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May 27th, 2014 - TriconEyeCare 2 

2 office visits on the same DOS from 2 different doctors/facilities/specialties

I work for an ophthalmologist, and I have a patient that was seen at a free-standing emergency care clinic for an injury sustained at work. The patient was then immediately sent to our office for an emergency foreign body removal. We were also informed that he had a corneal abrasion and conjunctivitis that we needed to evaluate and treat.
We are one of the only ophthalmologists in our area that accepts worker's compensation insurance, so same day emergency referrals are something that usually happen several times a week. However in this case, the insurance is denying our office visit because another office visit was performed on the same DOS. I called and was told that the denial was due to the visit by the emergency care physician.
I'm not a certified coder, but I don't see any reason that our claim should deny. The two office visits were from two different doctors in two different facilities and with two different specialties. We have patients come in all the time that have visits with multiple doctors from different specialties and different facilities scheduled on the same date of service. I'm sure you all know how it is, they're always rushing us because they have another appointment with Dr. ABC or Dr. XYZ that they have to leave for in 15 minutes. But still, we've never had a claim deny like this. I've appealed the claim, and had it sent back for review when the appeal denied. Is there anything else I can do?

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May 27th, 2014 - ch76606 123 

re: 2 office visits on the same DOS from 2 different doctors/facilities/specialties

Do the providers have the same Tax ID (in the same group with different specialties)? If so, have you tried modifier 27 (Multiple Outpatient Hospital E/M Encounters on the Same Date)?

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May 27th, 2014 - TriconEyeCare 2 

re: 2 office visits on the same DOS from 2 different doctors/facilities/specialties

No, they were from a completely different facility.

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May 27th, 2014 - shanbull 51 

re: 2 office visits on the same DOS from 2 different doctors/facilities/specialties

If it was outright denied, you can submit the charges as part of the litigation or arbitration stage of the W/C case. Ask for the patient's attorney's info and contact that attorney to find out what you need to do to involve your denied claims in the case.

These things take a long time to wind through the system, so be prepared to not receive the money for months, if not years. Still, if you're persistent it will almost certainly end up being paid.

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May 28th, 2014 - LBAROGIANIS 250 

re: 2 office visits on the same DOS from 2 different doctors/facilities/specialties

Hello, I would find out if there is a second level appeal, exhaust all efforts there. I am not sure what state your from, but some states actually have Obudsman that help patients and/or providers with issues like this. Go to the State Workers' Compensation website, see if there is a complaint for insurance companies, but before you go to that trouble, contact the patient explained that there WC case manager is denying this bill and ask them to call the case worker and explained that the ER sent them over to your office. I have told me many a patients to call their case worker and explain the situation and it has worked out in our favor with payment.

Hope this helps!!!

Update: I would also tell that insurance company, that since it's so much trouble to get paid by Work Comp, you might as well opted out of taking it and let all their claimants go to the ER only and rack up higher bills.

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May 28th, 2014 - TriconEyeCare 2 

re: 2 office visits on the same DOS from 2 different doctors/facilities/specialties

Thank you all. I'll keep trying!

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