Posted in #Medicareadvantage, #unitedhealthcare, Training, Updates

Dialysis Billing Update: UHC Medicare Advantage

If you have patients with UHC Medicare Advantage Plan? Then this blog post is for you.

Starting October 1st 2021 UHC Medicare Advantage Plan updated their billing information in order to avoid Denials.

Modifiers: UHC Medicare Advantage Plan requests that providers bill the dialysis treatment with the following modifiers: CG or KX for dialysis treatment

Revenue Codes: 821 and 881

CPT code: 90999

Coverage: Dialysis treatments that exceed 14 treatments in a calendar month will be reviewed per CMS Frequency of Hemodialysis (A55703) LCD

If you would like to read the whole CMS Frequency of Hemodialysis (A55703) LCD please click here.


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Posted in #unitedhealthcare, Training, Updates

UHC Community Health (NY): nerve block reimbursement policy


Most commonly I receive the questions regarding separate reimbursement of nerve blocks like TAP (Transversus abdominis plane (TAP) block for abdominal surgery)- codes 64486 – 64489 Transversus abdominis plane (TAP) block. Unfortunately every insurance payer has its own policy regarding nerve block reimbursement. So, making sure that your medical biller knows where to look for that information is imperative to reduce unnecessary denials and improve your A/Rs.

If you are a surgeon that accepts UHC Community health patients then this blog post is for you!

According to UHC Community Health Provider communications: the below policy will be effective for DOS on or after 07/01/2021.

This change is made to align with NY State regulations.

The following is said:

“Administration of a nerve block (either as a component of the anesthesia itself or a postoperative pain management protocol) is considered part of the anesthesia time for the surgery. This will not be reimbursed as a separate and distinct procedurals services when performed by the same provider (or his/her associate) that has provided the same anesthesia for the surgical procedure itself.

Also Post Op visits are included in the total value for anesthesia services.


Healthy Medical Coding and Billing Practices: FREE MEDICAL BILLING AND CODING ADVICE!

It is important to make sure you are billing the proper codes. Billing code 69990 is not acceptable for TAP done for Laparoscopic procedure. Billing this code will trigger unnecessary denials and if you are an OON provider will not be as a “covered procedure” and the “provider total charge” will be applied to patient responsibility.


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#nerveblock #cpt69990, #cpt64486, #denials, #uhccommunityhealth, #reimbursement

Posted in Cinga Insurance, Updates

Cigna Update: Change to Shoulder Arthroplasty Coverage Review, 06/01/21

The following policy is effective 06/01/2021 and applies to Cigna Fully Insured and Self-Funded Plans.

Background: CMS and an evidence-based guidelines from MCG Health designate shoulder arthroplasty procedures (CPT codes 23470 & 23472) as outpatient, when medically appropriate.

Picture via Mayo Clinic 2014.

Starting 06/01/2021- Cigna may deny CPT 23470 & 23472, when requested for inpatient level of care. (inpatient setting).

eviCore will review the inpatient level of care requests for medical necessity and level of care. eviCore will base its review of medical necessity based on MCG Health criteria.

Denials will include the medical necessity appeal rights.

The above policy is basically the site-of-care policy for Cigna Fully Insured and Self-Funded Plans.

Possible Solution to avoid unnecessary Denials: Make sure you review the Cigna Shoulder Arthroplasty Policy and CIGNA Site-of-Care Policy. Site-of-Care policy will give you the criteria for the patient to qualify for the inpatient setting and receive inpatient level of care as oppose to outpatient setting (ASC).

(Shoulder Arthroplasty Policy is updated for 07/01/2021) Please visit the links above for the FULL CIGNA POLICIES.