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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.
Coding / J0702 and an NDC not listed in FDA NDC list
« Last post by wpj371 on July 10, 2018, 11:30:17 AM »
Good morning all,

I don't have that much experience with different J-code scenarios, so I want to throw this one out at you...

A podiatrist is billing 20550 for a tendon sheath injection and J0702 for a betamethasone solution.  All payors have paid it except that UHC has begun to deny stating missing or invalid NDC code or unit of measure. We WERE having issues with the NDC not being transmitted, but I got that fixed and the denials continue. The remarks seem to be indicating more specifically that it is a mismatch now.

I will admit that I haven't called UHC to discuss yet, but I did find that there are only two active NDC codes on the FDA list for this particular solution, and the NDC on the vial is neither of those. This NDC does not show up in any NDC lookups or the list I downloaded from the FDA. Doctor buys it from a compounding pharmacy in Alabama I think, don't know if that really matters at all.

Advice?  Is there any j code we should use that's for an unlisted drug? Do you think I'm on the right track that this NDC code is the issue? Are you gonna make me call UHC first? :-)

Give me all your advice. I need to decide if I should advise the doctor to buy the ones that are actually on the list, or if we can make this work AND get some of these prior claims paid. Doctor is going to be unhappy if he can't use the drug he already bought, so I want to get as much info as I can before I advise him.

It can be done! I was in your position 4+ years ago. No experience, no clients, little cash, very little knowledge about how to do medical billing, and no clue about where to start. through these forums, it's the best free education you'll get. Start out with a small work area and some basic equipment i.e. computer and printer. Make up your mind to market consistently (even after you start landing clients) you won't get anywhere unless you do. You may lose some clients along the way if you're not very knowledgeable, but you'll learn as you go. Keep marketing, keep working, keep going. It's a heavy lift, but it can be done!  :)
Facility Billing / Re: Return to ASC for bleeding on 1st post op visit
« Last post by kristin on July 09, 2018, 03:09:25 PM »
In my opinion, there is nothing you can bill for here. The bleeding/hematoma is directly related to the surgery, and as a result is considered a post-op complication, which is part of the 90 day global period.
Facility Billing / Return to ASC for bleeding on 1st post op visit
« Last post by EDREIBELBIS on July 09, 2018, 02:35:57 PM »

I am at a loss on the best way to handle the billing for this visit; if we CAN bill anything for the visit outside of the post-op. Patient had excision of bone in left foot on June 29th. On July 2 patient came in to the office for his first post-op and it was noted that he had uncontrolled bleeding, he had to be taken into our adjoining ASC to open the surgical site control the bleeding and re-close. The opt note in regards to the visit is below. Additionally, I don't know if it would matter, but original procedure was NOT preformed in our ASC, but at local medical center as outpatient surgery.

Would we be able to bill for this secondary closure with a 78 mod? My provider wants to at least bill for a facility fee, but I'm not sure what we can do in this case. Primary payer is Medicare.

"1st post Ėop

On exam, it was obvious that there was a hematoma at the surgical site. On suture was removed and the area compressed. Approximately, 10cc of congealed hematoma was expressed. At this point, a stready steam of bleeding was noted. The area was compressed for about 20 minutes, but this failed to stop the bleeding.

The patient was then brought into the operating suite in our office. A sterile prep and drape were performed after a local nerve block. An above-ankle pneumatic tourniquet was applied and inflated to 250 mmHg. All remaining sutures were removed. The bleeding vessel was identified and clamped with a hemostat and ligated using 3-0 vicryl suture. The tourniquet was released and no further bleeding was noted. The skin was closed with 4-0 nylon. A dry,s terile dressing was applied."

Thank you in advance!
Billing / Re: J0717
« Last post by Michele on July 06, 2018, 10:07:00 AM »
Are you saying it was 400mg?  Are you billing the 96372 twice?  If so, why?  It should have an ICD10 dx on the claim, not sure what you mean by "do I need crosswalk a ICD10". 
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