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    Wiki Making sense out of a 99213

    Right? This is a personal injury claim which points to suspicious behavior. I see it all the time. However, I have never seen such blatant disregard for the standard of care. It seems like the requirements about a physical exam are vague though. Thanks.
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    Wiki Making sense out of a 99213

    Can someone please clarify. Can a provider exclude a physical exam when billing and coding for a 99213? I am auditing a record and the provider treated a patient for nearly 2 years and only documented one exam in November 2021 and never documented another physical exam again despite 13 repeat...
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    Wiki POS 11 vs 49

    I am auditing a medical record wherein the patient received injections at a clinic but they billed a "facility" fee as well as a provider fee. Is this allowed? The place of service code on the 1500 Claim form is 49. This is the same address and place of service that has previously seen the...
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    Wiki Speech Therapy codes/billing

    I am auditing a rehabilitation billing claim for speech therapy and the provider billed out 92507 with 4 units attached. Can this be billed more than one time in a session? I am under the impression this is a service-based code and it doesn't matter how long it takes, it can only be billed...
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    Wiki Tele Health Neuropsychologist evaluation

    This was in Colorado, and no, there were no units listed. Because this is a personal injury case and the patient is represented by an attorney, the providers usually bill extremely high. When I called the place of service they said that their evaluations can run up to 8k for one day and I bet...
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    Wiki Tele Health Neuropsychologist evaluation

    Hello, I am auditing a medical record and the neuropsychologist billed $2,250.00 for a 96116 (did not use the modifier 95 even though the evaluation took place via video). When I do a search for the UCR reimbursement, the amount is $198.11 for November of 2021. I use Find-a-code for my UCR...
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    Wiki Outpatient surgery billing/reimbursement

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    Wiki Outpatient surgery billing/reimbursement

    No, although they bill as if they are. They are not attached to an inpatient hospital and it is owned by a private physician. https://www.laredosurgicalcenters.com/ It seems that the term OP surgery is vague and can apply to several different types of entities.
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    Wiki Outpatient surgery billing/reimbursement

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    Wiki Outpatient surgery billing/reimbursement

    I know and I apologize for the vague question. I do not have access to that information because all I have access to is the bills with codes. I do auditing for a 3rd party liability company for personal injury cases and we are at the mercy of valuing the billing based on UCR figures. Does that...
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    Wiki Outpatient surgery billing/reimbursement

    I know and I apologize for the vague question. I do not have access to that information because all I have access to is the bills with codes. I do auditing for a 3rd party liability company for personal injury cases and we are at the mercy of valuing the billing based on UCR figures. Does...
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    Wiki Outpatient surgery billing/reimbursement

    I am wondering if outpatient surgery centers get reimbursed for each cpt code. For example, for someone who goes in for multiple injections on different regions, such as cervical MBBB, Lumbar ESI, and Stellate Ganglion injection with MAC do outpatient surgery centers get reimbursed for each...
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    Wiki Calculating UCR

    I am doing an audit for my insurance company (3rd party liability for a personal injury) and the claimant had an outpatient lumbar discectomy/laminectomy one level. Do outpatient facilities get reimbursed for each line item on the bill or for a "procedure" cost like a package? The bill has...
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    Wiki COVID cleaning supply charge

    That's what I thought. It is interesting that most bill audits I have done recently have no billing for 99072 after 2021. Perhaps most clinics were not getting reimbursed for it. I don't know. Honestly, it is silly to me considering that cleaning a room in between patients should be done...
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    Wiki COVID cleaning supply charge

    When did the CPT code 99072 end for billing purposes? I assume it ended on May 11th but I am not sure. I have seen clinics charging for it and some that don't.
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    Wiki Coding for a spine sugery

    Thank you for the info. I figure if the hospital billed it that way then so should the surgeon. This is a totally different situation than billing to a commercial or worker's comp carrier but it's good to have that info at hand.
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    Wiki Coding for a spine sugery

    For disc herniation
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    Wiki Coding for a spine sugery

    The operative note states bilateral L3-4 and L4-5 hemilaminectomy with microdiskectomy.
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    Wiki Coding for a spine sugery

    Well, because this provider is trying to increase his payments. This is a lawsuit and the rules don't seem to apply to providers when there is a personal injury. So I guess he can only bill for a 63030 and 63035 bilateral. Is that correct?
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    Wiki Coding for a spine sugery

    I am auditing a surgeon's bill for a bilateral L3-4 and L4-5 microdiscectomy and he has used 63030-50, 63035-50, 63047, 63048, and 72100-26. When I do an NCCI check it tells me that he cannot bill for a 63030 with a 63047, but when I eliminate the 63030 it tells me that I have to have a code...
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    Wiki Physician coding different than facility coding

    Thank you for that information. Appreciate it.
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    Wiki Physician coding different than facility coding

    Is it fairly common for an ED provider to bill out a 99284 when the facility bills a 99283? If so, what criteria is different for the provider than for the facility?
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    Wiki DRG payments for IPPS.

    I am auditing a hospital bill and need clarification of the "Per Diem" charges. According to Find-a-code, when using IPPS for a DRG, the ancillary per diem is a per-day charge whereas the ICU and Standard Bed fees are a one-time charge. Is this correct? If the patient stayed in the hospital...
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    Wiki Billing for new patient by two separate physicians in the same office on the same day

    Thank you so much!!
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    Wiki Calculating a UCR for a DRG

    Yes I have both. I am a Legal Nurse Consultant so I have a good grasp on the medicals. I just haven't had much experience with the UB-04 (most of what I audit are chiro and pain intervention) The claimant was injured on the job and so WC paid for his treatment. I just need to compare what...
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    Wiki Calculating a UCR for a DRG

    I am comparing the billed with what is reasonable because we are a 3rd party insurance for the purposes of bodily injury. Usually the providers increase their billed amounts because they hope to make money. Our claimant's are usually represented by Plaintiff's attorneys
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    Wiki Billing for new patient by two separate physicians in the same office on the same day

    Yes, you guessed it. It is a personal injury claim and we are the 3rd party liability insurance carrier.
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    Wiki Billing for new patient by two separate physicians in the same office on the same day

    Thank you!!
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    Wiki Calculating a UCR for a DRG

    I am doing a bill audit for an IPPS for DRG 956 and on Find-a-code there are per diem amounts. Am I understanding correctly that the ancillary services are a daily charge and the ICU/Standard Room charges are total for the LoS? I am new at this so this may seem like a stupid question to some...
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    Wiki Billing for new patient by two separate physicians in the same office on the same day

    It's not the new or established that I am wondering about. It's the billing for two different MDs in the same clinic on the same day. I am not a coder.
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    Wiki Billing for new patient by two separate physicians in the same office on the same day

    I am doing a bill audit for claimant and she was seen by two different providers on the same day for the same complaints. One is an orthopedic and one is a pain management/interventionalist. Is this allowed?
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    Wiki EWOT therapy billing

    I am reviewing a bodily injury claim and the claimant went to a neurological clinic that uses Exercise With Oxygen Therapy for most of their patients and charges enormous prices. They also bill for oxygen concentrator use with code E1390 for each visit. I believe they are using this HCPCS code...
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    Wiki Specialist Reimbursement rates

    How do I know what the UCR is for a specialist visit, such as a neurologist or an orthopedic? Are they reimbursed the same?
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