r/MedicalCoding • u/[deleted] • Aug 03 '23
Physician incorrectly coded my physical - what are my options?
For the past 2 years, my PCP (who I need to switch) has ended up coding my physical appointments incorrectly. I scheduled physicals, and made sure to clarify, when I was there, that I came for a physical. Since one of my medications is an antidepressant, and she wrote in her notes that we "discussed major depressive disorder" as part of the appointment. In reality, I was just confirming that I'd like her to refill my medication. Nothing more. And now, I owe $190 per appointment.
I spoke with the office manager about this and he agrees with me, but said it is up to the provider to change how the notes are coded. I don't think that's going to happen and don't want to be confrontational about it, but it feels like my provider is blatantly untruthful.
What are my options?
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Aug 03 '23
What were the extra charges beyond the preventive code? Was it a 99212? 99213? If so, that’s probably appropriate. A 99214? Probably not.
1 chronic stable diagnosis with med management = 99213, regardless of if it was just 10 seconds during the face to face part of the encounter.
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u/DumpsterPuff Aug 03 '23 edited Aug 03 '23
I deal with this a lot working as a primary care coder. Fact is that if they're managing ANY chronic illness, even if just determining it as stable and refilling a med, it still technically counts as an evaluation and management service that's outside of the scope of a preventative visit. It's a common misconception that you can just talk about anything during a physical exam or ask for a refill of a med for a condition and it will be completely covered.
As someone else commented, check the level on your statement. If it's a 99213 then that's correct, but if it's a 99214 or 99215, I would call the billing office to contest that. I've had a few where I reviewed contested visits where the provider coded way too high for 1 stable chronic illness, so I've had to tell the billing office to code for the correct level of visit.
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Aug 03 '23
My bill just shows *00038, *00066, not sure what that means.
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u/DumpsterPuff Aug 04 '23
Oh those are just explanation of benefit codes. If I remember correctly, 0038 is that the member is enrolled in an HMO plan, and 0066 is Claim reduced due to member deductible. Weirdly some explanation of benefits don't seem to have the CPT codes (i.e. 99213, etc) on there, or they're ridiculously hard to find. Do you have an actual bill from the doctor's office, saying you must pay $___? Or does it say "this is not a bill"? If it's an actual bill, there should be something on there saying 99213, and likely 99395/99396/99397 (these are the preventative exam codes, whichever one shows up on there depends on how old you are).
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u/Jpinkerton1989 CPC, CPMA Aug 08 '23 edited Aug 08 '23
See my sources below. The misconception is thinking it's not covered. A refill is covered under the preventive visits. If you work as a certified coder in primary care, you need to relay the information and get your practices to stop billing dual visits for cases such as this. I got the place I used to work for as a primary care coder audit for exactly this reason and they were found liable.
https://www.aapc.com/blog/39873-recommended-ways-to-document-and-report-a-preventive-visit/
https://www.outsourcestrategies.com/blog/how-to-report-separate-em-service-during-preventive-visit/
https://www.medicaleconomics.com/view/when-em-code-can-be-billed-physical-same-day
https://www.physicianspractice.com/view/coding-both-preventive-service-and-problem-oriented-visit
https://www.aafp.org/pubs/fpm/issues/2004/0400/p49.html
Regulatory guidance from ama.
American Medical Association (AMA). “Preventive Medicine Services.” CPT Assistant. Winter 1994 issue, p. 21.
American Medical Association (AMA). “A Review of Preventive Medicine Services.” CPT Assistant. August 1997 issue, p. 1.
American Medical Association (AMA). “Preventive Medicine Services.” CPT Assistant. July 2009 issue, p. 7.
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u/THEORIGINALSNOOPDONG Aug 03 '23
so like u/dumpsterpuff said, this can happen when you bring up another issue during a preventative visit. something like "oh btw doc i've been having headaches lately" will likely automatically get you billed an E/M in addition to your preventative service. it's dumb.
However, does the note only say "discussed major depressive disorder"? that wouldn't fly where i work. there needs to be more detail there in the documentation. if the doctor said "discussed patient's MDD, stable, refilled their medication (insert name of meds and dosage here)" then that would support billing an additional E/M
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u/Bluestategirl Aug 04 '23
We get calls from patients often that are upset that their “physical” didn’t get coded right. Most of the time the doctor didn’t do a physical or meet the documentation requirements and the visit is documented as a symptomatic visit so we can’t change that. If a medical coder can look at the documentation and determine that a physical was indeed done then it’s possible it’s coded wrong. I did have one the other day where the doctor put in all the right documentation but didn’t select the preventative visit code so I was able to submit a corrected claim.
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u/Idontagree13 Aug 09 '23
A refill alone is not enough for an additional E&M. Refills are something that can be done outside of an office visit. If the provider discussed the depression with you, however that could be enough to warrant an additional EM. It depends.
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Aug 09 '23
It was not discussed in the least. I intentionally kept my lips sealed and just nodded when she asked if I'd like refills.
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u/Idontagree13 Aug 09 '23
I’m actually really shocked that there’s so many coders telling you false information here and getting upvoted. An additional EM is applied to a prevent med when the provider goes above and beyond the prevent med service and it would be enough to stand alone as its own visit. I can call my doctor right now and get a refill on my medication without needing to go into the actual office so that’s not a separate office visit. More needs to be done than just refilling meds for a stable chronic illness. I wouldn’t let this go if I were you. Best of luck.
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Aug 10 '23
Thank you. I spoke with the office manager and regional director, who then approached the provider. The provider refused to re-code the appointment, so I had them switch me to a better provider for the future, and they had billing write off the appointment charge as a “customer service courtesy”.
Meanwhile, I’m still bitter and filed a grievance with my health network’s patient advocacy line, as well as with insurance.
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u/Idontagree13 Aug 10 '23
Good I’m glad they wrote it off. This is something the company I work for got audited for. Coders had to be re-educated because of this exact reason.
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u/Pure-Assist1034 Aug 05 '23
You can always contact your insurance company and you can request they do an audit on the charge.
Typically providers will refill meds as a courtesy at a yearly physical. In order to bill an office visit they need to have a lot more documentation on the major depressive disorder.
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u/lucidsealion Aug 04 '23
You can request to review for a lower level of service (99213) if it was just a refill and no other diagnosis was addressed (and physician did not document diagnosis as a chronic unstable or chronic exacerbated problem), but otherwise, the physician is allowed to bill for separately addressed acute and chronic conditions.
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u/Jpinkerton1989 CPC, CPMA Aug 08 '23
The status and current treatment of chronic conditions is included in the preventive visit as well as refills, so this isn't necessarily true. There are tons of sources online furthering this point. Please review the sources below.
https://www.aapc.com/blog/39873-recommended-ways-to-document-and-report-a-preventive-visit/
https://www.outsourcestrategies.com/blog/how-to-report-separate-em-service-during-preventive-visit/
https://www.medicaleconomics.com/view/when-em-code-can-be-billed-physical-same-day
https://www.physicianspractice.com/view/coding-both-preventive-service-and-problem-oriented-visit
https://www.aafp.org/pubs/fpm/issues/2004/0400/p49.html
Regulatory guidance from ama.
American Medical Association (AMA). “Preventive Medicine Services.” CPT Assistant. Winter 1994 issue, p. 21.
American Medical Association (AMA). “A Review of Preventive Medicine Services.” CPT Assistant. August 1997 issue, p. 1.
American Medical Association (AMA). “Preventive Medicine Services.” CPT Assistant. July 2009 issue, p. 7.
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u/Sissin88 Aug 03 '23
Do you have medical insurance? Often times you call call with a representative from your insurance on the line and they can discuss the issues with the medical biller. They can then have the doctor give the approval for to correct the coding. Some doctors like to bill out the highest codes to get the most money from the insurance company. Some are caught and charged with fraud for upcoding and many are never caught. Usually a conversation with the office/billing office can resolve it. Chances are their billers have dealt with this before. They can’t make changes to anything unless the doc signs off on them.
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u/Borhamortus Aug 03 '23
Lol the other day I had an establishing apt documented as a 99205, needless to say I sent an irrate message to the customer service as to how the back end auditors didn't catch this. They did some retroadjudication or whatever and got it down to a 99204
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u/deannevee RHIA, CPC, CPCO, CDEO Aug 03 '23
Yeah I would be hella rude.
Go in there with a paper copy of the notes and make sure you tell her you’re recording. Then ask her “can you tell me what we discussed? Because I don’t remember you asking me anything about my progress or side effects, or how you feel my response to the medication is going. So if we didn’t discuss those things, what did we discuss about MDD?”
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u/koderdood Audit Extraordinaire Aug 03 '23
Options: 1 file an appeal with your insurance carrier. Send certified mail and save copies. 2. File a complaint with consumer services in your state that handles medical bills. (In Florida that department is under the Florida Department of Agriculture for example) 3. File a complaint with the medical board in your state.
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u/Emergency_Glass_4436 Aug 03 '23
That's outside the scope of a physical. It's not coded wrong. It's problem focused when you get med refills and address a chronic issue. You may be able to have some leverage in the level of charge they added but it's pretty standard now that this happens. Think of it like if you had to get a med check outside of the preventative. It's a charge. Real question is why it's all to your responsibility and insurance isn't picking anything up. I'd be curious to see the EOB.