The DOC

Feb 2021 | Get the latest from the best RBP advocates and auditors 

Audit Spotlight

Cynthia Swanson, RN, CPC, CEMC, CHC, CPMA

Senior Audit Manager

Audit of surgery performed in a ambulatory surgery center results in major savings

Case Scenario

The member received a spinal neurostimulator pulse generator during surgery performed in an ASC located in Chicago, IL. The primary ICD-10-CM diagnosis code reported on the UB-04 claim or electronic equivalent was T85.193A, defined as mechanical complications of the implanted electric neurostimulator.

The ASC submitted their claim to insurance with total charges of $110,905. In this case, the surgical procedure code reported/billed on the claim was CPT code 63685, defined as, insertion or replacement of spinal neurostimulator pulse generator or receiver for a charge of $65,905, and HCPCS code C1820 defined as, generator, neurostimulator (implantable), with a rechargeable battery and charging system for a charge of $45,000. Read More....

Client Savings

Comprehensive line-by-line claim auditing by healthcare professionals is used to uncover errors typically not caught. ClaimDOC publishes a sample of five recent client savings audit results bi-monthly. See the savings below and know that together we can make healthcare affordable.

1. Raleigh, NC

Hospital outpatient services for the treatment of knee injury and related surgery

High-Dollar Services:

Implant(s): $28,397.88
Operating Room: $10,613
Medical/Surgical Supplies: $6,003.78

Savings Summary:

Billed Charges: $51,434.23
ClaimDOC Allowed: $6,676.63
Plan Savings: $44,757.60
Reduction: 87%

2. Cocoa Beach, FL

Two-day hospital stay for the treatment of kidney cancer

High-Dollar Services:

Operating Room: $51,006.41
Medical/Surgical Supplies: $10,324.77

Savings Summary:

Billed Charges: $77,522.10
ClaimDOC Allowed: $13,113.30
Plan Savings: $64,408.80
Reduction: 83%

Disclaimer – The analysis of any medical billing or coding is dependent on numerous facts, regulations, payer policies and codes, as well as the controlling plan description. The information contained herein is intended to provide a real-life example of opportunities for savings through ClaimDOC services but is not intended to provide medical, legal, or financial advice.

Member Experience

Feedback from a Member

My member advocate Allyson is the best! I have praised her to so many people. She always helps me. I can't tell you how nice it is to speak to someone. I can understand her and she's very helpful and doesn't just say, what she has to to get me off the phone like other support services I have experienced with healthcare in the past. I’ve really appreciated all her help this past year.

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