Wiki Bill According to higher allowable? is this right?

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cgifford

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I had a physician ask me if he could bill a knee injection (kenalog) with an office visit. I said normally the OV is included in the Injection unless there is something else significant that was done to constitute an office being billed.

He then asked me to look up the allowable for the Injection and the Office visit for that particular payer and bill whichever allows/pays more.

Im fairly new to coding and feel you should bill what you did, meaning the injection but if the injection pays less he wants me to bill the office visit, is this right? your thoughts?
 
While I don't disagree with substituting codes being wrong, I don't believe that is the scenario which is being described.

Both services are rendered and supported from a coding perspective. From a billing perspective both services are payable. The problem stems from them being performed together since the policy will only allow for 1 of the services to be billed on a particular date of service.

If you perform 2 services and can only bill for 1, common sense is going to say to bill the one with the higher reimbursement. This is not a substitution, both services were rendered. This isn't a correct coding issue anymore, this is a billing issue based on payer guidelines. The same way we order our procedure codes by listing the highest RVU code first followed by the rest in descending RVU order on claim forms.

I am unable to find anything supporting which code must be chosen to report in this situation. All I can find is documentation stating to only report 1 of the codes. See below.


http://wpsmedicare.com/j5macpartb/claims/denial/bundling-denials.shtml

When a code pair that is governed by the NCCI is billed, only one of the two procedure codes can be billed unless an appropriate modifier is applied to override the edit.


I don't think there is anything in the false claims act that deals with this scenario. I would however be very interested in seeing documentation that supports a particular way to choose which procedure is reported in a case where both are done but only 1 can be reported.

Just my take on it,

Laura, CPC, CPMA, CPC-I, CANPC, CEMC
 
you need to check in to the false claims act like Deborah mentioned. Regardless of what "pays more", we are to follow coding guidelines. If the injection was preplanned, you would only bill the the injection. If the documentation does not support a separately identifiable E/M, you only bill the injection. Your provider is trying to make the most money he can, which is "abuse" per the OIG. This is not what proper coding/billing is about.
 
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