Forum - Questions & Answers

Jul 7th, 2016 - G1974728 12 

OV Surgery billing before and after actual procedure

I recently had a fistula removed at an out patient facility.
Before the procedure I had a first time appointment with the specialist in his office. He talked to me about my issue, confirmed what I did have was a fistula by just looking at it and we scheduled the surgery for the following week.
I paid my specialist copay upon leaving the office and they scheduled a follow up appointment for after the surgery.

4 weeks after the surgery I go in for my follow up. They take a look and my wound to make sure it is healing correctly. Unless I have any other issues it is considered done.

Now weeks later I get a balance bill from the specialist office visit before and after the surgery. Both have an OV Surgery bill with a balance left for me to pay.

What constitutes an Office Visit Surgery? I wasn't administered anything, nor was a cut on at all. It was like they just viewed the fistula and that was it.

If anyone can help me understand if this is a mistake or why it should be billed this way. Thanks

Jul 7th, 2016 - alpjeffrey 14 

re: OV Surgery billing before and after actual procedure

It all depends on your insurance in a lot of cases. At least from my experience. Some insurance apply specialist visits to your deductible instead of just charging you a copay. Sometimes we don't know that at the time of your visit. Your surgery itself may not have the global time period so you may be charged for the post op visit as well.

It really just depends on what CPT® codes they used. If you could get an itemized statement with the codes that'd be a help.

Most of our in office surgeries range in the 50000 code sets.


Jul 11th, 2016 - G1974728 12 

re: OV Surgery billing before and after actual procedure

I got the CPT® codes emailed to me over the weekend.

Looks like the outpatient surgery was billed as, CPT® 46275.
Would that code cover the follow up appointment?

As far as the office visits before and after the surgery, I am not sure which is which as they are not dated, but the codes are.

CPT®
46275
45300

CPT
99204
45300

Jul 7th, 2016 - G1974728 12 

re: OV Surgery billing before and after actual procedure

I am not 100% sure that these are the codes, but they are on my insurance explanation of benefits.

For the pre-surgery visit it has 2 different codes.
491 and 705 are what I am seeing. My insurance said that they coded this visit as a basic Specialist Office Visit and as a OV Surgery.

For the post-surgery visit ( follow up) they said just the OV surgery billing code was used, which I believe is 705.

I am just confused that these 2 visits were considered an Office Surgery.

I have had previous Office Surgery bills with my regular doctor before I found out that I needed an outpatient procedure. I had actually had this done a couple of different times there and was aware of what they would charge me. Now one time they just looked at it and didn't use any needles or knives so it wasn't billed as an office surgery.

Thanks for your reply.

Jul 7th, 2016 - alpjeffrey 14 

re: OV Surgery billing before and after actual procedure

Those wouldn't be the CPT® codes. The insurance probably won't have the CPT® codes on the EOB that they send to you or at least my insurance doesn't provide that type of information. If this was the first time to see the specialist, you would be looking for a 99202-99205 type CPT® code for the office visit. The post op visit would be either 99024 or 99212-99215 depending on the level complexity. If you don't have those listed somewhere, I'd call the office and ask for them or even call your insurance company or go on their website and see a detailed claim from the dates of services.

Who is your insurance carrier?

Jul 7th, 2016 - petunia 195 

re: OV Surgery billing before and after actual procedure

If you've never seen the provider before and he/she examine you and complete a profile and determine that a procedure needs to be done they can bill it without a problem. If the fistula repair code was a 90 day global then an OV should not be billed after unless the saw and treated or managed another condition that was outside of the fistula repair for 90 days.

Jul 7th, 2016 - G1974728 12 

re: OV Surgery billing before and after actual procedure

http://www.gpatpa.com/

out of Dallas, Texas is my provider.
I asked for a explanation of benefits with the billing codes. I will see what they email me. Even if the codes are correct, would just looking at the fistula be considered a Office Surgery? My previous Doctor didn't bill it that way when he just looked at it.

Jul 7th, 2016 - G1974728 12 

re: OV Surgery billing before and after actual procedure

I requested the CPT® codes for actual out patient surgery.

4/21/16 - was my first visit at the doctors office
4/29/16 - I had the out patient surgery at a surgery center
5/17/16 - Was my fallow up in the Doctor's office.

Thanks for all your help, hopefully they email me the codes by tomorrow.

Jul 7th, 2016 - petunia 195 

re: OV Surgery billing before and after actual procedure

The first visit is a billable visit as long as his/her documentation stands up to the service billed. No responsible provider would operate on a patient without evaluation and exam first. I would certainly question the post op visit if the procedure was greater than a 10 day global unless they managed or treated something unrelated to the fistula repair.

Jul 7th, 2016 - G1974728 12 

re: OV Surgery billing before and after actual procedure

No they didn't do anything but review the fistula repair from 4/29/16.

The first visit I did have my specialist copay when I left. Like I figured I would but there is an extra charge of $100 they say I am responsible for, for the Office Visit Surgery, which is separate from standard office visit copay.

Then on the Post-OP visit I was just billed another $100 for a Office Visit Surgery, there was no regular visit copay I guess cause it was a follow up.

If that makes sense? I am not sure I am explaining it correctly.

Jul 8th, 2016 - afgbilling 59 

re: OV Surgery billing before and after actual procedure

I would call your insurance company and they will be able to tell you what your responsibility is. They will be the ones to tell you if the provider is billing you correctly or not. It's hard for any of us to help without knowing the exact codes and seeing what they are billing you for but your insurance company will be able to give you an answer right away.

Jul 8th, 2016 - G1974728 12 

re: OV Surgery billing before and after actual procedure

Before posting here I asked insurance why I was being billed for it and I question the validity of it being an Office Surgery. Maybe the person I got wasn't very good at her job, but she told me to call my doctor and ask them if it was billed correctly.

So I was trying to get some info before I go calling them. If my insurance doesn't send me the Codes today I will give them another call and hopefully get someone more helpful.

Jul 11th, 2016 - G1974728 12 

re: OV Surgery billing before and after actual procedure

I got the CPT® codes emailed to me over the weekend.

Looks like the outpatient surgery was billed as, CPT® 46275.
Would that code cover the follow up appointment?

As far as the office visits before and after the surgery, I am not sure which is which as they are not dated, but the codes are.

CPT®
46275
45300

CPT
99204
45300

Jul 11th, 2016 - petunia 195 

re: OV Surgery billing before and after actual procedure

46275 is a 90 day global. If the service after the surgery was only for the fistula follow up with no other issues treated or managed they should not be billing the follow up office visit.

Jul 11th, 2016 - petunia 195 

re: OV Surgery billing before and after actual procedure

46275 is a 90 day global. If the service after the surgery was only for the fistula follow up with no other issues treated or managed they should not be billing the follow up office visit.

Jul 11th, 2016 - afgbilling 59 

re: OV Surgery billing before and after actual procedure

46275 is for the fistula repair
45300 is for a Proctosigmoidoscopy
99204 is for a new patient office visit

I believe you got a hold of someone from your insurance company that wasn't very willing to help you. You need to call back and hopefully get someone different that can help you. You also need to ask for an itemized statement from the physician's office, this will show you exactly what was billed and the dates. Did they do the Proctosigmoidoscopy on the same day as the fistula repair?
As stated earlier by Petunia, they cannot bill you for the follow up visit UNLESS you had a new problem on that day. If they checked the repair and asked how you were doing and you had no new complaints/problems then they cannot bill you for that follow up.

Jul 11th, 2016 - G1974728 12 

re: OV Surgery billing before and after actual procedure

I got the CPT® codes emailed to me over the weekend.

Looks like the outpatient surgery was billed as, CPT® 46275.
Would that code cover the follow up appointment?

As far as the office visits before and after the surgery, I am not sure which is which as they are not dated, but the codes are.

CPT®
46275
45300

CPT
99204
45300

Jul 11th, 2016 - G1974728 12 

re: OV Surgery billing before and after actual procedure

I got the CPT® codes emailed to me over the weekend.

Looks like the outpatient surgery was billed as, CPT® 46275.
Would that code cover the follow up appointment?

As far as the office visits before and after the surgery, I am not sure which is which as they are not dated, but the codes are.

CPT®
46275
45300

CPT
99204
45300

Jul 11th, 2016 - G1974728 12 

re: OV Surgery billing before and after actual procedure

I got the CPT® codes emailed to me over the weekend.

Looks like the outpatient surgery was billed as, CPT® 46275.
Would that code cover the follow up appointment?

As far as the office visits before and after the surgery, I am not sure which is which as they are not dated, but the codes are.

CPT®
46275
45300

CPT
99204
45300

Jul 11th, 2016 - G1974728 12 

re: OV Surgery billing before and after actual procedure

I got the CPT® codes emailed to me over the weekend.

Looks like the outpatient surgery was billed as, CPT® 46275.
Would that code cover the follow up appointment?

As far as the office visits before and after the surgery, I am not sure which is which as they are not dated, but the codes are.

CPT®
46275
45300

CPT
99204
45300

Jul 11th, 2016 - G1974728 12 

re: OV Surgery billing before and after actual procedure

I got the CPT® codes over the weekend.

Looks like the outpatient surgery was billed as 46275.
Would that code have a global that would cover the follow up appointment?

As far as the office visits before and after the surgery, I'll list the codes below. I'm not sure the order they should be as the bills are not dated.

CPT® codes:

46275
45300

99204
45300



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