Wiki BILLING ANTEPARTUM FOR AN INS CHANGE

[TESSA2019]

QUESTION #1: Am I billing this correctly??
An Ob patient had Uhc ins (term date 09/25/2020) and was seen on the following dos:
05/20/20
06/19/20
07/17/20
08/14/20
bill cpt code 59425 to Uhc with beginning dos 05/20/2020 thru dos 08/14/20.

then her ins changed to Bcbs (effective date 09/25/2020) and she was seen on the following dos:
09/25/20
10/09/20
10/23/20
11/06/20
11/13/20
11/20/20
11/24/20
delivered Vbac on 11/28/20
bill cpt code 59610 to Bcbs with dos 11/28/20

QUESTION #2: Why are some being paid and some being paid and some being denied with the same dx codes?? AND... is this pt responsibility??
cpt code 76811 (ultrasound) was billed to ins with the following dx codes: "SOME" of them were denied not medically necessary and the balance was turned to the patient as patient responsibility (** BELOW **) and then some were paid by ins with the same dx codes: IM SO CONFUSED!!

CPT code 76811 w/dx codes: Z3482 & Z3A21
CPT code 76811 w/dx codes: O26842 & Z3A18
CPT code 76811 w/dx codes: Z3402 & Z3A18

** Its my understanding that when ins denies as not medically necessary that it is a coding issue (dx code is not supporting the cpt code or you have used the wrong cpt code ) and needs to be corrected and refiled.

**It is also my understanding that you can not bill the patient when something is denied by ins as not medically necessary. The eobs do not list the balance as the patients responsibility

QUESTION #3
An Ob pt transfers into our practice at 25 wks and we take over care for the remainder of the pregnancy, which includes the rest of the antepartum (7 or 8 visits) , delivery and postpartum. Do we bill the cpt global delivery code ?

 

[nishwitzp]

question 2 - I think the Z3A codes are only used when you have an O code first. Not to be used with Z34 codes????

question 3 - I would bill the cpt global delivery code if there are at least 7 prenatal visits

 

[Cmama12]

It is my understanding that with an insurance change, global codes should not be used, even with 7+ visits. That being said, we discovered at my organization that coders were not on the same page, with some billing a global if there were at least 7 with one insurer. So the decision was made to bill that way. However, as UHC will definitely deny global codes billed to them with a change of insurance, we bill (the correct way ) to UHC.

As far as 76811 goes, I would be very surprised to hear that any got paid with a Z34 code. These should not be billed out unless there is medical necessity and Z34 is for a normal pregnancy and therefore has no medical necessity. Most insurers have a list of codes they will accept . Adding the Z3A code, while not necessary with Z34, would not be the reason for the denial. So if your providers are trying to bill this for the standard 20 wk ultrasound, it is incorrect. They should be billing 76805

 

[TESSA2019]

It is my understanding that with an insurance change, global codes should not be used, even with 7+ visits. That being said, we discovered at my organization that coders were not on the same page, with some billing a global if there were at least 7 with one insurer. So the decision was made to bill that way. However, as UHC will definitely deny global codes billed to them with a change of insurance, we bill (the correct way ) to UHC.

As far as 76811 goes, I would be very surprised to hear that any got paid with a Z34 code. These should not be billed out unless there is medical necessity and Z34 is for a normal pregnancy and therefore has no medical necessity. Most insurers have a list of codes they will accept . Adding the Z3A code, while not necessary with Z34, would not be the reason for the denial. So if your providers are trying to bill this for the standard 20 wk ultrasound, it is incorrect. They should be billing 76805

View attachment 4990

Thank you so much for the info. Def helps!!