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Billing / Re: Podiatry billing question
« Last post by brendab on December 13, 2017, 03:00:29 PM »
Thank you
Thank you for your response! My business address is actually a lock box with a psychical street address. I will be billing commercial insurance and patients only. I know Michele said she collected a clients payments directly. Looking for some more information on how this is done as far as the return address on insurance claims being mailed (minimal majority will be EDI) and patient statements.
General Questions / Re: Help needed with Medi-Cal Rates
« Last post by Michele on December 13, 2017, 07:21:13 AM »
I'm not sure I understand what exactly you are asking for.  Are you looking for allowed amounts for certain CPT codes or are you looking for how they calculate those amounts?
Coding / Re: HCPCS coding question
« Last post by Michele on December 13, 2017, 07:19:43 AM »
I think it is in how you are wording your question.  You need to ask them to explain the denial because you don't understand it.  You aren't asking them to "code or bill" you are asking them to explain the denial code.  Are they paying some of the codes but denying others or are they denying the entire claim?
« Last post by PMRNC on December 12, 2017, 07:46:24 PM »
Do payers not have to adhere to the Greatest of Three rule? Even if it is out of network, it can still be paid at an in network rate, or whichever is higher.

No, not at all. Non contract they pay based on U&C. They use the 80th percentile in determining U&C The insurance plan then calculates the amount payable on the claim on the basis of this U&C fee or what 80 percent of physicians would charge for that service in that geographic reason, whichever is less.
Not a good idea at all. Medicare wouldn't allow it anyway. Plus you have to go and change address's and do W9's with all carriers. It's really not worth the hassle at all. Look into a lockbox.  You should also look into laws in your state if your collecting funds because you may need a surety bond.  I don't collect any funds on behalf of clients, way too much liability.
Billing / Re: Podiatry billing question
« Last post by kristin on December 12, 2017, 03:17:20 PM »
The code 28230 is for a tenotomy of the foot, not the toe. Therefore, you don't use T modifiers with that code, which is what is causing the denial issue. Tenotomy code for toe(s) is 28232.  While you can use the 28230 for a tenotomy that will correct an issue with toe(s), the surgical incision is on the foot itself, thus no T modifier is applicable. Also, when you use two modifiers on a claim line, always put the one affecting the payment first, such as the 59. Then informational modifiers go second(T mods, RT, LT, etc). And yes, you bill multiple tenotomies in one session.
I want to make sure I have the correct setup moving forward. Per my client they wish to have all payments come to my business address. I will be handling their deposits. What address should be printed as a return address on envelopes going out? Their business name with my business address?

What about my Business voicemail? My business name?
General Questions / Help needed with Medi-Cal Rates
« Last post by socorros on December 12, 2017, 01:35:47 PM »

I'm new to this forum, and I am by no means in the medical billing profession so please excuse my ignorance!  I need to do some calculations to see approximately what Medi-Cal would've paid for various services if the patient had utilized Medi-Cal as opposed to attorney liens. I'm trying to use the Medi-Cal Rate site where you can look up CPT codes and find the unit value, basic rate, conversion index, etc ( I also found the Medi-Cal Notes to Rates page ( but I'm having trouble figuring out how to actually do the calculations. 

Are both unit value AND basic rate added together, or is it one or the other?  Do you multiply unit value times conversion factor (as opposed to conversion index)? Seems like you're supposed to use the conversion chart ( to find the conversion factor based on the conversion index & facility type. What number do you multiply the prof % based on?

If anyone is familiar with this and is willing and able, it would be super helpful to see just one example, such as based on the CPT code 99205 (office visit, new patient - with physician).

If you're able to help, I give you a million thanks in advance.

Coding / Re: HCPCS coding question
« Last post by PT Biller9200 on December 12, 2017, 11:32:56 AM »
The insurance company is BXBS.
I have already made phone calls and told them it appears to be a clean claim and I need more information about denial and what is flagging it. The response is, "we aren't coders and are unable to advise you in anything regarding billing and coding".
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