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Billing / Re: New York Work Comp
« Last post by Michele on Today at 08:35:44 AM »
Yes, us too.  It is not uncommon for them to request the notes.  But technically you do not have to submit them with the C4.  However, it cuts down on rejections to attach the notes with the C4.
Billing / Re: Claim denied with PR 172
« Last post by kristin on July 16, 2018, 10:23:54 PM »
Is that code within the scope of practice for your provider? If so, you need to appeal using the guidelines set out by your MAC.
General Questions / Re: Help PQRS/ Macra Reporting
« Last post by kristin on July 16, 2018, 04:47:41 PM »
Here is a website from CMS that explains options, and where you can get further information:

If that isn't what you need, try Googling "reporting MIPS to Medicare", and there are lots of hits.
General Questions / Help PQRS/ Macra Reporting
« Last post by TammyL on July 16, 2018, 11:47:36 AM »
What website do I go to for reporting PQRS and Macra and how to report it without buying a book or attending a class that is over $200
Billing / Claim denied with PR 172
« Last post by Adnare01 on July 13, 2018, 09:51:01 AM »
Billing Question!

We keep getting denials on the claims from Medicare Michigan which are billed with CPT code 99358 (Prolonged E&M service) with denial reason as PR-172 (Payment is adjusted when performed/billed by a provider of this specialty). Provider is a Ph.D (Clinical Psychologist). I have no clue to get them paid. Any help would be highly appreciated.

Best Regards,
Coding / Re: Undercoding?
« Last post by kristin on July 11, 2018, 11:48:14 PM »
The simple way to look at this is that medical necessity is the overarching criterion for any service that is billed to insurance. So if there is no medical necessity for a service performed, then that service should not be billed to insurance. The cost incurred to the patient is not the concern, even if the doctor feels that it is. If these U/S's are not medically necessary, then they should not be billed to insurance, and if the doctor wants to eat the cost of doing them, that is their choice.

Under-coding is something else entirely... for example: Performing a medically necessary procedure and just billing an E/M code, or performing a higher level E/M code such as a 99214, and reducing it down to a 99212, for instance.
General Questions / Re: Genetic Billing Help
« Last post by PMRNC on July 11, 2018, 04:26:41 PM »
You will want to verify benefits with every claim. MOST carriers will not pay for genetic testing.
Billing / Re: New York Work Comp
« Last post by PMRNC on July 11, 2018, 04:24:24 PM »
We have had to submit notes when requested.
Coding / Undercoding?
« Last post by Medbill12 on July 11, 2018, 11:44:39 AM »
If a physician sees a patient for their routine obstetric care and does an ultrasound each time  for no medical reason other than the patient wants one or expects to have one every visit is this under coding If the physician does not bill it to the insurance? The physician has stated he does not want the patient to incur  costs for these ultrasounds so they donít bill them and just waive the ultrasounds.

Keep in mind there is no E/M code billed out because these are routine visits.
Coding / Re: J0702 and an NDC not listed in FDA NDC list
« Last post by kristin on July 10, 2018, 06:36:18 PM »
It does sound to me like the issue is he is using an "off-label" version of the injectable, therefore UHC won't pay. You could try using the J3490 unlisted drug code, or he can start using one of the two types that do have reportable NDC codes.
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