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    Wiki Inpatient foster care placement

    Are you looking for what revenue code to bill for the R&B or are you asking about procedure codes for professional services such as physician visits? Also, what state are you in because if you are assuming the payer is Medicaid at this point it is going to be dependent on what the state's...
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    Wiki Inpatient foster care placement

    Who are you trying to bill for these services? Medicaid or commercial insurance?
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    Wiki Transport of non-critical & critical of neonate questions

    I work for an insurance company so my responses are going to be based on how an insurance company might consider the claim scenarios you posed. 99468 has a note to "code also interfacility critical care transport services by same or different provider, same or different specialty group, same...
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    Question Mod 51 vs 59

    For CPT 24075 the MUEs for an OP facility, which includes an ASC, is 5 units per DOS, 25075 is 6 units per DOS and 25071 is 3 per DOS, regardless of anatomical site. So, on patient 1, I would expect you would have 2 units of 24075 denied as in excess of the MUEs for the DOS. On patient 2, I...
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    Wiki Billing for Record Review

    If the provider never performs an E&M I would say that the provider cannot bill 99358 per the following layperson description of the code: The codes in range 99446-99452 require a request for a consultation from the treating provider, additionally codes 99446-99449 it requires a verbal and...
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    Wiki Board certification for Hand specialty

    I have a few questions about your question. Do both providers have the same taxonomy code, or are they different? If the providers have the same taxonomy code, most payers are going to consider the hand specialist as the same specialty as the referring provider in the same group. If they are...
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    Wiki 97550 Caregiver training

    I don't believe that 97750 would be appropriate for wound care training of a caregiver as the code is defined as: Caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community (eg, activities of daily living [ADLs], instrumental ADLs...
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    Wiki NDC reporting for multiple vials used

    I think you are going need to check with your payers but from my end working for an insurance company, I would say that it should be billed on 2 lines with the number of units of the drug administered listed with each NDC number. That way you are advising the payer we administered X units of...
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    Wiki cpt 95251 requirement confusion- Endocrinology help

    You need to check your payer guidelines on the frequency for which they will allow 95251 to be billed. It appears based on a quick google search that many payers limit coverage of 95251 to 4 times per year. I didn't see anything defining a month as a 30 day period, so in theory you could bill...
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    Wiki No authorization for Physician Services while Patient was Inpatient

    Did the procedures that are being denied require prior authorization themselves? An approved PA for an inpatient admission, assuming that it was not converted from IP to OBS, would only be for the IP admission and doesn't necessarily include all procedures performed.
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    Wiki AMBULANCE BILLING

    There should be at least one additional code to explain the reason for the denial using CARC 96-Non-covered charge(s). At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT.) What other codes are...
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    Wiki Medicare Wellness

    Medicare doesn't cover the preventative care E&M codes in ranges 9938x & 9939x, so your 99397 is not going to be covered. Also, modifier 59 is not appropriate for G0439 as it is a provider visit (technically it isn't an E&M but it is considered the same for modifier 25 & 59 purposes. You...
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    Wiki CS modifier

    What dates of service are you using modifier CS on your claims? Per the description of modifier CS, it was only effective during the Public Health Emergency (PHE). The PHE officially ended on May 11, 2023. There a great issue-brief from KFF titled Timeline of End Dates for Key Health-Related...
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    Wiki How do get patients to tell you they are in a SNF

    What type of provider do you code/bill for? How are the patients referred to your provider(s) and what information are you given about the patient prior to the service and/or at the time of service?
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    Wiki Caregiver Training 97550 - Initial 30 minutes

    You would only report 1 unit of 97550 per DOS per provider for the first 30 minutes of training. For additional units of caregiver training with the same provider, you would report 97751 for each additional 15 minutes of training. Per the CPT section guidelines: Codes 97550, 97551 are used to...
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    Wiki Pre-travel motion sickness diagnosis

    I don't know if you use coding software, we use EncoderPro and I put in the search term "motion" and found there is actually a code range specifically for motion sickness, T75.3. If you are planning to bill insurance for this service the Z code you specified is unlikely to be covered as it...
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    Wiki Preventive Service and Medical Clearance

    99392-Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established...
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    Wiki NDC reporting for multiple vials used

    Question was this all done on the same patient on the same DOS? I'm asking because you are asking about billing 2 or 3 lines on the claim and that makes me think it is a single encounter with the same patient. On as side note, I will tell you as someone who works for an insurance company and...
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    Wiki 90847 Couples/Family Counseling

    Did your provider receive notification that 90847 is covered as a CPT code, or were they specifically told that couples/family counseling would be covered. I don't believe Medicare would cover 90847 with Z63.0 because there is not underlying medical or behavioral health condition being treated...
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    Wiki Medicare Annual Wellness Visit and Annual Physical Visit

    Medicare, and most Medicare Advantage plans do not cover the preventative E&M codes in the range of 9938x & 9939x. If you bill them both on the same claim to Medicare or an MA plan mostly likely the 9938x or 9939x code is going to be denied. The question is will it be denied as patient...
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    Wiki 90847 Couples/Family Counseling

    I have not heard that Medicare is covering 90847-Family psychotherapy (conjoint psychotherapy) (with patient present) is being covered for couples or family counseling. My understanding it represent family psychotherapy services for the treatment of mental disorders. So, the focus of the...
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    Wiki PROVIDER OUT OF NETWORK

    You're welcome. I try to help where I can with the information and knowledge I have working for health insurance companies for over 20 years.
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    Wiki PROVIDER OUT OF NETWORK

    Unless Anthem is going to back date the effective date of the provider's contract to cover the dates of service that the patient has received checks for, then yes, the patient needs to cash the checks and if she hasn't already paid your office pay you what she owes. If Anthem is going to back...
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    Wiki Good Faith Estimate

    What exactly are you looking for in a "policy" regarding GFE? CMS is very clear on what the requirements are and there are a ton of resources on their website under the No Suprises Act section which is listed on the home page for CMS.gov.
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    Wiki IUD insertion failed

    I don't know how other insurance companies would cover the IUD device if it the packaging was opened but not utilized but the company, I work for would typically not cover the device. It seems to me that this question has been posed before and I would suggest searching the forums for the term...
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    Wiki J7327 Modifier ?

    In reviewing the FAQ from CMS regarding JW & JZ modifier usage the verbiage actually isn't specific to "vials" it states the following: So, I would say that the requirement to use modifier JZ is still applicable to J7327. Based on the fact that the entire syringe is typically administered the...
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    Wiki billing 93976 with 78656

    Were both procedures performed during the same session/encounter, if so, why would you bill 93976 in addition to 76856 since the services represented by 93976 are inclusive of 76856? Just because the codes can be billed together and the edit on 93976 can be overridden with modifier 59 doesn't...
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    Wiki 11305 being billed 7 times on one claim

    I just checked the NCCI MUE table for 11305 and it shows that 4 units are allowed per DOS with a MUE adjudication indicator (MAI) of 3. Per MLN Matters # MM8853 Revised Modification to the Medically Unlikely Edit (MUE) Program MUEs for codes w/a MAI of 3 are a DOS edit. The document goes on to...
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    Wiki Medicare is not paying for A7045

    It appears that A7045 is only covered for use with a CPAP machine, even if the ventilator is being used CPAP therapy. So you may not have a way of getting this reimbursed by Medicare. The following information in L33800 is what leads me to believe this is the case because if they won't cover...
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    Wiki 11055-11057 Dx Issues - HELP!

    Have you look at the LCD and Billing and Coding Article for the Florida Part B MAC First Coast Service Options? The LCD Routine Foot Care L33941 and the corresponding Billing and Coding Article Routine Foot Care A57188. The billing and coding article A57188 has the lists of various DXs for...
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    Wiki G0447 POS

    Have you reviewed the Medicare NCD 210.12 Intensive Behavioral Therapy for Obesity which references that these services are to be performed by a qualified primary care physician or other primary care practitioner and in a primary care setting? They do not consider a SNF and most likely a...
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    Wiki J7327 Modifier ?

    They are looking for information on whether the entire vial was administered or if there was drug waste. If the entire vial was administered, then you would bill JZ-Zero drug amount discarded/not administered to any patient. If the entire vial was not administered, then you need to bill 2...
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    Wiki DME for LVAD

    What in the world is provider trying to bill for as a per diem with Q0508 because the Abbott Labs HCPCS guide for HeartMate II & HeartMate III LVAD accessories shows that believe Q0508 is to be coded for a per diem service. Their HCPCS table shows the following accessories should be billed with...
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    Wiki Help please....99244 billed with circumcision performed on same visit.

    Seems like you have a new patient E&M, not a consultation, which you can level based on time if the provider documented the amount of time spent on E&M services, not including any time spent on the procedure once the decision for surgery was made and consent was given by the parents. If the...
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    Wiki ER Visit

    The lowest E&M for an ER visit is actually 99281-Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional. The following additional information is provided by EncoderPro for Payer...
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    Wiki Help please....99244 billed with circumcision performed on same visit.

    Billing for all of the physician's services provided during the visit should not be billed with an E&M code alone as the CPT for the circumcision itself should be billed. It seems like either of the follow codes would be appropriate for the procedure described in the note: 54150-Circumcision...
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    Wiki Repeat x-ray performed by different provider and facility

    Is the denial a bundling edit denial, if not what exactly is the denial reason code or message? I don't know why modifier 77 didn't work to override the denial except that maybe the payer thinks that the was intentionally as a repeat procedure, when in fact you didn't know the procedure had...
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    Wiki This is fraud right? Or am I losing my mind?

    I'm asking the following questions purely insurance company's perspective, setting aside the issue that in Michigan only the MD or DO can diagnosis the patient. If I'm understanding you correctly, the front office staff sent the new PT order to the referring physician due to a coverage issue...
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    Wiki Is there a global period after making an interim obturator prosthesis 21079

    There is a coding tip in EncoderPro for Payers that actually references multiple surgical revisions during the healing phase which should not be billed separately. This appears to indicate you may have issues with receiving payment for revision surgeries after the standard 90-day global period...
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    Wiki Independent Contractor Physician surgery question

    I work in insurance and for us our prior authorizations are specific to the provider ID # we assign to the providers and if they are practicing as part of multiple provider groups, their ID # is different for each provider group. So, for us, in this scenario where the PA was approved for the...
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    Wiki Self Insured Commercia policies and External Appeals IRO

    The Federal Safe Harbor External Review rights are only available to the patient, or their authorized representative. If the financial liability lies with the provider and the patient has not financial liability, then they don't have internal or external appeal rights.
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    Wiki Outpatient psychotherapy documentation - start/stop times?

    According to the guidelines for the CPT add-on codes for psychotherapy performed during the same visit as an E&M don't specifically state which way the time should be documented for the psychotherapy code, so either using start & stop times or total time spent on the psychotherapy service is...
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    Wiki Diagnosis for PSA labs

    I think that the provider claiming to always use "Nocturia or something" is a bit concerning as they should be using the diagnosis or symptoms specific to the individual patients for each encounter. So to clarify when they state "or something" are they meaning that they are using a diagnosis or...
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    Wiki Referral screening (T1023) and assessment (90791)

    You will need to check with your state's Medicaid program, most likely there will be a provider manual that has information regarding the coverage of these services and when they are allowed to be billed.
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    Question how would we charge 2 nights home sleep studies 95800-26 reports lists time for 1st night and time of 2 night

    There are a few questions about this question: First question: does the payer you are submitting these claims to accept 95800 for unattended HST, or do they require one of the HCPCS created specifically for HSTs G0398-G0400? Also, most payers are requiring PAs for sleep testing, so have you...
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    Wiki 97799 and 92507

    In general, any time you use an unlisted code you should be including a description of the service, whether it is on the claim form or in the medical records. If you are providing the description in the medical records, that should suffice but from an insurance company's perspective it is...
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    Wiki Referral screening (T1023) and assessment (90791)

    Would you be billing T1023 to your state's Medicaid program? Medicare does not cover this code and most commercial insurance companies would not cover this service either. I know that the insurance company I work for does not cover this code for our MA plans and commercial plans.
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    Wiki cpt code 57135

    The MUE units per DOS for this procedure is 2 units, so if 2 cysts were removed, I would say it is not appropriate to bill 1 unit of 57135 with modifier 22. I would say it would be appropriate to bill 1 unit 57135 and 1 unit 57135-51 as MSR applies to this procedure code.
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    Wiki 97799 and 92507

    What is the service being provided that you are billing with 97799-unlisted physical medicine/rehabilitation service or procedure? Are you sending Aetna a description of the services billed with 97799 as well as medical records supporting use of the unlisted code? It can be difficult to get an...
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    Wiki compounded semaglutide administration guidance

    You need to also consider whether the patient's insurance covers weight loss related services/treatment. They may phrase the exclusion of this treatment as "treatment and or services related to weight management, weight loss management, obesity or morbid obesity..." in which case the E&M and...
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