Tag: #health

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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Posted in #reimbursement, BCBS Empire NY, NY Providers, Updates

Empire BCBS NY: Pharmacy Reimbursement Policy update 1/1/24

Posted on by KR2Medical Billing

According to the announcement by Empire BCBS for the state of NY- the payer added a new INFORMATIONAL modifier to represent the unused drug when the provider uses a single vial of medication/biologic. This policy applies to commercial Plan types.

Reimbursement Policy Number: C-11031. https://www.empireblue.com/docs/public/inline/C-18001_NY.pdf

Although the effective date of the policy is 6/17/23 the policy will only apply to the drugs/biologics that are administered to the member for DOS 1/1/24 and thereafter

JW modifier is not permitted when the actual dose of a covered drug/biologic administered from a single dose vial is less than the billing unit, as indicated in the HCPCS code description.

When administering medication/biologic, the provider needs to be conscious of what amount of medication the patient needs for their treatment. For example, if the provider requires 20 units and the medication/biologic drug comes in a 10 or 50 mil vial, then the provider should use the 2 10 mil vials to administer the needed dosage instead of using the 50 mil vial and appending the JW modifier to the unused portion of the medication/biologics.

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Posted in BCBS (Various States), Training, Updates

Empire BCBS Ohio: new AIM Specialty Health phone numbers

Posted on by KR2Medical Billing

If you are a physician that is accepts Empire BCBS Ohio members and requests services through AIM Specialty Health then this blog post is for you!

The following AIM Specialty Health phone numbers are effective 04/01/2022

StateAIM phone number
effective April 1, 2022
Indiana(833) 775-1952
Kentucky(833) 419-1357
Missouri(833) 305-1807
Ohio(833) 404-1678
Wisconsin(833) 342-1253

The old AIM Specialty Health Numbers will NO LONGER be active on August 15, 2022 and thereafter.

Physicians are encouraged to utilize self service via AIM is to use the ProviderPortalSM .

There physicians can:

  • Check order status and view order history
  • Print/save PDF of order summary
  • Use multiple staff members to enter/view the practice’s orders
  • Increase payment certainty
  • Reference desk training and tutorials, including clinical criteria and CPT lists

To register your practice in ProviderPortal. If you are not already registered, go to providerportal.com to register.

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