Billing > Billing
RADIOLOGY ULTRASOUND
RichardP:
--- Quote from: Billergirlnyc on May 29, 2013, 07:01:15 PM ---Also, the CPT codes you posted here are global codes, which means the doctor owns ...
--- End quote ---
Just curious here. Did you actually mean to say this: Also, the CPT codes you posted here are global codes, which should only be used when the doctor owns the equipment, supplies, has tech support, and interpreted the results (thus wouldn't be billed using any modifier b/c they're global codes) ...
Using global codes could mean nothing more than the doctor is not coding correctly. I would hate to think that the doctor bought all of that equipment, supplies, and tech support without finding out whether he is authorized by the insurance carriers to use them. I refer you to MTLOPEZ's comment THEY DENIED BECAUSE DOCTOR SPECIALTY, AND THE ALSO SAID HE IS NOT ALLOWED TO DOIT. If this doctor is using global codes because he owns all of the equipment that is not appropriate to his specialty ... :-\
Billergirlnyc:
Of course that's what I mean. If the OP says he's using those codes W/O any modifiers then I'm assuming he knows then he's billing for the global services, which includes both the technical and professional component.
But let me state this: -----> The OP was very specific with their question and to be very honest anyone knows these 2 carriers and bills for Radiology could've answered this question without the CPT codes you asked him to give. In fact I answered his original question and only touched on the codes because he posted them after you asked him, but I didn't need to know the CPT codes to answer his question and or direct him to links to get the answer he's seeking. The key components to his questions included that the doctor is a PCP, they're radiological ultrasounds, and that 2 major carriers in the northeast area Horizon BCBS of NJ (originally) and then he added Oxford on a follow-up response, are denying saying the doctor isn't authorized to do the services, and BOTH these carriers have adopted CareCore policies regarding privileging (for a while now) where diagnostic radiological imaging services are concerned. I know this because I code and bill Radiology for a large client of mines who has 4 free standing radiology facilities throughout the 5 boroughs in NYC. I knew why he was being denied at least by these 2 carriers.
Even if he used say CPT 76536 (global and has both a technical and professional component) he would only need to append the modifiers to show technical or professional if that's the case. So to say the code he's using is wrong is incorrect in my professional opinion. The code itself is CORRECT, the only thing that would be wrong is if he's suppose to use a modifier, which you broke down for him on which possible ones he could use. Again, I'm more than sure (due to the specifics) of the OP's questions he's not questioning WHICH CODE TO USE TO GET PAID, he's questioning WHY these aforementioned 2 carriers DENIED his doctor as not authorized, and I gave him links to what I believe is the answer. I work with both these carriers daily (as they're huge commercial payers in the northeast, in particular tri-state area (NY, NJ, CT) and I know all about their privileging policies for diagnostic radiology imaging services.
When Horizon BCBS of NJ says the doctor isn't AUTHORIZED they mean UNDER the policies they've adopted and implemented, thus why I suggested he verify with each carrier before rending diagnostic radiology services to a patient.
Lastly, there are PLENTY of doctors who ASSUME because Medicare allows and pays them then all carriers will, but in this instance where diagnostic radiological images are concern for Horizon BCBS of NJ and Oxford, it's just not the case, THUS my original response.
RichardP:
Dalia, it seems to be your opinion that the doctor was denied payment because he wasn't authorized by the specified carriers to do those services. It also seems to be your opinion that the doctor might have been paid for the Professional Component if he had billed for that rather than billing for global services.
Those were the exact two points I made in my initial response. I expanded on those two points and tied them to the issue of taxonomy codes in my second response, to provide some background information for others that might pass by this thread. Yet I can't figure out if your last post above is agreeing with me or taking issue with my answer.
Billergirlnyc:
Richard, even if this doctor had billed w/the professional component he WOULDN'T be paid by either Horizon BCBS of NJ or Oxford (although he can confirm w/ Oxford b/c their link doesn't state it, but I know from billing them they don't allow professional or technical components if the ORDERING PHYSICIAN isn't privilege to do it - they want you to REFER out to a Radiology facility for those services the doctor isn't privileged for) because NEITHER allow a PCP to do radiological ultrasounds aka the CPT codes he posted. The links clearly state this. Furthermore Horizon BCBS of NJ link also states that the ONLY way the professional or technical component will be paid by them is if the POS is 21, 22, or 23 (basically inpatient hospital, outpatient hospital, or in the ER). So, no we DON'T agree on this point, because telling the OP to bill for the professional component will still render the services denied by these 2 carriers if these services were done in the office.
I'm pretty sure I never stated for him to bill w/either modifier, because again, I knew WHY he was being denied without even seeing the actual CPT codes as stated in my last comment. I also stated in my original comment:"Also, the CPT codes you posted here are global codes, which means the doctor owns the equipment, supplies, has tech support, and interpreted the results (thus wouldn't be billed using any modifier b/c they're global codes),but if the carrier doesn't allow this particular doctor to do these services none of this will matter, which again it's best to check beforehand." . I think you may be confusing that I clarified on HOW the code can be billed, but I never stated he should bill either Horizon BCBSNJ or Oxford like this. I even stated he's not questioning the CPT codes or how to bill them, but why he was denied by these 2 carriers.
Direct quotes taken from the Horizon BCBNJ links:
"Horizon BCBSNJ does not consider a multi specialty practice with a radiologist on site as a freestanding radiology center. Any examination
that is performed outside of the ordering specialist’s privileging will not be reimbursed and will be the liability of the
specialty practice."
"All codes contained within this document represent global codes. Billing of Professional (PC) and Technical (TC) components are only acceptable in place of service (POS) 21, 22 or 23."
Now, Horizon does break down that certain PLANS are excluded from this, like a Medigap, etc., but I'm assuming the patient didn't have any of these plans, thus the denials the OP received, but I suggest he review the links to confirm, and IF the patient had one of the excluded plans, then appeal w/proof and copy of their policies stating the plan is excluded. That is my ONLY suggestion on this matter where these 2 carriers are concerned. Otherwise there is nothing more that will get either to be paid. But I hope my links are utilized by the OP so he knows the policies of these 2 carriers going forward and can inform/educate his doctor on them.
RichardP:
Thanks for the response.
--- Quote from: Billergirlnyc on May 30, 2013, 09:21:06 AM ---So, no we DON'T agree on this point, because telling the OP to bill for the professional component will still render the services denied by these 2 carriers if these services were done in the office.
--- End quote ---
I think we will have to agree to disagree that we actually do agree with each other. I was not telling the OP what to do. I was raising issues that needed to be considered, and added this caveat:
--- Quote from: RichardP on May 25, 2013, 03:25:56 PM ---Note that if your doctor is taking the picture, reading the picture, and implementing a procedure(s) based on the results of the read, you need to bill for both the TC and PC components. But that doesn't mean the insurance carrier will pay for either component charge.
--- End quote ---
It still seems to me like you and I are on the same side of the larger issue that I was addressing. That is, taxonomy matters when talking about what procedures the insurance carriers will pay the doctor for. The only difference in our comments is that I wasn't certain what the insurance carrier would pay for (we don't deal much with Horizen BCBS) and so was not being specific. You were certain, because you knew, and so gave a more specific answer. That is, I was not giving an answer specific to Horizon, but you were. I was only giving a general response regarding the issue of taxonomy. Again, thanks for the feedback.
Navigation
[0] Message Index
[#] Next page
[*] Previous page
Go to full version