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  1. #1
    figurer is offline Junior Member
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    Dr. coding post-op visits wrong to get more $

    What is the name of your state (only U.S. law)? Ohio

    I recently had outpatient surgery on my ankle. Two days after the surgery, I called the drs. office because the bandages were causing my toes to turn purple and they said to come in. I went in and he looked at the incision and re-wrapped my foot....using the same splint I had been given in the hospital and they reused the same ace bandage.

    Two days later, I went in for a regular post-op check up that was part of the treatment plan. Again, he unwrapped it, changed the dressing that directly touched the wound and re-wrapped it with the same splint and ace bandage.

    Two more follow-up visits were for removal of the sutures he placed during surgery and cleaning up the wound and the last one was just a regular scheduled post-op visit to check on the incision and give me instructions for when to start physical therapy, when it was ok to put weight on it, etc.

    According to my insurance company, all post-op visits are covered 100% with no copay.

    Last week I rec'd a bill from the dr for $125 for the first two visits for "replacing the splint" (which would take at least 2 hours each visit, I was there maybe 15 minutes each time) and then $30 for each of the four visits for co-pays.

    Contacted the insurance office, they said the dr. is not coding the visits as "post op" even though the admit that they are all visits AFTER surgery. They said there is nothing they can do, that it's up to the dr. to code the bills however he wants.

    Is this even right? These are POST-OP visits! There would be no other reason I would be visiting this dr other than to follow up on surgery HE performed. And he did not change the splint at all, he reused the same one.

    So now I have a huge bill due when I was told before surgery it would be $xxx deductible (which I had already met) and 100% covered for all post op visits. He's obviously doing this to get more money since he knows he's already been paid for my care.

    What should I do?
  2. #2
    ecmst12 is offline Senior Member
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    When you called the doctor's office, what did they say?

    The problem visit will probably not count as post op. The routine checkup should.
  3. #3
    figurer is offline Junior Member
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    When I called the drs. office, they said that they put a new splint on. When I told them they didn't put a new splint on (on either of the dates they're billing me $125 plus a $30 copay), they said "oh, well we're just allowed to bill for it even if he didn't make a new splint, we can bill because he took off the wrapping and re-wrapped it."

    When I look at the EOB for the hospital charges, it shows the splint charge, which was covered 100% by my insurance. So two days after the surgery, when I went it because there was a lot of swelling causing the wraps to be too tight, all he did was take the ace bandage off and re-wrap it with the same splint. The same thing happened a few days later at my scheduled post-op visit, except that time he took xrays.

    Another quirky thing I just noticed a few minutes ago is that I have met my deductible for the year and shouldn't have any "co-insurance" charges (which I understand are different from co-pays). But when I looked at the EOB that the dr. submitted on the insurance website, it's showing it's my responsibility because it's "co-insurance". They're both pointing the finger at each other but sending the bill to me
  4. #4
    tranquility is offline Senior Member
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    "While I understand I have little knowledge of medical billing, it seems I have some liability based on the particular codes you have supplied to my insurance company. Please supply your requests, and the reason why you have requested those particular items, so that I can better communicate with my insurance company. Otherwise, I will have to explore my legal remedies."

    Send it to the MD along with the specific facts. Let us know of the response.
  5. #5
    Ben@drcotliar is offline Junior Member
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    2 things:

    One - The doctor is apparently billing incorrectly and cannot charge you for his mis-billing.

    Two- The insurance company can certainly do something. In fact, most insurers will automatically call visits post-ops unless there is a specified not related to the surgery service that is performed.

    So the insurance company shouldnt be accepting the billing as is, and the doctor shouldnt be billing, unless there is more to the story than meets the eye.

    What insurer do you have, btw?
  6. #6
    ajkroy is offline Member
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    Actually, it depends on whichever code he billed for the surgery. Many surgeries have post-op "global" periods that cover any routine issue that comes up during the post-op period. That period can be 90 days to no time at all, depending upon the surgery.

    The rewrapping should not be charged again if it is within the appropriate global period, because that is not a true complication and can be a natural consequence of the surgery. But if the patient went against medical advice and went to the beach and got the dressing wet and filled with sand, that could be billed during the global period.

    Either way, a billed post-op must be billed with an appropriate modifier. I would tell the OP to call the insurance again and explain what is happening. In my experience, insurance companies do not need a valid reason to refuse to pay a claim, so it puzzles me to think that they wouldn't investigate this one.

    Here is a link to the CMS guidelines for global billing:

    [url]http://www.cms.gov/manuals/downloads/clm104c12.pdf[/url]
  7. #7
    Ben@drcotliar is offline Junior Member
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    Quote Originally Posted by ajkroy View Post
    Post
    You are correct about the global period, but according to the op, this was a routine post op. Additionally, the insurance's response is very strange, I would like to know which insurance company it is.

    According to the op, the insurance company says it is up to the doctor to bill the claims however he wants, which is not the case with any insurance company I have ever dealt with, and I have dealt with a lot of them.

    I would try calling again... perhaps the rep you got was misinformed, or gave you the wrong information.
  8. #8
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    "Replacing a split" doesn't mean throwing away the parts that are meant to be reused, such as the Ace bandage. Gauze is made to be tossed. Hardware isn't. Taking it off and putting it back on in replacing it. Replace also means to move and put something in a new place.

    We need to know more info to determine whether the charges are legit. OP needs to let us know if there was a global fee, what led to the split needing to be replaced/rewrapped, etc..
  9. #9
    Zigner is offline Senior Member
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    Think "re-place" vs "replace"
  10. #10
    lealea1005 is offline Senior Member
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    The answer to this question....


    We need to know more info...... what led to the split needing to be replaced/rewrapped, etc..
    is.....

    Two days after the surgery, I called the drs. office because the bandages were causing my toes to turn purple and they said to come in. I went in and he looked at the incision and re-wrapped my foot....using the same splint I had been given in the hospital and they reused the same ace bandage.
    The splint & ace needed to be removed and replaced to check the incision and assess circulation.

    This visit may not be considered part of the global surgical fee.

    I am confused by the insurance company rep's stating that they have no control of paying an incorrectly coded claim. I'd be interested in what Diagnostic and procedural codes were used.

    ETA: BTW...did I miss reading whether this Physician was contracted or in network with your insurance company?
    Last edited by lealea1005; 06-29-2010 at 06:23 PM.
  11. #11
    ecmst12 is offline Senior Member
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    Well, the insurance company has to process the claim as it is submitted. But they CAN intervene if it's a clear case of incorrect coding. But they can't actually process the claim differently until it is resubmitted with the correct codes. Right now all they can do is make a phone call.
  12. #12
    lealea1005 is offline Senior Member
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    Quote Originally Posted by ecmst12 View Post
    But they CAN intervene if it's a clear case of incorrect coding.
    That's why I'm saying I find OP's statement confusing. In my experience, regardless of the coding during a post-op period, the insurance company verifies the nature of the office visit by requesting office notes before making a decision on coverage/payment.

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