This issue has come up a few times over the years. Indeed, I’ve already been asked the question twice during 2016 and it’s only January 11th too.
Consider if, during the initial consultation, you advise your patient surgery is required. The patient is therefore given a CCSD code equating to the surgical episode to quote to his or her insurance company. The patient goes away, quotes the CCSD code to his insurance company and is given a pre-authorisation code for, as an example, AB1234 by his insurance company. The patient then contacts your secretary and passes over the pre-auth number. Everybody is happy.
But what happens if, during surgery, you realise a change of surgical procedure is necessary? Does it make a difference? Not to the patient. It also doesn’t make a difference to you either for you have performed the surgical procedure you deemed to be the absolutely correct procedure at the time.
The point at which it does make a difference, however, is the fee the amended surgical procedure attracts. For example:
The original code of AB1234 may, for example, generate a fee of £452. But if during surgery, a different procedure was necessary a different code will be applicable. For example: XX4268 instead of the original procedure code of AB1234. XX4268 generates a fee of £619.00 whereas AB1234 generates £452.
So the question: which code do you charge for? The XX2468 obviously. But…
There is a step to be taken before the invoice is raised. Best practice is to call the insurance company and explain the situation. All insurance companies are very used to such calls from MHM. Some request a letter from the consultant surgeon explaining why the change was necessary. Some do not.
And thus MHM invoices the correct fee and you get paid the right fee.
What happens if you do NOT make the call to the insurance company and just invoice for a different CCSD code to that authorised? Having never ever done that I wasn’t sure. So I called two of the major private medical insurance companies. Both said the same. At best the invoice will be seriously delayed pending their request for an explanation. In the worse case, the invoice will be declined.
pete@medicalhealthcaremanagement.co.uk
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