Tag: #medicalcoding

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 HealthFirst, NY Providers, Payer Updates, Training, Updates

HealthFirst: new vision insurance payer

Posted on by KR2Medical Billing

HealthFirst members will no longer have coverage through Davis Vision and Superior Vision effective 1/1/24.

Optometry and Ophthalmology specialists that perform routine vision services and medical optometry services for HealthFirst members will now need to get contracted with the new vision insurance payer: EyeMed.

Starting 1/1/24, EyeMed will handle network management, prior authorization process, member and provider services, as well as claim payments for all routine services and medical optometry services (HealthFirst members)

Providers please contact EyeMed at EyeMedInFocus.com/Join to start the xontracting process.

Below please see the list (not all inclusive) of services that require prior authorization.

Not all inclusive

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