Posted in In The Know Series, My services, Training, Updates

Empire NYSHIP Plans and member cost-sharing for diagnostic allergy and asthma testing: year 2020 and beyond

This post is for Allergy & Asthma providers that accept Empire NYSHIP (TPA UHC) patients and perform diagnostic asthma/allergy testing in the office setting (POS 11).

Commonly used CPT codes in Office Setting (w/ short description)

1. 95004- skin prick allergy testing

2. 95024- intradermal allergy testing

3. 95044- patch allergy testing

4.95018- Medication (Penicillin) allergy testing

5. 94200- Peak flow

6. 95012- NIOX or FENO

Member cost-sharing/patient co-pays for year 2020 and beyond:

Most of the Empire NYSHIP plans (there are various types), have updated their co-pay to $25 per office visit (specialist) Please click here to visit my post on the updated Empire NYSHIP co-pays.

However, as recent as last year, the Empire NYSHIP plans also started to add, an extra $25 member cost-sharing fee, to the above mentioned CPT codes. In order for your office not to leave this uncollected revenue on the table, please make sure to inform your front office staff of this change!  

Now  let’s take a look at 2 (TWO) examples.

Ex. 1. Patient comes in for the first time and has the environmental skin prick testing done the same day. The billing would be:  99204 25 with 95004X40 -the total patient financial responsibility would be $50: $25 for OV and $25 for testing.

Ex. 2. Patient with DX of Allergic Asthma (J45.30) is coming in for a follow up visit. The billing would be: 99213 25 with 94200 59 and 95012 59. In this instance the second co-pay would be applied to 94200 and 95012 would be paid. So, the patient will still pay only $50 co-pay.

Now, If you have any more questions about this post, Empire NYSHIP patients cost-sharing or something else, please go on my (SERVICES) page and contact me for a free 30-min Evaluation ($250 Value).

Posted in Insurance, Payers and CPT reinbursement, Training

Anthem BCBS Plans and CPT code 95012-updated medical reimbursement policy.

Is your private office practice seeing an increased number of denials for CPT code 95012? Well, maybe this is the answer why.

Some history for the CPT code 95012 first:

FENO (or NIOX) – CPT code 95012, has not been the most popular code amongst payers. In the last 5 years some payers listed in their medical policies that it was an investigational  and is not considered medically necessary.

Insurance payer 1199 has paid only for 2 (TWO ) of the CPT 95012 per 1 (ONE) year.  In early of 2019- payer SEIU 1199 changed its policy and is now paying for CPT 95012 when done more than 2(TWO) times per 1 (ONE) year.

However, this is about the most recent change. The change that was published on 02/27/2019 by  Anthem BCBS. Local plans like TUR, MFX, MYF-are affected.

The following is the Medical Policy Position Statement:

” Investigational and Not Medically Necessary: The measurement of exhaled nitric oxide or nasal nitric oxide is considered investigational and not medically necessary in diagnosis and monitoring of asthma or other respiratory disorders.” This is followed by a lengthy rationale and the cpt codes including the CPT code 95012.