Q.  If we cannot find a CPT code that exactly describes the procedure done, can we bill a code that closely describes the procedure?

A.  If a service is performed for which you cannot find a CPT code, it is always best to use an unlisted procedure code rather than the closest possible code. Within the CPT book are a number of specific codes that have been designated for reporting unlisted procedures. They are listed at the end of each section. By billing a code that was not performed completely, it may be interpreted as fraud because it involves billing for services that were not performed.

Q. What is the site of service differential and how does it affect reimbursement?

A. There is a listing of procedures that are most often performed in a physician’s office. If these services are provided in another location, such as in a hospital outpatient setting, payment for these services is reduced.

Q. Is there a difference between a copayment and coinsurance?

A. People often use these two terms interchangeably. However, there is a difference. A “copayment” (or copay) is the out-of-pocket expense to the patient at the time of service, usually $10, $10, or $25, and is common with an HMO-type insurance plan. “Coinsurance” refers to the patient’s out-of-pocket expense after the insurance has paid its liability in a traditional health insurance plan. For example, if a patient has such a plan that pays 80 percent after their calendar year deductible, the patient’s coinsurance would be 20 percent. This is the amount the patient is responsible for and can be collected by the physician’s office either at the time services are rendered or after the insurance has paid its percentage of covered charges.

Q. Can I just look up ICD-9 codes in Volume 2, the Alphabetic Index? What is the purpose of Volume 1, the Tabular section?

A. You should never code directly from the Index. Fifth digits are often omitted from the Index entries. You should always confirm a code from the Index by looking it up in the Tabular section. The Tabular section contains additional instructions, Includes and Excludes notes, flags that indicate when a 4th and 5th digit is required, and other valuable information that will aid you in proper code selection. Depending on just the Index for code selection is to invite error.

Q. We had a claim denied due to “concurrent care.” What does this mean and how do we handle this?

A. Concurrent care is when a patient is being treated by two different providers for different problems at the same time. For example, a patient may be hospitalized by a general surgeon for an operation and may also be seen while hospitalized by a cardiologist for an unrelated cardiac condition. Frequently claims will be denied as a duplication of services when the patient was seen by two physicians on the same day when no duplication actually occurred. Each claim must have a different ICD-9 code for the services provided by each physician, which support and justify the need for the services provided.

Q.  I am having trouble getting a commercial insurance carrier to pay on a claim. Any suggestions?

A. You might want to try getting the patient involved. The insurance contract is between the insurance carrier and the patient. The provider is an outside party. If you are not getting a response from an insurance carrier on an unpaid claim, let the patient know you are having a problem and ask them to contact the insurance carrier. In many cases, this will result in a quick resolution of the problem.

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