coding/billing question

Nurses General Nursing

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question: i am seeing an ortho doc for two different things (actually the result of the same fall) and they wont see me for both on the same visit/day....."because the ins co wont let them", well that was a red flag....called the ins com, they could give a rat's hind most part how many things i am seen for, but will only pay for one visit.....now, wouldnt being seen for two things be coded higher (more money) than one thing?

i am really ticked off, as the guy at the is co pointed out, not only are they getting paid twice by ins, but I am paying TWO co pays.....usually i am not on the ins co side.....BUT.......so any info would be appreciated from the biller/coders in the "audience", lol

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Specializes in Pediatrics.

Maybe they want two appointments because the time that would be necessary to cover the two issues appropriately would take up two appointment slots? If it would make a 15 min appointment go 30 minutes I could see why the office would want you to schedule two appointments.

And two dx versus one does not equal a higher code for the most part. The diagnosis doesn't really matter, the level and procedures determines the cost. Sometimes seeing a pt for more than one thing would increase the level of the visit if it means that you did more stuff. But often not enough to justify the time spent with the pt.

For example, if I see a pt with an ear infection and it takes me 15 minutes, that is usually a level III. And charges for that visit would be say 60.00.

If the same pt came it with an ear infection AND pneumonia with wheezing (1st occurence), I could check their pulse ox, administer a breathing treatment, teach them how to use an inhaler plus everything else I normally do. This level of care usually takes 30 minutes and would be coded as a level 4. Some ins won't pay for pulse ox or inhaler education or neb tx in out pt, so I am out that money. The level 4 code would increase to charges of maybe 80.

So in that 30 minutes I have lost 40.00. I could have seen two level III at 60/each for a total of 120, but I saw one level 4 for 80.

Maybe someone else could explain it better, but this is the easiest way I could explain. Sucks for you, but I can understand why the doc wants two appointments.

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thanks for the input, one issue is simply to clear for back to work for hamstring tear....and the other is to "go over" a shoulder mri......just seems unethical to me....especially when i was told "the ins com wont ALLOW it"......that is what set me off.....so....they could require me to come in for three days in a row, to be seen for three dif inj all do to the same fall???? it took 13 days before i could even drive....what about all the elderly who cant drive, etc......

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Specializes in Critical Care, Education.

It seems obvious to me - income from two visits is better than one. Seems ridiculous - any doc can look at multiple things during the same visit -- otherwise, my 85 yo dad would spend half his time just going for office visits.

If this was a Worker's comp or Medicare/aid situation, you could rat them out for violating several Federal statutes and probably collect a reward for your trouble... However, with a private insurer, you only options are just to accept it or 'vote with your feet' and choose another doc with higher standards of integrity.

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It seems obvious to me - income from two visits is better than one. Seems ridiculous - any doc can look at multiple things during the same visit -- otherwise, my 85 yo dad would spend half his time just going for office visits.

If this was a Worker's comp or Medicare/aid situation, you could rat them out for violating several Federal statutes and probably collect a reward for your trouble... However, with a private insurer, you only options are just to accept it or 'vote with your feet' and choose another doc with higher standards of integrity.

i assure you, i had thought of the medicare issue...not old enough.....but the ins co is now aware of this, because i called them to clarify.....he just laughed.....not a new thing...but as he pointed out it is costing ME another co pay as well.....being out of work, 15$ is not something to sneeze at....

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Specializes in Pediatrics.

Thanks for the clarification. I would think those two things could be easily managed in a single time slot. SO def sounds like a money only issue.

The main problem I get that deals with 1+ issues are if they are completely unrelated. I have lots of parents coming in for sick visits and "by-the-way" wanting to discuss their child's overweight issues as well. NO go for me, that is a separate appointment altogether because of the level of teaching and time it takes to talk about diet and obesity.

Same with parents bringing in their kid with a cold and wanting them checked for ADHD.

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Thanks for the clarification. I would think those two things could be easily managed in a single time slot. SO def sounds like a money only issue.

The main problem I get that deals with 1+ issues are if they are completely unrelated. I have lots of parents coming in for sick visits and "by-the-way" wanting to discuss their child's overweight issues as well. NO go for me, that is a separate appointment altogether because of the level of teaching and time it takes to talk about diet and obesity.

Same with parents bringing in their kid with a cold and wanting them checked for ADHD.

thanks for the validation,,,to be fair to doc, this is a multi doc practice, and i am sure there is a "business" manager.....with whom i think i shall have a little chat....AFTER i get my referral to PT,lol....

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