Work related and Insurance billed visit

Good Morning/afternoon experts,

If a patient comes in and sees the physician for both a work related and non work related visit. The physician bills for both visits, two separate E/M codes, one to the patients health plan, the other to the work related insurance carrier. The patients work related claim gets denied and refers the clinic to bill the patient health insurance.

The question is, do you then combine both of the notes and select appropriate E/M code and bill that to the health plan? How would the experts handle this situation? Any and all thoughts are greatly appreciated!!

Thank you,
Angela

Comments

  • edited May 2017
    It will depend on the payer. Medicare has Q0091 for the pap which I would assume was done with a pelvic exam, G0101. Some private payers pay for both and some only allow the Q0091. Many payers consider it all part of a preventive exam. For those payers you are going to have to ask them specifically how they want split preventive care billed!

  • Good Morning/afternoon experts,

    If a patient comes in and sees the physician for both a work related and non work related visit. The physician bills for both visits, two separate E/M codes, one to the patients health plan, the other to the work related insurance carrier. The patients work related claim gets denied and refers the clinic to bill the patient health insurance.

    The question is, do you then combine both of the notes and select appropriate E/M code and bill that to the health plan? How would the experts handle this situation? Any and all thoughts are greatly appreciated!!

    Thank you,
    Angela
  • Hi,

    Thanks for your response, but this is not for a preventative. Does anyone have any similar visits like this they can offer any advice?

    Thanks,
    Angela
  • edited May 2017
    First I would question the work related denial with the patient and employer. It may not be a valid denial.

    Sent from my iPhone

  • I would certainly be reviewing the medical records and re looking at this encounter as 1 and not 2 from a coding perspective. . More than likely your E&M level of the visit will probably be higher and if it is then I would send in a corrected claim to the health insurance. Good chance they may request medical records. So you can be proactive if you like and send a cover letter and/or the medical records for the visit or be reactive. But I would be re looking at this.


    Gerry Malloy, Partner
    Global Health Management Services, LLC
    Tamaqua, PA 18252
    888-610-2455
    www.globalhealthmgt.com



  • edited May 2017
    Logistically, as a biller, I would first find out why the work-related claim denied for 'bill patient's insurance.' Was the entire Work Comp case denied? Was there a diagnosis code issue for the claim that was sent to Work Comp? Too often times we take insurance plan denials at face value and need to look a little deeper.

    Be certain what was coded was also submitted in the same manner. There are other factors on the claim (date of injury, etc) that are needed to support the Worker's Comp claim.

    When all is said and done and the decision is to combine both visits and send a corrected claim, you might be lucky enough to get another $20.00, and it would have cost more to determine that internally than to secure additional payment.

    Karen A. Hurley, BS, CMM, CPC, CNA
    President, HPMSI
    PO Box 409
    Parrish, FL 34219-0409
    Tel: (941) 776-4822
    Fax: (240) 368-0059
    Web: www.hpmsi.com

  • Karen certainly has a point. Never use dollars to chase pennies.


    Gerry Malloy, Partner
    Global Health Management Services, LLC
    Tamaqua, PA 18252
    888-610-2455
    www.globalhealthmgt.com



  • Thank you everyone. Yes I agree with Karen also. Unfortunately, the billing department is completely separate from the coding department. The only information the coders get, is, "the claim is being denied and told to bill the health plan" so this is what we have to go off of. I appreciate everyone taking the time to answer.

    Thank you,
    Angela
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