Surgery???

[sah0001]

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

I went to a doctor because of suspected toenail fungus. During the office visit he gave a prescription which could cause potential liver damage. He clipped free edge of toenail to send for testing and said results would be in about a week but go ahead and start the meds. About 4 weeks later, still no call from Dr but had not started meds because of fear of liver damage. Got EOB from insurance and he had billed insurance for surgery for clipping the toenail. Since deductible was not met insurance said we had to pay. When I called about the "surgery" 4 weeks after the office visit, he finally said that the test for fungus was negative. I don't think he would have told that until the follow up appt 3 months later. He said that toenail clipping was surgery as he had billed insurance, but then sent a bill to my house with it called biopsy instead. Were any of his actions illegal?

[Zigner]

Originally Posted by sah0001

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

I went to a doctor because of suspected toenail fungus. During the office visit he gave a prescription which could cause potential liver damage. He clipped free edge of toenail to send for testing and said results would be in about a week but go ahead and start the meds. About 4 weeks later, still no call from Dr but had not started meds because of fear of liver damage. Got EOB from insurance and he had billed insurance for surgery for clipping the toenail. Since deductible was not met insurance said we had to pay. When I called about the "surgery" 4 weeks after the office visit, he finally said that the test for fungus was negative. I don't think he would have told that until the follow up appt 3 months later. He said that toenail clipping was surgery as he had billed insurance, but then sent a bill to my house with it called biopsy instead. Were any of his actions illegal?

There are many definitions out there, but I think this one is the best in this situation:


Surgery:

An operation. A medical procedure to examine, remove or repair a diseased or potentially diseased portion of the body.
([url]www.mesotheliomanews.com/medical/medical-glossary/[/url])

ETA: No, nothing illegal

[ecmst12]

We would know more if you posted the specific 5 digit CPT code that he was billing for, but yes this is considered a minor surgical procedure.

[lya]

definition of biopsy:
A sample of tissue removed from a living body by a medical provider for diagnostic purposes.

definition of surgery: (previously posted)
An operation. A medical procedure to examine, remove or repair a diseased or potentially diseased portion of the body.

Compare the two definitions. They are essentially the same; and, it only makes sense that to examine a piece of toenail, it has to separated from the toe. Clipping a toenail is considered a surgical procedure and requires a physician's order, unless performed by a physician.

[tranquility]

Medical billing seems an art and not a science. If you have an argument with the doctor with the amount of the bill, talk with him. Don't jump to thinking illegal or litigation when such things are part of their knowledge and job.

[barry1817]

Originally Posted by sah0001

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

I went to a doctor because of suspected toenail fungus. During the office visit he gave a prescription which could cause potential liver damage. He clipped free edge of toenail to send for testing and said results would be in about a week but go ahead and start the meds. About 4 weeks later, still no call from Dr but had not started meds because of fear of liver damage. Got EOB from insurance and he had billed insurance for surgery for clipping the toenail. Since deductible was not met insurance said we had to pay. When I called about the "surgery" 4 weeks after the office visit, he finally said that the test for fungus was negative. I don't think he would have told that until the follow up appt 3 months later. He said that toenail clipping was surgery as he had billed insurance, but then sent a bill to my house with it called biopsy instead. Were any of his actions illegal?

I have a lot of problems with billing amounts and coding being changed depending on who is being billed.

In cases that I have been involved in as an expert, in dental not medical, such billing practices have been called into question.

[ecmst12]

Nothing has suggested that the CODE was being changed, only the DESCRIPTION of the code. Surgery is the general category, biopsy is more specific. Both are correct. Without knowing the exact code, we don't know whether it was billed correctly, but on the surface nothing seems amiss.

[lya]

The change in terms bothers the OP; but, it seems to me that the change was made because the OP told the MD the term, "surgery", bothered him/her.

I don't think there is a 'win' in the answer column for the OP. Perhaps, he/she can choose which billing code and term suits him/her the best and inform the physician. The next step is to find a new physician. (I don't think the original MD will care to continue treating this patient.)

[lealea1005]

Since the Physician cannot submit a claim stating "removed part of toenail", the claim must be submitted with a 5 digit CPT code and the diagnosis code (as suggested above). Everything is a code/number. The INSURANCE COMPANY makes the decision to classify the procedure as "surgery"/office visit/procedure, etc.. Sometimes biopsies are also classified as "surgery".

Why get mad at the Doctor or immediately jump to the conclusion that something illegal was done? I've seen EOBs come back with, freeezing off a wart, cleaning out ear wax, relieving the pressure of a hematoma under a fingernail, and even venipuncture, all classified as "surgery" by different insurance companies.

Personally, I would not have changed the wording when the bill went out. Just because he changed the wording to appease you doesn't mean the coding was changed. It is what it is.

OP, you never did come back with the CPT code. We're still waiting.

[sah0001]

the code was 11755.
I never signed a surgical consent form. He did not even wear gloves or use a sterile instrument.

[Some Random Guy]

I never signed a surgical consent form. He did not even wear gloves or use a sterile instrument.

Are you now claiming that you did not consent to having your toenail clipped?

Are you claiming that you were damaged in some way because he did not wear gloves?

Are you claiming that the non-sterile instrument caused in infection?

Go down to the store to buy a lottery ticket. You did not win the malpractice lottery today.

[lealea1005]

Originally Posted by sah0001

the code was 11755.
I never signed a surgical consent form. He did not even wear gloves or use a sterile instrument.

11755: Biopsy of nail unit, any method (eg. plate, bed, matrix, hyponychium, proximal and lateral nail folds) separate procedure (CPT 2007, American Medical Association)

Was there another CPT code used in addition to this one?

Sterile instruments are not necessary since the area is already infected ("dirty"). He must have used scissors that were wrapped and non-sterile gloves. How else would he take the nail off?

ETA: No need to sign a separate surgical consent form since you most likely gave the Physician permission to treat you "as deemed necessary" when you signed the registration form the first time you were at the office. That consent covers treatment, labs & diagnostics done at the office.

[barry1817]

Originally Posted by lya

The change in terms bothers the OP; but, it seems to me that the change was made because the OP told the MD the term, "surgery", bothered him/her.

I don't think there is a 'win' in the answer column for the OP. Perhaps, he/she can choose which billing code and term suits him/her the best and inform the physician. The next step is to find a new physician. (I don't think the original MD will care to continue treating this patient.)

A procedure that a professional does, is that procedure. It does not get to be changed after the fact, without calling into question why it wasn't that procedure at the beginning.

Billing statements are usually signed, which signify that the procedure has been done and the reporting is a truthful reporting of the treatment.

Changing something after the fact leaves a person to question if what was truthfully reported, was in fact the truth, if it gets changed, especially if one questions why the change was made.

As to a nail clipping being considered a surgery, wonder if what a barber does is surgery as he is clipping body tissue that can be defined in a doctor's office as a surgery. Makes for an interesting discussion.

[lealea1005]

Originally Posted by barry1817

A procedure that a professional does, is that procedure. It does not get to be changed after the fact, without calling into question why it wasn't that procedure at the beginning.

Billing statements are usually signed, which signify that the procedure has been done and the reporting is a truthful reporting of the treatment.

Changing something after the fact leaves a person to question if what was truthfully reported, was in fact the truth, if it gets changed, especially if one questions why the change was made.

As to a nail clipping being considered a surgery, wonder if what a barber does is surgery as he is clipping body tissue that can be defined in a doctor's office as a surgery. Makes for an interesting discussion.

Barry... the procedure code 11755 description is "biopsy". It IS a procedure that is classified as "surgery" by insurance companies for coverage purposes. Procedures/"surgery" is covered differently, under a deductible in a lot of cases. No matter what anyone wants to call it (office visit/procedure/surgery/tea with the queen) the CODE doesn't change.

[ecmst12]

A barber is not performing surgery because he is not a doctor. I don't know the code, but I would expect that if a similar test was performed on a hair, it would be similarly coded as a biopsy.

The code was not changed. The only difference is when the insurance company wrote up the EOB, they referenced the GENERAL CATEGORY of that code, which is surgery. When the doctor billed the patient, they used a more specific description. BOTH are correct and accurate and NOTHING was done that could be considered the slightest bit questionable.