Tag: #reimbursement

Posted in #aetna, #Medicareadvantage, #reimbursement, Payers and CPT reinbursement

Aetna: reimbursement update ventral hernia

Posted on by KR2Medical Billing

This change will apply to the dates of service on 4/1/26 and thereafter.

The plans that ate affected are commercial and Medicare.

Bundled payments:

The following codes will no longer be reimbursed separately-15374 and 49649, when billed with the following codes: venrtal hernia

Less than 3 cm- 49591 to 49594 and 49613 to 49616

3cm  to 10 cm- same codes.

For Washington members/plans-fpr commercial plans- the effective date will be given following a regulatory review.

For Texas- for fully ensured plans- this will be only if such changes comply with regulatory requirenments. For all other plan types are affected by this change

Find this type of information useful? Follow my blog for more payer updates!

Posted in #reimbursement, NY Providers, Payer Updates, Payers and CPT reinbursement, Pharmacy (Various Insurance Payers), Training

Healthfirst Pharmacy Update Contrast agent reimbursement

Posted on by KR2Medical Billing

The following information applies to the members in the following plans: Managed Medicaid Plans and Personal Wellness Plans (HARP)

Back in 2023, NYS DOH announced that there will be a change to the pharmacy benefits for MMC, HARP members- the pharmacy benefits will be covered but NYRx.

This change was finally implemented in April 2025.

To align closer with this policy Healthfist will NO LONGER reimburse separately for the the following contrast agents used in radiological testing.

Coding: the following codes are affected:

Images via Healthfirst website

NYS Medicaid Pharmacy website: information here

Find this information useful? Follow my blog for more payer updates #medicalbilling #medicalcoding #reimbursement #pharmacy

Posted in #reimbursement, NY Providers, Payer Updates, Payers and CPT reinbursement, Training

NYS Medicaid to cover TCM (Therapeutic Transcranial Magnetic Stimulation)

Posted on by KR2Medical Billing

The information discussed below applies to straight NYS Medicaid members for the DOS 10/1/25 and effective for any DOS on or 11/1/25 and thereafter for any Managed Medicaid Members.

What is TC? A non-invasive form of brain stimulation using magnetic pulses on specific areas of the brain. This therapy is used to improve the symptoms of major depressive disorder when conventional treatments have failed.

Who can perform these services?

A qualified psychiatrist with specialized training and certification.

Coding: providers please use the following codes-

Images via NYS Medicaid

Criteria:

  1. Any patient 18 years and older
  2. With a DX of major depressive disorder (please see the image below)
  3. Documented failure to achieve a satisfactory clinical response following at least two trials of antidepressants at adequate dosage, duration, and adherence.
  4. TCM is not the first line treatment
Image via NYS DOH

Find this type of information useful? Follow my blog! Learn payer updates #medicalbilling #medicalcoding #reimbursement.