Roundtable Talk

Please use the Comment Field (Must be logged in) to Ask and Answer Pediatric Healthcare Administration/Management/Billing/Coding Inquiries. 

CPF will monitor this page to make sure all inquiries are being answered. We will try our best to connect you to helpful resources if your peers don't know the answer!

 

Comments

Madalyn McCauley's picture
Madalyn McCauley /

Watch the webinar "ICD-10: Swiftly transition and reap the benefits" here

Stephanie Lanham's picture
Stephanie Lanham /

Our practice has bee billing a separate E/M code with well visits if the patient presents with a problem during a well visit (ear infection, strep throat). Insurance companies are applying a copay to these visits because it is a well visit and (sick visit). Parents are getting upset about the copay due to plans covering well exams 100%. Please let me know how everyone is handling this.

Cathy Stevens's picture
Cathy Stevens /

That is tough but I tell the patient that the doctor treated the sickness and that diagnosis is on the claim so that part is not the well exam so it triggers the copay. I don't even get into the 2nd OV because alot of the time the insurances down code it anyway. This also sets the precedent to the patient that if they come in and want to get treated for two things they will probably have to pay a copay.

Stephanie Lanham's picture
Stephanie Lanham /

Thank you, I will forward your response to my physician and billing manager.

Susie Stokes's picture
Susie Stokes /

Copays are applied to sick visits regardless if it is scheduled sick visit or on the same day as a well visit. We just try to explain that to the parents so they also have an understanding of how the insurance works and also that we have kept them from having to reschedule the well visit. They seem to appreciate that. No matter what you say or do or what hoops we jump through we are NEVER going to make everyone happy!!

Stephanie Lanham's picture
Stephanie Lanham /

Thank you. I really forward your response to my physician and billing manager.

tpg316@comcast.net's picture
tpg316@comcast.net /

Yes indeed! Some insurance companies do apply a co-payment to the sick visit charge. Always safe to let patient know up front that a co-payment might be applied to the services, so that they are not surprise if they see this charge.

Stephanie Lanham's picture
Stephanie Lanham /

We let them know in advance already however parents are not happy when the bill comes in the mail. :-(

Susie Stokes's picture
Susie Stokes /

1. Has any one ever hired and used a Locum Tenens? If so, how did you do the billing?

Kathi Carney /

This is a good article that gives an overview. It covers the CMS guidelines, which as pediatrics, I realize may not be the actual carrier coverage, however; the basic concept is the same. Make sure to check with your individual local carriers as to their policies.

http://www.locumtenens.com/media/48747/billingforlt_-_general.pdf

Stephanie Lanham's picture
Stephanie Lanham /

Does anyone have a recommendation for a good collection agency? Also, I have a question about patients that are treated in an ER or urgent care center the same day they are seen in your office. We have been told that insurance will not pay for services rendered in our office if patient was seen at the ER or urgent care the same DOS. However, often our patients are seen in the ER overnight. Does it go by admission date to ER or discharge? Please clarify.

Madalyn McCauley's picture
Madalyn McCauley /

I'm not sure but I think several CPF members use Fox Collections-

joann.birdwell@foxcollection.com

I'm looking for someone to answer the insurance part :)

Cathy Stevens's picture
Cathy Stevens /

I think the answer is in the place of service and tax ID# so if they go the ED it is a different place of service as well as tax ID. Check with your carriers on that.

tpg316@comcast.net's picture
tpg316@comcast.net /

Hi All,

Aetna insurance is refusing to retro HPV vaccine charges for males over 15, stating that the denial is due to the drug being experimental for males 15 y/o and older. Even though the HPV for males over 15 y/o was allowed by Aetna as of 6/27/15, Aetna insurance still will not cover this if given prior the 6/27/15 allowed date.

Has anyone had similar problems with Aetna covering the HPV vaccine for males over 15 y/o prior to 6/27/15?

Thanks,
Sherese Collins
Terrace Pediatric Group

Stephanie Lanham's picture
Stephanie Lanham /

To my knowledge, our office has not received any denials for this problem.

Stephanie Lanham's picture
Stephanie Lanham /

How are your practices getting reimbursed for the 99420 code (Lead, Cholesterol, and Healthy Eating assessment)? We are billing with 25 and 59 modifiers for office visit and 99420, Which is considered an E and M code. Most of the denials are from Tenncare. Any help would be appreciated.

Madalyn McCauley's picture
Madalyn McCauley /

"We are using the modifier and billing one unit. Most insurances are paying.  "

Madalyn McCauley's picture
Madalyn McCauley /

On behalf of one of your peers:

"Is anybody having reimbursement issues with Bicillin?  We’re paying about $100 per dose and the reimbursement is about $20 for the immunization and less than $10 for the administration fee. We're using J code J0561 and CPT code 96372 with a 59 modifier.  The units billed is 1.2 u."

Lesley Ostrander's picture
Lesley Ostrander /

Is anyone else having issues with Aetna denying the 96110 when billed with well visit? They are denying it as 'benefit max has been met'. And they are not denying all--it is just a select few. But when we call customer service they tell us that we can only bill this code 5 times within a certain time span. We sometimes bill this code twice on a visit if they do the MCHAT plus ASQ. We've got modifier -59 on the second 96110 and a -25 on the OV, too. Aetna is so hard to get a straight answer out of so just trying to see if anyone is/was having the same issue and what they've done. We've never seen them do this prior to 2016. Thanks in advance for your help!

Madalyn McCauley's picture
Madalyn McCauley /

From one of your peers:

Some payers and specific plans will only cover 96110 for a certain number of encounters. For example, if the policy only allows 5 in one year, for a newborn to age 1, that will be used up quickly. Even if it is billed correctly, the payer goes by the specific plan.

Madalyn McCauley's picture
Madalyn McCauley /

"I need help with getting both of the flu tests paid by insurance. I bill 2 line items but the second (test?) inevitably gets denied.

Any suggestions on what’s going on?

I am using Modifier 76 only and 59 with 76…"

Madalyn McCauley's picture
Madalyn McCauley /

1. 

If they are using 87804 and testing for A and B with an E/M, it should be reported like this:

99213-25

87804

87804-59

 

2. Our office is being paid for both, we bill as follows:  one line item as 87804 QW and the other as 87804 QW, 59.  Let me know if you have questions.

 

3. We bill flu test as follows and receive payment on both lines:

87804

87804   59

 

4. For us we bill any BCBS and Amerigrouo as 2 units on one line the other insurances we bill two lines and the second line with a 59 modifier attached and we get paid 

Madalyn McCauley's picture
Madalyn McCauley /

Peer Question

"We recently received a new group contract from United Healthcare and I need some advise.
Currently, our doctors are under individual contracts but they would like for us to all switch to this group one.

Has anyone had this happen and if so why should we do it or not do it?

Any feed back would be greatly appreciated."

Madalyn McCauley's picture
Madalyn McCauley /

New Peer Inquiry

Topic: I am looking for advise about filing insurance on new patients and new problems under our Nurse Practitioners NPI. 

Details: We would like for our NP to be able to see new patients and new problems.

Questions:

1. In this case, is it required to file under the NP’s NPI in order for her to see new patients?
2. I know each insurance company is different, will most insurance companies pay less money if we file under the NP’s NPI? (I know she will need to be credentialed with every insurance that she isn’t already credentialed with.)
3. Do other offices bill under the MD’s NPI or do they bill under the NP’s NPI?
4. What are the downfalls to billing under the NP’s NPI? 

Madalyn McCauley's picture
Madalyn McCauley /

New Peer Inquiry
"I’m having trouble getting insurance to pay for 92552 for hearing screening on physicals.  Does anyone have any advice?"

Madalyn McCauley's picture
Madalyn McCauley /

Hi Everyone,

 

The Asthma Action Plan is coded under a CPTII code – 5250F.  Practices have had success getting this to go through their clearing houses by using a penny code, while others have had difficulty if their practice manager program does not accept the alpha character. 

 

If you have other questions, please do not hesitate to post here, let Madalyn know, or feel free to contact me directly.

 

Thanks,

Beverly

 

Beverly Puckett, RN, BSN

Population Health Associate

cid:image001.png@01CF1E7D.641A1550

3401 West End Avenue

Suite 290

Nashville, TN  37203

Office 615-875-8609

Fax 615-523-2103

Beverly.j.puckett@vhan.com

billing@brentwo... /

Is anyone billing for MCAT - code 96110 and getting reimbursed for it ? If so what are the rules regarding this .

Tiffany Lohner's picture
Tiffany Lohner /

We bill under the Well exam ICD-10 code, with a modifier 25 on the Preventive Code and are being paid by all payers, private and Tncare.