[Maryland] I suspect my Doctor is upcoding – what are my next steps?

Hi all –

So I’ve recently had a couple of visits to my dermatologist, and after receiving the invoice for both, I suspect that one of the billing codes is higher than it should be (i.e upcoding).

Some details:

June visit: This is where I described my problem and how long I’ve had it, they quickly diagnosed the issue, and prescribed me two items for treatment. They recommended I come back in 2-3 months for a follow-up to see how things are improving. It got coded as an “Office Visit: Level 3”, which is defined as: “Expanded Problem, focused, history exam, straight forward medical decision making, problems low to moderate, and face-to-face time of ~15 minutes”). I’d say this all matched up with the visit, and I would agree with that assessment and coding. September visit: I came in for my follow-up, and they noted that my problem was much more improved. The visit ended up being 8-10 minutes of face time, and amounted to them recommending I continue taking the two prescribed items on an as-needed basis going forward. It got coded as an “Office Visit: Level 4”, which I was unable to get a full description from the billing office on, but they did confirm it’s for visits with a face-to-face time of ~25 minutes.

What I’ve done:

In late Sept, I called the billing department and told them that I felt the September visit was coded incorrectly, as it was a shorter visit than the first and was simply a follow-up. I argued it should likely be a Level 2 – or at most – a Level 3. They said they would submit an appeal back to the Dr’s office. In late-Oct, I got another copy of the same bill (still showing the Level 3 June visit and Level 4 September visit). I called billing again, and they informed me that my appeal was denied by the Doctor’s office in mid-Oct, with a note stating “the codings are correct” I then called the Dr’s office directly, and asked them for further clarity on why they denied the appeal. The gentlemen on the phone was not my Dermatologist, but said when he looked in the system on his end, he saw that both visits were showing as Level 4 (whereas my latest bill still shows a 3 for June and a 4 for Sept. He said he would check with my Dr and get back to me (but that was two days ago).

Maybe I’m over-thinking, but now I’m worried that they’re changing the June visit to a Level 4 to match Sept, as a way to argue that Sept should stay a Level 4?

What should my next steps be here? Call the Dr back? Submit a complaint somewhere? Any help is appreciated.

submitted by /u/NeedFilmAdvice
[link] [comments]Hi all – So I’ve recently had a couple of visits to my dermatologist, and after receiving the invoice for both, I suspect that one of the billing codes is higher than it should be (i.e upcoding). Some details: June visit: This is where I described my problem and how long I’ve had it, they quickly diagnosed the issue, and prescribed me two items for treatment. They recommended I come back in 2-3 months for a follow-up to see how things are improving. It got coded as an “Office Visit: Level 3”, which is defined as: “Expanded Problem, focused, history exam, straight forward medical decision making, problems low to moderate, and face-to-face time of ~15 minutes”). I’d say this all matched up with the visit, and I would agree with that assessment and coding. September visit: I came in for my follow-up, and they noted that my problem was much more improved. The visit ended up being 8-10 minutes of face time, and amounted to them recommending I continue taking the two prescribed items on an as-needed basis going forward. It got coded as an “Office Visit: Level 4”, which I was unable to get a full description from the billing office on, but they did confirm it’s for visits with a face-to-face time of ~25 minutes. What I’ve done: In late Sept, I called the billing department and told them that I felt the September visit was coded incorrectly, as it was a shorter visit than the first and was simply a follow-up. I argued it should likely be a Level 2 – or at most – a Level 3. They said they would submit an appeal back to the Dr’s office. In late-Oct, I got another copy of the same bill (still showing the Level 3 June visit and Level 4 September visit). I called billing again, and they informed me that my appeal was denied by the Doctor’s office in mid-Oct, with a note stating “the codings are correct” I then called the Dr’s office directly, and asked them for further clarity on why they denied the appeal. The gentlemen on the phone was not my Dermatologist, but said when he looked in the system on his end, he saw that both visits were showing as Level 4 (whereas my latest bill still shows a 3 for June and a 4 for Sept. He said he would check with my Dr and get back to me (but that was two days ago). Maybe I’m over-thinking, but now I’m worried that they’re changing the June visit to a Level 4 to match Sept, as a way to argue that Sept should stay a Level 4? What should my next steps be here? Call the Dr back? Submit a complaint somewhere? Any help is appreciated. submitted by /u/NeedFilmAdvice [link] [comments]Read Morer/HealthInsurance

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