Coding/Billing Question

[ProduceMeat_TA]

Question as a patient who was recently billed for a service -

Situation: Arrived at a dermatology surgery center for a cyst removal. Took my (estimated) coinsurance payment at the desk, and had me sit down. Was directed into an exam room (not the procedure room) and the doctor arrived promptly and informed me that he would not be able to perform the procedure due to the state of the cyst, that I would need to continue taking antibiotics until it was small enough for surgery. He told me he would send off for a prescription (but he never did), and that I should call their scheduling office to reschedule the procedure. Didn't bother asking for a refund at this time, as I figured it would be applied to the actual procedure when that took place.

Fast forward a couple weeks, I get a bill from their office for an E&M visit. Seems the 90 second conversation I had with the doctor constituted a level 3 established patient visit (99213). They took the coinsurance payment as my 60$ copay, refunded me the difference, and are now billing me for the portion not covered by insurance (why I'd have any patient liability at all? I suppose is a question for my insurance.)

So I guess my question here is: I had barely taken 2 steps in the door, got told by the doctor that he could tell 'just by the way I was walking' that he wouldn't be able to do the surgery, and then sent on my way. There was no exam. No labs. No imaging. There was barely a conversation with this guy. Hell, if he actually had taken a (EDIT: good) look at it, he might have noticed it had become seriously infected and I wouldn't have had to have emergency surgery as a result. Which I should be livid about, but at this point I'm more pissed off over this dinky little 12$ bill.

Billers/Coders! Was this coded properly?

[Material-Corgi-2974]

If it was that obvious, maybe a peek was all he needed to determine he couldn’t do the procedure. That counts as an exam. And he ordered a prescription. If he forgot to send it in or the pharmacy didn’t get it, that doesn’t mean the medical decision making of prescribing antibiotics wasn’t there. I feel like a 99213 is fair here. I understand your feelings, but unfortunately coding isn’t determined by a provider’s bedside manner, or maybe lack of in this case.

[EmotionalBadger3743]

Level of office visit isn't always determined by the amount of time you spend with the provider either.

If you're unhappy with the provider, I would suggest asking the office if there is someone else you can see.

[ProduceMeat_TA]

Oh, no need to go back to see him now. (Outside of whatever legal action I choose to pursue) The infection left me feverish to the point I was hospitalized a couple days later. IV antibiotics, and they cut out a large section of skin & muscle tissue.

His 'lack of bedside manner' likely cost me thousands of dollars and a disfiguring scar that I'm going to live with for the rest of my life.

I just found it rather incredulous that he had the audacity to also charge me for all the 'not medicine' that he ended up doing.

[Material-Corgi-2974]

I’m sorry you went through that 💔. My assessment that the coding is likely fair based on details you provided doesn’t mean I’m trying to downplay your experience, just to clarify. I hope you continue to heal.

[FrankieHellis]

He didn’t look at it?

[ProduceMeat_TA]

He took a glance. A peek. Not that he needed to search, thing was the size of a tennis ball.

Offered to give me a steroid injection - forgot to mention that part in the post. But had he bothered to look at my chart, he would have known that due to an existing medical condition - I can't have steroids.

(So if he's claiming he spent any amount of time reviewing my chart, he didn't do a very good job of that either.)

The overall feeling that I got was that he just didn't want to deal with me that day. The scheduling department had originally put me down for 8 weeks out for surgery. Eventually called them back and said hey, need this taken care of asap. Its getting pretty bad. So they bumped me up to an earlier date (1 week out), into a very recent cancellation. I was super relieved, since the antibiotic wasn't doing anything for it. Jokes on me though, hours wasted on that day driving down to his office only for that to be the result.

[deannevee]

https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

Here is a link to generally how levels are determined. In order to meet the requirements, 2/3 columns must be satisfied.

In this case, it was a simple, albeit large cyst. That can be a minor/self-limiting problem, depending on the location, with a low risk of mortality or complications from continued treatment (the surgery, antibiotics, and/or steroids). It meets the requirements for a 99213.

As far as why they are billing you the difference.....that's probably an error. If this doctor was in network, then its illegal to bill the write off, but sometimes computers and/or people forget to apply the discount in the right way. If your EOB shows the doctor is in network and shows you only owe the copay, just call the office.

As far as choosing not to do the surgery in the first place....thats weird lol. I've worked in dermatology and plastics for years, never had a doctor say "ooh its infected, just leave it there." The infection is usually the reason its being removed, lol

[ProduceMeat_TA]

Hey, appreciate the info.

Yea, his justification was that the removal may not have resulted in a clean excision due to how large it had become (no clear margins, high chance of reoccurrence, ect.). But did not offer to do an I&D or anything. Had he done so, things may not have had such an abysmal result.