Medical billing question?

[merwin]

I went to our family practice's urgent care center because I was having trouble breathing and couldn't get rid of a cough a few weeks after I got the flu and my regular doc couldn't fit me in for a few days. The cold happens pretty much every time I get sick apparently because of my eosinophilic esophagitis & Normally I either get Tylenol 3 or an Albuterol inhaler (depends on the doc)... codeine usually works best at controlling the coughing, which controls the throat spasms (OTC cold meds barely make a dent in the symptoms...), but Albuterol works also (I can breathe again, but still coughing madly).

In any case, I was looking over the bill and I got a charge for $28 for CPT code 94664, which is described as:
"Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device."

As I recall (even though I told him that I had used Albuterol several times in the past) he went and grabbed a sample, opened the box, showed me the inhaler (didn't do anything with it) and put it back in the box. I asked him how many puffs were in it, and he said about 200. That was the extent of our conversation. Leads me to believe that they pretty much charge this code whenever a sample is given out.

They also billed it as a Level 4 visit (99214), which I really don't think is justified. I spent like 5 minutes total with him (not counting the nurse/assistant/whoever taking my bp/temp/weight. He did the quick chest, nodes, and ear check, grabbed the Albuterol and sent me on my way. No follow-up questioning on me saying that this is a chronic thing every time i get the flu, most of the time ends up with a respiratory infection of some sort if not treated. Not even a "make an appointment with your primary care doc".

It fits a "moderate" classification like changing the oil on a car would qualify as a "moderate" difficulty for a service technician.

I'm paying something like 25 or 30 percent out of pocket until my 3k deductible (rates have gone up 50% in the last 3 years and I got a job that pays half as much as my previous job with no medical benefits, had to scale back the cost).

My question here is.... would I be justified in calling up the doc's office and asking for the justification of the charges?

[phillysuse]

1. Looks like upcoding to me

Level 4 Office Visit (99214)

This code represents the second highest level of care for established office patients. Internists used this code for 27.3% of established office patients in 2003 for a total of 15,275,698 visits, making this the second most commonly selected level of care for these encounters. The reimbursement for this visit is approximately $81.00. Usually the presenting problems are of moderate to high severity. This code ranks 2nd among the most frequently used CPT codes.

The documentation for this encounter requires TWO out of THREE of the following :

1) Detailed History
2) Detailed Exam
3) Moderate Complexity Medical Decision-Making

Or 25 minutes spent face-to-face with the patient if coding based on time. The appropriate documentation must be included.


http://emuniversity.com/Level4EstablishedOfficePatient.html

[HuckleB]

2. Yes, you're justified in calling your doc's office on this.

Very justified.

[mopinko]

3. coding "errors" are common. i would call for sure.

usually, they are fixed without much trouble. if the doc isn't helpful, call the insurance company. they will protect their end, which will filter down to you.
done it many, many times, myself.

[uppityperson]

4. Having experience as a patient and with billing, yes. Call.

Be polite, ask about the bill and codes, explain what happened. You may wish to write them, to have a record of your communication so all are clear as to what is being questioned and what answers were given.