Category: Payers and CPT reinbursement

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

NYS Medicaid POC Syphilis testing coverage

Posted on by KR2Medical Billing

Effective for any DOS August 2025 and thereafter Point of Care testing for Syphilis is covered for all fee fo service Medicaid and Managed Medicaid Members.

Where is this test covered (POS)?

physician/nurse practitioner/licensed midwife private office setting

What kind of POC is covered and reimbursed?

Currently there is only one FDA approved test -Clinical Laboratory Improvement Amendments-waived, rapid syphilis test, Syphilis Health Check™, for the detection of Treponema pallidum antibodies.

Coding:

86780 – Antibody; Treponema pallidum.

Reimbursement Rates:

Physician- https://www.emedny.org/ProviderManuals/Physician/ – select medicine fee schedule

Midwife- https://www.emedny.org/ProviderManuals/Midwife/ select fee schedule

Nurse Practitioner- https://www.emedny.org/ProviderManuals/NursePractitioner/

For more guidance on which providers are allowed reimbursement please read the NYS PDF file here.

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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

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

North Carolina Medicaid- self collected HPV test info.

Posted on by KR2Medical Billing

In March of 2024- FDA apprpved a self collecting HPV test.

It is a self collected HPV testing in a healthcare setting- patient uses a swab or brush in a private room (like in a doctor’s office) to collect their own vaginal sample for cervical cancer screening.

As of May 1st 2025, NC Medicaid added a new code 87624 or 87626.

87624- (2020) (infectious agent detection by nucleic acid [DNA or RNA]; Human Papillomavirus [HPV], high risk types) is eligible for reimbursement only when billed with ICD-10-CM diagnosis code Z11.51 

87626- Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), separately reported high-risk types (eg, 16, 18, 31, 45, 51, 52) and high-risk pooled result(s)

Eligibility:

-Only ages 30–64 years for routine cervical cancer screening

-No symptoms of abnormal bleeding, no active menstrual bleeding or use of vaginal products within 2 days

-Not HIV positive

-No history of cervical cancer

-Asymptomatic and eligible for primary HPV testing

Follow up recommendations based on the results:

-HPV negative – Repeat screening in 3 years

-HPV 16 or HPV 18 detected – Refer or return visit for colposcopy

-HPV types 56/59/66 detected with extended genotyping – Retest in 1 year at clinician’s discretion

-Other HPV detected with extended (or without) extended genotyping – Return visit for clinician-collected cervical specimen for cytology or dual stain

Resources:

1.American Cancer Society:  -https://cervicalroundtable.org/wp-content/uploads/2024/10/Self-Collection-Clinician-Communication-Guide.pdf

2. National Cancer Institute guidelines: https://dceg.cancer.gov/news-events/news/2025/self-collection-hpv-testing

3. NC Medicaid-

https://medicaid.ncdhhs.gov/blog/2025/05/02/changes-clinical-coverage-policy-1e-7-family-planning-services

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