(Fort Worth , Tx)
I work as an admissions clerk at a hospital, a patient had a CT of head w & w/o contrast & CT of neck w & w/o contrast. The pre-registration department created the estimate with 2 charges, the patient was looking at about a little over $1,000 to pay because of a large Ded. to meet.
Is there supposed to have a modifier on there? Is this considered fraud?? The amount that was going to insurance was about $4,000. We have had certain issues with over charging the patient. Do you think I should talk to my manager on this one? Also it was the same diagnosis for both CTs?
I can’t answer the specific coding questions as I’m not up on coding a CT and certainly don’t want to give a wrong answer. The notes may also need to be reviewed to understand why they were coded the way they are. However I invite visitors to comment if they have experience with coding and modifiers for similar situations.
I also would encourage you to ask your management about the charges. A reputable healthcare organization should have nothing to hide and will want to do the right thing. Of course the insurance payer will certainly scrutinize the charges as well and may reject some or all charges if there are not valid or look questionable – they are very good at identifying these things. I don’t always fault the provider because it’s not always clear what their reimbursement policies are – but if something doesn’t look right to you than you are doing the right thing to ask.
Great question – Thanks!