OBGYN coding and reimbursement of Antepartum Visits

This is a multipart message in MIME format.



I have a well-written appeal to BCBS FEP about an incorrect payment for
59426 - 7+ Antepartum Visits. It included the CPT Assistant article for the
proper billing of the code.



For this bulk billing code, the physician was paid $92.92.



At the lowest E/M level, if 99212 was billed for each visit, the provider
would have received 7 x $59.39 = $415.73. I wrote the appeal requesting a
reconsideration of payment and was told the plan allowance was $92.92 was
correct and no further payment would be made. It is overly apparent they
have an incorrect RVU assignment for this code.



And, since most billers take advantage of auto-downloading of BCBS payments,
you would not see the discrepancy if you didn't monitor each claim.



The amount paid for 7 visits does not cover the provider's care (which
included transferring the patient to a high-risk facility), administrative
costs, nor the costly malpractice premiums.



It is rare for this code to be billed and there is *always* a problem with
payment - ALWAYS. There is also a processing problem by the health plans
for 59425 (4 - 6 visits).



I want ACOG and the AMA to see this, it is time for me to use my credentials
and 38 years of experience to push this issue and protect the OB's right to
be paid when a patient transfers out for any reason.



Any contact information at either organization would be most appreciated.



Thank you,



Karen A. Hurley, BS, CMM, CPC, CNA

President, HPMSI

PO Box 409

Parrish, FL 34219

Tel: (941) 776-4822

Fax: (240) 368-0059

Web: www.hpmsi.com



Since 1996, Celebrating 20 years of Service to Physicians



Comments

  • Keisha Sutton at ACOG is their coding/reimbursement expert.

    ksutton@acog.org

    Beth Aldridge, CPC
    Coding Manager

    Northern California Medical Associates, Inc
    Phone: (707) 573-6145
    Fax: (707) 573-6932

  • The Medicare National Non-Facility RVU for 59426 is 23.42 (work=11.16, PE=9.72, Malpractice=2.54), for a fee allowance of $840.51.
    The Medicare National Non-Facility RVU for 59425 is 13.08 (work=6.31, PE=5.29, Malpractice=1.48), for a fee allowance of $469.42.

    Don't know if that will help, but it's a little more ammunition.



  • edited May 2017
    This is a multipart message in MIME format.



    Yes, I had this information, thanks so much !!!!!



    It's obvious from the payment, the RVU assignment is incorrect, but there
    are no ears at BCBS in the Appeal Department that will listen.



    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com



  • This is a multipart message in MIME format.

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    Not sure if I got back to the list on this, but here's the scope of the
    story:



    CareFirst Blue Cross Blue Shield (DC/MD/VA) - was reimbursing the value of
    one visit when CPT's 59425 or 59426 were being billed for antepartum care.
    I had appealed, providing the CPT Assistant citation on proper billing and
    Medicare's RVU assignment.



    They still denied any additional payment. (These CPT's are for a series of
    visits, not just one).



    After contacting the rep - and resending the appeal to her, she stated that
    CareFirst BCBS *does not* use RVU's when calculating payments for services,
    therefore that part of my appeal did not hold weight. She also stated they
    rely on industry experts to help them decide the proper billing method for
    CPT, along with specialty societies and CMS. None of these support the
    billing method they require.



    In a nutshell, to bill 59425 or 59426, you bill like this:



    01/01/2017 - 59425 (4-6 antepartum visits)

    01/15/2017 - 59425 (4-6 antepartum visits)

    01/22/2017 - 59425 (4-6 antepartum visits)

    01/29/2017 - 59425 (4-6 antepartum visits)



    It requires an over-ride in our system to price accordingly - and alters the
    units of how often this code is billed.



    Very frustrating to have to bypass the copyrighted CPT codes and descriptors
    to accommodate their misinterpretation. The sad thing is that a clinical
    reviewer supported their method.



    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com



    Since 1996, Celebrating 20 years of Service to Physicians



    Disclaimer: Advice or comments given in this email are specific only to the
    recipient and the presented issue. It is not intended to be used as a
    global solution for future similar events. Reproduction of the information
    requires approval by the author.





    From: Erika Utsler, CPC [mailto:eutsler@CHMBinc.com]
    Sent: Wednesday, February 22, 2017 11:32 AM
    To: Multiple recipients of list PARTB-L
    Subject: RE: [partb-l] OBGYN coding and reimbursement of Antepartum Visits



    The Medicare National Non-Facility RVU for 59426 is 23.42 (work=11.16,
    PE=9.72, Malpractice=2.54), for a fee allowance of $840.51.

    The Medicare National Non-Facility RVU for 59425 is 13.08 (work=6.31,
    PE=5.29, Malpractice=1.48), for a fee allowance of $469.42.



    Don't know if that will help, but it's a little more ammunition.







    From: Karen Hurley CMM CPC [mailto:karenhurley@hpmsi.com]
    Sent: Wednesday, February 22, 2017 8:21 AM
    To: Multiple recipients of list PARTB-L
    Subject: RE: [partb-l] OBGYN coding and reimbursement of Antepartum Visits



    Thank you, Beth!



    This is a start !!



    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com



    Since 1996, Celebrating 20 years of Service to Physicians



    Disclaimer: Advice or comments given in this email are specific only to the
    recipient and the presented issue. It is not intended to be used as a
    global solution for future similar events. Reproduction of the information
    requires approval by the author.





    From: Beth Aldridge [mailto:beth.aldridge@ncmahealth.com]
    Sent: Wednesday, February 22, 2017 10:44 AM
    To: Multiple recipients of list PARTB-L
    Subject: RE: [partb-l] OBGYN coding and reimbursement of Antepartum Visits



    Keisha Sutton at ACOG is their coding/reimbursement expert.



    ksutton@acog.org



    Beth Aldridge, CPC

    Coding Manager



    Northern California Medical Associates, Inc

    Phone: (707) 573-6145

    Fax: (707) 573-6932



    ** CONFIDENTIALITY NOTICE ***
    This e-mail transmission may contain PHI (Protected Health Information). If
    so, this e-mail is HIGHLY CONFIDENTIAL. It is intended for the exclusive
    use of the addressee. It is to be used only to aid in providing specific
    healthcare services to this patient. Any other use is a violation of
    Federal Law (HIPAA) and will be reported as such. If you have received this
    e-mail in error, please notify the sender immediately by reply e-mail.
    Please destroy all electronic and hard copies of the communication,
    including attachments.

    From: Karen Hurley CMM CPC [mailto:karenhurley@hpmsi.com]
    Sent: Wednesday, February 22, 2017 6:40 AM
    To: Multiple recipients of list PARTB-L
    Subject: [partb-l] OBGYN coding and reimbursement of Antepartum Visits



    I have a well-written appeal to BCBS FEP about an incorrect payment for
    59426 - 7+ Antepartum Visits. It included the CPT Assistant article for the
    proper billing of the code.



    For this bulk billing code, the physician was paid $92.92.



    At the lowest E/M level, if 99212 was billed for each visit, the provider
    would have received 7 x $59.39 = $415.73. I wrote the appeal requesting a
    reconsideration of payment and was told the plan allowance was $92.92 was
    correct and no further payment would be made. It is overly apparent they
    have an incorrect RVU assignment for this code.



    And, since most billers take advantage of auto-downloading of BCBS payments,
    you would not see the discrepancy if you didn't monitor each claim.



    The amount paid for 7 visits does not cover the provider's care (which
    included transferring the patient to a high-risk facility), administrative
    costs, nor the costly malpractice premiums.



    It is rare for this code to be billed and there is *always* a problem with
    payment - ALWAYS. There is also a processing problem by the health plans
    for 59425 (4 - 6 visits).



    I want ACOG and the AMA to see this, it is time for me to use my credentials
    and 38 years of experience to push this issue and protect the OB's right to
    be paid when a patient transfers out for any reason.



    Any contact information at either organization would be most appreciated.



    Thank you,



    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com



    Since 1996, Celebrating 20 years of Service to Physicians



    Disclaimer: Advice or comments given in this email are specific only to the
    recipient and the presented issue. It is not intended to be used as a
    global solution for future similar events. Reproduction of the information
    requires approval by the author.












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    Not sure =
    if I got back to the list on this, but here’s the scope of the =
    story:

     

    CareFirst Blue Cross Blue Shield (DC/MD/VA) – =
    was reimbursing the value of one visit when CPT’s 59425 or 59426 =
    were being billed for antepartum care.  I had appealed, providing =
    the CPT Assistant citation on proper billing and Medicare’s RVU =
    assignment.

     

    They still denied any additional payment.  (These =
    CPT’s are for a series of visits, not just one).

     

    After =
    contacting the rep – and resending the appeal to her, she stated =
    that CareFirst BCBS *does not* use RVU’s when calculating =
    payments for services, therefore that part of my appeal did not hold =
    weight.  She also stated they rely on industry experts to help them =
    decide the proper billing method for CPT, along with specialty societies =
    and CMS.  None of these support the billing method they =
    require.

     

    In a nutshell, to bill 59425 or 59426, you bill like =
    this:

     

    01/01/2017 – 59425 (4-6 antepartum =
    visits)

    01/15/2017 – 59425 (4-6 =
    antepartum visits)

    01/22/2017 – =
    59425 (4-6 antepartum visits)

    01/29/2017 – 59425 (4-6 antepartum =
    visits)

     

    It requires an over-ride in our system to price =
    accordingly – and alters the units of how often this code is =
    billed. 

     

    Very =
    frustrating to have to bypass the copyrighted CPT codes and descriptors =
    to accommodate their misinterpretation.  The sad thing is that a =
    clinical reviewer supported their method.

     

    Karen A. Hurley, BS, CMM, CPC, =
    CNA

    President, =
    HPMSI

    PO Box 409

    Parrish, FL 34219

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com

     

    Since 1996, Celebrating 20 =
    years of Service to Physicians

     

    Disclaimer:  Advice or comments given in this email are =
    specific only to the recipient and the presented issue.  It is not =
    intended to be used as a global solution for future similar =
    events.  Reproduction of the information requires approval by the =
    author.

     

     

    From: Erika Utsler, CPC =
    [mailto:eutsler@CHMBinc.com]
    Sent: Wednesday, February 22, =
    2017 11:32 AM
    To: Multiple recipients of list PARTB-L =
    <partb-l@list.partbnews.com>
    Subject: RE: [partb-l] =
    OBGYN coding and reimbursement of Antepartum =
    Visits

     

    The Medicare National Non-Facility RVU for 59426 =
    is 23.42 (work=3D11.16, PE=3D9.72, Malpractice=3D2.54), for a fee =
    allowance of $840.51.

    The Medicare National Non-Facility RVU for 59425 =
    is 13.08 (work=3D6.31, PE=3D5.29, Malpractice=3D1.48), for a fee =
    allowance of $469.42.

     

    Don’t know if that =
    will help, but it’s a little more =
    ammunition.

     

     

     

    From: Karen Hurley CMM CPC [mailto:karenhurley@hpmsi.com] =

    Sent: Wednesday, February 22, 2017 8:21 AM
    To: =
    Multiple recipients of list PARTB-L <partb-l@list.partbnews.com=
    >
    Subject: RE: [partb-l] OBGYN coding and reimbursement of =
    Antepartum Visits

     

    Thank you, =
    Beth!

     

    This is a start !!

     

    Karen A. Hurley, BS, CMM, CPC, =
    CNA

    President, =
    HPMSI

    PO Box 409

    Parrish, FL 34219

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com

     

    Since 1996, Celebrating 20 =
    years of Service to Physicians

     

    Disclaimer:  Advice or comments given in this email are =
    specific only to the recipient and the presented issue.  It is not =
    intended to be used as a global solution for future similar =
    events.  Reproduction of the information requires approval by the =
    author.

     

     

    From: Beth Aldridge [mailto:beth.aldridge@ncmahea=
    lth.com
    ]
    Sent: Wednesday, February 22, 2017 10:44 =
    AM
    To: Multiple recipients of list PARTB-L <partb-l@list.partbnews.com=
    >
    Subject: RE: [partb-l] OBGYN coding and reimbursement of =
    Antepartum Visits

     

    Keisha Sutton at ACOG is their =
    coding/reimbursement expert.

     

    ksutton@acog.org

     

    B=
    eth Aldridge, CPC

    C=
    oding Manager

     

    N=
    orthern California Medical Associates, Inc

    P=
    hone: (707) 573-6145

    F=
    ax:     (707) 573-6932

     

    ** =
    CONFIDENTIALITY NOTICE ***
    This=
    e-mail transmission may contain PHI (Protected Health =
    Information).  If so, this e-mail is HIGHLY CONFIDENTIAL.  It =
    is intended for the exclusive use of the addressee.  It is to be =
    used only to aid in providing specific healthcare services to this =
    patient.  Any other use is a violation of Federal Law (HIPAA) and =
    will be reported as such. If you have received this e-mail in error, =
    please notify the sender immediately by reply e-mail. Please destroy all =
    electronic and hard copies of the communication, including =
    attachments.

    From: =
    Karen Hurley CMM CPC [mailto:karenhurley@hpmsi.com] =

    Sent: Wednesday, February 22, 2017 6:40 AM
    To: =
    Multiple recipients of list PARTB-L
    Subject: [partb-l] OBGYN =
    coding and reimbursement of Antepartum =
    Visits

     

    I have a well-written appeal to BCBS FEP =
    about an incorrect payment for 59426 – 7+ Antepartum Visits.  =
    It included the CPT Assistant article for the proper billing of the =
    code.

     

    For this bulk billing =
    code, the physician was paid $92.92. 

     

    At the lowest E/M =
    level, if 99212 was billed for each visit, the provider would have =
    received 7 x $59.39 =3D $415.73.  I wrote the appeal requesting a =
    reconsideration of payment and was told the plan allowance was $92.92 =
    was correct and no further payment would be made.  It is overly =
    apparent they have an incorrect RVU assignment for this =
    code.

     

    And, since most =
    billers take advantage of auto-downloading of BCBS payments, you would =
    not see the discrepancy if you didn’t monitor each =
    claim.

     

    The amount paid for 7 =
    visits does not cover the provider’s care (which included =
    transferring the patient to a high-risk facility), administrative costs, =
    nor the costly malpractice premiums.

     

    It is rare for this =
    code to be billed and there is *always* a problem with payment =
    – ALWAYS.  There is also a processing problem by the health =
    plans for 59425 (4 – 6 visits).

     

    I want ACOG and the =
    AMA to see this, it is time for me to use my credentials and 38 years of =
    experience to push this issue and protect the OB’s right to be =
    paid when a patient transfers out for any =
    reason.

     

    Any contact =
    information at either organization would be most =
    appreciated.

     

    Thank =
    you,

     

    Karen A. Hurley, BS, CMM, CPC, =
    CNA

    President, =
    HPMSI

    PO Box 409

    Parrish, FL 34219

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com

     

    Since 1996, Celebrating 20 =
    years of Service to Physicians

     

    Disclaimer:  Advice or comments given in this email are =
    specific only to the recipient and the presented issue.  It is not =
    intended to be used as a global solution for future similar =
    events.  Reproduction of the information requires approval by the =
    author.

     

     

     

     

     

     * =
    * *Part B-L is sponsored by Part B News (www.partbnews.com), which is =
    published by DecisionHealth (http://www.decisionhealth.com)=
    . Call us toll-free =
    877-602-3835 To =
    unsubscribe: Go to http://www.decisionhealth.=
    com/partb-l
    ; Type in your email address; Click ?My Forums?; Click =
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    vacation? Set your membership to no email. Here?s how: http://www.decisionhealth.=
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    ; Type in your email address; Click ?my account?; Look =
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    list, use partb-l@list.partbnews.com=

     

     

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    published by DecisionHealth (http://www.decisionhealth.com)=
    . Call us toll-free =
    877-602-3835 To =
    unsubscribe: Go to http://www.decisionhealth.=
    com/partb-l
    ; Type in your email address; Click “My =
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    ; Type in your email address; Click “my =
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    *Part B-L is sponsored by Part B News (www.partbnews.com), which is =
    published by DecisionHealth (http://www.decisionhealth.com)=
    . Call us toll-free =
    877-602-3835 To =
    unsubscribe: Go to http://www.decisionhealth.=
    com/partb-l
    ; Type in your email address; Click ?My Forums?; Click =
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    ; Type in your email address; Click ?my account?; Look =
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    . Call us toll-free =
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    com/partb-l
    ; Type in your email address; Click “My =
    Forums”; Click =
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  • The idiocy of some payers never fails to surprise me!

    Sent from my iPhone

    > On Apr 15, 2017, at 6:17 AM, "Karen Hurley CMM CPC" wrote:
    >
    > Not sure if I got back to the list on this, but here’s the scope of the story:
    >
    > CareFirst Blue Cross Blue Shield (DC/MD/VA) – was reimbursing the value of one visit when CPT’s 59425 or 59426 were being billed for antepartum care. I had appealed, providing the CPT Assistant citation on proper billing and Medicare’s RVU assignment.
    >
    > They still denied any additional payment. (These CPT’s are for a series of visits, not just one).
    >
    > After contacting the rep – and resending the appeal to her, she stated that CareFirst BCBS *does not* use RVU’s when calculating payments for services, therefore that part of my appeal did not hold weight. She also stated they rely on industry experts to help them decide the proper billing method for CPT, along with specialty societies and CMS. None of these support the billing method they require.
    >
    > In a nutshell, to bill 59425 or 59426, you bill like this:
    >
    > 01/01/2017 – 59425 (4-6 antepartum visits)
    > 01/15/2017 – 59425 (4-6 antepartum visits)
    > 01/22/2017 – 59425 (4-6 antepartum visits)
    > 01/29/2017 – 59425 (4-6 antepartum visits)
    >
    > It requires an over-ride in our system to price accordingly – and alters the units of how often this code is billed.
    >
    > Very frustrating to have to bypass the copyrighted CPT codes and descriptors to accommodate their misinterpretation. The sad thing is that a clinical reviewer supported their method.
    >
    > Karen A. Hurley, BS, CMM, CPC, CNA
    > President, HPMSI
    > PO Box 409
    > Parrish, FL 34219
    > Tel: (941) 776-4822
    > Fax: (240) 368-0059
    > Web: www.hpmsi.com
    >
    > Since 1996, Celebrating 20 years of Service to Physicians
    >
    > Disclaimer: Advice or comments given in this email are specific only to the recipient and the presented issue. It is not intended to be used as a global solution for future similar events. Reproduction of the information requires approval by the author.
    >
    >
    > From: Erika Utsler, CPC [mailto:eutsler@CHMBinc.com]
    > Sent: Wednesday, February 22, 2017 11:32 AM
    > To: Multiple recipients of list PARTB-L
    > Subject: RE: [partb-l] OBGYN coding and reimbursement of Antepartum Visits
    >
    > The Medicare National Non-Facility RVU for 59426 is 23.42 (work=11.16, PE=9.72, Malpractice=2.54), for a fee allowance of $840.51.
    > The Medicare National Non-Facility RVU for 59425 is 13.08 (work=6.31, PE=5.29, Malpractice=1.48), for a fee allowance of $469.42.
    >
    > Don’t know if that will help, but it’s a little more ammunition.
    >
    >
    >
    > From: Karen Hurley CMM CPC [mailto:karenhurley@hpmsi.com]
    > Sent: Wednesday, February 22, 2017 8:21 AM
    > To: Multiple recipients of list PARTB-L
    > Subject: RE: [partb-l] OBGYN coding and reimbursement of Antepartum Visits
    >
    > Thank you, Beth!
    >
    > This is a start !!
    >
    > Karen A. Hurley, BS, CMM, CPC, CNA
    > President, HPMSI
    > PO Box 409
    > Parrish, FL 34219
    > Tel: (941) 776-4822
    > Fax: (240) 368-0059
    > Web: www.hpmsi.com
    >
    > Since 1996, Celebrating 20 years of Service to Physicians
    >
    > Disclaimer: Advice or comments given in this email are specific only to the recipient and the presented issue. It is not intended to be used as a global solution for future similar events. Reproduction of the information requires approval by the author.
    >
    >
    > From: Beth Aldridge [mailto:beth.aldridge@ncmahealth.com]
    > Sent: Wednesday, February 22, 2017 10:44 AM
    > To: Multiple recipients of list PARTB-L
    > Subject: RE: [partb-l] OBGYN coding and reimbursement of Antepartum Visits
    >
    > Keisha Sutton at ACOG is their coding/reimbursement expert.
    >
    > ksutton@acog.org
    >
    > Beth Aldridge, CPC
    > Coding Manager
    >
    > Northern California Medical Associates, Inc
    > Phone: (707) 573-6145
    > Fax: (707) 573-6932
    >
    > ** CONFIDENTIALITY NOTICE ***
    > This e-mail transmission may contain PHI (Protected Health Information). If so, this e-mail is HIGHLY CONFIDENTIAL. It is intended for the exclusive use of the addressee. It is to be used only to aid in providing specific healthcare services to this patient. Any other use is a violation of Federal Law (HIPAA) and will be reported as such. If you have received this e-mail in error, please notify the sender immediately by reply e-mail. Please destroy all electronic and hard copies of the communication, including attachments.
    > From: Karen Hurley CMM CPC [mailto:karenhurley@hpmsi.com]
    > Sent: Wednesday, February 22, 2017 6:40 AM
    > To: Multiple recipients of list PARTB-L
    > Subject: [partb-l] OBGYN coding and reimbursement of Antepartum Visits
    >
    > I have a well-written appeal to BCBS FEP about an incorrect payment for 59426 – 7+ Antepartum Visits. It included the CPT Assistant article for the proper billing of the code.
    >
    > For this bulk billing code, the physician was paid $92.92.
    >
    > At the lowest E/M level, if 99212 was billed for each visit, the provider would have received 7 x $59.39 = $415.73. I wrote the appeal requesting a reconsideration of payment and was told the plan allowance was $92.92 was correct and no further payment would be made. It is overly apparent they have an incorrect RVU assignment for this code.
    >
    > And, since most billers take advantage of auto-downloading of BCBS payments, you would not see the discrepancy if you didn’t monitor each claim.
    >
    > The amount paid for 7 visits does not cover the provider’s care (which included transferring the patient to a high-risk facility), administrative costs, nor the costly malpractice premiums.
    >
    > It is rare for this code to be billed and there is *always* a problem with payment – ALWAYS. There is also a processing problem by the health plans for 59425 (4 – 6 visits).
    >
    > I want ACOG and the AMA to see this, it is time for me to use my credentials and 38 years of experience to push this issue and protect the OB’s right to be paid when a patient transfers out for any reason.
    >
    > Any contact information at either organization would be most appreciated.
    >
    > Thank you,
    >
    > Karen A. Hurley, BS, CMM, CPC, CNA
    > President, HPMSI
    > PO Box 409
    > Parrish, FL 34219
    > Tel: (941) 776-4822
    > Fax: (240) 368-0059
    > Web: www.hpmsi.com
    >
    > Since 1996, Celebrating 20 years of Service to Physicians
    >
    > Disclaimer: Advice or comments given in this email are specific only to the recipient and the presented issue. It is not intended to be used as a global solution for future similar events. Reproduction of the information requires approval by the author.
    >
    >
    >
    >
    >
    >
    >
    >
    >
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    Content-Type: text/html;
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    The idiocy of some payers never fails to surprise me!

    Sent from my iPhone
    On Apr 15, 2017, at 6:17 AM, "Karen Hurley CMM CPC" <karenhurley@hpmsi.com> wrote:

    Not sure if I got back to the list on this, but here’s the scope of the story:

     CareFirst Blue Cross Blue Shield (DC/MD/VA) – was reimbursing the value of one visit when CPT’s 59425 or 59426 were being billed for antepartum care.  I had appealed, providing the CPT Assistant citation on proper billing and Medicare’s RVU assignment. They still denied any additional payment.  (These CPT’s are for a series of visits, not just one). After contacting the rep – and resending the appeal to her, she stated that CareFirst BCBS *does not* use RVU’s when calculating payments for services, therefore that part of my appeal did not hold weight.  She also stated they rely on industry experts to help them decide the proper billing method for CPT, along with specialty societies and CMS.  None of these support the billing method they require. In a nutshell, to bill 59425 or 59426, you bill like this: 01/01/2017 – 59425 (4-6 antepartum visits)01/15/2017 – 59425 (4-6 antepartum visits)01/22/2017 – 59425 (4-6 antepartum visits)01/29/2017 – 59425 (4-6 antepartum visits) It requires an over-ride in our system to price accordingly – and alters the units of how often this code is billed.   Very frustrating to have to bypass the copyrighted CPT codes and descriptors to accommodate their misinterpretation.  The sad thing is that a clinical reviewer supported their method. Karen A. Hurley, BS, CMM, CPC, CNAPresident, HPMSIPO Box 409Parrish, FL 34219Tel: (941) 776-4822Fax: (240) 368-0059Web: www.hpmsi.com Since 1996, Celebrating 20 years of Service to Physicians Disclaimer:  Advice or comments given in this email are specific only to the recipient and the presented issue.  It is not intended to be used as a global solution for future similar events.  Reproduction of the information requires approval by the author.  From: Erika Utsler, CPC [mailto:eutsler@CHMBinc.com]
    Sent: Wednesday, February 22, 2017 11:32 AM
    To: Multiple recipients of list PARTB-L <partb-l@list.partbnews.com>
    Subject: RE: [partb-l] OBGYN coding and reimbursement of Antepartum Visits The Medicare National Non-Facility RVU for 59426 is 23.42 (work=11.16, PE=9.72, Malpractice=2.54), for a fee allowance of $840.51.The Medicare National Non-Facility RVU for 59425 is 13.08 (work=6.31, PE=5.29, Malpractice=1.48), for a fee allowance of $469.42. Don’t know if that will help, but it’s a little more ammunition.   From: Karen Hurley CMM CPC [mailto:karenhurley@hpmsi.com]
    Sent: Wednesday, February 22, 2017 8:21 AM
    To: Multiple recipients of list PARTB-L <partb-l@list.partbnews.com>
    Subject: RE: [partb-l] OBGYN coding and reimbursement of Antepartum Visits Thank you, Beth! This is a start !! Karen A. Hurley, BS, CMM, CPC, CNAPresident, HPMSIPO Box 409Parrish, FL 34219Tel: (941) 776-4822Fax: (240) 368-0059Web: www.hpmsi.com Since 1996, Celebrating 20 years of Service to Physicians Disclaimer:  Advice or comments given in this email are specific only to the recipient and the presented issue.  It is not intended to be used as a global solution for future similar events.  Reproduction of the information requires approval by the author.  From: Beth Aldridge [mailto:beth.aldridge@ncmahealth.com]
    Sent: Wednesday, February 22, 2017 10:44 AM
    To: Multiple recipients of list PARTB-L <partb-l@list.partbnews.com>
    Subject: RE: [partb-l] OBGYN coding and reimbursement of Antepartum Visits Keisha Sutton at ACOG is their coding/reimbursement expert.  ksutton@acog.org Beth Aldridge, CPCCoding Manager Northern California Medical Associates, IncPhone: (707) 573-6145Fax:     (707) 573-6932 ** CONFIDENTIALITY NOTICE ***
    This e-mail transmission may contain PHI (Protected Health Information).  If so, this e-mail is HIGHLY CONFIDENTIAL.  It is intended for the exclusive use of the addressee.  It is to be used only to aid in providing specific healthcare services to this patient.  Any other use is a violation of Federal Law (HIPAA) and will be reported as such. If you have received this e-mail in error, please notify the sender immediately by reply e-mail. Please destroy all electronic and hard copies of the communication, including attachments.From: Karen Hurley CMM CPC [mailto:karenhurley@hpmsi.com]
    Sent: Wednesday, February 22, 2017 6:40 AM
    To: Multiple recipients of list PARTB-L
    Subject: [partb-l] OBGYN coding and reimbursement of Antepartum Visits I have a well-written appeal to BCBS FEP about an incorrect payment for 59426 – 7+ Antepartum Visits.  It included the CPT Assistant article for the proper billing of the code. For this bulk billing code, the physician was paid $92.92.   At the lowest E/M level, if 99212 was billed for each visit, the provider would have received 7 x $59.39 = $415.73.  I wrote the appeal requesting a reconsideration of payment and was told the plan allowance was $92.92 was correct and no further payment would be made.  It is overly apparent they have an incorrect RVU assignment for this code. And, since most billers take advantage of auto-downloading of BCBS payments, you would not see the discrepancy if you didn’t monitor each claim. The amount paid for 7 visits does not cover the provider’s care (which included transferring the patient to a high-risk facility), administrative costs, nor the costly malpractice premiums. It is rare for this code to be billed and there is *always* a problem with payment – ALWAYS.  There is also a processing problem by the health plans for 59425 (4 – 6 visits). I want ACOG and the AMA to see this, it is time for me to use my credentials and 38 years of experience to push this issue and protect the OB’s right to be paid when a patient transfers out for any reason. Any contact information at either organization would be most appreciated. Thank you, Karen A. Hurley, BS, CMM, CPC, CNAPresident, HPMSIPO Box 409Parrish, FL 34219Tel: (941) 776-4822Fax: (240) 368-0059Web: www.hpmsi.com Since 1996, Celebrating 20 years of Service to Physicians Disclaimer:  Advice or comments given in this email are specific only to the recipient and the presented issue.  It is not intended to be used as a global solution for future similar events.  Reproduction of the information requires approval by the author.      * * *Part B-L is sponsored by Part B News (www.partbnews.com), which is published by DecisionHealth (http://www.decisionhealth.com). Call us toll-free 877-602-3835 To unsubscribe: Go to http://www.decisionhealth.com/partb-l; Type in your email address; Click ?My Forums?; Click ?unsubscribe? Going on vacation? Set your membership to no email. Here?s how: http://www.decisionhealth.com/partb-l; Type in your email address; Click ?my account?; Look for ?Membership type? and click the arrow next to the box; Select no email; Click ?save changes?; Click ?log out.? If you belong to more than one of our forums, simply click on one of the forums and follow the same directions as above. The selection you make, e.g., ?no email,? should apply to all of your forums. To post to this list, use partb-l@list.partbnews.com    * * *Part B-L is sponsored by Part B News (www.partbnews.com), which is published by DecisionHealth (http://www.decisionhealth.com). Call us toll-free 877-602-3835 To unsubscribe: Go to http://www.decisionhealth.com/partb-l; Type in your email address; Click “My Forums”; Click “unsubscribe” Going on vacation? Set your membership to no email. Here’s how: http://www.decisionhealth.com/partb-l; Type in your email address; Click “my account”; Look for “Membership type” and click the arrow next to the box; Select no email; Click “save changes”; Click “log out.” If you belong to more than one of our forums, simply click on one of the forums and follow the same directions as above. The selection you make, e.g., “no email,” should apply to all of your forums. To post to this list, use partb-l@list.partbnews.com    * * *Part B-L is sponsored by Part B News (www.partbnews.com), which is published by DecisionHealth (http://www.decisionhealth.com). Call us toll-free 877-602-3835 To unsubscribe: Go to http://www.decisionhealth.com/partb-l; Type in your email address; Click ?My Forums?; Click ?unsubscribe? Going on vacation? Set your membership to no email. Here?s how: http://www.decisionhealth.com/partb-l; Type in your email address; Click ?my account?; Look for ?Membership type? and click the arrow next to the box; Select no email; Click ?save changes?; Click ?log out.? If you belong to more than one of our forums, simply click on one of the forums and follow the same directions as above. The selection you make, e.g., ?no email,? should apply to all of your forums. To post to this list, use partb-l@list.partbnews.com    * * *Part B-L is sponsored by Part B News (www.partbnews.com), which is published by DecisionHealth (http://www.decisionhealth.com). Call us toll-free 877-602-3835 To unsubscribe: Go to http://www.decisionhealth.com/partb-l; Type in your email address; Click “My Forums”; Click “unsubscribe” Going on vacation? Set your membership to no email. Here’s how: http://www.decisionhealth.com/partb-l; Type in your email address; Click “my account”; Look for “Membership type” and click the arrow next to the box; Select no email; Click “save changes”; Click “log out.” If you belong to more than one of our forums, simply click on one of the forums and follow the same directions as above. The selection you make, e.g., “no email,” should apply to all of your forums. To post to this list, use partb-l@list.partbnews.com



     
     
     
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  • Ain’t it the truth :(



    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219-0409

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com



    Since 1996, Celebrating 20 years of Service to Physicians



    Disclaimer: Advice or comments in this email are specific only to the recipient and the presented issue. It is not intended to be used as a global solution for future similar events. Reproduction of the information requires approval by the author.



    From: Jan Rasmussen [mailto:janrpcs@aol.com]
    Sent: Sunday, April 16, 2017 10:19 AM
    To: Multiple recipients of list PARTB-L
    Subject: Re: [partb-l] OBGYN coding and reimbursement of Antepartum Visits



    The idiocy of some payers never fails to surprise me!

    Sent from my iPhone


    On Apr 15, 2017, at 6:17 AM, "Karen Hurley CMM CPC" wrote:

    Not sure if I got back to the list on this, but here’s the scope of the story:



    CareFirst Blue Cross Blue Shield (DC/MD/VA) – was reimbursing the value of one visit when CPT’s 59425 or 59426 were being billed for antepartum care. I had appealed, providing the CPT Assistant citation on proper billing and Medicare’s RVU assignment.



    They still denied any additional payment. (These CPT’s are for a series of visits, not just one).



    After contacting the rep – and resending the appeal to her, she stated that CareFirst BCBS *does not* use RVU’s when calculating payments for services, therefore that part of my appeal did not hold weight. She also stated they rely on industry experts to help them decide the proper billing method for CPT, along with specialty societies and CMS. None of these support the billing method they require.



    In a nutshell, to bill 59425 or 59426, you bill like this:



    01/01/2017 – 59425 (4-6 antepartum visits)

    01/15/2017 – 59425 (4-6 antepartum visits)

    01/22/2017 – 59425 (4-6 antepartum visits)

    01/29/2017 – 59425 (4-6 antepartum visits)



    It requires an over-ride in our system to price accordingly – and alters the units of how often this code is billed.



    Very frustrating to have to bypass the copyrighted CPT codes and descriptors to accommodate their misinterpretation. The sad thing is that a clinical reviewer supported their method.



    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com



    Since 1996, Celebrating 20 years of Service to Physicians



    Disclaimer: Advice or comments given in this email are specific only to the recipient and the presented issue. It is not intended to be used as a global solution for future similar events. Reproduction of the information requires approval by the author.





    From: Erika Utsler, CPC [mailto:eutsler@CHMBinc.com]
    Sent: Wednesday, February 22, 2017 11:32 AM
    To: Multiple recipients of list PARTB-L
    Subject: RE: [partb-l] OBGYN coding and reimbursement of Antepartum Visits



    The Medicare National Non-Facility RVU for 59426 is 23.42 (work=11.16, PE=9.72, Malpractice=2.54), for a fee allowance of $840.51.

    The Medicare National Non-Facility RVU for 59425 is 13.08 (work=6.31, PE=5.29, Malpractice=1.48), for a fee allowance of $469.42.



    Don’t know if that will help, but it’s a little more ammunition.







    From: Karen Hurley CMM CPC [mailto:karenhurley@hpmsi.com]
    Sent: Wednesday, February 22, 2017 8:21 AM
    To: Multiple recipients of list PARTB-L
    Subject: RE: [partb-l] OBGYN coding and reimbursement of Antepartum Visits



    Thank you, Beth!



    This is a start !!



    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com



    Since 1996, Celebrating 20 years of Service to Physicians



    Disclaimer: Advice or comments given in this email are specific only to the recipient and the presented issue. It is not intended to be used as a global solution for future similar events. Reproduction of the information requires approval by the author.





    From: Beth Aldridge [mailto:beth.aldridge@ncmahealth.com]
    Sent: Wednesday, February 22, 2017 10:44 AM
    To: Multiple recipients of list PARTB-L
    Subject: RE: [partb-l] OBGYN coding and reimbursement of Antepartum Visits



    Keisha Sutton at ACOG is their coding/reimbursement expert.



    ksutton@acog.org



    Beth Aldridge, CPC

    Coding Manager



    Northern California Medical Associates, Inc

    Phone: (707) 573-6145

    Fax: (707) 573-6932



    ** CONFIDENTIALITY NOTICE ***
    This e-mail transmission may contain PHI (Protected Health Information). If so, this e-mail is HIGHLY CONFIDENTIAL. It is intended for the exclusive use of the addressee. It is to be used only to aid in providing specific healthcare services to this patient. Any other use is a violation of Federal Law (HIPAA) and will be reported as such. If you have received this e-mail in error, please notify the sender immediately by reply e-mail. Please destroy all electronic and hard copies of the communication, including attachments.

    From: Karen Hurley CMM CPC [mailto:karenhurley@hpmsi.com]
    Sent: Wednesday, February 22, 2017 6:40 AM
    To: Multiple recipients of list PARTB-L
    Subject: [partb-l] OBGYN coding and reimbursement of Antepartum Visits



    I have a well-written appeal to BCBS FEP about an incorrect payment for 59426 – 7+ Antepartum Visits. It included the CPT Assistant article for the proper billing of the code.



    For this bulk billing code, the physician was paid $92.92.



    At the lowest E/M level, if 99212 was billed for each visit, the provider would have received 7 x $59.39 = $415.73. I wrote the appeal requesting a reconsideration of payment and was told the plan allowance was $92.92 was correct and no further payment would be made. It is overly apparent they have an incorrect RVU assignment for this code.



    And, since most billers take advantage of auto-downloading of BCBS payments, you would not see the discrepancy if you didn’t monitor each claim.



    The amount paid for 7 visits does not cover the provider’s care (which included transferring the patient to a high-risk facility), administrative costs, nor the costly malpractice premiums.



    It is rare for this code to be billed and there is *always* a problem with payment – ALWAYS. There is also a processing problem by the health plans for 59425 (4 – 6 visits).



    I want ACOG and the AMA to see this, it is time for me to use my credentials and 38 years of experience to push this issue and protect the OB’s right to be paid when a patient transfers out for any reason.



    Any contact information at either organization would be most appreciated.



    Thank you,



    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com



    Since 1996, Celebrating 20 years of Service to Physicians



    Disclaimer: Advice or comments given in this email are specific only to the recipient and the presented issue. It is not intended to be used as a global solution for future similar events. Reproduction of the information requires approval by the author.












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