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MedicalCoderHelp's avatar

Question for those familiar with medical billing: Was I upcoded?

Asked by MedicalCoderHelp (9 points ) October 17th, 2012

I went to an Orthopedic to get a simple second opinion about neck\back pain and arthritis. I brought him an MRI, the report for the MRI, and X-rays from a chiropractor. I gave the nurse my MRI disc and report and the doctor was in to see in in five minutes. I explained my symptoms and he said I was fine. He put my XRAYS up and told me I was good. He stated my arthritis is very mild and it is normal for about 20% of people my age. He did a 2 minute examination of my reflexes and I pulled on his arms. I asked him about the pain and he suggested exercise, physio, and said that I did not need surgery thank god. He spent a total of 10, maybe 15 minutes (thats pushing it) face to face. The examination was brief. There was no “coordination of care” or “medical history analysis.” I would say the “medical complexity” was straightforward. I was an “in and out” patient. He billed me using code 99203. I feel as if 99202 or 99201 would be more appropriate based on what I’ve been reading about CPT codes. This was a “corporate doctor” and these codes were most likely generated by EMR software. I am a cash patient that was told the bill would be about $80 but was hit with a $120 bill. Was I upcoded?

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15 Answers

gailcalled's avatar

Call the office and speak to someone in the billing section. How can we possibly answer this question?

MedicalCoderHelp's avatar

Because a medical billing and coding person knows what codes should be used for what….. and knows what upcoding is.

So if the office told me that that visit warranted a 99205 (high complexity, hour+ long visit) if I came in with the sniffles I should just accept it? They can just say whatever they want? Hell they might as well throw in some codes for “diagnostic tests” that were never done. No, that’s called upcoding, it is illegal, and it is done more often than you think.

I want to get the opinion of a medical billing and coding expert, based on my description of the events, just so I know if Im justified in disputing this.

zenvelo's avatar

Welcome to Fluther. We are not medical billing and coding experts, so you are probably more knowledgeable than the rest of us.

Why do you say there was no medical history analysis? He looked at the stuff you brought, and evaluated it. Bingo! You get charged. And if he is evaluating arthritis as compared to other causes, that adds some complexity to an area of orthopedics that can be quite complicated. Bingo#2, billed for Medical Complexity.

Since you are not submitting this to an insurance company, why not negotiate with the billing office over the total bill? I doubt you can “dispute” this, there is no one to appeal to other than small claims court, and I would imagine you would have a hard time disputing what services were performed in small claims.

JLeslie's avatar

I wanted to look up the description of the codes, but it seems you can’t easily look up CPT codes for some reason?

Anyway, in my opinion it doesn’t matter how it was coded, the doctor decides how much he is going to charge you, unless it is one of those large practices where the doctor is basically just an employee. If it were me I would call billing and say you asked the price upfront, was told $80, and it looks like there has been a mistake in billing. See how they respond. Don’t say upcoding or any technical speak, because they just get defensive, hold that back until the time they actually refuse you. Hopefully, they will simply adjust your bill before it gets to that point. If their billing is handled by a third party, well, that just sucks. Medical billing is disgusting all too often, but I will try not to go on a rant. If it is handled by a third party then call the office manager.

It is just ridiculous. We can’t easily get information for how much medical costs, we never know know until we actually get the bill, and often it is a surprise. Legislation to correct this has been knocked down by both republicans and democrats. It’s awful.

Let us know if you have any success.

jca's avatar

You are better off negotiating with the billing staff. I have found that at doctors where I paid, as opposed to them billing the insurance company, the staff is less likely to bend with their billing coding as they are when they have to kiss up to the insurance companies for “payment in full.” It’s more like you’re at their mercy, as opposed to them being at the mercy of the insurance company. It seems like in these situations, like you are faced with, they will bill for whatever they can get.

JLeslie's avatar

@MedicalCoderHelp I know you said you are paying cash, but is it outside of insurance? Or, are you paying because you have a deductable or something like that?

@jca Can you clarify? You are saying they will bend more in their coding when dealing with insurance companies? I find that confusing. I am not saying you are wrong, it just seems counterintuitive to me.

Plus, can’t doctor’s charge whatever they want? The code is the code in the end. Either a prcedure met the legal description or not.

jca's avatar

@JLeslie: In my experience, when the doctors’ offices are dealing with insurance in order to get paid, they are more willing to re-code something in order to get it paid, whereas I’ve found (just my experience so not sure how it compares to the experiences of others) that once the doctors’ offices have my payment (from me personally) in their hot sweaty hands, they don’t care to re-code your invoice so that you can be reimbursed. Times I’ve gone to a provider from my insurance company (in other words, a doctor that is supposed to take my insurance as payment in full) they will bend over backwards to code in such a way that they get paid, even if they have to get creative with what the doctor supposedly did.

JLeslie's avatar

@jca I actually agree with you. I didn’t realize the OP already paid. I wonder if she actually paid cash cash, or charged it? She could call the charge into question through her credit card company if the doctor’s office is stubborn. She most likely won’t win, but at least it will be annoying for them to deal with it.

She also can write the better business bureau if it really bothers her. Or, just take it as a learning experience and pay the higher price this time.

Seaofclouds's avatar

I found this chart that compares the codes 99201, 99202, 99203, 99204, and 99205. 99203 is right in the middle and based on what you said (with the doctor looking over your xrays/MRIs (he probably looked at those before coming in to see you), I think 99203 could fit.

Either way, if you were originally quoted $80, you should ask the billing office why there is a difference in what you are being charged compared to what you were quoted. If they can’t give you an answer, ask to speak with the office manager.

jca's avatar

Perhaps they will be willing to stick by the original price they quoted for another reason – when the insurance company pays them, they pay at such a reduced rate, and doctors accept it because they get the quantity of patients referred by the insurance company. I know my insurance company pays my doctor visits at around $27 per visit. For you, having paid $80 is probably 3 times what they’d get from the insurance company, so they should be (hopefully) willing to cut the crap and charge at what they said that they’d charge.

JLeslie's avatar

@jca I find that is all over the map. I have some things that the doctor makes more self pay and some they make more from insurance.

gorillapaws's avatar

Remember that you’re a new patient visiting a specialist. This means that this doctor will be legally obligated to keep track of your records for the next 7 years, that means HIPPA secure storage, and destruction costs 7 years from now. He could potentially be called to testify in court, or held legally liable for anything related to your treatment. $140 is pretty cheap, all things considered.

wildpotato's avatar

Hi, I have been in medical coding and billing for years, used to work for a physiatrist, and have billed 99203 many, many times. @zenvelo As our motto remarks, we’re all experts in something :) Welcome to Fluther!

You probably got billed 99203 not because the EMR software generated the code, but because the doc circled on or near that number on your chart (even though most places do use EMR and type-written notes, certain pieces of paper are still in use at every practice I’ve worked at). There are several possibilities:

The specific piece of paper is called a superbill, and here is an example of one. See how close together the CPT codes are, stacked right on top of each other? Docs rarely circle them precisely, and we billers are expected to make our best guess, sometimes. So your doc may have actually intended to bill you 99202, but did not mark the superbill precisely enough.

Another possibility is that they intended to bill you 99203, either via superbill or directly in the software. This makes sense to me – it is the most common code we used for an office visit – because 99203 represents an amount of time that insurances find it most reasonable to reimburse for. Even though you are self-pay, the front desk may not have communicated this clearly to the doc (some offices are better about this than others), and so he acted on autopilot, so to speak, and used 99203. This doesn’t make the doc an evil opportunist, by the way – he would have assumed that it would be to everyone’s benefit to fill out the superbill in a way that would ensure maximum insurance reimbursement and would also be most likely to furnish you with a reason for a continued plan of care.

Because you are in fact self-pay, you should certainly feel upcoded. Face-to-face time is the last word on this – if you got no more than 15 minutes, talk to the billers about adjusting the bill and then the doc if the billers won’t help. They should, though – I would have. Also, if you make this happen, remind them to have the doc write an addendum to your medical note for the office visit with the correct, updated CPT code, and request a copy of this mailed to you to make sure – such things can accidentally get forgotten easily, particularly because the medical notes in this case will never get sent out to insurance.

chyna's avatar

The doctors in my office have taken a class or classes to learn how to bill to get the most reimbursement for their services. However, they do have a criteria they have to meet to be able to charge the way they do. And they have to have notes to prove they met the criteria. For example, they may have to examine 7 body parts to be able to bill the higher codes. But the 7 body parts can be eyes, nose, ears, throat, lungs, etc. You may not even be aware they have observed these things.
However, nothing is in stone and I would definitely call and talk to the office manager. State your case without getting upset or threats and I bet the office manager will work with you on this especially when he/she finds out you are a private pay.

JLeslie's avatar

Medical billing is so annoying. 7 body parts? I can’t believe it. I believe it, I just find it annoying. I had never heard anything like that before @chyna. Very interesting.

@wildpotato I wish I had remembered you were in medical billing! Awesome you found this Q.

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