1. J

    Wiki Reimbursement rate for modifiers U7 and SA

    Hello! I was curious - for dermatology outpatient, does the use of modifiers U7 or SA affect reimbursement rate at all?
  2. J

    Wiki JW Medication waste billing

    Has anyone come up with an efficient strategy to deal with reporting RX waste charges, when a vial size is used that leaves waste beyond the optimal vial size combination? "The units billed should where possible correspond with the smallest dose (vial) available for purchase from the...
  3. H

    Wiki How do I find out what payers reimburse a test?

    Hi all, I would like to know what payers reimburse the test PLA/CPT 0342U, IMMRAY PanCan-d. Does anyone know where I could find that information? I don't have the budget to use find-a-code. There must be some other way? Best regards, Mart
  4. T

    Wiki Aetna Medicare: Zilretta Policy

    Hi all, I'm inquiring about the Aetna Medicare Zilretta Injection Policy. Does a patient have to wait 3 or 6 months between Zilretta (J3304) Injections? I cannot find that information anywhere! Thanks!
  5. N

    Wiki Does the ICD-10 Name/Description make the code INVALID?

    Hello, we are having Rejections and errors due to ICD-10 Codes coming over with different names/descriptions. IE M46.1 being Bilateral Sacroiliitis instead of Sacroiliitis, not elsewhere specified. We are even getting claims denied because of M54.16 being Radiculopathy of lumbar region instead...
  6. M

    Wiki Molina is automatically downcoding office visits without requesting medical records.

    I do billing for an internal medicine physician who specializes in weight management. Most of his visits are coded as 99214 or 99215 + 99401 or 99402. We do not have a lot of Molina patients, but of the ones we do have, every single claim gets downcoded from 99214 to 99213. We do not receive a...
  7. N

    Wiki Does anyone have experience with billing Lymphoseek A9520?

    Our breast imagers only perform the injection of the radiopharmaceutical for lymph node mapping and possible biopsy which are performed by a surgeon at a separate visit. So, we only bill 38792 and the radiopharmaceutical. The radiopharmaceutical that is normally used is not available right...
  8. M


    Hi, I am looking to get further training in Inpatient Coding via AAPC CIC training course. Does anyone know if AAPC accepts tuition assistance from employers? The health system I work for provides tuition assistance and I would like to use that for this course by AAPC but can't figure out if...
  9. P

    Wiki 99072 reimbursement?

    Anyone have luck yet with 99072 reimbursement? Medicare is still not paying, correct? Any luck with other payers? Thank you! Pam
  10. E

    Wiki Office Anesthesia

    When diagnostic aortagram, angiogram, pacemaker changes, and similar procedures are performed in an Office suite (POS 11) do you have any issues with reimbursement to the CRNA's who provide anesthesia and bill separately from the facility for their services ? (State of Missouri)
  11. O

    Wiki Inconsistent OON Reimbursement Rates (same patient, different claims)

    Hello all. I work for a bariatric surgeon. Recently we have noticed payers like Aetna and UHC reimbursing us at wildly different rates (we are out of network with them). For example, a patient will have an upper endoscopy that is paid almost in full ($11K). The EOB states the reimbursement is...
  12. M

    Wiki Help!! 99211 and Lab Only

    Hello coders! Can anyone please advise and clarify how and when to use and bill a 99211 for lab only services. We generally use 99211 for nurse f/u and lab visits on established patients. The RN's are doing STD exams and coding only the 99211. The CMA is doing the collection. Some of our...
  13. K

    Wiki Fee Schedule Question

    Hello, If a payer reimburses for a code at your full charge, and when you reach out to the payer you realize your allowable is higher than your charge, is it okay to send a corrected claim with higher charge on the code to maximize reimbursement for that service? If yes, can you send the...
  14. C

    Wiki Physican billing for Car Seat codes 94780

    Are any insurances reimbursing physicians for these Car Seat testing codes? 94780-94781. My Pediatric Hospitalists want to charge and Revenue Dept states they will deny. They are listed on the AAP coding for Newborn decision Tool for 2021 and listed under Medicine/Allergy/Clinical Imm in the...
  15. I

    Wiki OBL

    Does anyone know where i can find all the procedures that can be done in an OBL (Office Based Labs), Medicare reimbursement for them as well? Any insight would be greatly appreciated.
  16. T

    Wiki Intra-operative monitoring technical component

    Hello, I work for a small IPA and we are trying to figure out what is correct for the technical component of IOM. I have been denying them because I assumed the technical component was payable to the facility, but I am not sure that is correct, because there is a tech and the neurologist. Does...
  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. C

    Wiki 96118 Neuropsych Billing

    Hello- I started this position 1/2017 and only had a few days of training from a biller who was with this practice for 6 years. I had noticed that she was billing 96118 with 12 units but we were only getting paid anywhere from 2.5-4 units, only being paid 4 units when its BCBS. Though this year...
  19. B

    Wiki Reimbursement for Orthognathic surgery from Tricare

    Normally we bill dentally for most of our dental procedures. There are the few medical but set fee schedules help determine the over all out of pocket cost for patients. In billing medical for Orthognathic surgery, mainly Tricare, if we have the authorization/approval letter, how do I bill out...
  20. K

    Wiki Mohs

    Hi - I work for a Dermatology Practice. Our Mohs surgeon performed Mohs on a patient's ear. The surgery had a total of 8 stages. I billed 17311 at 1 unit Then 17312 at 7 units I'm pretty sure only 6 units are allowed for 17312, but how do I account for the 8th stage on the claim? Please...
  21. L

    Wiki Revenue cycle management

    I am a experienced Revenue Cycle Specialist and I am looking for a remote position in Revenue Cycle Management. Skills: AR, Billing, Payment Posting, Authorizations, Medical Audit Review and Recovery and Refunds
  22. E

    Wiki Remote Physicians Office Alaska - New Practice Credentialing/Reimbursement Schedule

    I am currently working for a group practice that serves both the Anchorage, AK area and the Kodiak, AK area. Kodiak being a remote service location with minimal clinic and hospital coverage for maternity care. The practice is new and wants to be able to charge a higher remote service location...
  23. B

    Wiki NJ Workers Comp Appeals

    As many of you know, many NJ Workers Comp insurers pay poorly. There is no fee schedule in place, which is a good thing...but, has anyone found a means of leveraging a higher reimbursement? Though we're sometimes successful by submitting redacted comparable EOBs to these payers, most of the...
  24. C

    Wiki Outpatient Provider Based Facility-CCM codes Reimbursement

    I am trying to find out the Part A facility reimbursement methodology for a provider based hospital owned outpatient clinic that is more than 250 yards from this hospital and started billing for services after November 2, 2015. My understanding is that starting in 2017, the above described...
  25. H

    Wiki Corrected claim with new prices

    Hello all, I have recently discovered our out of network practice has been under billing for a procedure. Based off our zip code from the Fair Health UCR rates, we should have been billing $1600 for 20553 but have only been billing $800. Can I reach out to the insurance companies and change...
  26. B

    Wiki Appeal techniques for OON claims

    One of our providers recently decided to go out-of-network with major insurance companies. I'm looking for some tips on what to include in our appeal letters to these payers for increased reimbursement. We are mentioning: FAIR Health rates for our geographical area Relevant aspects of the...
  27. A

    Wiki Behavioral Health in-home

    Does anyone have any experience or knowledge as to whether psychotherapy (codes 90791-90834-90837-90846 provided by LCPC/LCSW) can be reimbursed if the visit took place in home? It appears that Medicare will reimburse for POS 12 for LCSW but I can't find any clarity on other license levels or...
  28. S

    Wiki Multiple same site x-rays for pre and post reduction of fractures/dislocations

    We are having a hard time deciding how to bill for these types of procedures. It is multiples of the exact same study, i.e. shoulder x-ray for a dislocation, the first study to see the problem, and the second/subsequent to make sure it is set correctly. My first question is, since these are all...
  29. B

    Wiki J1094 & j3490

    I have a rheumatologist who is billing for J1094. I know this code is not payable anymore per the Medicare Fee Schedule, and per previous form posts I billed J3490. Medicare is denying the J3490 stating the code is not valid for these date of service. They are all dates of service for the end of...
  30. H

    Wiki Early Stage Med Device Company looking for Assistance & Feedback about Economic Study

    Early Stage Med Device Company looking for Assistance & Feedback about Economic Study Our company is conducting an economic study to determine potential cost savings associated with the use of our device in an inpatient setting. We believe our device has the ability to assist medical...
  31. H

    Wiki Economic Study Methodology for Cost Savings

    Hello, Our company is developing a non-invasive brain monitor for diagnosing and continuously monitoring various neurological conditions. Our device is positioned as a supplement to EVDs (External Ventricular Drains) and as a way for physicians to immediately understand if there is any...
  32. 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.
  33. V

    Wiki Trying to Find Answers for Outpatient/Inpatient PPS

    There are questions on the practice exam relating to PPS such as what services are included/excluded for inpatient/outpatient reimbursement. I found some of these on the web but if anyone can help me with a list, that'll be great! Thanks!
  34. 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...
  35. H

    Wiki Cerumen Removal - Does a physician have to remov

    Does a physician have to remove cerumen to bill 69210 or 69209 or can a nurse remove it and still bill? Has anyone billed the 69209 and what is the reimbursement for it?
  36. F

    Wiki Professional fee -- for 0266t 0273t

    Hello All, Need your help to find the physician's reimbursement for these two procedures. Thanks, Fami
  37. J

    Wiki Advanced Care Planning Services - Medicare

    Medicare has approved coverage for Advance Care Planning Services for 2016. I know the codes are 99497 and add on code +99498. Has anyone heard what the RVU's and reimbursement rates are? Looking to maximize our revenue by using ACP codes in addition to our usual code set or using prolonged...
  38. M

    Wiki Prolia (J0897)

    Hi, The Dr. I work for would like to offer Prolia injections to patients with bone density issues. I've been looking for any information regarding reimbursement. Can anyone help me with this? Thank you! :)
  39. K

    Wiki Reimbursement same or different for same day procedure w/OV?

    I have been told that for a particular procedure billed to an insurance with and without an OV, the reimbursement would be less vs. if they were scheduled separately. If billed together we use with modifiers. Can someone kindly assist? Thank you, Karla
  40. C

    Wiki Long Term Acute Care Hospital

    I would appreciate if someone could guide me with the coding and reimbursement guidelines and rules for Long Term Acute Care Hospitals (LTACH). Regards, Chithra
  41. R

    Wiki Zarxio

    Is anyone dispensing the new Neupogen replacement drug Zarxio? Our doctors are looking into it and the drug rep said "everyone" is using it and "no one" is having reimbursement issues (sales pitch or what). So far haven't found any other practices using it.
  42. K

    Wiki urine drug screening with an analyzer

    We are a pain management practice looking to purchase or lease a desktop analyzer to complete our urine drug screenings. I have some concerns about reimbursement from various insurance carriers. Can anyone let me know exactly what the reimbursement is for the screening test? I can get Medicare...
  43. V

    Wiki Reimbursement of Mirena IUD

    We are running into a situation where our cost for a Mirena IUD is greater than our carrier reimbursements. Is there a way to bill these with the cost information to obtain a higher reimbursement rate?
  44. L

    Wiki Facility reimbursement for multiple colonoscopies

    Should facilities be paid for multiple colonoscopies performed on the same date for same patient? For example: 45380 & 45385 (billed with mod -59). A Medicare RAC report reported that hospitals should not be paid for more than one colonoscopy per day per patient. However, different facility...
  45. jshields

    Wiki Gardasil Feedback?

    Has anyone had any feedback with the new Gardasil(HPV) vaccine? Any major reimbursement issues? Any specific carrier problems?