Question Billing Secondary Insurance

rbetton

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When billing to secondary insurance, if the CPT code originally billed to primary is not recognized by the secondary can you change the CPT code?
 

unicorn80

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You should never change a procedure code even if it is not recognized by a secondary insurance as this constitutes fraud. Providers are paid by the services they perform so if you change the CPT code that could mean the provider would be paid more or less for that procedure. If the procedure code that was originally billed to the primary is not recognized by the secondary insurance there are modifiers that you can add to the procedure code when billing the secondary insurance.
 

SharonCollachi

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I will respectfully disagree with the above answer. There are insurances who will instruct you to change the CPT code. If their computer systems don't have the CPT code, it isn't going to get paid by adding a modifier. Bill it on paper, with the EOB.
 

csperoni

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I believe that link is about how to request a change to the definition or description of a CPT code by the AMA.
For example, 38900 is an add on code, with specific codes listed as the primary code. A new technology developed a few years ago that resulted in physicians performing the exact description of 38900, but with procedures not listed as one of the primary codes. Those physicians struggled to get paid for the services provided because they could not bill for 38900. By submitting the request to the AMA explaining the new technology and procedures, starting in 2019, additional codes were added to the primary list.
 
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You should never change a procedure code even if it is not recognized by a secondary insurance as this constitutes fraud. Providers are paid by the services they perform so if you change the CPT code that could mean the provider would be paid more or less for that procedure. If the procedure code that was originally billed to the primary is not recognized by the secondary insurance there are modifiers that you can add to the procedure code when billing the secondary insurance.
Hello-
For Telehealth claims, when the secondary payer requires a different POS type than the primary payer (ex: Medicare wants typical POS (11, 22, etc) and BCBS wants POS 02)...is it fraudulent to change the POS type to what the 2ndry plan requires on the 2ndry claim? I think it is, but I can't find any documentation to support that it is or isn't...especially not with the flexed guidelines for COVID claims.
 

csperoni

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Selden
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Hello-
For Telehealth claims, when the secondary payer requires a different POS type than the primary payer (ex: Medicare wants typical POS (11, 22, etc) and BCBS wants POS 02)...is it fraudulent to change the POS type to what the 2ndry plan requires on the 2ndry claim? I think it is, but I can't find any documentation to support that it is or isn't...especially not with the flexed guidelines for COVID claims.
I never change anything on a secondary claim.
99% are automatic crossover anyway, so they will get the claim from Medicare as it originally billed. If secondary denies for POS, I would write an appeal letter, not change the way the claim is billed. I do not have any specific reference for this. It's just what I would do.

Everything I am seeing between primary or secondary payers says to use place of service 2. They also say to use one of two modifiers GQ or 95 with the appropriate CPT code.
https://capturebilling.com/telemedicine-billing-tips/
That link is to what is now a very outdated article. It seems to have been written mid-March, and the rules changed 20 times since then.
Very brief summary for those who previously did not qualify for telehealth:
MCR telehealth (audio/VIDEO), billed E/M with POS 11 (or whatever it would have typically been) and -95. Private carriers each have their own rules. Most mirror MCR, but not all.

Since the rules have changed so much, I am only using CMS or MAC guidance for Medicare. For private carriers, I am using whatever the guidance is on their website.
 
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Rio Rico, AZ
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I will respectfully disagree with the above answer. There are insurances who will instruct you to change the CPT code. If their computer systems don't have the CPT code, it isn't going to get paid by adding a modifier. Bill it on paper, with the EOB.

With the suggestion to bill paper with the EOB, the EOBs still do not match and we are getting rejected as noncovered or invalid CPT. Example is Medicare UGS primary and commercial secondary. We are an FQHC and we need to bill Medicare with G2025, but commercial wants us to bill with an E/M and a modifier. How do we go about this?

Thank you in advance.

Leslie Pou
 

daedolos

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Long Beach
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A secondary insurance is obligated to pay any amount left after the primary has paid on the allowable amount per contract. If there was no secondary then this amount would have been forwarded to the patient. The protocol would be for the patient to address the issue with the secondary. A colleague of mine mentioned that if the commercial insurance was obtained through work, then it probably should have been listed as primary and depending on the payer and plan, you would've known from the get go if a service was covered or not.

Peace
@_*
 

rbetton

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Audubon, Pennsylvania
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Thank you everyone for your input. I'm not convinced that i should change a code. I am coding telephone visits - Submitted to primary insurance as 99442 - secondary insurance only wants G2012.
 

jlasker

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You should never change a procedure code even if it is not recognized by a secondary insurance as this constitutes fraud. Providers are paid by the services they perform so if you change the CPT code that could mean the provider would be paid more or less for that procedure. If the procedure code that was originally billed to the primary is not recognized by the secondary insurance there are modifiers that you can add to the procedure code when billing the secondary insurance.
Hello, I wonder if you have or know where I can find something in writing stating this. I am setting up a policy for our department and need to include something on this.
 

unicorn80

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Neenah, WI
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I must have misunderstood the question being asked. If I knew which insurances were being billed under one cpt code, for example, BCBS for primary and Medicare for secondary I would have said that Medicare has their own codes so a standard cpt code is not going to be recognized by Medicare. The codes he/she ended up billing makes more sense if this is the case. I couldn't find anything on whether a CPT code can be changed if not recignized by a seconday insurance.
 
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