Insurance Fraud cont Coloboma

[rmet4nzkx]

What is the name of your state? IL
The original thread is locked https://forum.freeadvice.com/showthread.php?t=318516
MattUNI2001
sent me the following PM with the CPT because the thread was locked

Code
The code they used was 92225. For some reason my thread got locked.

Remember he had a routine eye exam which was covered in total by his VSP coverage and the provider billed for an exam because Matt told the provider he had Coloboma which is a congenital condition, billing $144 of which BCBS covered 75%

What I discovered is that the proper ICD-9 code was not used but that is another issue, the CPT was 92225 which includes in the cost a routine eye exam which was already billed to VSP, so in essence the routine eye exam was double billed because they billed 2 different carriers. Then the question is whether or not the correct codes or tests were given. This is at least a billing error.

OPHTHALMOSCOPY

Routine ophthalmoscopy is part of general and special ophthalmic services whenever indicated. It is a non-itemized service and is not reported separately.

92225 Ophthalmoscopy, extended as for retinal detachment (may include use of contact lens, drawing or sketch, and/or fundus biomicroscopy), with medical diagnostic evaluation; initial
92226 Subsequent

 

[MattUNI2001]

Hey, thanks a lot for looking into this. I really appreciate it. I don't want to take this all the way to small claims or anything, I just wanted to see if I was right. In the very least, when I sent in the check, I will send in the evidence you found and summarize it all so they can see that they were definitely wrong. It won't really be worth going too much further than this. I have yet to call the BCBS fraud line, so now it looks like I definitely will do that tomorrow and inform them of the information you gave me.


In the very least, this was a good learning opportunity for me! Thanks again!!