Wiki Billing questions

Create Wiki
1. It depends on if it really was a duplicate or not. If they are saying they already processed the claim, then request a copy of the original eob/decision.

2. No, it is not the same. Our office, pain management, does not take patients on self-referral. A new patient cannot just call our office and make an appointment. We have decided that every patient MUST be referred by their primary care doctor. We want to know what the primary has done for their pain, as we are not the first choice for pain - the primary doctor should make an effort to alleviate it before giving up and sending them to us. We also want to know what else is wrong with them, for instance, if their diabetes is out of control, then we cannot control their pain (uncontrolled diabetes makes pain a lot worse, so we need to know that the PCP is actively working on their diabetes).

A pre-authorization is when the insurance company issues an approval for a service. We cannot see hospital patients on an HMO without an authorization (or pre-authorization, or pre-approval - all interchangeable terms) from the HMO.
 
A duplicate claim denial can stem from multiple issues and you need to research further, which will likely require calling the insurance plan to ask questions. The top 3 reasons we get duplicate denials at my office are:
  1. There is another claim for the same date/same service already in the billing system. Verify the services and void the duplicate charges.
  2. The claim processed the first time as a zero pay and we didn't receive that explanation from the payer. You will need to call the insurance or check their portal to look for a prior remit.
  3. Hospital claims will often deny duplicate when another provider sees the patient on the same day and bills the same visit level as your physician has billed. You can usually get these reprocessed by calling the insurance and explaining you were the only physician of "x" specialty to see the patient. Of course, you need to confirm this.
If you have more information about the denial and/or claim involved that you can share, you might get more specific advice.

Referrals are not the same as a pre-auth. Referrals are for visits; pre-authorization is for procedures, treatments, radiology, etc.
 
trarut said:
Referrals are not the same as a pre-auth. Referrals are for visits; pre-authorization is for procedures, treatments, radiology, etc.
Click to expand...

Small clarification: Some insurance plans (some HMO plans) require a pre-authorization for an office visit. We dumped all of those plans because we thought that was ridiculous, but they are out there.
 
Thanks for the clarification, Sharon. Is that a California "thing"? I don't know that I've ever had a plan require pre-authorization for a visit, just referrals. And, of course, with our local VA, the referral and pre-authorization are the same document (because that doesn't confuse anything).
 
trarut said:
Thanks for the clarification, Sharon. Is that a California "thing"? I don't know that I've ever had a plan require pre-authorization for a visit, just referrals. And, of course, with our local VA, the referral and pre-authorization are the same document (because that doesn't confuse anything).
Click to expand...
It could be a California thing. The biggest plan we dropped was a Medicaid HMO plan that required pre-auth for visits to anyone that was not the PCP. We told them, politely, to go pound sand. The commercial HMOs don't require auth for us as a specialist for office visits.
 
We were told there are specific drugs that can only be captured as one initial per encounter. Does anyone have a listing of those drugs or the ones most commonly used?
Only one initial infusion can be captured per encounter unless 2 separate IV sites are medically reasonable and necessary. What constitutes medically reasonable and necessary?
Can anyone provide examples?

Thank you so very much,
Suzanne
 
gucciardosue said:
We were told there are specific drugs that can only be captured as one initial per encounter. Does anyone have a listing of those drugs or the ones most commonly used?
Only one initial infusion can be captured per encounter unless 2 separate IV sites are medically reasonable and necessary. What constitutes medically reasonable and necessary?
Can anyone provide examples?

Thank you so very much,
Suzanne
Click to expand...
I have never heard of any such list of drugs. It's my understanding that there are certain drugs that aren't compatible with others and therefore can't be run through the same lines, so that would warrant separate sites. That's a decision for the pharmacist and/or physician to make. It's not really up to the coder to determine what's medically reasonable and necessary, only to code what is documented. It's pretty rare to see this, but if the documentation indicates that infusions were running concurrently at two separate sites, then I would assign a second initial infusion code (with modifier 59 or XS) to show this. From my understanding, you would not use a second initial infusion code in other circumstances, such as if a new line had to be restarted because the old one clotted or could not be used any more.
 
You must log in or register to reply here.
Top