Category: NY Providers

Find Medical Billing and Coding guidance for any Providers that operate in NY State

Posted in #reimbursement, NY Providers, Payer Updates, Payers and CPT reinbursement, Training

NYS Medicaid to cover TCM (Therapeutic Transcranial Magnetic Stimulation)

Posted on by KR2Medical Billing

The information discussed below applies to straight NYS Medicaid members for the DOS 10/1/25 and effective for any DOS on or 11/1/25 and thereafter for any Managed Medicaid Members.

What is TC? A non-invasive form of brain stimulation using magnetic pulses on specific areas of the brain. This therapy is used to improve the symptoms of major depressive disorder when conventional treatments have failed.

Who can perform these services?

A qualified psychiatrist with specialized training and certification.

Coding: providers please use the following codes-

Images via NYS Medicaid

Criteria:

  1. Any patient 18 years and older
  2. With a DX of major depressive disorder (please see the image below)
  3. Documented failure to achieve a satisfactory clinical response following at least two trials of antidepressants at adequate dosage, duration, and adherence.
  4. TCM is not the first line treatment
Image via NYS DOH

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Posted in #reimbursement, HealthFirst, NY Providers, Payer Updates, Payers and CPT reinbursement, Training

HealthFirst Telehealth mental health modifier update

Posted on by KR2Medical Billing

This update applies to HealthFirst following plan types: Medicaid, Personal Wellness Plan (HARP), and Medicaid Advantage.

Which services are affected?

Telehealth services done through a NY OMH licensed and or designated outpatient program.

Please refer to OMH modifier and rate code chart here.

Image via NYS OMH

To ensure the providers receive proper reimbursement, please make sure you go over payment rate changes and use the proper modifiers:

Modifier FQ- used for outpatient telehealth services, audio-only, for dual enrolled members.

Modofier 93- OMH providers – use this modifier for qualifying telehealth and audio-only mental health services, for members that are only enrolled in Medicaid.

The changes apply to the services performed on or after July 1st 2025.

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Posted in #aetna, #Medicareadvantage, #reimbursement, NY Providers, Prior Authorization Insurance Carrier Updates, Training

Aetna Medicare Advantage: reminder- certain post acute, skilled nursing and home health require pre- approval

Posted on by KR2Medical Billing

This change applies to the providers located in the following states:

NJ, NY, PA, VW

The pre-apporoval applies to some post-acute , skilled nursing, and home health services.

The following HCPCS are affected:

  • G0151: Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
  • G0153: Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.
  • G0155: Services of a clinical social worker in home health or hospice settings, each 15 minutes. 
  • All the codes until G0162

As well as the following codes:

G0299- Direct skilled nursing services of a Registered Nurse (RN) in the home health or hospice setting, each 15 minutes.

G0300-Direct skilled nursing services of a Licensed Practical Nurse (LPN) in the home health or hospice setting, each 15 minutes.

G0463- Skilled services by a Registered Nurse (RN) for observing and assessing a patient’s condition.

G0496- Skilled services by a Licensed Practical Nurse (LPN) for training or educating a patient or family member.

Inpatient Revenue code:

128- daily medical management, skilled rehab services, and regular physician (MD/NP/PA) oversight for intensive rehab patients

Skilled Nursing levels: 1,2,3,4.

Pre-auth process:

1. Go to EviCore.

2.Call 1-888-622-7329 during normal business hours.

3.Fax a request form to 866-705-3574 (Aetna Home Health), 855-633-8631 (AETNA PAC Initial) or 877- 502-0810 (AETNA PAC Concurrent)

For any urgent requess, when  member requires services in less than 48 hours, please call eviCore.

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