Category: Payers and CPT reinbursement

Posted in #aetna, Education, Payer Updates, Payers and CPT reinbursement, Training

AETNA Commercial Plans: compression supplies non covered codes.

Posted on by KR2Medical Billing

Please note that this policy update applies to the members that have commercial plan types.

The affected codes: for any DOS on or after Jan 1st 2026, Aetna will consider the following codes for compression stockings to be a disposable supply and a standard benefit exclusion.

Codes:

For Texas Providers:

These changes apply to fully insured plans written in Texas and only if such changes are in accordance with applicable regulatory requirements. Changes for all other plans will be as outlined in this article.

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Posted in #Medicareadvantage, #reimbursement, MVP (NY/VT) Insurance Payer, NY Providers, Payer Updates, Payers and CPT reinbursement, Training, Updates

Oral-Only Phosphate Binders reimbursement- MVP Medicaid, HARP plans

Posted on by KR2Medical Billing

To align with NYS Medicaid ESRD reimbursement for oral-only phosphate binders- MVP will include the reimbursement in the newly aligned Dialysis center APG reimbursement. Effective for any DOS 1/1/2026.

Higlights:

  1. Oral only Phosphate binders for ESRD members no longer will be dispensed through the pharmacy NYRx benefit
  2. The Phosphate binders will be dispensed by the dialysis center
  3. Reimbursement- no separate reimbursement will be made for oral only phosphate binders instead it is included in the new APG dialysis rate
  4. Dialysis centers should not bill a separate claim for these phosphate binders (ESRD patients)
  5. Oral only phosphate binders affected by this change: sevelamer carbonate, lanthanum carbonate, sucroferric oxyhydroxide, and ferric citrate.

NYS APG rate:

The FFS APG weight for APG 168 (dialysis) has increased from 1.3651 to 1.5302. 

For the NYS Medicaid announcement click here .

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

Understanding Nursing Home vs PDN Coding-NYS

Posted on by KR2Medical Billing

In order for us to understand the coding difference between the nursing home visit codes and PDN (private duty nursing) codes, we need to go back to the basics.

Definitions:

Nursing Home services/visits- the necessary intermittent or part-time nursing care provided for a patient in the patient’s home or home substitute on a per visit basis. These services are usually no more than 2 hours per day and are performed by the Certified Home Health Agency.

Private Duty Nursing services/visits- nursing services that are one on one more personal level, for medical fragile members, that are performed on continuous basis. The purpose of Private Duty Nursing is to assist the caregiver/family members to help the member to remain safely at home. There is a separate code set for PDN services and a corresponding fee schedule.

image is via NYS Medicaid website

Reimbursement:

Nursing Home Visits: are reimbursed in the increments of 15 min

PDN services/visits: are reimbursed by hour.

Exception: the following 2 code are reimbursed per diem because they represent the 13-hour shift

T1030- nursing care by RN, per diem, at home- 13 hour shirt

T1031- nursing care by LPN, per diem, at home- 13-hour shift

Coding–

I. Nursing Home Visits/Services:

a. T1002- RN services, up to 15 min

b. T1003- LPN services, up to 15 min

II. PDN services/visits:

a. S9123- RN services, per hour

b. S9124- LPN services, per hour

Please note that when you are billing the T codes you cannot bill them with the “other nursing codes” , listed below, or when the codes listed below better represent the nursing services that are authorized, performed.

Other Nursing Codes:

image via UHC website

Need more information about NYS Medicaid Home and Community LTC codes: please visit here

PDN services fee schedule, here.

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