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Thread: Ethical?

  1. #1

    Default Ethical?

    AAPC: Back to School
    Okay here goes........

    I have a situation where a patient came in for an elective abortion. The doctor had coded out himself a 99205 and the abortion CPT. The insurance did pay for both. The patient paid her $40 copay and the coinsurance ended up being like $35.00 or something.

    Anyway, the patient got the bill and called the billing staff irate that she had been charged an E/M code, she stated she was in coding herself and knew that 99205 was not appropriately billed because 1) she never saw the doctor face to face 2) the doctor knew why she was coming in so therefore an E/M would be inappropriate and 3) her condition in no way would have warranted a level 5. She told the staff that she wanted a refund for her copay and to have the insurance reprocess it as if it were never billed.

    Now, they're calling me and asking what they should do. I guess the physician was asked before me and he told the billing staff that "he did see her face to face, she was under anesthesia, he did the exam" He told them don't refund the copay, don't have insurance reprocess, and just to write off the coinsurance.

    This is kind of awkward and I'm not quite sure what to tell them.
    I personally think the use of the E/M was inappropriate. It seems unethical to bill an E/M when the patient is under anesthesia for an elective procedure.

    Last edited by ARCPC9491; 10-09-2008 at 11:32 AM. Reason: typo

  2. #2
    Join Date
    Apr 2007
    Kokomo, IN

    Default ethical?

    I agree with you, how can the physician get any information from the patient if she's under anesthegia and at least 2 of the 3 elements of this exam would not be done. He can't possibly have a comprehensive history, and how can he get a comprehensive examination if she can't answer him?

    I can't see how he can possibly approve charging this. Just my two cents.

  3. #3
    Join Date
    Apr 2007

    Default No E/M done = no E/M charge

    Ouch. This is a sticky situation for many reasons.
    I agree with both of you and the patient. There is no way the provider could get all three elements if the patient was under anesthesia. The patient makes a good point--she was not "evaluated" face to face. The decision to do the procedure was made before this visit, therefore there is no E/M to code. I would not feel like I was being ethical if I charged for the E/M.
    Carrie, BS, CPC

  4. #4


    I also agree with the patient on this one. If she wanted to pursue it she would have every right to report the office.. I would highly suggest refund her money and notifying the ins co that the E/M service was billed in error and to refund their money as well. If the patient makes enough of a ruckus to her ins co about the billing practices you will be under review with the special investigatiosn unit of her ins co.

    Believe me I know as I was a senior fraud investigator and many of the cases we opened were due to a patient complaint such as this.
    Kelly Long CPC, CFE
    Manager Audit and Compliance

  5. #5


    Ok good- I'm glad you guys feel the same way.

    The other thing is, he's probably doing this for everyone that comes through the office. It just so happened that this patient knew about coding. This is why it's like a double edged sword here - do I ask about the other patients? and if he's doing it that way, do I tell them it's fraudulent and to correct and refund the insurances for the overpayments?

    I don't want to get caught up in a mess. I guess I will just tell it in black and white, the right way he should be doing it .. explain why it was inappropriate .. and it's up to them to take a corrective action. I will document what I tell them and explain I will not be further involved. I don't know how else to handle it? ..... Suggestions?

  6. #6


    I agree you should tell the provider what he is doing wrong and leave it up to the practice to correct future billings. It is unlikely the provider will refund past payments he rcvd from other patients. Just stress the importance to the office that he can no longer bill this way.
    Kelly Long CPC, CFE
    Manager Audit and Compliance

  7. #7
    Join Date
    Apr 2007

    Default Document everything!

    I would document your discussion with the provider as much as possible. Maybe having the provider sign off on something will make it more real to them. I would make sure the document states his/her understanding that this is not correct billing and will agree to bill correctly from now on.
    After this is done, I would check up on claims and make sure the provider is billing correctly.
    Just my opinion...
    Carrie, BS, CPC

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