1. H

    FQHC Performing Neuropsychological Testing

    Does anyone have advice on how a FQHC could bill Medicare for neuropsychological testing? This is a fairly new service my organization has started rendering, and I am trying to figure out the billing portion of it. As an FQHC billing with the PPS system, there are only a certain number of BH...
  2. K

    Wiki Too many DX Codes for Medicare?

    I have a physical therapist wanting to submit a claim to Medicare with 6 DX codes for their evaluation (97163 GP & 97110 GP). Their primary diagnosis is G35 (MS) but the provider has also added M21.372, M54.6, M54.59, M25.552, M25.562. I am worried this will lead to a denial. Thoughts?
  3. bekka

    Wiki Medicare billing dental

    Is anyone billing the new accepted dental codes to Medicare with success on more than one line item? For example we billed a D7210- 4 times each separate line and they are paying one and denying the others as duplicates? Any one have any suggestions. No matter the code they are only paying one...
  4. C

    Medicare 92083 denials

    I am an auditor with an eye consulting company and had a physician reach out regarding 92083 getting denied on every patient. Looking through the documentation all patients had Fourth Nerve Palsy and visual discomfort (which is an approved code with cms for 92083)...
  5. E

    Wiki Billing 96127 and Medicare

    Are any behavioral health offices billing 96127 with Medicare? If so, what are the requirements? Documentation and screening? Thanks!
  6. E

    Wiki Help with New PA-C

    My office hired in a new grad PA-C (eff. 9/2023). Her first day with us was October 30, 2023 and we've ran into a few bumps in the road. Our biggest concern is: She is not yet credentialed with Medicare. I am not quite sure if since she is not yet credentialed with Medicare, if she's able to...
  7. E

    Wiki Coding for different insurance types?

    What do beginning CPC medical coders need to know about coding for different insurance types (Medicare, private payer, etc.)? I feel that the CPC course and textbook didn't go over this enough, and I didn't find good resources explaining this online.
  8. T

    Wiki CPT code confusion - Medicare

    Hello, I am in desperate need of guidance. I am doing coding for a internal med doc. I got a message today that there's a bunch of Medicare insured patients that are being denied with CPT code G0439. Previous person had been billing 99397; which had also been denied. I think it may be because...
  9. Q

    Wiki Medicare vs. Medicare Advantage

    Whose coverage guidelines would take precedence between Medicare (MCR) NCD and a Medicare Advantage (MA) clinical policy, where the MA's policy was more restrictive? For example: If MCR guideline allowed for treating a certain condition, but the MA plan's guidelines require additional criteria...
  10. R

    Wiki Colonoscopy Screening - Medicare

    How would you code a colonoscopy screening for Medicare? Patient has personal hx of polyps and is coming in for surveillance. A coworker is telling me she codes as below. Do you agree? 45380 - PT Z12.11 Z86.010 K63.5 K57.30 PREOPERATIVE DIAGNOSIS: 1.History of colon polyps...
  11. M

    Wiki 92285 for WPS Medicare

    When questioning why a provider group wasn't billing 92285 ocular photography to WPS Medicare the provider responded they had previously found these were not payed by WPS Medicare & gave the 2 links below. I do see that there is an NCCI edit between 15823 & 92285 but are they still considered...
  12. L

    Question Mental health codes primary diagnosis in family practice setting.

    I was recently told that in the family practice setting mental health diagnosis can never be primary because the insurance will always deny, in this case Medicare. Has anyone had this same experience? There are times when the patient is coming in for a 3 month visit to only address med refills...
  13. N

    Wiki Medicare GYN Exam- G0101

    Hello, I was asked by one of our physicians to explain in more detail what is all included within a G0101- Breast and Pelvic Exam. For starters, our physicians see quite a few Medicare patients for breast and pelvic exams and up to this point have been billing the G0101 only but also ordering...
  14. B

    Wiki Medicare 59400 with mod 22

    Hello, I have a question for anyone who can help regarding billing a vaginal delivery 59400 to Medicare with modifier 22. We billed it out with mod 22 attached since primary dx is O09.523 for elderly pregnancy and got this SMARTEDIT rejection back: "SMARTEDIT PATTERN 26411 MODIFIER 22 IS NOT...
  15. T

    Wiki MUEs

    Hello everyone, Can someone please help me understand MUEs? I understand for Medicare there are caps on units that you can bill... but I don't know how to find these for other private payers. Can someone point me in the right direction or enlighten me on MUEs? Thank you!
  16. M

    Wiki Office visit + preventative counseling for MEDICARE patient

    Hello, I do medical billing for a "weight management" doctor (AKA a primary care physician whose niche is providing weight loss medicines and counseling). As some of you may know, Medicare does not accept the typical weight prevention counseling codes other commercial carriers accept...
  17. A

    Wiki Medicare denial 64635 but payment allowed for 64636

    I'm scratching my head on this one. We have two instances were Medicare has denied CPT 64635 Destruction RFA due to "information submitted does not support this many/frequency of services". However, for these same claims they have paid the add on code of 64636. I simply do not understand this, I...
  18. C

    Wiki Medicare Secondary Payer CO-16 N245 denials?

    I'm located in Florida (First Coast Service Options region), is anyone else have a ton of issues suddenly this year with Medicare Secondary Payer denying all claims for CO-16/N245 denials saying something is missing about the primary insurance? We are submitting claims exactly as we always have...
  19. N

    Wiki CP PC for Medicare

    I'm not sure if this even makes sense. But does anyone have any information regarding Clinical Pathology PC billing? From what I can find, if billing Medicare, the lab must bill the Hospital for the PC portion; and if billing commercial, the lab must bill the insurance directly with 26 modifier...
  20. L

    Wiki Remote patient monitoring

    What are the reqirements to bill RPM with medicare? Can an urgent care clinic bill for the services with RPM and receive payment? Or does it have to be credentialed as a Primary care facility? We are just starting CCM and are trying to polish out all of the details.
  21. K

    Wiki MEDICARE: Accepting cash in lieu of billing

    Wondering if anyone can assist- I’m working for a clinic with several providers- many of whom have opted out of Medicare, meaning we are able to enter into a private contract with patients who would like to pay cash in lieu of submitting a claim to their insurance. My question is this: The MDs...
  22. C


    I have a patient who came in with bilateral knee pain and right shoulder pain. Doctor Injected 40 MG Kenelog into RT knee, 40 MG Kenelog into LT knee, & 40 MG Kenelog into RT shoulder. How can I code this properly for it to go through with Medicare Primary and BCBS secondary? I tried J3301 -...
  23. A

    Wiki Medicare ABN

    Good morning all. I am extremely frustrated. Maybe someone can offer some guidance. We are a dentist office that deals with Medical. We are a non-par Medicare DME supplier for medical oral appliances. I have told our staff and provider repeatedly that they cannot have every medicare patient sign...
  24. KStaten

    Wiki Are Medicare's Guidelines for E/M CPT Codes the same as AMA's?

    Hello, Everyone. :) I would greatly appreciate it if you could please share documentation that shows how "closely" Medicare bases its guidelines in comparison to AMA's rules/ guidelines regarding levels for E/M-- specifically, the MDM table. 😐 It has recently been suggested to me that the rules...
  25. J

    Wiki Allergy Testing Medicare Denials

    We just started seeing A TON of denials for allergy skin testing (CPT 95004) from Medicare. They said it's due to medical necessity/insufficient documentation and that we have been using non-covered ICD-10 codes since the LCD update on 7/11/2021 (L36241). I reviewed the updated LCD and can't...
  26. S

    Medicare Split Visit Question

    There is some confusion of when it is appropriate to split a visit for Medicare IPPE/Initial or Subsequent AWVs utilizing the new E/M MDM if not based upon time for each (IPPE/AWV vs OV) Can a visit be split if all other Medicare requirements are met and the patient has 2+stable chronic...
  27. C

    Wiki DME and KV Modifier

    I have been running into trouble with Knee brace denials that need to be billed with the KV modifier to Noridian . The trouble I am having is that our Medicare patients come back in for a DME fitting for the brace with a MA, and we are unable to bill an E/M out. Due to this I can not use the...
  28. E

    Wiki Medicare, Private Payers and Mental Health Professionals

    I bill for a Clinical Psychologist who has opted out of Medicare. She has a new client hoping to see her who has 1. Medicare, 2. Aetna Retiree (self), and 3. Aetna Retiree (spouse). I am woefully underinformed when it comes to Medicare and was hoping someone who knows more about it could help me...
  29. C

    Wiki Medicare denying claim for missing procedure modifier

    Last Update: My supervisor says she doesn't want me doing denials. At least, not yet. It was a co-worker who had asked for my help in getting it done. I had wanted to try doing denials anyway, but since I was dropped into the deep end without a float, I felt frustrated and stuck when the...
  30. B

    Wiki Clearinghouse limiting # of Diags on a claim! Help

    Hi all, I am running into an issue with a Practice I work with. They are stating that their Clearinghouse is only allowing 4 ICD10 Diagnosis codes to be submitted on a claim, despite them adding the additional diagnosis on the Medicare form appropriately. Now I know that on the electronic...
  31. G

    Wiki LPC Billing Question

    Our LPC (Counselor) has a patient that has Medicare as Primary and Blue Cross as Secondary. The LPC cannot bill Medicare. So how do we get the secondary to pay for the visit without the Medicare EOB?
  32. G

    Wiki 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...
  33. I

    Wiki 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.
  34. 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...
  35. S

    Wiki 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?
  36. S

    Wiki 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...
  37. KStaten

    Wiki 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...
  38. E

    Wiki Medicare

    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...
  39. E

    Wiki 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...
  40. S

    Wiki 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?
  41. K

    Wiki 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...
  42. K

    Wiki 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...
  43. K

    Wiki 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...
  44. L

    Wiki 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...
  45. D

    Wiki 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...
  46. C

    Wiki 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.-...
  47. 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...
  48. H

    Wiki 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.
  49. J

    Wiki 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...
  50. Mtee

    Wiki 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...