Coding error on my insurance claim

bjhines

Hello everyone. First I would like to say to everyone out there fighting this monster (BC) I pray for you often and while I can't understand what you go through I certainly can empathize and I do. With that said, I am not diagnosed with breast cancer, thank God. However, I have always gone to my local health department for my annual exams and when I turned 40 they scheduled me for my first mammogram in December 2012. At that time my income was low enough that I qualified for assistance through the health department so all the tests were done at no cost to me. My first screening they saw some spots that were of concern to them and my results were very cloudy so they wanted me to come back in for a diagnostic view. I went back, still under the payment assistance of the health department with no insurance at that time, and they were still a little concerned so they did an ultrasound and wanted another follow-up ultrasound at 6 months. So I went back in July 2013 for the follow-up ultrasound, all still covered through the health department, and there were no changes so they said I would be fine until my next annual screening in December 2013. I went for my annual in December and due to a huge mess with getting me enrolled in my employer sponsored health plan I kept postponing my mammogram until January 24, 2014. I went for the mammogram and they did a diagnostic on both breasts and an ultrasound on the right breast. Nothing had changed so the spots were determined to be calcification deposits. No follow-ups were recommended. A couple of weeks later I get a bill from the imaging center for $792.27 my health insurance had denied my claim and put the bill under my deductible. I called my employers insurance rep, who called the hospital, who told them the health department would have to resubmit their order with the proper code in order for them to resubmit their claim using the preventative care benefit under my insurance policy. I called the health department and was told the hospital would have to change it because they are the one submitting their claims not the health department. I called the billing office at the hospital and was told that the health department wrote up their order using code 79380, which is abnormal mammogram, unspecified, and the health department would have to resubmit the order to the hospital using the correct code for them to resubmit the claim. This does make sense because the hospitals supporting documents must support the codes used on the claim. So I call the health department back and tell them what the billing office told me and she proceeds to tell me that because they did a diagnostic and ultrasound I will have to pay for my screening this year and next year it will go under the preventative care clause of my insurance plan. Here is where things get a little strange. I then get another bill for the radiologist who read the test results for $229.00 it too was denied because they submitted under someone else's policy number. So I went onto their website, updated my insurance information, and they resubmitted their claim. The insurance company paid that claim 100% I owe nothing. My question now is why would they pay for the radiologist to read the test but not cover the test under preventative care? The radiologist's claim was submitted using code G0204 and code 76645. The hospital coded their claim using code 0401 and 0402 according to my EOB and 79380 according to the billing clerk at the hospital. The hospital says the health department provided these codes on their order but the health department refuses to correct their coding so the hospital can resubmit with the proper codes. I have been tossed around like a hot potato with this from my employer's insurance rep, to the health department, to the hospital numerous times back and forth. Has anyone had an issue like this before and if so did the insurance eventually end up paying under the preventative care clause? I'm trying to decide whether to take the health department for their word or just keep fighting and arguing or get an attorney involved, if I have to, to force the health department to correct their coding error. Any thoughts or advise would be greatly appreciated! 

MelissaDallas

Only screening mammograms are covered on preventative benefits (i.e. "Free" no deductible) mammograms. Since I have LCIS I am always supposed to get diagnostic ones so this is a fight every single time. My guess is they pay the radiologist regardless because it always has to be read, screening OR diagnostic. It is a huge PITA. I have a meltdown every time I go to the clinic because they warn me every time that my mammogram will probably not be covered because "high risk surveillance" doesn't cut it...last time they started with a screening and immediately called me back for more views for findings, so THAT made it covered...ugh!

bjhines

Thanks for the reply Melissa. I know exactly what you mean it is very frustrating. Sounds like you need to tell them each time to do the regular screening and follow-up so your insurance will cover. Maybe that's what they should have done with mine but what I don't get is under my benefit overview it says "mammogram, high risk patient, co-insurance 100%" and "mammogram, low risk patient, co-insurance 100%". But what the hospital is telling me is that the health department wrote the order up as abnormal mammogram instead of the annual screening and that's why the insurance isn't paying. They coded it like a follow-up from an abnormal mammogram when actually it was my annual screening. The follow-ups where in 2013 and those ended in July when they said there were no changes and I could go back to my regular screenings. There are other employees on the same plan and they have had diagnostic and ultrasound during their annual screenings also and they paid 100% just like it says in the benefit overview. I have done a lot of research on this in the past week and I found a prime handbook for Humana at http://www.humana-military.com/south/bene/tools-resources/handbooks/prime/clinical-preventive-services.asp. It says 

Mammograms: Covered annually for all women beginning at age 40. Covered annually beginning at age 30 for women who have a 15 percent or greater lifetime risk of breast cancer (according to risk assessment tools based on family history such as the Gail model, the Claus model, and the Tyrer-Cuzick model), or who have any of the following risk factors:

• History of breast cancer, ductal carcinoma in situ, lobular carcinoma in situ, atypical ductal hyperplasia, or atypical lobular hyperplasia
• Extremely dense breasts when viewed by mammogram
• Known BRCA1 or BRCA2 gene mutation¹
• First-degree relative (parent, child, sibling) with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves¹
• Radiation therapy to the chest between ages 10 and 30
• History of Li-Fraumeni, Cowden, or hereditary diffuse gastric cancer syndrome, or a first-degree relative with a history of one of these syndromes¹

I would fall under the "Extremely dense breasts when viewed by mammogram" criteria which is what they told me when they called me to come back in for a diagnostic from my very first mammogram at age 40 in 2013 that started this whole fiasco. Don't get me wrong I'm very glad that they followed up and did the extra tests but I don't want to just fork over the $792 under my deductible and suck it up just because there was a coding error and someone refuses to correct it. That's just not right. I pay $61.28 a week for this health insurance I should not have to pay out almost $800 because someone made an error and refuses to correct it.

jdlott74

I am in the medical field.  I work for a company that owns/manages ambulatory surgery centers and surgical hospitals.  Maybe this will help explain what is happening just by what our process is.

The surgeon/doctor sends over an order to our facility to schedule a procedure with a certain DX.  We get benefits on that procedure with that DX.  We don't do mammography's at the ASC, but do I think at the Surgical Hospital.  We do though do colonoscopies and the same policy applies.  If the Dr. sends over for a screening/preventative/annual visit to be scheduled, we usually try to get the benefits for a med DX as well.  The surgeon performs the services and then sends over what was actually performed (his dictation). We bill based off his dictation.  Our coders code based on his dictation, and then it is sent to billing to be billed based off what the coders put down.

Could it be the surgeon/Dr. sent it over after you had the mammography as a diagnostic procedure and with a medical diagnosis?  We see this happen all the time.  We have to go back and have the surgeon re-dictate as a screening and not a medical DX. 

The G0204 is a Medicare code, not a commercial insurance.  The 401 and 402 is a revenue code, not a procedure code.  The 79380 is a ICD-9 diagnosis code (793.80).  You can call the Hospital billing office and ask them what procedure codes were billed along with the DX, or call your insurance company and make them tell you.  When a facility bills they bill with a revenue code and a procedure code, and then have a diagnosis (whether it be a screening, or medical DX)

Does that make sense?