Wiki Coding visits instead of procedures?

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tg

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Hello,

If an insurance company won't cover a minor procedure (toe nail removal) under certain circumstances, are we allowed to bill an office visit instead and leave out the procedure code?

Thank you for your help.
 
You cannot code a visit just to ensure payment. Many minor procedures include the office visit in with the payment for the procedure. It is not the providers fault not problem that a pt's insurance does not cover toenail removals. You have to code the procedure.
 
correct billing

The patient should be informed before the procedure is done regardless of the insurance but if the patient has Medicare you can present them with an ABN (Advanced Beneficiary Notice). The patient can then make the choice to go through with or to not have the procedure.

To bill the insurance, code the procedure/services as performed. If the insurance returns for non-coverage the patient is then responsible for payment (unless it's Medicare without an ABN or Medicaid). Most commercial plans will tell their beneficiary they are responsible to know the coverage guidelines are for the plan they selected.
 
Thank you.

This particular insurance only covers toe nail removals for patients until age 21 or for patients with diabetes. In my mind, if they are not paying then they are saying they don't think it was necessary. In that case I think the doctor should get paid for seeing the patient and the procedure would be part of the medical decision making; it would be included in the E&M.

What is wrong with that?
 
the dr will get paid for treating the patient. He simply will be getting paid for the services by the patient and not the payer.
And yes, for Medicare and ADV plans, the pt should be signing a completed ABN form. This is the only way you can legally bill a MCR patient for a non covered service.
 
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