1. G

    Kyphoplasty and Medicare

    We have recently received a Medicare denial for a claim billed out for Kyphoplasty. 22513 x 1 22514 x 1 CCI edit states the family of codes (22513-22515) should only list "One" as the primary code and list the other as add on procedure for the additional level, which we normally do when done...
  2. I

    Question Ketamine Infusions

    Hello, Does anyone have any experience with billing these ketamine infusions/injections? What are the codes to use? Does Medicare pay these infusions? Any help would be appreciated.
  3. J


    Hello Everyone! I am trying to determine if Medicare paid their 80%, but I am having trouble calculating the amounts. I was looking online for the exact formula to follow, but I am getting a lot of info and I was not sure what to use. I know that for a participating provider Medicare will pay...
  4. S

    Where can you get a complete list of G code to CPT code crosswalk?

    I have been looking for a list of G codes and the equivalent commercial code. Does anyone know if Medicare publishes this somewhere or another source?
  5. S

    Question FQHC and Revenue codes

    We are a FQHC and have been getting denials from Medicare stating that the revenue codes are invalid or missing. Here is one example. We are currently billing the 0521 revenue code for our 99213 and a 0636 revenue code for J1885. Should the J1885 be billed for the 0521 as well? Any help or...
  6. KStaten

    Answer What qualifies as a "change" in the plan of care for Outpatient Incident-To Billing Rules?

    Hello Everyone! 🙂 Soo.... Incident-to Billing can be tricky, as even references sometimes vary in their wording/ interpretation of the rules. It has been to my understanding that any time a change is made in the physician's current plan of care, it no longer qualifies as incident-to services...
  7. eharloff


    Hello, I'm in Michigan and a lot of the schedulers at the office I'm at have been scheduling Medicare annual visits too early...Medicare has to be 366 days after the last physical, correct? Now what about lab work. We have patient's who leave for Florida and like to get their annual lab work...
  8. eharloff

    Medicare denying G0444

    I'm in Michigan and when we do a Medicare Annual Wellness Exam, we always bill G0444-59 for reporting purposes when eligible. For some reason Medicare has denied it with CO-236 This procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier...
  9. S

    Question Medicare billing-9944x with Z11.59 covid screen code

    We have billed this with the -CS modifier and are getting the denial: ROUTINE EXAM OR SCREENING PROCEDURE PART OF A ROUTINE EXAM. I see in a medicare COVID FAQ that this seems to be how it should be billed. Any one else had this issue and/or know how to fix it?
  10. K

    Contracted with Medicare/other insurances but not Medicaid

    If a practice is contracted with Medicare and other commercial insurances, but not medicaid.. Does the patient legally have to pay their primary insurance co-pay? For example, the patient's primary insurance is United, but their secondary is some type of medicaid plan. If United decides there...
  11. K

    COVID testing for asymptomatic Medicare patients

    My practice is getting denials from Medicare for patients who are coming in to get tested to abide by travel mandates in our state, wanting to ensure they don't have the virus before visiting a local family member or just want to be tested for peace of mind. The argument is that the above listed...
  12. K

    Question Medicare: Telephone Visit Guidelines & Referrals

    I believe I have a comfortable grasp on what can be coded during the COVID-19 changes for my FQHCs but I'm running into a semantics issue and would love some input. Normally there would be a medical service for multiple conditions and some of those may be referred to other specialists. A common...
  13. J

    Medicare Hospice

    Hello, I work as a Medicare Insurance Follow-Up representative (my first job since earning my CPC-A in August) for the physician billing dept of a large healthcare system. One of the biggest confusions I've had for the last 9 months has to do with Medicare hospice claims. My co-workers and I...
  14. L

    Question CEEG-Special EEGS> Palmetto GBA

    When reading the breakdown of special EEGs, the new Continous EEGS have replaced the old 95951, 95953. I understand it is now comprised of the Technical and Professional Component and can also include the set-up/breakdown/education if applicable. We are doing the 2-12hrs and do provide and...
  15. D

    Billing a PA as an AS for Medicare

    I am trying to bill out an Assistant Surgeon - who is also a PA - to Medicare and the claims keep getting denied as either Remark Code N259: MIS/INC/INV 2ND ID or PR172: PYMT ADJ WHEN PERF BY PROV OF THIS SPECIALTY. The primary surgeon - who is an MD - was paid. Anyone have any insite on how...
  16. C

    Question Medicare LPC billing

    Hello, Currently, I am coding for three behavioral health providers, one of which is an LPC. Currently, Medicare does not reimburse for any LPC billing. -There is a current bill out to get this updated and get more help for Medicare patients with more provider options within behavioral health.-...
  17. R

    Wiki Tumescent, Lymph-Sparing Liposuction for Lipedema Reimbursement

    I would like to help with the many misconceptions concerning treating lipedema with tumescent, lymph-sparing liposuction [FEB 2020]. This is considered reconstructive surgery, medically necessary, and reimbursed by some (but not all) insurance carriers. Most have to be appealed at least one...
  18. H

    Question Multiple Ekg's done on the same day

    Can someone clarify how to bill 4 ekgs done on the same day by the same provider? I know it needs the 76 modifier. But can it be billed on 1 line with 4 units? This is for a SC medicare pt.
  19. J

    Medicare COB Question for IP Stay

    When a member becomes eligible for Medicare Part A in the middle of their Inpatient stay, how is the biller to submit a claim? The patient had Medicaid State SSI as coverage upon admission which fell to secondary payor once the patient was entitled to Medicare Part A. Is SSI responsible for the...
  20. Mtee

    Medicare A and B billing

    Hello, I am looking for references for what claims forms are billed to Part A and Part B. I think it is that the UB-04 goes to Part A and the CMS-1500 form goes to Part B, but I would love any official reference to verify this. I'm also looking for a list of what services are billed to Part A...
  21. A

    Question New vs Established Patient Clarification

    Hello Fellow Coders, I have a new provider to our group who saw a patient that he previously saw 2 1/2 years ago at his old practice, which has a different tax-id. The patient has Medicare and received a denial that only one evaluation and management code at this service level is covered...
  22. S

    Question SNF vs Long Term Care

    One of the providers I bill for currently sees patients in a nursing home. He is thinking of switching floors and if so, would be seeing long term care patients instead. I currently bill using CPT codes 99306-99316. I know Medicare A has different coverage for long term vs short term...
  23. D

    Collecting Medicare Deductible

    I had a recent experience where a surgery center insisted I pay my Medicare deductible to them when I presented for my surgery. I explained I had met part of the Medicare deductible for 2019 already from other medical bills. The reply was "we collect the Medicare deductible from all of our...
  24. L

    Observation Services

    Per Medicare guidelines, only the ordering physician is allowed to bill observation codes. All other physicians who furnish consults or additional evaluations/services must bill the appropriate outpatient service codes. In our particular case, another physician order observation status. Our...
  25. K

    Medicare over payment

    We are getting over payments from medicare for one and two cents on a corrected claim. Are you refunding medicare for the pennies or are you adjusting off or giving it to patient credit?
  26. L

    Hospice Location Modifier

    I work for an ambulance provider and lately, we've been seeing people who have elected hospice and are being transported to a relative's home to receive hospice care. Would the destination (relative's home) be considered an R (residence) modifier or an S (scene) modifier? I can't find anything...
  27. L

    Medicare Hospice Location Question

    I work for an ambulance provider and lately, we've been seeing people who have elected hospice and are being transported to a relative's home to receive hospice care. Would the destination (relative's home) be considered an R (residence) modifier or an S (scene) modifier? I can't find anything...
  28. L

    Billing Medicare DME outside of my jurisdiction.

    Hi all. I have a few Medicare recipients that are snow birds. My DME claims are getting denied because I am in JC and their policies are in JA. Medicare(CGS) told me to bill to that jurisdiction. I have tried to bill the jurisdiction they are in but get denied their as well. Any advice on...
  29. L

    Low Dose Lung CT Certification

    I had a client in IL ask me today where were are able to upload the Certification once certified for this screening. They weren't for sure if it would be in PECOS or not. I checked today and I do not see the option for these as you do Mammo Certification. For those of you who have been...
  30. A

    Rural Health Clinics and Federally Qualified Health Centers

    Calling all RHC, CAH, FQHC coders and billers! I am a new RHC coder, and have been having a hard time finding information or resources on RHC coding and billing practices. It would be great to have our own discussion forum here, but I see very few posts pertaining to any of our unique practices...
  31. S

    Medicare code for "squeezing" a Medicare patient into an already busy schedule

    Medicare code for "squeezing" a Medicare patient into an already busy schedule Hello all, I have a kinda off question: My Provider seems to think that there is a code out there, to be billed to Medicare, for "fitting/squeezing" a Medicare patient into an already full schedule (ie: double...
  32. R

    90732 with 90471 vs G0009

    Hi Everyone. I am fairly new to coding for family practice. I have a Medicare patient who had the Pneumovax Vaccine. I just want to verify that it should be billed with G0009 for the administration code and not 90471. Or are they both billed with it? Also then 90670 is billed the same way...
  33. B

    HELP!! Medicare rejecting I10 (hypertension) as non specific

    Since the 10/1/18 ICD-10 update, Medicare is rejecting our claims if I10 is on it as a diagnosis. My providers tell me this is the proper code to diagnose the patient and further specificity is not correct. Is anyone else having this problem? If so, what can we do?
  34. C

    86003 and 86001 laboratory

    Hi, Has anyone experienced these codes being denied by medicare if the 86003 is over 50 we add another line with modifier 91 and if 86001 is over 20 we do the same . Medicare has been denying the 2nd lines and we have to appeal. Is there another way to keep these from denying? Thank you!
  35. J

    Medicare Annual Wellness Visit and additional Well Woman Exam

    Hello, fellow coders: One of my providers performed an AWV and a separate well woman exam on two different dates of service. Since both were preventive, triggering use of G0468 (we're an FQHC), Medicare paid the first well woman visit, but denied the AWV. My billing manager wants the...
  36. C

    Novitas Solutions JL bundling of benign lesion of .5cm or less with closure

    Medicare is bundling excision of benign lesion .5cm or less with intermediate closure. Based on the CPT manual instructions that intermediate and complex closures should be reported separately, my physician wants to add a 59 modifier to the closure. It is my understanding that Medicare...
  37. K

    Can PAs and NPs see a NEW Medicare Patient?

    Hi there, I work in a Dermatology practice and there has been some discussion over billing for PAs and NPs... I'm wondering: Can PAs and NPs see NEW Medicare Patients? Thanks!!
  38. L

    Help with Modifier for cpt 61635 & 61630

    We recently got a new Medicare MAC which is Palmetto. I am now getting denials for cpt 61630 & 61635 stating I am missing a required modifier. This wasn't required with our old MAC. I've talked to Palmetto several times to no avail as to where to look for the appropriate modifier. I know these...
  39. U

    2 billing companies for the same medical group

    Hi, A medical group in LA wants to try a second billing company for Medicare claims, Noridian as MAC and for CCM (chronic care management) related claims only. For the rest of their billing, they want to keep their current biller. What is the exact process that the group, the current biller...
  40. S

    Modifier for Medicare E/M help

    Hi, My colleague and I would be grateful to someone who could advise us on the proper modifier to use for Medicare when the E/M rendered is unrelated to the patient's primary disability plan? Thank you!
  41. G

    Looking for reliable software that estimates Medicare pricing

    I'm looking for software that will, as accurately as possible, estimate Medicare pricing for outpatient hospital and ASC claims when coding has been added; something similar to the CMS PC pricer for inpatient claims. Maybe an APC grouper. Does anyone have any resources where I can find...
  42. M

    CAC Member?

    Does anyone know any of the carrier advisory committee (CAC) members for any of the MAC jurisdictions? Thank you.
  43. E

    Medicare Denials - Infusion Coding Guidelines

    Recently, Medicare has denied some infusion, injection, and hydration charges on our observation claims due to not having an initial service billed for each date of service on the claim. Our HIM Dept is stumped because we have always followed the coding guidelines that only 1 initial service...
  44. K

    Help! Nurse practioners and xrays incident to?

  45. O

    Drug Screen Billing

    Was wondering if we have pts sign a Drug Screen Attestation are we allowed to bill them Medicare Rates when their insurance denies as excessive.
  46. S

    Credentialing question

    We have had some issues getting credentialed with Medicare. Our group effective date is 7/31/17, but our provider(we only have 1) is not assigned to the group effective until 10/1/17. Does anyone know of a way to get the claims from 7/31/17 to 9/30/17 processed without the providers name on the...
  47. L

    Looking for Guidance for CGx billing for FCSO (Florida Medicare)

    Hi, I recently received denials for upper tier moldx codes because I billed two units per line. I had someone call a rep and the rep indicated they were denied because we billed more than one unit per line, and advised to only bill one unit per each CPT per line. Most of my experience says...
  48. J

    Office Visit Before Colonoscopy (medicare)

    Medicare patient here for Office Visit before setting up a Colonoscopy, due to Personal History of Colon Polyps. Sent for EKG - will possibly need clearance before procedure, am I correct that I cannot charge for this visit as it is included in the Medicare global fee for Colonoscopy?
  49. B

    Newly Hired Auditor - What To Study/Learn?

    Hello! I was recently promoted to an auditor with my organization. Other than the OIG Work Plan, what other documents and/or books should I read to get up to speed on what is important in auditing for 2018? I would greatly appreciate any suggestions and advice. Thank you.
  50. R

    WHO SHOULD GET THE REFUND? Both Medicare and Aetna paid as primary

    We have a patient in which both Medicare and Aetna paid for multiple dates of service as primary payers. Our office contacted both insurance companies who assured our office that they were in fact the primary payer. In turn, we contacted the patient to ask that they contact Medicare and Aetna...