# Payers tell the patients we should change the diagnosis



## Pam Brooks (Jun 16, 2011)

Is anyone else having this problem?

Here's the scenario:  Our patients (primary care) are given a lab slip in preparation for their upcoming annual physical. The patient has a pre-existing condition.   The provider (correctly) puts the diagnosis on the lab slip relative to the patient's condition, because these labs are for surveillance.  For example, if the patient is diabetic, and the doc is ordering a HgA1C to be reviewed when the patient comes in for the pe, then the doc would code 250.XX. 

Of course, because the patient has a previous diagnosis, and it doesn't fall under routine care, the payer is processing the lab charge against a deductible and co-insurance, and the labs are not being paid at 100% for 'preventive care'.  The payers are telling our patients that we coded these wrong, and should use the V72.62..._lab work ordered as part of a routine general medical examination_.  I say, that since the labs are drawn for surveillance of the DM, we should not use the V code, but should code for the reason for the lab....diabetes.  Unless things have changed, we can't prevent a condition that is already established, which is the whole point of preventive care!  But the payers are telling patients that we are coding incorrectly, and we look like the bad guys.  We all know that "they didn't code it right" is secret insurance language for "we don't like you because you're sick, and you have our cut-rate policy".  

Is anyone else having this problem?  Should I code the V72.62 first, and then the 250.xx?  That just goes against the ICD-9 rules, which state you should code the symptom or condition, if it exists, so I'm reluctant to code in order to satisfy coverage requirements. 

I would really appreciate feedback!  Thanks!


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## gost (Jun 17, 2011)

I've worked on both sides, for payers and for doctors.  I would be curious to know who the payer is.  Actually, I would like to know if it was a small payer or a TPA.  I have found that small payers, TPA's especially do not provide adequate, if any training on coding to their employees.  Most likely, if you bring this to the attention of someone a little higher up in the payer's heirarchy, you can get this stopped, at least until the next new rep is hired.  However, I have dealt with a few TPAs that had NO ONE who understood coding.  Good luck.

Oh, and before anyone gets too upset, I have dealt with many more payers who DO understand coding and provide quality training to their employees.  I have also dealt with MANY providers who were lost when it came to billing and coding and have had some suggest the same thing Pam just mentioned.  For the record, I work for a payer.  I try to be an equal opportunity offender.


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## tpontillo (Jun 17, 2011)

I have had problems with patients calling and saying that there insurance said if you change the code then it would get paid.  These are from the big insurance companies, BC, United Health and Humana.  The problem that I am finding out is that the people who are answering the phone dont know anything about coding.  I had BC tell a patient that if we change the code, instead of telling him to fill out the preexisting form that they were waiting for him to send back before paying our claim, then the claim would be paid.  They didnt have my office notes to even see what was done.  I had called BC and made a complaint.  I have also had United Health call me and tell me that I put the modifier on the wrong procedure and that is why the claim was denied.  When I told her that the modifier was on the correct procedure and that the modifier goes on the procedure with lesser RVU she had no idea what I was talking about.  I then asked her to speak with someone who knew about coding, She said there was no one else to talk to.  I was also on three way with a patient whose insurance (BC) said that we billed a procedure (EGD) as an emergency.  I had told the rep that we did not bill it as an emergency and that there was no way on the HCFA to put it as an emergency. Then he tells me that he made a mistake and didnt look at the claim properly.  I can keep going on.  The insurance companies are just hiring anyone to answer the phones and are just saying anything to get that patient off of the phone and unfortunately they are making the doctors office look like the bad guy.

I will agree with Gost that alot of doctors office's employ people who dont know anything about coding, I have worked for plenty.  I have not worked for an insurance company, so I cant say that the people that we are *not allowed* to talk to have coding knowlege.


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## Pam Brooks (Jun 17, 2011)

Thanks....I was beginning to second-guess myself!  

I'm asking our customer service people to track these complaints and let me know which payers are doing this.  I know that Anthem is a big offender.   Then I'm going to our state MGMA, where we have a third-party-payer forum, and I'm going to make a ruckus.


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## DMRgn2010 (Jun 17, 2011)

*Sounds like fraud to me...*

... the payors should know that they can't do that. That sounds like fraud. I wonder if they realize that? Does that sound like fraud to anyone?


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## DMRgn2010 (Jun 17, 2011)

*Found this info, hope it helps...*

I just found this information:

Down-coding or changing of codes
Payers must pay for the services as billed or deny the
codes/modifiers not supported by the presented
documentation and/or Relative Values for
Physicians/DOWC rules. Payers are required to be
very clear and specific on why they are denying the
billed codes. *Payers cannot change billed codes,*
*unless the provider agrees.* The provider has 60 days
to resubmit the denied codes and modifiers with​
_additional information_.

http://www.coworkforce.com/dwc/physaccred/level%20i%20accreditation/2009/common_payment_issues.pdf


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## mitchellde (Jun 17, 2011)

tpontillo said:


> I have had problems with patients calling and saying that there insurance said if you change the code then it would get paid.  These are from the big insurance companies, BC, United Health and Humana.  The problem that I am finding out is that the people who are answering the phone dont know anything about coding.  I had BC tell a patient that if we change the code, instead of telling him to fill out the preexisting form that they were waiting for him to send back before paying our claim, then the claim would be paid.  They didnt have my office notes to even see what was done.  I had called BC and made a complaint.  I have also had United Health call me and tell me that I put the modifier on the wrong procedure and that is why the claim was denied.  When I told her that the modifier was on the correct procedure and that the modifier goes on the procedure with lesser RVU she had no idea what I was talking about.  I then asked her to speak with someone who knew about coding, She said there was no one else to talk to.  I was also on three way with a patient whose insurance (BC) said that we billed a procedure (EGD) as an emergency.  I had told the rep that we did not bill it as an emergency and that there was no way on the HCFA to put it as an emergency. Then he tells me that he made a mistake and didnt look at the claim properly.  I can keep going on.  The insurance companies are just hiring anyone to answer the phones and are just saying anything to get that patient off of the phone and unfortunately they are making the doctors office look like the bad guy.
> 
> I will agree with Gost that alot of doctors office's employ people who dont know anything about coding, I have worked for plenty.  I have not worked for an insurance company, so I cant say that the people that we are *not allowed* to talk to have coding knowlege.



I agree for the most part but, payers are not to tell us how to code a line item nor can they tell us what the dx is.  Sometimes the dx code is not the diabetes or the osteo or the a fib but it should be the V58.83 for medication monitoring and that alsways works for me and always matches the reason for the test, also FYI the modifier does not always go on the lower RVU, it needs to go where it will do the most good.  Several instances the component code which needs the modifier is also the one with the higher RVU, if you put the modifier on the lower RVU then you did not unbundle the procedure.  I just though I would alert you to this as it is a common error I have found on many rejected line items.


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## ollielooya (Jun 18, 2011)

*modifier placement rationale*

"...., also FYI the modifier does not always go on the lower RVU, it needs to go where it will do the most good.  Several instances the component code which needs the modifier is also the one with the higher RVU, if you put the modifier on the lower RVU then you did not unbundle the procedure.  I just though I would alert you to this as it is a common error I have found on many rejected line items.[/QUOTE]

Debra, could you please furnish an example?---Suzanne E. Byrum CPC


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## mitchellde (Jun 18, 2011)

ollielooya said:


> "...., also FYI the modifier does not always go on the lower RVU, it needs to go where it will do the most good.  Several instances the component code which needs the modifier is also the one with the higher RVU, if you put the modifier on the lower RVU then you did not unbundle the procedure.  I just though I would alert you to this as it is a common error I have found on many rejected line items.



Debra, could you please furnish an example?---Suzanne E. Byrum CPC[/QUOTE]
26115 is a component of 26210 and is modifiable but 26115 has the higher RVU, so if you put the modifier on the 26210 you will not unbundle the 26115.  This was the most recent one I have corrected.  There have been many others but I do not have them in front of me.
I do not have the codes but the larngoscopy with biospy is mutually exclusive with the direct operative layngoscopy with tumor removal but it is modifiable, however it is not a 59 and it is not applied to the biopsy it is a 58 and it goes on the direct operative since that is the one that is staged.  But the direct operative has the higher RVUs.


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## Pam Brooks (Jun 20, 2011)

We're not having any issues for denials/unbundling, etc.  This has to do with payers telling the patients that we should code as routine in order that they can process the claim without a copayment/deductible, even if the claim is not for routine or screening services.

I rarely have issues with line items for modifiers.  This issue is diagnosis-driven only.  While I'm not sure the payer is committing fraud since they're not changing the codes themselves, it's a slimy business practice to suggest that we should commit fraud in order that they can process the claim to the patient's satisfaction.  The payer isn't going to tell the patient that their policy has coverage limitations when the patient has a chronic condition....they'd rather blame the provider.


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## jgf-CPC (Jun 24, 2011)

I recently had to appeal my own colonoscopy because the provider DID NOT use the screening code that was on the order. The colonoscopy was normal and should have had the V-code given. I would have gladly paid towards co-insurance or dedutible if the provider was correct but they did not code it correctly. The insurance company did tell me it was coded incorrectly but would not give me what was used so it took me going all the way to the physician himself that performed the colonoscopy to straighten it out. He was sincerely upset that his office did not code what he had read to me off of the report. The new healthcare reform has to be looked at closely and your policy itself to get things in the right perspective.


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## Pam Brooks (Jun 27, 2011)

Jackie, I do agree that errors are made on the physician side,  but what we're experiencing is that payers are telling the patients that if services were 'coded differently', they would be paid.

In your case, you knew the difference, and understood that it was an error.  For most patients, the coding rules aren't common knowledge, and they don't seem to understand why it would be wrong to code for a screening lab, when they already have the disease.  And the payers, rather than telling our patients that they simply have different coverage for disease management vs. preventive care, insist that we made a coding error.  

To me, that is very, very wrong, and I plan to elevate this at my next state MGMA meeting.


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## MnTwins29 (Sep 4, 2018)

*Things haven't changed...*

Hi - while I see this is quite an old thread (it was in my list of "similar" ones from something else I posted) I can say that this is still the same.  I have been getting more requests like this - not only in the type of scenario that Pam described in the opening message, but also when a patient complains about their ER bill.  Either the payer or our patient liaison will tell the patient that they will see if the ER level is correct and maybe that would lower the bill.  So while not directly being told the code was wrong, the patients are calling asking for it to be reviewed - and that still doesn't make them happy.  Even if we can reduce from say 99284 to 99283, they are still going to be billed for a significant amount - not what they want to hear, they believe that all we have to do is change the code and they won't be responsible for anything.  *sigh*


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## MnTwins29 (Sep 4, 2018)

*Patient Portas*

Something else that may fall under this category - watch what diagnoses go into the patient portal as those that the patient says they have will end up there if coded.  I had one patient tell me I HAD to remove his DM because he insisted he didn't have it - it was documented on the physician's notes, it was the dx for which the outpatient tests were ordered and the results had "borderline".  But because his insurance didn't cover it AND he was concerned about the implications of that appearing on the portal, he insisted we take that off because "the doctor said I didn't have it."  Well, we spoke to the doctor, offered him a chance to amend the record properly - but the MD said he was sticking with his original documentation.  Just wanted to add that now this has patient portal implications as well to increase the fun.

Lance


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