1. A

    Wiki 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...
  2. S

    Wiki 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...
  3. D

    Wiki 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...
  4. L

    Wiki 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...
  5. K

    Wiki 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?
  6. L

    Wiki 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...
  7. L

    Wiki 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...
  8. L

    Wiki 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...
  9. L

    Wiki 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...
  10. A

    Wiki 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...
  11. S

    Wiki 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...
  12. R

    Wiki 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...
  13. B

    Wiki 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?
  14. C

    Wiki 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!
  15. J

    Wiki 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...
  16. C

    Wiki 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...
  17. K

    Wiki 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!!
  18. L

    Wiki 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...
  19. U

    Wiki 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...
  20. G

    Wiki 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...
  21. M

    Wiki CAC Member?

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

    Wiki 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...
  23. K

    Wiki Help! Nurse practioners and xrays incident to?

  24. O

    Wiki 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.
  25. S

    Wiki 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...
  26. L

    Wiki 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...
  27. H

    Wiki Help Finding ICD-10 Codes for Medicare

    Hi, I need help finding ICD-10 codes for a Medicare patient. Our provider feels she needs IV Vancomycin due to a bacteria infection. We have had trouble getting intravenous antibiotics for her in the past. How can I go about determining what ICD-10 codes support medical necessity for the IV...
  28. J

    Wiki 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?
  29. B

    Wiki 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.
  30. R

    Wiki 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...
  31. J

    Wiki Billing Medicare for NP services in an outpatient rehab hospital

    I have run into a situation with a NP doing Botox injections for spasticity in POS 22. First, am I right in thinking that it is not appropriate to bill Medicare incident to in POS 22 even if there is a supervising physician? Right now we are billing using just the NP NPI and CPT code 64642 is...
  32. J

    Wiki Billing California Medicare Facility Charges

    We are billing for an ASC in California, and having either the facility or professional charges deny as a duplicate charge. We own the ASC so the tax ID is the same. We have contacted Medicare, their suggestion has been to just appeal the denial or add a 77 modifier. This does not seem like...
  33. S

    Wiki Dental claims-Medicare & E&Ms

    I have a oral surgeon specialist, can they bill E&Ms to Medicare when a covered or non-covered procedure is being done?
  34. L

    Wiki help with coverage for 11055/11056/11057 for straight Medicare

    Hello all, I'm still new to Podiatry billing. I work at a FQHC. For pts without a systemic disease, will the M codes for pain in foot/toes, or difficulty walking (R26.2) assist with straight Medicare coverage if these dx are appropriate? Laura
  35. D

    Wiki Deana

    I recently received a remittance from Noridian Medicare (Hawaii) Part B. One of the claims that was processed on the remit had an additional adjustment I had never encountered previously. This patient has a dual plan. Medicare/Medicaid. Enrolled with straight Medicare and has HMSA (BCBS of...
  36. 5

    Wiki Crna billing medicare

    We bill for the service of the CRNAs that work in our clinic. If we have a new CRNA that has started to work for us, and we are in the process of getting the enrollment approved with Medicare. How would we bill out the services that are being provided? Do we hold the claims until all the...
  37. G

    Wiki Working Medicare without Medicare FISS DDE system

    Does anybody here have any advice for working Medicare denials when you don't have access to the FISS DDE system? My practice is having a terrible time getting denials fixed. Every time we resubmit something, it will get denied as "M80" which is essentially a duplicate. Medicare describes it...
  38. K

    Wiki HELP! Medicare G Modifiers: When to use which one?!

    Hello, I work in a public health agency and our contract with Medicare is as a immunization roster biller only (we can only bill/receive payment for Influenza and Pneumococcal vaccines). Since we are a public health agency, we do not turn away a patient with Medicare if they want something other...
  39. S

    Wiki DME- Second garment (E0731) for kneehab unit- MEDICARE HELP PLEASE

    I need assistance with billing for a second garment for use with the kneehab unit (E0745). :confused: Previously, Medicare had covered bi-lateral garments, since they can not be used interchangeably. They have stopped paying for the second garment within a 12 months period stating it is not...
  40. D

    Wiki Medicare Reimbursement for Kyphoplasty code 22514

    Our practice has had an issue lately with getting our kyphoplasty (22514) surgeries paid through Medicare. They are getting denied based on medical necessity. We used correct supporting ICD-10 codes but we cannot seem to get Medicare to pay for these surgeries. According to the LCD, this...
  41. C

    Wiki 76706 Screening AAA for patient over 75

    Hi any advice for CPT 76706 if done on a patient over 75? The medicare guidelines state they cover this screening for male age 65-75 who has smoked. From the report below, is 76706 the only option? This seems not to be a screening because the patient has a known infrarenal aaa. Could CPT 93978...
  42. K

    Wiki Medicare PT and OT, different offices, different days

    Quick compliance billing question for a Medicare patient. He is currently receiving outpatient PT at our office for Parkinson's related weaknesses/pain. He also just started seeing an outpatient OT for Parkinson's related weakness/dysfunction. Will Medicare pay for two outpatient offices to...
  43. C

    Wiki medicare billing reimbursement

    Does anyone know where I could find billing reimbursement for medicare screenings? thank you!
  44. 5

    Wiki Puraply - skin grafts

  45. S

    Wiki Medicare Set Aside Exhausted - Private Insurance Required Auth

    Has anyone else had a patient with a third party administering the patient's Work Comp Medicare set-aside account, and the funds became exhausted, and your office was not notified? This company actually issued an EOB, but never funded the amount allowed on the EOB. The additional issue here is...
  46. J

    Wiki Medicare - modifier for same day visit, different provider

    A patient has come in for treatment code 97140, and we later found out they went to another provider on the same day with different specialty who billed the same code. Which modifier would be appropriate for this to resubmit? Thanks.
  47. D

    Wiki Medicare Contract 855R

    We are a new physician group and is applying for Medicare 855R. Contract has not been sent in but we will start seeing patients on June 1st. Probably won't have contract finalized before then. Can we hold all of our claims for Medicare and bill later after contract is final. And if so how...
  48. J

    Wiki Denial Billing secondary with G code.

    I need help, keep getting secondary denials because of the g code used when billing medicare as primary. Secondary denies because of the g code but we must use that when billing medicare, tried billing secondary without the g code but then it denies because it doesn't match the primary amounts...
  49. A

    Wiki UHC Medicare Solutions denying PPD

    We are currently having an issue with UHC Medicare Solutions denying our claims for 86580 (PPD) with diagnosis code Z11.1. They are not dropping it to patient responsibility. They are telling us we must write it off. In conversations with them, they are saying we must get an ABN signed so...
  50. I

    Wiki TENs unit and Medicare

    Good afternoon, I am looking for guidance on billing a TENs unit to Medicare. E0720. We used modifier NU (new) initially but that was rejected. We used modifier KX (greater than 3 months pain) and the claim was denied for POS. Medicare is stating this can only be billed by inpatient and...