billing, non-reimbursed procedures

[ctts]

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If you do a procedure that does not get reimbursed by payor, what would you expect to happen? A recent example of mine would be billing 22899 for a Bertolotti pseudojoint injection, which I guess technically cannot be billed as a 64493 facet joint injection. Perhaps some of you are in academic setting and maybe it does not matter if a particular procedure gets reimbursed or not? Private practice would be different I am sure. Do you look through the numbers yourself to make sure you are getting paid? Do you have an office manager keeping tabs, to let you know when things are not getting reimbursed? Do you get notifications from your biller? To what extent does one just accept that for various reasons, somethings just are not going to get reimbursed? To what extent is this type of loss (hopefully rare/occasional) acceptable or not? I am just curious to know your general thoughts and how you handle this.

 

[deleted875186]

I would like to know as well, from any of the private practice people. I’ve heard billing companies are expensive, and they offer no gaurentee in terms of percent of claims they will get correct or reimbursed. How do you communicate with these billing companies? Reimbursement I hear takes at least 3 months, so potentially yojr doing a lot of procedures before you find out they are getting denied.

 

[pmrmd]

I would bill it as a payable code to start. If its a pseudojoint with some kind of capsule or something, I would bill a ligament injection under fluoro and move on.

 

[nvrsumr]

64493 is a “paravertebral” joint..

 

[RoloTomassi]

You could also do both the pseudo joint and the L5-S1 joint, then bill for the L5-S1 and at least you get paid for one.

 

[ctts]

Thanks everyone for the feedback in regards to billing of pseudojoint injection. Was not necessarily meant to be the focus of this thread, but it is helpful.

I would bill it as a payable code to start. If its a pseudojoint with some kind of capsule or something, I would bill a ligament injection under fluoro and move on.

Would the procedure note have to specifically mention "ligament" though?

64493 is a “paravertebral” joint..

The CPT description is: "paravertebral facet (zygapophyseal) joint". It does not say paravertebral "or" facet joint, but I suppose that is a technicality and one could stretch the definition...not sure if our biller would be willing to go along with that though.

You could also do both the pseudo joint and the L5-S1 joint, then bill for the L5-S1 and at least you get paid for one.

I would generally prefer for to do one or the other for more diagnostic specificity if possible, especially if considering the possibility of surgical resection of the pseudojoint. Also I would not want to put the patient through an additional injection if not necessary. But I suppose where there is pseudojoint pain, there is probably some facet joint pain too. So I can see how it is not unreasonable.

 

[drusso]

I just charge the patient cash.

 

[Ducttape]

I Bill for tpi under fluoro (20551 and 77003) if I am not mistaken.

 

[SSdoc33]

its not a TPI, and its not a paravertebral joint injection. this is the same problem as when you inject a pars defect. there is no code for it. if you call it anything else, technically it is fraud, but nobody is gonna chase you. you are "supposed" to go with the spine injection NOS code, whatever that is. basically it usually doesnt get paid and you eat the cost

 

[myrandom2003]

Can’t you just bill it as a 20610 or 20605 and use 77002 for fluoro?

 

[clubdeac]

are you getting prior authorization before you do these? If not, I would and if they deny it then don't use that code and resubmit prior authorization with a different code.

 

[Ducttape]

for the ones that I have done, I have gotten approval for trigger point with fluoro.

 

[painfree23]

for the ones that I have done, I have gotten approval for trigger point with fluoro.

So do you tell them ur injecting in a pseudo joint for the approval?

 

[NJPAIN]

How about MEDICARE?

- patient wants a three level MB RFN.
- patient wants Coolief not conventional
RF
ETC
Can you get an ABN and bill the patient??

 

[drusso]

How about MEDICARE?

- patient wants a three level MB RFN.
- patient wants Coolief not conventional
RF
ETC
Can you get an ABN and bill the patient??

Yes. Just imagine how cruel a world we would have if old people couldn't open up their own wallets and pay cash for medical treatment...

 

[Pain Applicant1]

If you do a procedure that does not get reimbursed by payor, what would you expect to happen? A recent example of mine would be billing 22899 for a Bertolotti pseudojoint injection, which I guess technically cannot be billed as a 64493 facet joint injection. Perhaps some of you are in academic setting and maybe it does not matter if a particular procedure gets reimbursed or not? Private practice would be different I am sure. Do you look through the numbers yourself to make sure you are getting paid? Do you have an office manager keeping tabs, to let you know when things are not getting reimbursed? Do you get notifications from your biller? To what extent does one just accept that for various reasons, somethings just are not going to get reimbursed? To what extent is this type of loss (hopefully rare/occasional) acceptable or not? I am just curious to know your general thoughts and how you handle this.

I have my own practice and have been doing my own billing for several years. Billing is very complex and I could write several pages on it but to summarize:

1. Always prior auth all procedures. This is no guarantee of payment but if it's authorized you can usually fight any denials. Make sure you always document names, times, dates, and reference numbers of all authorizations.
2. You must f/u on claims to learn what's being reimbursed and what's not. You also have to learn which payers pay for which procedures. It's almost like trial and error. In order to learn this, you literally must f/u on every single claim, or at a minimum all of the denied claims. After a while, you'll learn what you'll get paid for and what you won't get paid for. Then you simply just don't do the procedures for the payers which don't pay for them.
3. You must be able to access and audit all claims. You must understand how to do this with whichever billing company you're using.
4. Accept that you will not get paid for everything you do and it's just part of the business.
5. Try not to get too aggravated when dealing with billing it will only hurt you in the long run. The payers could care less. Don't blow your top when you wait on hold for an hour, someone picks up and the call disconnects after 30 seconds.

Billing is a very complicated system and dealing with it (along with the insurance companies) is the worst part of the job for me. I personally think it's set up this way on purpose as it makes it easier to deny claims. If credit card companies can have loads of data and information on a tiny credit card there is no reason this can't happy with healthcare. Why would it be so hard to have a simple program where you swipe the pt's card or enter in data and the deductible, copay, co-insurance, allowed procedures, etc populate a screen just like your data populates when you log in to your financial site?

 

[geauxg8rs]

I have my own practice and have been doing my own billing for several years. Billing is very complex and I could write several pages on it but to summarize:

1. Always prior auth all procedures. This is no guarantee of payment but if it's authorized you can usually fight any denials. Make sure you always document names, times, dates, and reference numbers of all authorizations.
2. You must f/u on claims to learn what's being reimbursed and what's not. You also have to learn which payers pay for which procedures. It's almost like trial and error. In order to learn this, you literally must f/u on every single claim, or at a minimum all of the denied claims. After a while, you'll learn what you'll get paid for and what you won't get paid for. Then you simply just don't do the procedures for the payers which don't pay for them.
3. You must be able to access and audit all claims. You must understand how to do this with whichever billing company you're using.
4. Accept that you will not get paid for everything you do and it's just part of the business.
5. Try not to get too aggravated when dealing with billing it will only hurt you in the long run. The payers could care less. Don't blow your lid when you wait on hold for an hour, someone picks up and the call disconnects after 30 seconds.

Billing is a very complicated system and dealing with it (along with the insurance companies) is the worst part of the job for me. I personally think it's set up this way on purpose as it makes it easier to deny claims. If credit card companies can have loads of data and information on a tiny credit card there is no reason this can't happy with healthcare. Why would it be so hard to have a simple program where you swipe the pt's card or enter in data and the deductible, copay, co-insurance, allowed procedures, etc populate a screen just like your data populates when you log in to your financial site?

Agree on all points, sage advice