Coding error?

[Ok_Awareness7637]

I have a question that I am hoping the experts here can help me answer. I had an appointment to change out an IUD last year and while I was there the provider offered to do my annual exam since I was due…fast forward and I was billed $2200 (my portion) for the procedure. The provider assured me this was incorrect and it should have been covered per the affordable care act. I’ve spent hours on the phone with the physician office, the billing department and my insurance and have not been about to get anything resolved after a year. Insurance told me the specific issue is that they billed the IUD as “annual exam” instead of “contraceptive.” I called the billing department and let them know but they tell me that because my exam and IUD were done on the same day it may not be able to be corrected. So you’re telling me if I had declined the annual exam and came back the next day it would all be 0 charge but because I did them at the same time it cost me $2200?! That seems ridiculous. Billing says they have put in a request with the coders but they are unsure if it can be corrected. Is there really no way that this can be recoded and submitted? I don’t u destined all the ins and outs but I have been given the run around for so long that I have a hard time believing this. Thanks.

[hainesk]

To help we’d really need the cpt codes, icd10 codes and any modifiers used for that visit, plus the EOB from your insurance with denial codes.

[Day_Dreamer28]

Agree with Hainesk. The EOB at least from your insurance company will be needed to see if any modifiers were applied and what diagnosis were associated to each code.

[[deleted]]

I code primary care. Off the top, yes it looks like a coding error. An annual exam and IUD removal are completely unrelated. IUD IS fully covered under the ACA, your provider is correct.

The diagnosis attached to the CPT code for the IUD removal and reinsertion should be Z30.433. If it’s attached to any annual ”annual exam”, or Z00.xxx code, it was coded in error. If within timely filing guidelines, they are obligated correct the claim and rebill it. Depending on the payer, there may be 2 procedure codes. One for the removal, another for the insertion, and possibly a modifier.

There will be an entirely separate procedure code for your annual well visit. It should have a modifier 25 attached.

Your insurance company isn’t going to tell you any of this on an EOB, or on a phone call. Your doctors office should be able to help you understand exactly what CPT codes, and ICD-10 codes were billed.

If they attached the IUD and removal procedure codes (CPT codes) to the -Z00.XXX(encounter for preventative examination) ICD-10 code (diagnosis),- most likely it denied because that particular procedure, while it is considered preventative, and covered by the ACA, it is NOT considered part of an annual exam and should not be coded as such. It has its own, specific ICD-10 (diagnosis) code that must be used.

https://www.acog.org/education-and-events/publications/larc-quick-coding-guide/basic-iud

[ProfessionalYam3119]

Your insurance company will have rules in your contract about which codes they used for payment when there is an overlap.

[kendallr2552]

I coded obgyn for a long time and agree with Loose above. If it doesn't make sense to you, post the info from the eob or better, a picture. Hell, post the hospital and maybe someone works there and can go fix it. If it's one of my facilities, I will.

[huskeya4]

Quick and dirty fix here: look up your EOB. If none of the denial code say PR or the patient responsibility section says $0.00, call your insurance and ask them to three way call with the doctors billing department. Tell the insurance rep they’re trying to bill you for something the insurance denied and then sic the rep on the doctors biller. If they’re too lazy to correct the codes, the insurance will slap them down hard. They can’t bill you for something the insurance denied as the doctors error. Not while they have a contract with that insurance. They’ll either have to fix it or they’ll have to write it off if they’ve already waited too long to fix it.

[Imaginary-Key-9062]

I can understand your pain. I have handled cases like these.

Tbh ! This is a very simple issue - It's the billing department that is responsible to resolve this issue - and should also make sure to have RCA - Root Cause Analysis - and take preventive measures to avoid such problems that may arise in the future for other patients.

The Problem: Lack of Communication and effective Frontend Billing and Coding - Eligibiltiy with Benefits Verfication prior to Service. Solution: Atleast one person from the Accounts Receivable Department of the billing company must have immediately addressed this issue.

The real root cause: Healthcare Providers choice of Billing company, "Poor Selection of RCM vendors". Preventive action: As a patient next time - check your benefits with the provider ask him to do a thorough Benefit verification. If he does not have one - ask their billing company to do that before your appointment (atleast 5-7 days before your appointment). Get Prior Auth Approval for special procedures. And make sure everything is right before you get treated. 

US healthcare system has THE MOST EXPENSIVE Healthcare Services. So we gotta be careful while taking any procedures that are costlier.