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Any coding/insurance experts?

I'm questioning the medical claims that my MO's office is generating, for my Zoladex injections. I have to pay coinsurance on the medication (which is now being reimbursed under a rebate, thank goodness), but I also get charged a specialist office visit copay. I checked with the insurance, and they said it's being coded as an office visit, and that it's correct. Another person at the insurance said it's HOW it's being coded and that there's a way to code under a nurse. The doctor's office told me that because of my insurance ("and some insurances are like that") no matter what happens anytime I step foot into that office I will be charged a specialist co-pay.

I don't know. It all sounds shady to me. But I know nothing about billing. I check in, the nurse checks vitals and gives me my shot. I don't see a provider. I read about "nurse visit" codes, but none of it makes sense to me. I saw something about how taking a BP automatically makes it a billable visit with a co-pay. I don't know why they're checking my vitals each time, honestly.

I thought about reaching out to their billing office to question, but if it's their standard office practice, then really what's the point? They were nice to me by getting that rebate set up, maybe I should just stop fussing and be happy it's only $50/month?

Just to clarify, this is an employer sponsored, low-deductible commercial plan.

?

Comments

  • lw422
    lw422 Member Posts: 1,375
    edited July 2022

    I believe that for any doctor I see that isn't my PCP, I get billed as a "specialist." So my MO, RO, SO, etc. are all specialists. (I have no idea about billing/coding so I'm really no help.)

  • olma61
    olma61 Member Posts: 1,016
    edited July 2022

    I just found out that with Medicare, the days I would go in for injection/infusion and I only see a nurse who does it and not see the doctor - there is NO doctor visit co-pay. Not sure it would be the same for your insurance but yes, it may have something to do with how they are coding that visit. Seems if you dont see the doctor, they should not code the visit as if you did.

  • gb2115
    gb2115 Member Posts: 551
    edited July 2022

    They never ask for money at the front desk when I check in for an injection (they do when it's an appointment to see the doctor), but when the EOB comes back, sure enough there's an office visit co-pay on there.


  • quietgirl
    quietgirl Member Posts: 165
    edited July 2022

    it can’t hurt to reach out to the billing department. It’s not like you are calling them 80 times a day or something that might be viewed as excessive. You aren’t being a pain by calling them, you are asking a question so you understand. At one point I had to sign paperwork that I knew I would get two bills one from my doctors and one from the hospital (even though I’m not at the hospital). They were really up front about it so it wasn’t a surprise because they are required to by law the No surprise act of 2022. So go ahead and as

  • weninwi
    weninwi Member Posts: 745

    The Diagnosis and I assume the Billing Code for my breast cancer changed after my last office visit. At earlier visits the diagnosis was always written as "Metastatic Breast Cancer" (I have mets to liver & bone). But after my most recent visit my MO wrote "Metastatic Adenocarcinoma to Liver". I thought this was a mistake and contacted my MO's office and the billing department. My MO's nurse got back to me and explained that basically either or both diagnoses is correct and then the My Chart record was edited to now read "Metastatic Adenocarcinoma to Liver" and "Primary Malignant Neoplasm of Breast with Metastasis". Does this sound right? I'm not sure if I should drop it or make a few more phone calls? I have Medicare and Tricare. Thanks for any comments offered.

  • momgoose
    momgoose Member Posts: 71

    This would be ok. It would also be even more accurate if the codes were Primary Malignant neoplasm of the Breast with metastasis, Metastatic Adenocarcinoma to Liver and Metastasis to Bone. That's how I would code it if it was all documented. What is coded is (should be) solely based on what the doctor documents in the note, so while the diagnosis shouldn't change, if it does, it may be that the doctor is more/less specific sometimes. Hope that helps a little!

  • weninwi
    weninwi Member Posts: 745

    momgoose,

    Thank you for your helpful explanation.

  • momgoose
    momgoose Member Posts: 71

    You are very welcome. I wish I had the answer to help the original poster as well, but I don't do that type of coding, so I wouldn't want to tell you something incorrect.

  • gb2115
    gb2115 Member Posts: 551

    Just to update. I'm under a new insurance who now does the normal coinsurance for this, like I would expect.