Forum - Questions & Answers

Mar 27th, 2013 - sjsmurph 1 

Question regarding fraud or abuse

There was a patient who came in to our office and we billed a 99214(office visit) and 99406(counseling for stopping smoking). There doctor listed these diagnoses in this order tobacco abuse, dermatitis, chronic back pain, hypertension, edema, and osteoarthritis. So when the coder coded it, she listed tobacco abuse as the primary diagnosis just as the dr listed it. Well it turns out that the code 305.1(tobacco use) is an exclusion under the patients insurance plan so they denied the 99214. My question is, can I take off the diagnosis of smoking cesation and resubmit the claim so they pay the 99214 since there were other problems addressed? Or would this be considered fraudulent or abuse? I wasnt sure if this would be considered making changes to a claim just to get it paid? There are situations like this that happen all the time. Can you give my any clarification on this matter?



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