an emergency. I had told the rep that we did not bill it as an emergency and that there was no way on the HCFA to put it as an emergency. Then he tells me that he made a mistake and didnt look at the claim properly. I can keep going on. The insurance companies are just hiring anyone to answer the phones and are just saying anything to get that patient off of the phone and unfortunately they are making the doctors office look like the bad guy.

    I will agree with Gost that alot of doctors office's employ people who dont know anything about coding, I have worked for plenty. I have not worked for an insurance company, so I cant say that the people that we are not allowed to talk to have coding knowlege.
    I agree for the most part but, payers are not to tell us how to code a line item nor can they tell us what the dx is. Sometimes the dx code is not the diabetes or the osteo or the a fib but it should be the V58.83 for medication monitoring and that alsways works for me and always matches the reason for the test, also FYI the modifier does not always go on the lower RVU, it needs to go where it will do the most good. Several instances the component code which needs the modifier is also the one with the higher RVU, if you put the modifier on the lower RVU then you did not unbundle the procedure. I just though I would alert you to this as it is a common error I have found on many rejected line items.

    Debra A. Mitchell, MSPH, CPC-H

  8. #8
    Location
    Everett, WA
    Posts
    886
    Default modifier placement rationale
    "...., also FYI the modifier does not always go on the lower RVU, it needs to go where it will do the most good. Several instances the component code which needs the modifier is also the one with the higher RVU, if you put the modifier on the lower RVU then you did not unbundle the procedure. I just though I would alert you to this as it is a common error I have found on many rejected line items.[/QUOTE]

    Debra, could you please furnish an example?---Suzanne E. Byrum CPC

  9. #9
    Location
    Columbia, MO
    Posts
    12,531
    Default
    Quote Originally Posted by ollielooya View Post
    "...., also FYI the modifier does not always go on the lower RVU, it needs to go where it will do the most good. Several instances the component code which needs the modifier is also the one with the higher RVU, if you put the modifier on the lower RVU then you did not unbundle the procedure. I just though I would alert you to this as it is a common error I have found on many rejected line items.
    Debra, could you please furnish an example?---Suzanne E. Byrum CPC[/QUOTE]
    26115 is a component of 26210 and is modifiable but 26115 has the higher RVU, so if you put the modifier on the 26210 you will not unbundle the 26115. This was the most recent one I have corrected. There have been many others but I do not have them in front of me.
    I do not have the codes but the larngoscopy with biospy is mutually exclusive with the direct operative layngoscopy with tumor removal but it is modifiable, however it is not a 59 and it is not applied to the biopsy it is a 58 and it goes on the direct operative since that is the one that is staged. But the direct operative has the higher RVUs.

    Debra A. Mitchell, MSPH, CPC-H

  10. #10
    Location
    Dover Seacoast New Hampshire
    Posts
    1,970
    Default
    We're not having any issues for denials/unbundling, etc. This has to do with payers telling the patients that we should code as routine in order that they can process the claim without a copayment/deductible, even if the claim is not for routine or screening services.

    I rarely have issues with line items for modifiers. This issue is diagnosis-driven only. While I'm not sure the payer is committing fraud since they're not changing the codes themselves, it's a slimy business practice to suggest that we should commit fraud in order that they can process the claim to the patient's satisfaction. The payer isn't going to tell the patient that their policy has coverage limitations when the patient has a chronic condition....they'd rather blame the provider.
    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

Page 1 of 2 12 LastLast

Similar Threads

  1. Choosing the Diagnosis for Lab Order for DM Patients
    By jonique.dietzen in forum Diagnosis Coding
    Replies: 1
    Last Post: 05-04-2015, 10:51 AM
  2. Change Diagnosis; when is it fraud
    By svms in forum Diagnosis Coding
    Replies: 6
    Last Post: 06-04-2014, 11:26 AM
  3. Same OB Provider, 2 Different Payers...help!
    By minoweka in forum Billing/Reimbursement
    Replies: 0
    Last Post: 08-25-2013, 10:35 PM
  4. Change diagnosis for reimbursement
    By Tammy Hale in forum Medical Coding General Discussion
    Replies: 3
    Last Post: 10-22-2008, 10:43 PM

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?

Login

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.