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Phillips Esq.
Phillips Esq., Attorney-at-Law
Category: Legal
Satisfied Customers: 19653
Experience:  B.A.; M.B.A.; J.D.
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My mother-in-law who is 90 suffered an ankle fracture 4 months

Customer Question

My mother-in-law who is 90 suffered an ankle fracture 4 months ago. She had ankle surgery by an orthopedic doctor with metal hardware put in to keep the ankle together. At the end of the surgery her skin, wound - due to being extremely thin - did not completely hold together. This surgery was at a major city hospital and a plastic surgeon was brought in to do a skin graph. Her ankle bone has since healed and she is walking again, but still dealing with wound issues. In fact a second skin graph was done about 1 month ago and is cleaned regularly. My question is she received a letter stating that her medicare claim (her supplement is Tricare) was denied on February 20, 2016 due to information required to make payment was incorrect or missing. The procedure reference is procedure code 17999GC. The doctors must have resubmitted (the letter reads as if she did). The letter says that included were a fax coversheet, Medicare Part B Review Form, Explanation of Benefits,Operative Report and Discharge Notes. At the end of February it was denied again. She plans to talk with the doctor. My questions are - in this case should it have gone to Medicare Part B or Medicare Part A? A lengthy process for appeals is described. I would hesitate to ask the doctor to submit again and wonder if she should seek help from and elder care attorney that works with medicare?
Submitted: 1 year ago.
Category: Legal
Expert:  Phillips Esq. replied 1 year ago.
The surgery should be covered by Medicare Part B, which covers most surgical procedures and doctor's visits. Medicare Part A is for hospital admissions. The surgeon's office has a department that specializes in filing the insurance claims and the office should really know which code to use and which insurance policy to file the claim with. They need to resubmit the claim with the correct code or contact Medicare for the correct code. Kindly give a positive rating to my response so that I can receive credit for responding to your post. There is no additional cost to you for doing this. Thank you for your cooperation.