Tag: #medicalbilling

Posted in #unitedhealthcare, Insurance, Payer Updates, Prior Authorization Insurance Carrier Updates

UHC Knee/Hip Surgery documentation requirenments.

Posted on by KR2Medical Billing

Effective for services performed on Nov 1,2024 and there after, there will be new requirements for the prior authorization documentation applied to the Knee/Hip surgeries.

These changes/updates apply to self insured and fully insured plans nationwide.

Codes affected:

27445,27447, 27130 and 27132 

Knee Surgery Documentstion requirenments:

  1. Complete diagnostic imaging Reports: -Documented closure of skeletal plates (age less than 18 years)
    -Presence or absence of focal full-thickness articular cartilage defect
    -Size and location of focal cartilage defect
    -Outerbridge grade
    -Joint space and alignment
    -Ligament tear location and grade
  2. Diagnostic Images: – show the abnormality- MRI, Xray, Bone scan.
  3. Prior treatment documentation (prior year): -NSAIDs or acetaminophen ≥ 3 weeks*
    -PT or home exercise ≥ 12 weeks
    -Activity modification ≥ 12 weeks

*For TJR Knee ≥ 1 intra-articular corticosteroid injection may be used in place of NSAIDs.

For more information please click visit: https://www.uhcprovider.com/en/resource-library/news/2024/documentation-requirement-updates-total-joint-replacements.html

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#medicalpolicies, #reimbursement, #medicalcoding, #medicalbilling

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

Anthem BCBS (NY providers): PA/NP reimbursement

Posted on by KR2Medical Billing

According to Anthem BCBS (NY) starting for any DOS 11/1/24- the PA/NP will be updated to align with CMS guidelines.

Please note the following services will be eligible to be performed by the PAs/NPs and reimbursement reduction will apply:

– Preventative care services

-Radiology services

Services that are not going to be reimbursed separately:

-Drugs

-Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS)

-Laboratory Services and Laboratory Screening Services

Billing: PA/NP has to bill with their own TIN and NPI number.

For the full policy please click here:https://www.anthembluecross.com/provider/policies/reimbursement/

CMS payment for NP/PA services:

-NP services: 85% of Physician Fee for outside of hospital setting or SNF, or 80% of lesser billed charge

-NP services : incident to services done by auxiliary personnel outside hospital or SNF setting – 85% of Physician Fee Schedule

CMS link: https://www.cms.gov/medicare/payment/fee-schedules/physician-fee-schedule/advanced-practice-nonphysician-practitioners/advanced-practice-registered-nurses-aprns

-PA services: 85% of PFS- physician fee schedule.

CMS link: https://www.cms.gov/medicare/payment/fee-schedules/physician-fee-schedule/advanced-practice-nonphysician-practitioners/physician-assistants-pas

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Posted in #aetna, #Medicareadvantage, #reimbursement, Training, Updates

Aetna: Reimbursement for evaluations with G2082 and G2083 codes…

Posted on by KR2Medical Billing

According to Aetna, effective for DOS 3/1/24 and thereafter, evaluation codes 99212-99215, 99415–99417 will no longer be reimbursed separately when billed on the same DOS for the same member by the same provider.

This change will apply to Commercial and Medicare Advantage Plans.

Modifier 25 will not be able to override this claim edit and the payment for the E/M codes will be included in either code G2082 or G2083

G2082-temporary code for 2024- office or outpatient visit for evaluation and management of already established patient that requires physician or other qualified health care professional supervision up to 56 mg of esketamine nasal self- administration, includes 2 hours post-administration observation.

G2083-temporary code for 2024- office or outpatient visit for evaluation and management of already established patient that requires physician or other qualified health care professional supervision greater than 56 mg of esketamine nasal self- administration, includes 2 hours post-administration observation.

CTP codes 99415, 99416 are used to report the total amount of face-to-face time spent with the patient and/or family/caregiver by clinical staff in the office or
other outpatient setting, on a given date of service even if the time is not continuous. The
physician or qualified health care professional is present to provide direct supervision of the
clinical staff. Codes 99415, 99416 should not be used for prolonged services of less than 30
minutes total duration on a given date.

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