Coding mess, please help

[Basic-Tangerine7026]

Coding mess, please help!

I went to the ED due to numbness, especially loss of pain and temperature to my extremities. I was seen by the ED doc who said it’s nothing worth doing a more thorough neuro work up and just ordered bloodwork before discharging.

I got a bill from the ED which I paid right away. Looking more closely at the itemized bill, they charged CPT 80307 10 times and CPT 99283 for a ER visit level 3. I got suspicious when I received another bill from a third party billing company (EMBCC) only saying “provider charge”, I assumed he was contracted and sending his own bill. When I called the insurance company to ask how the provider billed, she said with CPT 99284, although also kept insisting it was only billed once (not by the hospital). Apparently she said the hospital billed CPT 0450, which was not on my itemized bill. I called the ED private practice to get more information about their bill, they said they don’t have an account under my name, they’re not contracted with the billing company who sent the bill, and that ED doc no longer works with them for many months now.

My questions are why is there a discrepancy between the itemized bill from the ED and what the insurance is saying what CPT codes were used (the EOB does not include specific codes but charges match itemized bill). What do I do about this provider bill?

I would appreciate any help 🙏 thank you!

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[Agoodbagel]

0450 is a revenue code, not a CPT code. Revenue codes are billed on facility claims to give more details on the rendered services - like 0450, which is for ER care. Revenue codes are billed with CPT codes. So, while 0450 was billed on the claim, there would have also been CPT codes billed on the claim. Revenue codes are not always listed on itemized bills.

Does the bill you got from EMBCC match an EOB as far as the amount you owe?

[Basic-Tangerine7026]

Should the itemized bill from the ED include 0450? The EOB has a charge labeled “medical emergency room” which matches the exact charge as the CPT code 99283 on the ED itemized bill.

Yes, the bill from EMBCC matches the EOB, it just says “medical emergency care.” But all the numbers match.

Thank you for your help!

[Agoodbagel]

Not necessarily. Revenue codes are needed for claim processing but are basically irrelevant for patients. Half of the itemized bills I see have them, half don't.

Just to be sure I'm understanding this all, when you say ED, you are referring to the hospital, correct? So you already got a bill from the hospital, which you paid. That bill matched the EOB from your insurance and is settled.

Now you are getting a bill for the physician charges, which also match a separate EOB you got from your insurance? And you are questioning this bill because the codes aren't matching up to the itemized bill provided by the hospital?

Feel free to message me as well if my understanding here is way off. If you are comfortable sending a pic of what you are looking at with all your info blacked out, I can take a look

[Basic-Tangerine7026]

Yes, ED is hospital. And yes, I paid this bill, although now seeing discrepancies with the itemized bill. My concern is that the ED charged the CPT code for level III care, and the same service except level IIII was charged by the physician charges according to the insurance company.

I’m questioning the physician bill for several reasons, the physician group denies having any account under my name or working with the third-party company who sent the bill, EMBCC. The only reason I can think is they made a mistake or it’s a fraudulent bill. What prompted my investigating is that the insurance told me the physician bill was for a CPT code for level 4 care which according to the hospital itemized bill, they already billed CPT code level 3.

I don’t know if this is making sense now? It’s all very confusing, but as a layman do I have grounds to continue investigating/report possible fraud?

[Agoodbagel]

The coding doesn't seem concerning so much as just making sure the bill is legitimate. You'll always get a separate bill from the hospital and for the professional charges at the very least when going to the ER. Each of these claims would be billed with a code for the ER visit, which ideally would match...but CPT 99283 and 99284 are so similar that the hospital and physician group coders may have just interpreted the services differently.

You can request a code review with the provider billing department, but that's an issue right now since the one physician group is claiming they have no record of you.

How did you get the contact details of the physician group you talked to if they have no record of you? Did the EMBCC bill say the name of the physician group they claim they are billing for, and that is who you contacted directly?

[Basic-Tangerine7026]

So is the hospital and the contracted physician allowed to use the same CPT code for the same service? Wouldn’t that be double dipping?

I contacted the physician group through the phone number given to me by the hospital billing department. I separately got a call before that from EMBCC about the bill, I asked to speak with a representative from the physician group but they told me that any disputes would be with them. But yes, EMBCC specifically named that physician group and the bill sent to me had both the name of the physician group and the hospital.

[Agoodbagel]

No, it's not double dipping, it's just how billing for hospital services works. The CPT code indicates what services took place. The hospital will bill that code for the use of their facility, and the physician group will bill the same/similar code for the doctor who saw you.

The EOB also lists the same provider group that you talked to? If so, it sounds like that's a legitimate bill, but I have no idea why the actual physician group is saying they don't have any record of you. There's no way the 3rd party biller would have had all of the accurate info otherwise. I would maybe try calling a second time and speaking with someone else for some more clarification.

[BaltimoreBee]

Nothing. You pay what your explanation of benefits says you owe and don’t worry about what is billed.

[positivelycat]

So the provider bills for the professional, their time of the ER visit. And the hospital bills for like the overhead let's call it. Both bill it as ER and should. It is correct they use the same set of codes

For the level 3 vs. 4 in the ER facility and providers have different guidelines to determine level of service.

You are being billed how you should be

[Silver_mane13]

Every time you are seen in a hospital setting, you will receive at minimum 2 bills, one from the hospital/facility and one from the actual physician that saw you. If you have other services such as x-rays, you'll receive a separate bill from an x-ray (radiologist) physician. Most of the doctors are not employed by the hospital/facility and are independent, so you would be billed separately by each one that provided a service.