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Tag Archives: requesting

PHC Requesting Reimbursment for Preventative Care CPT 99395

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I am looking for some help regarding Partnership Health Plan (CA Medicaid). We have received a request to refund the payment for several preventative encounters due to the wrong CPT Code being used. PHC is stating that the 99395 is to used for recipients ages 18-21. Their reasoning is they follow Medi-Cal’s guidelines. And per Medi-Cal’s guidelines :

Office visits for preventive medical care for children must be billed
using CPT-4 codes 99381 – 99385 and 99391 – 99395, as appropriate.
CPT-4 codes 99385 and 99395 are only to be used with recipients 18 – 21 years of age.
When these codes are billed inappropriately, reimbursement of claims is delayed for medical review and subsequently reduced to more appropriate rates.

Due to the above guideline they have completely left out all patient’s ages 22-39!!!

My billing department has written a letter providing the documentation showing the code description of CPT 99395 as well as explaining their error. They will not budge!

Can anyone provide any assistance? Should I provide an appropriate 99213-99215? Or let the billing department know we will need to refund PHC their money? :confused:

Medical Billing and Coding Forum

Requesting a Policy Exception

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Has anyone successfully gotten a policy exception from an insurance company, for additional PT/OT/SLP visits? This would not be an appeal.

It is a Premera Plan in Washington state. The policy very clearly has a 14 visit combined cap and between the 3 disciplines, we’ve hit the cap already. I realize there is no reason to appeal the future denied claims, because the denial is valid. There is nothing to argue.

For this patient, a child with Down Syndrome, 14 visits isn’t nearly enough to make any progress.

Does anyone have any tips for how I can make this happen? I know policy exceptions are generally for Drugs and out of network services.

Medical Billing and Coding Forum

Requesting Interview HIM Director and HIM Supervisor

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Greetings:

I am currently enrolled in the RHIA program at Tacoma Community College. I have an upcoming assignment in my Revenue Cycle Managment Class. Are there any HIM Directors that would be willing to participate in an interview with me regarding budgets, semi-fixed costs and variances?
This interview will only take about 15 minutes and I would be so appreciative of the chance to interview you.

In a addtion, for a future assignment(s) in Enterprise Health Information Managment and Data Governance, I will need to interview a HIM Director or Supervisor regarding RAC audits. In addition, I will need to interview HIM Director that can provide me information on the workflow process of scheduling a patient appointment.

If there are any vounteers within the AAPC community that is willing to speak with me and provide me details for any or all of the subjects, please respond to this post or email me at [email protected].

Regards,
Dara Barnes RHIT, CPC-I,CPC,COC,CPMA,NAC

Medical Billing and Coding Forum

Medicare requesting office notes for AK’s

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We have just received a two page remit asking for medical notes for charges that had office visit w/ mod 25 and AK’s, ISK’s or BX’s on the same day. Is anyone else receiving these requests. We use to get one every once in a while asking for notes but this is 10 claims on a remit at one time.

Medical Billing and Coding Forum

When requesting authorization from insurance

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Good afternoon fellow coders!

I have a provider who is planning a dx hscope 58555 with POSSIBLE LOA 58559 and POSSIBLE polypectomy 58558 for intrauterine filling defect (of which ICD10 I am unsure to use), recurrent pregnancy loss, and acquired absent fallopian tube.

When requesting authorization for the surgery, how would you recommend I proceed? Include all cpt’s?

Thank you in advance for your assistance!

Medical Billing and Coding Forum