Category: Payer Updates

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)
Image via Dreamstime.com

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

Find this information usefu Follow my blog for more information. #medicalcoding #medicalbilling #payerupdates

Posted in #reimbursement, #unitedhealthcare, Education, Payer Updates, Payers and CPT reinbursement

NJ Medicaid: Sickle cell Disease Generally Therapy- billing and coding

Posted on by KR2Medical Billing

Are you a provider in NJ that accepts NJ Managed Medicaid plans in your practice? Then this blog post is for you!

When: this applies for any services done on/and after Jan 1, 2026.

Who is eligible for reimbursement? Providers that are a member of the Center of International Blood and Marrow Transplant Research patient registry AND the provider must participate in the CMS study related to SCD gene therapies.

3. Which Plans- NJ Managed Medicaid Plans, ex. UHC Community Plan

Billing:

1. Professional Provider must bill on a separate professional claim (HCFA-1500)

2. Facility- drug must not be included on any facility claim, and added to any DRG or APC charges

3. SCD- must not be purchased at 340B program or be dispensed from 340B program inventory

Reimbursement:

4. Claims bust include the corresponding NDC, units, HCPCs and DX codes

Rebursement:

  1. The SCD is reimbursed at an invoice/ acquisition cost- the charges on the professional claim must equal to the Supplier invoice or the drug
  2. If the drug is billed through pharmacy (point of sale), the professional claim will not be reimbursed and will be processed as duplicate

Coding:

Please check out the following links for more coding info of the 2 drugs that fall under this policy:

Click to access billing-and-coding-guide.pdf

Lyfgenia Coding and Billing Resouces

Casgevy Billing and Coding Guide: https://www.casgevyhcp.com/sites/default/files/coding-and-billing-guide.pdf

Find this type of information useful? Follow my blog for more information. #medicalbilling #medicalcoding #reimbursent

Posted in EmblemHealth NY, HEDIS Measures, NY Providers, Payer Updates

Hedis Measure: Controlling Blood Pressure Controlling Blood Pressure

Posted on by KR2Medical Billing

Are you a provider that participates in reporting HEDIS measures? Then this blog post is for you!

What is this measure: the measure assesses if adults (18-85) with hypertension have their blood pressure adequately controlled, below 140/90 mm Hg. and below 130/80 Hg.

Documentation Requirements:

1. Adults 18-85 with a hypertension diagnosis. 

2. At least two visits during the measurement period with hypertension diagnoses, with a controlled reading occurring on or after the second diagnosis. 

3. Don’t forget to remove the members fhat were identified to have a nonacute inpatient admission during the measurement period.

4. Using remote devices to meet this HEDIS measure- some payers cover remote blood pressure devices ex. Emblem Health- place an order for the remote device through an In network DME provider- the cost cannot exceed $40. For this measure the patient read reading does not meet the medical criteria- the information should be transmitted to the provider from the device.

Coding: peoper codes to report the blood pressure measurements

  1. Systolic Blood Pressure CPT II:
    3074F – blood pressure less than 130 mmHg
    3075F – blood pressure 130-139 mmHg
    3077F – blood pressure greater than or equal to 140 mmHg
  2. Diastolic Blood Pressure CPT II:
    3078F – blood pressure less than 80 mmHg
    3079F – blood pressure 80‐89 mmHg
    3080F – blood pressure greater than or equal to 90

Find this information useful? Follow my blog for more information #HEDIS #medicalcoding #compliance