1. K

    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...
  2. S

    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...
  3. D

    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...
  4. C

    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...
  5. K

    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...
  6. C

    medicare billing reimbursement

    Does anyone know where I could find billing reimbursement for medicare screenings? thank you!
  7. 5

    Puraply - skin grafts

  8. S

    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...
  9. J

    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.
  10. D

    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...
  11. J

    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...
  12. A

    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...
  13. I

    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...
  14. D

    Noridian Medicare denial

    I've been assigned research on a claim denial for reason code "CO-50" = non-covered services not deemed necessity by payer. Patient came in for neck pain and doctor examined and applied trigger point injection in the posterior aspect of the neck then prescribed physical therapy. However, the...
  15. L

    11301 shave codes Medicare Denials

    Recently Medicare has been denying procedure codes 11300, 11301 etc... all the shave codes. We have never had an issue in the past not sure what is happening now. They are stating that it is not a covered service. We have sent path reports and physician notes and they still deny. Any insite...
  16. L

    Shave Codes being DENIED by Medicare

    Recently Medicare has been denying procedure codes 11300, 11301 etc... all the shave codes. We have never ha an issue in the past not sure what is happening now. They are stating that it is not a covered service. We have sent path reports and physician notes and they still deny. Any insite...
  17. S

    Medicare and MA plans denying 80307

    Our office performes presumptive drug testing on our pain management patients in our in house lab, we send out for definitive results. This year we are now filing 80307 for these presumptive drug screens. I've gotten a good many denials from Medicare and Medicare Advantage plans with the...
  18. T

    Rural Health Billing For Assisted Living Visit

    Our NP in the Rural Health Clinic is seeing patients at the assisted living facility. I am trying to find out how to bill for these visits. I have been told that we cannot bill Medicare as a facility as we do if the patient is in the office by some but then by others have been told that is...
  19. R

    Rebill after Appeal

    We are working with a clinic that billed incorrectly --> attempted to appeal and then came to us. Can we correct the bill and just rebill it? Medicare is the insurance
  20. S

    Medicare Hepatitis B Screening NCD effective 10/2016

    CMS made a final decision and released a NCD regarding Medicare coverage for HBV hepatitis B virus screening in 10/2016. The decision identifies "high risk" populations and supports increased access to HBV screenings .CMS will nower cover screenings for those identified in these "high risk"...
  21. kfrycpc

    AWV and IPPE

    This question is two fold and I need fresh opinions: We have a long standing issue in our office. When a physician bills a preventive visit for a Medicare pt, it has to be either an IPPE or AWV. 1. When the Dr bills a regular preventive and bills a 99396....we cannot convert the code to...
  22. J

    Out of sequence claims

    Can anyone tell me if they know the modifier for Medicare when submitting claims out of sequence.
  23. D

    Medicare/Medicaid secondary: HCPCS services non covered by Medicare paid by Medicaid

    Hi, I work for a community mental health center and most of our services that we render are HCPCS and covered by Medicaid. My question is: Since the services are not covered by Medicare do we bill Medicaid directly or do we still need to bill Medicare as primary? I have asked this question...
  24. L

    Coding for suboxone, H0033

    Does anyone know of an alternate code I could use for suboxone dispense(oral)? I have been using H0033, and some payers are reimbursing it however we are wondering if there is a way we could get payment for dispense for our Medicare patients. :confused:
  25. T


    Is anyone getting requests for documentation for Herceptin, we send what they are requesting and Medicare denies it. It meets guidelines i'm just not sure what were doing wrong. Has anyone experienced this?
  26. L

    Palmetto GBA- NC area Sleep Studies & Modifier 52

    Can anyone assist me? I have been having difficulty getting MCR to pay for sleep studies 95810, 95811 if less than 6 hours. According to their LCD it states 6 hours of recording with no mention about what to do for less than 6 hours. But according to CPT AMA if less than 6 hours you need to...
  27. B

    Billing CPT codes 17000, 11421, and 10060 to Medicare

    I currently work for a FQHC and I have been having problems with billing certain office procedures to Medicare. The following CPT codes are 17000, 11421, and 10060 are being denied by Medicare. When we bill out the claim, we just add the G code and no office visit because when the provider sees...
  28. B

    Charging Medicare deductibles/coinsurances up front

    Is it ok to charge Medicare patients for deductibles and/or coinsurances upfront?
  29. B

    Opt-Out of Medicare and Secondary Insurance

    One of our providers is debating opting out of Medicare entirely. Many of her patients have secondary insurance in the for of supplemental and true "commercial" secondary. Though I've contacted many insurance companies, about this, none of my reps have responded with a definitive answer... If...
  30. K

    Medcare ONLY covered CPT/HCPCS

    Hi! I've been searching everywhere on the net for Medicare ONLY covered CPT/HCPCS codes. Does anyone know a useful place I can obtain this information? Thank you, Katie
  31. S

    PQRS regarding type of anesthesia

    Coding the PQRS #13 requirement, "PACU Reintubation Rate", has a requirement of "Patient underwent general anesthesia facilitated by SGA or ETT". My question is whether Medicare considers LMA to be the same, included, with SGA? (SGA: supraglottic anesthesia. ETT: endotracheal tube. LMA...
  32. M

    Pessary Supply Billing

    Does anyone know how Humana Medicare wants the Pessary (A4562) billed? We have always billed place of service 11, but recently are getting denials as invalid place of service. I asked the Humana representative where to find the policy and her only answer was "we follow Medicare's guidelines...
  33. S

    QMB question

    I work for a provider who, up until late last year when I started in the department, had no idea about QMB and prohibition against balance billing these patients. Up until then, if a patient had Medicare & Medicaid, they told the patient we were not in network with Medicaid (which is true, we...
  34. D

    96372 with purchased medication

    Has anyone had success billing 96372 (Therapeutic, prophylactic, or diagnostic injection) and the injection with a zero charge to Medicare? Are you getting paid or am I missing something in the process? Any and all advice is welcome!!!:) Example: 96371 x 1 $27.00 J1630 x 1 $0.00
  35. M

    Patient responsibility after Medicare and other secondary

    Does anyone know from a billing aspect, when primary, Medicare, determines a charge to be patient responsibility (PR 96), secondary denies as non covered per contract, therefore not patient responsibility. this still patient responsibility due to Medicare rule?
  36. K

    Medicare - CPT 80053

    Hi, I keep coming across 80053 for Medicare denials. I know you can't use routine codes, but is there a list of ICD-10 diagnostic codes that Medicare would cover? Thank you.
  37. C

    Wiki Medicare Denials for Screening Bone Mineral Density DEXA CPT 77080

    Hello, we are receiving denials for screening dexa scans CPT 77080 with diagnosis Z13.820 screening for osteoporosis. Per Medicare article MM5521, screenings are allowed every 2 years, but we are being denied. The denial is for NCD, as Medicare NCD 150.3 does not list the Z screening code...
  38. 0

    ICD10 for antenatal screening labs for Medicare and Dept of Veterans Affairs

    Has anyone found a workable ICD10 for billing the antenatal screening labs when billing Medicare and the VA? They are denying our Z36 (which we thought would be the equivalent of V28.89 which they used to pay). The new Medicare NCD only shows the Non-covered ICD10 lists and does not provide...
  39. P

    Medicare Rates

    Does anyone know if there are Medicare Rates for SA Residential Treatment, SA PHP and SA IOP? I don't believe that there are but was asked to verify. Thanks!
  40. L

    Medicare reimbursement for e-stem (g0283)

    I am having trouble getting Medicare to reimburse the G0283 code for E-stem performed in the Chiropractic setting. Does it only cover it with certain diagnosis codes? Any help would be greatly appreciated.
  41. C

    Preventive physical exams, Medicare patient

    Hi everyone! Before I continue I want to clarify that this has absolutely nothing to do with the Medicare AWV. This is a hands on, head to toe, physical exam. A patient comes in every year and has the same thing, clearly documented, coded 99396 through age 64. Now this patient is on Medicare...
  42. U


    We have a patient who cannot tolerate the full dosage of bcg. If we give him only 1/3 of the dose can we bill for the waste? He is a medicare patient. Thank you
  43. J

    99053 and on call Orthopedist

    Can anyone tell me if a Hospital employed Orthopedist who is on-call can bill code 99053 for after hours in the ED? Our Orthopedist is insisting that he bill this code (which we have never billed) so that he can get the RVU credits for being pulled out of bed at night for a patient in the ED...
  44. M

    Pre-radiation tooth extractions

    Good morning. I have been searching the web this morning for an answer, but decided to ask here. I bill for Oral Surgeons, who at times extract carious teeth for Medicare patients who have cancer before they begin radiation treatment. Pre ICD 10 we used V07.8 with the cancer diagnosis and it...
  45. M

    Observation to Admit Status for Medicare Patient

    Previously if a patient was admitted for an observation status which turned into an admit status, an office would bill the admit charge as it was the highest level. However, there are some changes with Medicare and the guidelines of observation and 2 midnight stays? Can someone tell me what...
  46. V

    Needs assistance pls. - HCPCS

    Hi All, Is there a HCPCS CODE FOR CPT 99173 as per MEDICARE GUIDELINES? Thank you, IM
  47. L

    NCV denials from Medicare

    We are seeing an increased number of denials from Medicare for NCV testing (95911-95913) when billed alone (without the EMG). The denials state 'not deemed a medical necessity'. Dx codes used are included in the LCD. Anyone else having this problem?
  48. D

    Medicare payment of Code 29581

    Is anyone having difficulty getting payment from Medicare on this code post-op or after fx care management. Our clearinghouse instructed us to use a 58 modifier and a LT or RT modifier but they are still being rejected.
  49. N

    Lab services for Home Health patients- covered/not covered by Medicare??

    Question: A client (independent lab) is working with an Assisted Living Facility to provide lab services to its residents. The ALF has stated that when their residents are under home health care, "they don't get paid for lab services". Would laboratory services not be reimbursed by Medicare to...
  50. D

    Insurance Verification/ Medicare & Medicaid

    Part of my new position aside from coding is demo and insurance verification. For verifying Medicare and Medicaid aside from replacement policies. Is there a main website for Medicare and Medicaid to verify coverage with out having to get into separate state sites? If anyone has any info I would...