Topic: Any coding/insurance experts?

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Posted on: Jul 28, 2022 12:42PM - edited Jul 28, 2022 12:45PM by gb2115

Posted on: Jul 28, 2022 12:42PM - edited Jul 28, 2022 12:45PM by gb2115

gb2115 wrote:

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.

?

First Dx IDC in 10/16 at age 38, stage 2A, 1.2 cm ER/PR+ Her2-, Grade 2, 1/3 nodes. Lumpectomy + radiation + tamoxifen. Second Dx IDC recurrence in original location 5/21. 1.3 cm ER/PR+, Her2 -. Grade 2. 2/2 nodes. UMX + AC/T + Zoladex/Exemestane + Zometa.
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Jul 28, 2022 12:48PM lw422 wrote:

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.)

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Jul 28, 2022 01:17PM olma61 wrote:

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.

10/30/2017 Xgeva for bone mets 5/31/2018 Taxol finished! "If one just keeps on walking, everything will be all right” - Kierkegaard Dx 8/3/2017, IDC, Right, 2cm, Stage IV, metastasized to bone, Grade 2, ER+/PR+, HER2+, IHC Targeted Therapy 10/28/2017 Perjeta (pertuzumab) Targeted Therapy 10/28/2017 Herceptin (trastuzumab) Chemotherapy 10/30/2017 Taxol (paclitaxel) Hormonal Therapy 5/14/2018 Arimidex (anastrozole) Radiation Therapy 5/30/2019 External Local Metastases 5/30/2019 Radiation therapy: Bone
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Jul 28, 2022 01:52PM gb2115 wrote:

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.


First Dx IDC in 10/16 at age 38, stage 2A, 1.2 cm ER/PR+ Her2-, Grade 2, 1/3 nodes. Lumpectomy + radiation + tamoxifen. Second Dx IDC recurrence in original location 5/21. 1.3 cm ER/PR+, Her2 -. Grade 2. 2/2 nodes. UMX + AC/T + Zoladex/Exemestane + Zometa.
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Jul 28, 2022 04:43PM quietgirl wrote:

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

Surgery 2/7/2022 Lumpectomy (Right) Radiation Therapy 3/9/2022 Whole breast, Radiation boost: Right breast Hormonal Therapy 4/18/2022 Arimidex (anastrozole) Dx DCIS, Right, 3cm, Stage 0, Grade 2, ER+/PR+

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