1. daedolos

    Wiki 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...
  2. L

    Wiki 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...
  3. L

    Wiki 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...
  4. S

    Wiki 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...
  5. T

    Wiki 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...
  6. R

    Wiki 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
  7. S

    Wiki 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"...
  8. kfrycpc

    Wiki 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...
  9. J

    Wiki Out of sequence claims

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

    Wiki 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...
  11. L

    Wiki 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:
  12. T

    Wiki Herceptin

    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?
  13. L

    Wiki 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...
  14. B

    Wiki 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...
  15. B

    Wiki Charging Medicare deductibles/coinsurances up front

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

    Wiki 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...
  17. K

    Wiki 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
  18. S

    Wiki 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...
  19. M

    Wiki 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...
  20. S

    Wiki 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...
  21. D

    Wiki 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
  22. M

    Wiki 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?
  23. K

    Wiki 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.
  24. 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...
  25. 0

    Wiki 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...
  26. P

    Wiki 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!
  27. L

    Wiki 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.
  28. C

    Wiki 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...
  29. U

    Wiki Bcg

    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
  30. J

    Wiki 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...
  31. M

    Wiki 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...
  32. M

    Wiki 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...
  33. V

    Wiki Needs assistance pls. - HCPCS

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

    Wiki 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?
  35. D

    Wiki 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.
  36. N

    Wiki 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...
  37. D

    Wiki 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...
  38. A

    Wiki Studying for Family Practice Certification

    I am interested in sitting for the CFPC credential, but where I currently work does not bill Medicare. I was looking at the overview on what the test consists of and knowing the rules and regulations of Medicare billing is listed. I am unsure if just reading over the guidelines would be...
  39. F

    Wiki Billing for services by a Dietician

    I am in need of help on billing for a dieticians services, we have a new NP in our practice and he she as requested consults form our Dietician. Can the services provided by the Dietician be billed to Medicare even though she does not have a provider number? I am looking for instruction on how...
  40. K

    Wiki Question on billing outpatient - We are certified

    We are certified as a Rehab Agency by Medicare and bill Medicare on a UB. When billing outpatient PT, OT, ST in a private residence, do we enter our business name AND the patient's address (since it is the service address) in FL1?
  41. D

    Wiki How to code Medicare Preop evaluation

    What code should I use for a Preop evaluation for a patient that is going for cataract surgery and has Medicare for insurance? I use as first diagnosis Z01.818 and was denied. Do I have to use the Z code as a second diagnosis and code the reason of the surgery first?
  42. N

    Wiki IL medicare xover claims

    Recently our office has experienced claims NOT crossing over from IL Medicare to IL Medicaid. Has anybody else been seeing this happening?
  43. C

    Wiki Routine Laboratories

    Hello, I was really hoping someone can help me obtain the ICD-10 diagnosis code for routine labs? We have several Medicare patients who have had there labs denied because Medicare does not cover routine. What if the patients are healthy and the physician is screening for something that does not...
  44. P

    Wiki New VNG code for Audiologists

    I work for an Audiology practice in Southern California and we are billing with the new VNG code 92537 which replaces 92543 (4) units. This change was recommended by the American Speech Language Association and the American Academy of Otolaryngology Head and Neck Surgery. I verified in the 2016...
  45. K

    Wiki Gastroenterology - I have a claim that Medicare denied procedure

    I have a claim that Medicare denied procedure 97605 when billed together with 20102 stating invalid modifier billed with 97605. The procedures were billed as 20102-78-GC and 97605-59-78-GC. I verified in NCCI and these modifiers are appropriate. Does Medicare not want the modifier 78 on...
  46. P

    Wiki PQRI requirements for Neurology

    Does anyone know the PQRI requirements specifically for Neurology to qualify for Medicare reimbursement?
  47. J

    Wiki ABN/modifiers/moderate sedation

    I understand the following to be a question to and response from the AMA about time in moderate sedation: _______________________________________________________________________________________________________________________ Question: Is it appropriate to report the moderate (conscious)...
  48. L

    Wiki Billing Medicare as secondary

    We are Urgent Care and have an Ancillary contract with Cigna,UHC, and Aetna requiring us to bill S9083 at a flat rate regardless of what was done. I have a patient that is Medicare secondary. Cigna applied charges to pt deductible now I need to bill Medicare but they do not take the S codes...
  49. Y

    Wiki Medicare Mammogram Diagnosis Z12.31 or Z12.39

    I just received a notice that the diagnosis we used for a routine annual mammogram Z12.31 is not billable under Medicare. What diagnosis code should be used?
  50. M

    Wiki Ear swab culture

    We have always used 87070 when sending an ear swab for aerobic bacterial culture...starting this month the lab we use is changing this code to 87186 stating Medicare requires we use it. However Medicare is denying the code due to "not medically necessary", has anyone else received this? Doesn't...