How to bill these encounters?

[ODhopeful]

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Hi docs, I'm pretty new to coding and billing, so I need some advise to some situations that I run into fairly common. Thanks. I also have bought Dr. Tom Miller's book on billing and coding and found it very helpful, but still need some advise.

1. If a patient comes in with medical insurance and haven't met his/her deductible for the year. How would you handle this situation? Would you just charge you're lower private pay patient fee (i.e. S codes), or have the patient pay the maximum allowable for the 92xxx/99xxx codes, then file it toward their yearly deductible.

2. For medicare patients that have met their deductible for the year, do you charge 20% of the maximum medicare allowable for a 92xxx/92xxx, which is slightly lower than my U/C fee or do you actually charge 20% of your U/C fee?

3. If a patient comes in complaining dry eye or said he has cataract, but during the exam you find an ingrown lash and decide to epilate the lash, how would you code this encounter? Do I need to call the insurance to ask if they will pay for a specific test, procedure before I do it? Which modifier code would you use and do you attach the modifier code to the 92xxx/99xxx or the epilation code (67820). Please be specific if possible, thank you.

 

[PBEA]

Hi docs, I'm pretty new to coding and billing, so I need some advise to some situations that I run into fairly common. Thanks. I also have bought Dr. Tom Miller's book on billing and coding and found it very helpful, but still need some advise.

1. If a patient comes in with medical insurance and haven't met his/her deductible for the year. How would you handle this situation? Would you just charge you're lower private pay patient fee (i.e. S codes), or have the patient pay the maximum allowable for the 92xxx/99xxx codes, then file it toward their yearly deductible.

2. For medicare patients that have met their deductible for the year, do you charge 20% of the maximum medicare allowable for a 92xxx/92xxx, which is slightly lower than my U/C fee or do you actually charge 20% of your U/C fee?

3. If a patient comes in complaining dry eye or said he has cataract, but during the exam you find an ingrown lash and decide to epilate the lash, how would you code this encounter? Do I need to call the insurance to ask if they will pay for a specific test, procedure before I do it? Which modifier code would you use and do you attach the modifier code to the 92xxx/99xxx or the epilation code (67820). Please be specific if possible, thank you.

1) The type and level of service provided are not dependent on the ability to pay. If you provide a 92XXX, then you must bill for 92xxx. If you provide a SOXXX, then you must bill for SOXXX. Anything else might be considered fraud.

2)technically its 20% of medicare allowable, so you can either do it on the front end (date of service) which is better imo, or you can reimburse any overpayment once you receive the EOB (more work).

3)the last Ill leave to someone else, but would just say you likely will have to confirm any advice given here with the specific carrier. Good luck with that.

 

[ODhopeful]

1) The type and level of service provided are not dependent on the ability to pay. If you provide a 92XXX, then you must bill for 92xxx. If you provide a SOXXX, then you must bill for SOXXX. Anything else might be considered fraud.

2)technically its 20% of medicare allowable, so you can either do it on the front end (date of service) which is better imo, or you can reimburse any overpayment once you receive the EOB (more work).

3)the last Ill leave to someone else, but would just say you likely will have to confirm any advice given here with the specific carrier. Good luck with that.

Could you be kind enough to explain to me how your 92XXX and your S code visit differ, other than asking a few more questions and including DFE with your 92XXX. Thanks.

 

[eyestrain]

Could you be kind enough to explain to me how your 92XXX and your S code visit differ, other than asking a few more questions and including DFE with your 92XXX. Thanks.

MEDICAL NECESSITY. DFEs have nothing to do with it.

 

[ODhopeful]

I agree, but very few patients walk into my office saying I need to have a diabetic eye exam, they always say I want to have my eyes checked. I know this is probably against regulations or whatever, but I know many doctors do this. If a patient walks in saying they need their eyes checked, the patient has no insurance, unless something really serious is going on, the visit gets billed a S code. If the same patient comes in with medical insurance, then the doctor tries to elicit a medical condition and bill the insurance company a 92XXX. My patient base is pretty old and poor so I have to set my routine xm fee at 65, but because I don't want to lose out on insurance reimbursement so my 92004 is 135. I will never get anyone in my area to pay me 135 for a regular eye exam. It's sad and I know it's not right, but I rather do this and have patients to see then not do it and just sit there and stare at my receptionist.

I'm not trying to get into an argument over how to bill a 92 or S code. I just want to know how most docs handle the situation where patient wants to use his/her medical insurance, but haven't met the deductible. Do you offer a discount for paying at time of service (S code)? Otherwise, do you collect the maximum allowable for 92xxx and file it to their insurance? Other any other options that I'm not thinking of? Please help

 

[eyestrain]

Bill what you did. I understand your situation. A lot of doctors in this profession do this stuff wrong, which creates huge problems for the rest of us. But doing it wrong just because the other idiots are doesn't help and just perpetuates this mess.

So, for that medical visit with the high deduct, we'd charge our regular 92xxx fee and if they PAID THAT DAY, we'd give them a 20% prompt pay discount. In your case, that would bring things down closer to $100.

Also, an S-code is not a prompt pay discount. An S-code is it's own code used for a specific kind of exam.

 

[ODhopeful]

So, for that medical visit with the high deduct, we'd charge our regular 92xxx fee and if they PAID THAT DAY, we'd give them a 20% prompt pay discount.


If you don't make them pay the day of service, do you just bill them later? I've always thought that patients have to pay the day of service, otherwise I would think it be almost impossible to get reimbursed.

 

[eyestrain]

So, for that medical visit with the high deduct, we'd charge our regular 92xxx fee and if they PAID THAT DAY, we'd give them a 20% prompt pay discount.


If you don't make them pay the day of service, do you just bill them later? I've always thought that patients have to pay the day of service, otherwise I would think it be almost impossible to get reimbursed.

Well, to be honest, we usually just send it in first and see what happens. Occasionally a patient knows about the deduct and wants to just pay up front, which is great. If we send it in and it goes to deductible then we send a bill. At that point it's crapshoot on whether or not the patient will pay. Most of the time we get paid. But a fair amount just decide to blow it off. It's a royal pain. We should probably collect more money up front and then reimburse, but I haven't had a doctor do that to me yet, so I haven't started doing it in my office.

 

[PBEA]

I collect all deductibles, copays, coinsurance, etc upfront. Its more work, and more hassle, but my accounts receivable is in good shape.

 

[PBEA]

Could you be kind enough to explain to me how your 92XXX and your S code visit differ, other than asking a few more questions and including DFE with your 92XXX. Thanks.

I don't actually use scodes, and I don't provide any discounts off exam fees. In my office, "routine" exam is 92014 + 92015 (if they required a refraction) with V72.0 as the diagnosis.

 

[ODhopeful]

I have also been running into problems when I bill epilation.

For example, patient comes in with complaint of FB sensation and I decide it's the inturn lash so I would bill.

99213-25 379.91(pain in/around eye)
67820-E1 (trichiasis)
67820-E3 (trichiasis)

I have been getting paid on the 99213, but the insurance always denies the 67820, even when the patient has no deductible and have paid they specialist copay. Any clues?

 

[KHE]

I have also been running into problems when I bill epilation.

For example, patient comes in with complaint of FB sensation and I decide it's the inturn lash so I would bill.

99213-25 379.91(pain in/around eye)
67820-E1 (trichiasis)
67820-E3 (trichiasis)

I have been getting paid on the 99213, but the insurance always denies the 67820, even when the patient has no deductible and have paid they specialist copay. Any clues?

I'm always hesitant to get involved in these discussions but what works in one part of the country doesn't in another but here's what I would try:

Try bagging the E1 modifiers and submiting for just one unit.