Wiki Billing PPS Codes to Insurance


Lincoln, CA
Best answers
I work for an FQHC and we're required to put a PPS code on each claim. However, if we try billing these codes to private insurances (Blue Cross, Aetna, etc) they always deny the claims, stating that they aren't valid codes. This creates a problem when we have to bill a private insurance secondary to Medicare. Are any other FQHC billers having this same issue, and how do you get around it?
Category II codes

The FQHC I work with is having issues understanding when to use these codes and what diagnosis to associate them with on the claims. We were also instructed not to send them to Medicare because of claim issues. I would definitely like to know if there is an easy to understand document about these codes for how and when to utilize them, and if anyone else actually gets processable claims through to Medicare with the codes on the claim.

Any help is greatly appreciated!!!
This is where I get all my information regarding the PPS rate.

The PPS rate doesn't depend on diagnoses, they correspond to different types of E/M codes. So, whatever diagnoses are covered for your EM codes will work for the PPS rate code.

That's interesting that you were instructed not to send them to Medicare. Medicare is requiring us to use them on all facility (Part A) claims. If we just submit a 99213 and we omit the corresponding G0467 code, then the claim rejects.
So there are no FQHCs here having this problem??

Hi Robert,

We were having a lot of problems billing commercial insurances secondary to Medicare using PPS codes in 2015 when we started using those codes. We spent a lot time on the phone explaining PPS to our commercial carriers and they reprocessed our claims. We rarely get denials anymore and if we do, it is usually due to an update to their systems causing an error.

Lately I cannot get Blue Shield to reprocess any of their claims. I've called Blue Shield probably dozens of times and sent appeals, with no success. Does anyone know if there's a way I can report Blue Shield to some kind of watchdog organization for non-compliance with CMS regulations?
Medical biller

Was wondering if anyone had any more suggestions on the issues with the secondary's processing the FQHC medicare PPS g codes, we have tried to call the private insurances and we are told that medicare paid more then the allowed amount so its a contractual adjustment, I do not think this is correct, will appreciate any feed back.