Explaining the Health Insurance 'Explanation of Benefits' | State of …

Explaining the Health Insurance ‘Explanation of Benefits’

By Lynne Shallcross

We are wrapping up the first phase of our PriceCheck project. We’re trying to shine a light on costs of common health care procedures in California. We’re starting with screening mammograms, and already we’ve found that the cash price (for people who are uninsured or have gone out of network) varies from a low of $60 at the H. Claude Hudson Comprehensive Health Center in Los Angeles, a county-run clinic, to $801 at UC San Francisco on the high end.

We’re also asking you, the members of our community, to share what you’ve been charged — and what your provider has been paid — for common health procedures.

In order to do that, you need to get familiar with your insurance company’s “explanation of benefits” or EOB. That’s the form your insurer sends to explain what was paid, to whom, at what level and why.

Here’s a typical EOB, that we’ve marked with some explanations below:

An explanation of benefits from Anthem Blue Cross.

An explanation of benefits from Anthem Blue Cross.

For help in decoding the EOB, we talked to Pat Palmer, founder and CEO of Medical Billing Advocates of America.

The information included on an EOB isn’t consistent from one health care insurance company to the next, Palmer says, and they often include abbreviations and other language difficult for the average consumer to understand.

We’ve numbered items above and here are the descriptions of each:

1. “Paid Amount.” This is the total amount of money that the insurance company has paid directly to the provider, Palmer says. Or, in an out-of-network situation, it may be paid to the member. If you scan farther across that line to the right, you’ll see who the insurance company paid; in this case, it’s Mills Hospital.

2. “Total Billed.” These are the amounts being billed to the insurance company by the provider for each service — in this case, $51.50 for mammography (likely what the physician was paid to interpret the mammogram although it does not say) and $365.12 for the screening mammogram (likely the facility fee for the patient to have the mammogram done although it does not say). The charges are then totaled below the line.

In addition to an EOB, individuals will usually receive an itemized bill from their provider(s). Palmer says it’s important to be sure the total billed amount on the EOB — in this case, $416.62 — matches the total billed amount on the itemized bill from the provider.

3. “Patient Savings.” This is the difference between what the provider charged for this service and the amount they agreed to accept as a participating provider of your health insurance plan. That’s because when a doctor or other provider agrees to contract with an insurer, they agree to accept reimbursement at a lower price than the charged price. In American medicine, the amounts charged by providers generally bear little relation to what they are ultimately paid.

There should always be a code that identifies the reason for the savings, Palmer says. And although it’s a little hard to see, there is a “01” that follows each charge in this column — that “01” corresponds to the “detail message” in the box below. “It’s usually clearer than that,” Palmer says, adding that consumers reading this EOB may miss that little “01” mark after the charge. “It’s usually a separate column that says ‘remark’ or ‘reason,’ and they’ll put the ‘01’ in there.”

In this case, Palmer says the “01” remark indicates that the provider billed more than was allowed under their agreement with the insurer, and the individual is not responsible for the difference.

4. “Applied to Deductible.” Many health plans require members to pay out a certain amount of money, a “deductible,” before the insurance will begin paying, Palmer says. If the individual has not met the deductible and has to pay for these medical services, the amount that is being applied toward his or her deductible would be in this column. But the Affordable Care Act mandates that some services are provided outside the deductible, at no cost to patients. These services include some cancer screening tests, such as a mammogram. In this EOB, we see that the patient has no amount applied to deductible.

But even if the service is being applied to the deductible, Palmer says that the amount that goes in the “applied to deductible” column will be the lesser, agreed-upon amount — not the higher, original amount that the provider billed.

5. “Coinsurance, Copayment Amount.” This may vary depending on what health insurance you have. Sometimes, members must make a copay for an office visit, for example. That is a flat fee. Other services may require coinsurance, a percentage of the cost of the service. If the member on this EOB had been required to pay a copay or a coinsurance for the service, the amount would be listed here.

6.”Claims Payment.” The amounts in this column break down what the insurance company paid to the provider for each service, with a total at the bottom.

7. Palmer says this is an important part of this EOB. In this case, it’s the insurance company telling the member that it is not his or her responsibility to pay the difference in price between the agreed-upon charges for these services and the amount the provider billed. “It’s very easy to read this [as], ‘It is your responsibility to pay $104’ — somebody could misread it and think they owe $104.15,” Palmer says. “That word ‘not’ should be bold or stand out a lot more.” On some EOBs, Palmer says there is an additional line that says what the patient’s payment responsibility is; in this case, it would list it as $0.

But your EOB might look different from the example above. Or a mailed EOB may look different from what you see online. The above example is a mailed EOB from Anthem Blue Cross, a major health insurer in California. Below is an online EOB which is also from Anthem Blue Cross, yet it looks quite different. (The numbers in the EOB below line up with the explanations we’ve provided.)

Numbers 1, 2, 4 and 5 line up with explanations we have provided. But there are no terms on this EOB that line up with 3, 6 and 7 above. Yes, we know this is confusing.

An Explanation of Benefits from Anthem Blue Cross, retrieved online.

An Explanation of Benefits from Anthem Blue Cross, retrieved online.

Other things Palmer suggests paying attention to on an EOB:

• Look at the “provider of services” and “place of service,” listed on this EOB as “Mills Hospital” and “outpatient.” Palmer says insurance companies often pay a different rate depending on whether the service was provided in an inpatient setting, outpatient setting or a doctor’s office. “The insurance company is the one that wrote this up, and they may have miscoded the place of service,” Palmer says. “When they do, it will vary on how much your plan pays and how much you’re responsible for.”

• Look for a CPT code (Current Procedural Terminology). CPT codes were developed by the American Medical Association and  identify the health care service provided. Palmer says that most times, insurance companies print either a “type of service” (as is listed on this EOB) or a CPT code — but not both. And Palmer says having one, but not both, makes it a bit more difficult to determine if the provider is billing for the right services.

Palmer gives the example of a chest x-ray. If “type of service” is listed as chest x-ray, the individual can’t tell if the charge is for one view or three views, and the price will differ depending. Palmer says it’s often a good idea to call the insurance company to get the CPT code. If the CPT code is written on your EOB, instead of a description of service, Palmer says it’s easy to Google that code and see if it matches up with the service you received.

• Pay close attention to the message or comment box, Palmer says, and be sure you understand why a certain amount is not payable. If an insurance company says something is not payable, it could be a non-covered service that the individual is responsible for. Or, it could be a charge above what the provider and insurer agreed upon, meaning the individual does not have to pay. “Knowing that reason tells you whether you are responsible or not responsible for it,” Palmer says.

• Double-check the calculations on the EOB. Know the benefits that are part of your plan, Palmer says, and keep track of any payments you’ve made toward a deductible. Know where you are in your progress of meeting your deductible and when the insurance company is supposed to start paying.

If you scour your EOB and you do find an error, Palmer says you should determine who made the error — the provider or the insurer — and then follow up with them to correct the error.

Finding and correcting an error on an EOB may mean that you, as the individual member, aren’t overcharged, Palmer says. But it also may mean that the insurance company isn’t overcharged by the provider. While our natural instinct may not be to save a health insurance company some money, Palmer says that insurance companies will make profits regardless — so expensive errors only translate to higher premiums passed on to members down the road.


(MELA) MelaFind System Enabled Insurance Reimbursement …

(MELA) MelaFind System Enabled Insurance Reimbursement Process

IRVINGTON, N.Y., July 10, 2014  — MELA Sciences, Inc. (Nasdaq:MELA), announced today that it has taken the first step in the process of seeking insurance reimbursement for its Multi-Spectral Digital Skin Lesion Analysis (MSDSLA) procedure that is performed by dermatologists utilizing the MelaFind® system as an aid in the detection of melanoma. The company has submitted an application for a Current Procedural Terminology (CPT®) code, which is necessary for Medicare Part B reimbursement by the Centers for Medicare and Medicaid Services (CMS). MSDSLA could be eligible for payment under Part B as early as January 1, 2016. The company will also commence efforts to obtain reimbursement from private insurance companies as the CMS review process proceeds.

CPT codes are determined by the American Medical Association (AMA) under a rigorous review process. Currently, there is no CPT code available for the MelaFind process. The AMA’s CPT Editorial Panel ultimately decides whether to accept a new code, and will refer a new code to the AMA’s Relative Value Scale Update Committee (RUC). The RUC determines the relative value of physician work within the procedure or service and makes a recommendation to CMS. CMS then establishes the appropriate reimbursement level for the service. Obtaining Medicare reimbursement is critical in order to secure reimbursement from other public and private insurers.

Rose Crane, President and CEO of MELA Sciences, commented, “Our CPT application is the first concrete step in achieving our goal of obtaining insurance reimbursement for physician use of the MelaFind system. MelaFind’s ability to improve diagnostic accuracy without increasing the number of biopsies, as demonstrated with the data presented at the 2014 American Dermoscopy Association Meeting is very meaningful to both patients and physicians and ultimately can save costs in the healthcare system. We believe our application makes a compelling argument in favor of receiving the CPT code and for obtaining reimbursement from CMS.”

The poster presentation at the meeting measured the impact of the MelaFind information on a dermatologist’s decision to biopsy high risk lesions. The biopsy sensitivity of dermatologists (a measure of the percentage of lesions correctly identified as melanoma) increased from 68% to 89% with the addition of the MelaFind probability information, and specificity (a measure of the percentage of lesions correctly identified as not being melanoma) increased from 39% to 54%. The average percentage of benign lesions selected for biopsy decreased from 61% to 46%. The p-value in all three measurements was statistically significant at p<0.001. There was a non-significant change in the percentage of total lesions selected for biopsy.

About MelaFind  www.melafind.com

MelaFind is the first and only medical device with FDA Pre-Market Approval (PMA) for the U.S. and CE Marking certification for the European Union designed to assist dermatologists in the evaluation and diagnosis of melanoma at its most curable stage. The MelaFind® system utilizes innovative software driven technology and state-of-the-art 3-D optical imaging to non-invasively extract data 2.5 mm below the skin surface from patient’s pigmented ambiguous moles and objectively analyzes them with proprietary algorithms. MelaFind provides important additional perspective to physicians via 3-D spectral images and 100% objective data analysis to help them better understand the structural disorganization of a patient’s pigmented ambiguous moles (before cutting the skin) during the evaluation and diagnosis process for melanoma.

About MELA Sciences, Inc.  www.melasciences.com

MELA Sciences is a medical technology company dedicated to designing and developing innovative software-driven technology for the clinical early detection and prevention of skin cancer. MELA Sciences conducted the largest, positive prospective study ever done on the melanoma disease, and is the first and only medical technology company to receive both FDA Pre-Market Approval (PMA) for the U.S. and CE Marking certification for the European Union for a device of this nature.

Safe Harbor

This press release includes “forward-looking statements” within the meaning of the Securities Litigation Reform Act of 1995. These statements include but are not limited to our plans, objectives, expectations and intentions and may contain words such as “seeks,” “look forward,” and “there seems” that suggest future events or trends. These statements, including our expectations regarding our ability to obtain a CPT code and appropriate reimbursement for our MelaFind system, are based on our current expectations and are inherently subject to significant uncertainties and changes in circumstances. Actual results may differ materially from our expectations due to financial, economic, business, competitive, market, regulatory and political factors or conditions affecting the company and the medical device industry in general, as well as more specific risks and uncertainties set forth in the company’s SEC reports on Forms 10-Q and 10-K. Given such uncertainties, any or all of these forward-looking statements may prove to be incorrect or unreliable. MELA Sciences assumes no duty to update its forward-looking statements and urges investors to carefully review its SEC disclosures available at www.sec.gov and www.melasciences.com.

         Diana Garcia Redruello
         MELA Sciences, Inc.

         Andrew McDonald
         LifeSci Advisors, LLC

CPT Billing Codes for Low Level Laser Cold Laser Therapy …

Many practitioners are asking, “How can I receive insurance reimbursement when using a cold laser or low level laser for treating patients who only pay through their insurance.” The key is in understanding and using correct CPT Billing Codes for Low Level Laser and Cold Laser Therapy applications.

While not all insurance companies reimburse for cold laser therapy. The ones that do require proper use of the following CPT codes.

Current Procedural Terminology or CPT for short:

* CPT Codes are codes that are maintained by the American Medical Association. Following are “the most widely accepted medical nomenclature codes used to report medical procedures and services under public and private health insurance programs. “After a diagnosis is made and an appropriate code is assigned (see above), insurance billing is made under a particular CPT code.

Because cold laser or LLLT does not have its own CPT codes, the following codes are being used for reimbursement:

97039 Physical Medicine and Rehabilitation; constant attendance unlisted modality; 15 minutes

For billing, this code should be accompanied by a one-page description of the treatment and the therapy. Otherwise, it may be denied. When you submit the code, try this: “97039 Attended FDA cleared infrared laser therapy.” 97140 Manual Therapy Techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction); one or more regions; each 15 minutes.

This billing code is used for what you are doing and/or accomplishing, not the technique used (i.e. laser). If an insurance carrier requires documentation, state what area was treated and what was accomplished (i.e. drainage, mobilization, etc.).

97026 Infrared

This code refers to an infrared heat lamp, but cold lasers are not an infrared heating device. Consequently, reimbursement can be low. To improve reimbursement, list it as an attended modality or by adding a -22. Here are examples:

97026: Attended photonic simulation

97026: Attended infrared light therapy

97026–22: Attended infrared therapy

97032 Attended Electrical Stimulation; manual; one or more regions; each 15 minutes

This code can be billed in a number of ways. The code (97032) stays the same, but the description changes to reflect the service performed. For example:

97032: Attended Electrical-Photonic Stimulation

97032: Attended Electrotherapy/IR

97032: FDA Cleared Laser Photonic Stimulation

97139 Unlisted Therapeutic Procedure
This code is for a therapeutic procedure meaning that the doctor must have one-on-one contact with the patient. The strength of the code is that it tells the insurance carrier that the doctor is spending direct treatment time with the patient. The weakness of the code is that an unlisted procedure is more likely to be closely inspected by an insurance carrier.

97112 Neuromuscular Re-Education and Gait Training (movement, balance, coordination, kinesthetic sense, posture, and proprioception for sitting or standing activities); constant attended; each 15 minutes

97799 Physical Medicine and Rehabilitationâ??Unlisted Service or Procedure (requires documentation, fees negotiated)

97901 Acupuncture Modality

**Please note that CPT codes ending in “9? require documentation. For example, 97039-FDA Cleared Laser Therapy. Additional documentation explaining the therapy may also be required.


International Classification of Diseases, Clinical Modification, 10th Revision (ICD-10-CM)

According to the Centers for Disease Control, the ICD-10-CM “is the official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States.” These codes are used in billing and reimbursement for medical diagnoses and procedures.

Cold Laser or Low-Level Laser Therapy (LLTT) is used to treat a variety of medical conditions. The following list of diagnoses may be appropriate for cold laser therapy. Please consult your doctor or the ICD-10-CM TABULAR LIST of DISEASES and INJURIES available on cdc.gov.

Suggested Clinical Uses for Cold Laser Therapy:


  • Rheumatoid Arthritis
  • Epicondylitis
  • Carpal Tunnel Syndrome
  • Bursitis
  • Plantar Fasciitis

Primary Diagnosis

  1. Pain
  2. Restricted range of movement/stiffness
  3. Edema
  4. Effusion
  5. Paresthesia
  6. Inflammation
  7. adicular Pain
  8. Muscle Spasms
  9. Myofasciitis


  • Fibromyalgia
  • Bursitis
  • Lower back pain
  • Myofascial Pain
  • Fasciitis
  • Neck/Cervical pain

Primary Diagnosis

  1. Pain
  2. Restricted range of motion/stiffness
  3. Inflammation
  4. Effusion
  5. Edema
  6. Muscle spasms
  7. Mysofasciitis


  • Tendonitis
  • Tendon Ruptures
  • Sprains
  • Strains

Primary Diagnosis

  1. Pain
  2. Inflammation
  3. Restricted range of motion/stiffness
  4. Effusion
  5. Edema
  6. Muscle spasms
  7. Myofasciitis
  8. Radicular pain


Temporomandibular (TM) disorders

  • Ligament injury
  • Dislocations
  • Osteoarthritis

Primary Diagnosis

  1. Joint pain
  2. Inflammation
  3. Restricted range of motion/stiffness
  4. Joint effusion
  5. Edema


  • Muscle bruises/contusions
  • Muscle contractures
  • Muscle ruptures
  • Myositis

Primary Diagnosis

  1. Muscle Pain
  2. Inflammation
  3. Restricted range of motion/stiffness
  4. Muscle spasms
  5. Edema
  6. Myofasciitis


  • Ruptured disc
  • Prolapsed disc
  • Crush injuries
  • Neuritis

Primary Diagnosis

  1. Radicular pain
  2. Myofasciitis
  3. Decreased range of motion/stiffness
  4. Inflammation
  5. Muscle spasms
  6. Paresthesia
  7. Edema
  8. Effusion


  • Burns
  • Skin ulcers
  • Skin grafts
  • Surgical incisions

Primary Diagnosis

  1. Joint pain
  2. Inflammation
  3. Restricted range of motion/stiffness
  4. Edema

Sleight of hand: The SGR bill's important policy changes

What would you think if I told you that Medicare will require laboratories to disclose to CMS payment rates from private insurers? Or that they will identify physicians who order a high volume of CT tests and require them to pre-authorize those tests in 2020?  How about that CMS will begin its own analysis of the time and cost of providing services in order to determine RVUs, a job currently done by the AMA RUC committee? Would you be surprised?  Or, at least surprised you hadn’t heard about it?  Both the House and Senate have passed HR 4302, which provides another temporary fix to the sustainable growth rate (SGR) formula and a delay in the implementation of ICD-10.

In the furor over the manner in which the SGR fix bill was passed by the House and the accompanying howling about the delay of ICD-10, important policy changes included in the bill were left unmentioned. And some professional societies who had advocated for the ICD-10 delay weren’t happy with the bill, citing dismay at another temporary fix.  Perhaps there were objections to the three huge policy changes in the bill.

Section 216 is  “improving Medicare policies for clinical diagnostic laboratory tests.” The first section title, however, tells a fuller tale. “Reporting of private-sector payment rates for establishment of Medicare payment rates.” And the policy is just that. It requires that beginning in January 2016 laboratories report to Medicare their payment rates from private insurance companies. Laboratories will be required to report both the payment and volume including discounts on all non-capitated business. If the lab has multiple rates with one payer all of those rates must be reported.  A payer is defined as a health insurance company, a Medicare Advantage plan or Medicaid managed care plan. I don’t need to tell you why Medicare wants this information, do I? But, they aren’t being coy. It is in order to adjust their payment rates for lab services.

Section 218 will dismay some physicians who order high volumes of CT tests. (Whoever develops the titles for these sections is pure genius. This section is entitled “quality incentives for computed tomography diagnostic imaging and promoting evidence-based care.”) CMS wants to recognize the appropriate use of these technologies and be sure they’re used only for developed or endorsed indications. Starting in 2017 they will identify no more than 5% of ordering physicians who are outliers in ordering these tests and who have low adherence to the evidence-based guidelines. Beginning in 2020, it will require prior authorization for these high users to order these tests.  Exceptions are made for emergency care.

Most of you reading this know how relative values for CPT codes are set. The American Medical Association’s relative value update committee, commonly known as the RUC, researches the time and costs for providing every CPT code. They pass these values on to CMS, which accepts most of them without changes. Section 220 of this bill gives CMS authority to develop its own values and use them, instead.  The bill provides only $2 million each year for Medicare to collect information about the time expense and overhead of providing CPT services, so they can’t look at every CPT code, and will focus on codes they identify as misvalued.   Since some primary care groups have long complained about the RUC process as dominated by and favoring specialists, I expected cheering from them about this section of the bill.

This little bill is only 123 pages long. It provides a 0.0% change to the conversion factor, not a 24% decrease.  It addresses ICD-10 in one sentence, stating that CMS may not implement the ICD-10 code set prior to October 1, 2015. It extends policies.  But, perhaps, to paraphrase John Stewart you need a moment of Zen after the uproar about the bill.

Here it is,  a quote from the bill, your moment of Zen.

“Section 1898(b)(1) of the Social Security Act (42 U.S.C. 1395iii(b)(1) is amended by striking “$2,300,000,000” and inserting “$0.”

Betsy Nicoletti is president, Medical Practice Consulting and author of Auditing Physician Services. She blogs at Nicoletti Notes.

Fix My Practice – Consults In ER, April 2, 2014 | Physician Practice …

The Physicians Practice S.O.S. Group® www.ppsosgroup.com

Consults In ER

The question of how to bill for consults in the ER often comes into our “Ask A Consultant” forum.  Which typically goes something like this… our surgeon was called to the Emergency Room to see a patient in consultation. The patient was discharged from the Emergency Room. Can you tell us how to report this?

The Answer is:

First, the correct category of CPT code will be dependent on payor rules. According to the 2014 AMA CPT rules, the service is a consultation and the 99241-99245 codes are reported. Report the consultation code for all payors still recognizing this category of codes.

While, Medicare no longer reimburses the consultation service codes, you would report a CPT code from the Outpatient Codes (99201-99215) will be reported when the patient is seen in consultation in the Emergency Room and discharged to home. The emergency department of the hospital is an outpatient service thus picking from the outpatient codes instead of the inpatient codes. This would also apply if your physician did the consult on a patient in observation as this is also an outpatient department of the hospital. Your surgeon would not report the ED code 99281 – 99285 because the ED physician gets to bill these codes.

Practicing quality medicine while maintaining and managing the bottom line is a balancing act that provider’s face daily. The Physicians Practice S.O.S. Group is committed to and has helped healthcare providers across the country with new practice start ups, IRO needs, streamlining of their A/R and billing process, improving patient flow and providing practice management and compliance solutions. Feel free to call our office to discuss any needs you might have.

Current Procedural Terminology (CPT) | All About Medical Billing …

All billing and coding professionals will inevitably come across the term CPT, which refers to Current Procedural Terminology. CPT was and is developed by the American Medical Association (AMA) and is used today by all the major players in the health care system- medical providers, insurance companies, state and federal health care programs, and billing and coding professionals.

The alert reader will be wondering why there is a need for CPT when there is the ICD (International Statistical Classification of Diseases), the subject of a previous entry. The answer is that although CPT is similar to the ICD, CPT is focused on identifying medical services provided. The ICD is used more as a code source for diagnosing.

The AMA reports its CPT is the most widely accepted coding system in both the private and public health insurance. Medical billing and coding professionals will need to be familiar with CPT codes and classifications when they are providing their services. Although many state, federal, and private insurance programs require submissions according to CPT, the AMA holds the copyright on this system of classification. Therefore, using CPT involves official sanction by the AMA, typically through licensing fees covered by health care providers.

The AMA maintains an ongoing consultation with field professionals and releases new and amended CPT versions on at least an annual basis. As of this writing the most current version is the 2014 edition of CPT-4.

CPT is structured into three primary categories:

  • Category I contains codes with six main procedural sections:

    • Evaluation and management
    • Anesthesia
    • Surgery
    • Radiology
    • Pathology and laboratory
    • Medicine
  • Category II codes: these are determined through a highly collaborative process with the major players in the health care industry, and are aimed at categorizing patient services. This section is currently comprised of 11 sections including:
    • Physical exams
    • Therapeutic and preventative measures
    • Patient management
    • Diagnosis or screening measures
    • Patient safety
  • Category III codes are reserved for procedures involving emerging technologies and concepts. These can include the latest advances in treatments derived from gene sequencing or stem cell research to new techniques resulting from the most recent advancements in the understanding of psychology and human behavior.

The AMA offers a variety of products through its website designed to make coding and classification according to the CPT more easily accessible for medical billing and coding professionals.

CPT with Medicare and Medicaid

Medical billing and coding professionals who work with the federal Medicare and Medicaid programs will be familiar with the Healthcare Common Procedure Coding System (HCPCS). This is the system of classification/coding for reimbursement for services provided to patients covered under either of these two federal programs. HCPCS itself is divided into two subsystems: Level I HCPCS and Level II HCPCS.

As it so happens, Level I HCPCS uses the CPT-4 coding system developed by the AMA. This means billing and coding professionals who are already familiar with CPT should not have any problems creating or submitting claims that fall under the coverage of Medicare and Medicaid.

Level II HCPCS is a different story, and billing and coding professionals will have to learn the separate set of codes for these services which cover things like ambulance services and medical equipment such as orthotics and prosthetics.

Implementing CPT Codes – MEDCOR Revenue Service, Inc

Speech language pathologists are currently utilizing current procedural terminology or “CPT” codes when dealing with their billing. These codes are primarily service-based and timebased as well. Current codes however aren’t perfect and have limitations as well as a few problems, especially where auditory experts are concerned. Currently speech language pathologists can bill for the first hour of evaluation, the first 30 minutes of an STD evaluation, and aphasia evaluations. Of course they can also utilize codes for 15 minutes of oral rehabilitation but all other codes are procedure based and don’t give professionals the ability to mark specific times.

Whereas in years past some payers would pay speech language pathologists in increments of 15 minutes newer CPT codes now allow medical professionals to implement payment policies that are based on much stricter and defined CPT codes. Newer codes no longer indicate time frames but rather a typical session type or evaluation type. This allows professionals to comply with the new coding guidelines of the American Medical Association and be more accurate in their billing. These changes/new codes are designed to help both providers and payers with the changing billing policies, auditing, and revisions that are always present in the world of healthcare.

As with any changes in the fields of healthcare/medicine ASHA encourages speech language pathologists to be proactive in their approach to these new codes, especially when there are no time components associated with the codes that they need to use. Learning what these new codes are and how to use them properly can help a practice and any individual medical professional stay on top of their billing and avoid the headaches that come along with learning these codes on-the-fly and/or using improper codes.

Breast tomo CPT codes closer to becoming a reality – AuntMinnie.com

The application was accepted for three Category I CPT codes that include screening and diagnostic breast tomosynthesis, according to Hologic.

The action is a preliminary step, and codes are not assigned until just before the publication of the CPT Professional Edition 2015, the company said. Medicare payment rates for the proposed breast tomosynthesis codes will not be posted until the U.S. Centers for Medicare and Medicaid Services (CMS) issues its final Medicare Physician Fee Schedule in November. CPT codes and rates are scheduled for implementation on January 1, 2015.