Radiology Coding Alert

Question: Our compliance officer recently said we cannot bill a patient at the time of service if we have a contract with the patients insurance company. This issue arose when a carrier would not preauthorize a sinus CT (70486-70488) and we asked the patient to pay at the time of service. Is our compliance officer correct?

Georgia Subscriber

Answer: Not necessarily. Generally, your office cannot charge anything more than the co-pay from the patient for covered services. However, if the service is an elective procedure and will not be covered by insurance, payment may usually be collected at the time of service if the patient decides to have the procedure anyway.

According to Medicare, if a service is not a covered benefit, you must obtain a written waiver of notification before the service is provided and then collect the payment either in advance or by billing the patient. If the service is potentially covered but fails on post-billing review as not medically necessary, you can collect from the patient only if the patient has signed a waiver of notification. In this second circumstance, because Medicare might have paid the claim, you can collect from the beneficiary only after the claim was rejected and only if the proper waiver was signed.

For other payers, there is not a legal compliance issue, but a contractual issue. In each case you must investigate the terms and conditions of the participating provider contract to assess the practices and policies in force.