Category: 1199 SEIU Benefits Fund

Find medical billing and coding guidance for NY 1199 SEIU Benefits Fund Insurance Payer

Posted in #reimbursement, 1199 SEIU Benefits Fund, Education, NY Providers, Payer Updates

NYS Medicaid: Bariatric Surgery Medical Policy Update

Posted on by KR2Medical Billing

Do you accept NYS Medicaid or Managed Medicaid Plan members? Then this blog post is for you!

Non surgical treatment should be attempted: ex. diet and increased exercise.

Bariatric Surgery Adult Patient: 18 years old and over

  1. BMI index 35 kg/m or greater OR
  2. BMI index 30-34.9 kg/m and a serious weight-related health problem (ex. High blood pressure, type 2 diabetes or severe sleep apnea)
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Pediatric patients: 18 years and older – patients that are deemed physically, mentally, and emotionally mature by a team of various providers ex. Pediatric provider, bariatric surgeon, and or other specialty providers.

  1. BMI- more and equal to 35 kg/m or more than 120% of 95th percentile of age and sex, whichever is lower AND with a weight-related health problem: ex. diabetes type 2, obstructive apnea – index or Reapiratory Disturbance Index greater than 5, Blount disease, non alcoholic steatohepatitis, slipped capital femoral epiphanies, GERD, hypertension, insulin resistance; or depressed health-related quality of life
  2. BMI greater than 40 kg/m or greater than 140% of the 95th percentile of age and sex, whichever is lower

Coding:

Most common codes that related to Bariatric Surgery

43644: Laparoscopic Roux-en-Y gastric bypass.

43775: Laparoscopic sleeve gastrectomy.

43770: Laparoscopic placement of an adjustable gastric band


43645: Laparoscopic malabsorptive procedure (e.g., [[Mini-gastric bypass|Mini-gastric bypass]]).

43848: Revision of a gastric restrictive procedure (open). 

NYS Medicaid coding and fee resources:

1. Physician Fee schedule- https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fwww.emedny.org%2FProviderManuals%2FPhysician%2FPDFS%2FPhysician_Manual_Fee_Schedule_Sect5.xls&wdOrigin=BROWSELINK

2. Provider Manual- https://www.emedny.org/ProviderManuals/Physician/PDFS/Physician%20Procedure%20Codes%20Sect5.pdf

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Posted in 1199 SEIU Benefits Fund, Training, Updates

NY 1199 SEIU Benefits Fund: Drug testing Reimbursement Policy, retroactively affective 11/01/2020

Posted on by KR2Medical Billing

This NEW policy applies to 1199 SEIU Benefits Fund Members and outlines the reimbursement, covered and non-covered drug tests.

Under this new policy, 1199 SEIU Benefits Fund will pay for medically necessary toxicology testing services: when performed in a physician-supervised treatment setting. The 1199 SEIU Benefits Fund will cover Presumptive and Definitive toxicology testing.

Presumptive Drug Testing:

1199 SEIU Benefits Fund will cover 1 (ONE) unit per given DOS (date of service). The maximum number will NOT exceed 32 units per calendar year.

Definitive Drug Testing:

1199 SEIU Benefits Fund will cover 1 (ONE) unit per given DOS (date of service). The maximum number will NOT exceed 16 units per calendar year.

Prior Authorization:

Once the maximum number of test have been exhausted (presumptive or definitive) the other tests will NOT be covered, unless the provider requests an AUTHORIZATION. Providers can call Benefits Fund Prior Auth line: 646-473-6868.

The following codes are NOT COVERED AND WILL BE DENIED:

0006U, 0020U, 0007U, P2031, G4082, G0483

The following codes are included in the codes for the presumptive and definitive drug testing and WILL NOT BE reimbursed separately, when billed on the SAME DOS (date of service):

81000, 81001, 81003, 81005, 82570, 83986

Drug Tests ordered on BEHALF of a third party: schools, courts, etc; are NOT COVERED.

For more information about this NEW policy including more information about the two types of drug testing, please click here.