We're in the Office
Susan is going to the primary care doctor for a sinus infection. Susan's daughter Aimee is going to the primary care doctor for a routine physical. What benefit codes would be applied to Susan's medical office visit claim and what benefit code would be applied to Aimee's routine office visit claim?
What is benefit code 95 and 95R
Matthew makes a habit of going to his PCP every year on his birthday to get routine labwork done. How would we code those routine labs?
6R
Tom has been crummy all week with a cold and just wants it to go away ASAP. He goes to an out of network emergency room for treatment, and when Meritain receives the facility claim, they deem all associated codes billed as non-emergent since it was just a common cold. As an examiner, would you answer Yes to the claim prompt to "pay this claim at the INN (ppo) level" or would you answer no?
No. You only pay OON ER services at the INN level when a CPT or a dx associated with that day's ER charges emergent.
Billy bob had to go to the doctor for a temporary cast since he broke his thumb. How would we code the charges for the cast on a professional POS 11 claim?
90A
You receive a facility claim from an op hospital pos 22 that is billed with a surgery and medical supplies. What benefit code would we use on the surgery lines and the supply lines if the group has it? What would we do if the group doesn't have that special code?
3BB on all lines if avail, if not, 3 on all lines
You receive a claim with POS 11 that was billed with Chiropractic, P.T, or O.T. procedure codes billed by an M.D. The group eligible medical expenses state that only specialists for that particular service can render those services. What Benefit codes can you use to allow the eligible charges on those claims based on the POS?
90A- Per the Meritain Claims Manual, we can still allow the services to be paid using the MISC BC as long as that therapy or dx is not a group exclusion.
Daily Double
Meritain received a claim from an independent lab POS 81. This claim had a venipuncture code billed along with the blood lab cpt code. What are the two benefit codes some groups have for independent lab claims? Where should we look for the POS of the related office visit if no independent lab BC?
6AL/6IL if the group has it, if not, look in the dot comments under original info for the POS of the related office visit and use that POS to determine the BC.
Mountain Hill Facility billed a claim with a NON-Emergent diagnosis. This plan has a specific benefit for NON –Emergent ER charges. What is the BC?
3D
Daily Double
Theresa recommends that her son Luke go the doctor due to his snorning and tiredness throughout the day. The doctor refers him to get a sleep study and determines that he needs to use a Continuous Positive Airway pressure , also called CPAP. What BC would we use for the CPAP claim?
90D
Daily Double
Your group has a 6A and a 6U for pcp labs and specialist labs. The referring provider for the lab is an Aetna Provider. What 3 steps would you take to confirm if this Aetna Provider is a specialist per the group? What 3 steps for a non-Aetna Provider?
After getting their name, check the $SPEC screen for the provider specialty code, then in useful links get the description of the code and compare with the definition of a PCP in the group's plan document.
Same as above except you'd use the NPI number instead on the Claim Detail Screen.
Bobby has heard news reports recently about how the flu is spreading rampantly in his home town so he decided to go to his pcp for a routine flu vaccine. What BC would be applied?
90Z
Meritain received a claim for a lab. The cpt codes and dx have the words encounter, preventative, and routine in it. Where should I check first to determine the BC? If not indicated there, where should I check second?
Check the HCR-WP spreadsheet first since there is an indication that it's for a preventative service. If no prev code available for benefit, check the group's plan doc for a routine care benefit.
You received a claim from POS 23 ER, but there are no CPT codes that immediately show whether or not the charge is emergent. What else can we view to see if our charge is emergent, and using what command?
We can review all dx codes on that claim and any ER related claim for that day in claims history to determine the emergent status using command:
$XLDX10-in UI
LDX10-DG Prod
How would we code the claims for the tubing and mask for Luke's CPAP machine?
90/90A
You receive a claim for a DME rental and we have already paid 5 months of rental charges for that item. Can we pay any more months considering that the purchase price for the DME is not on file?
Yes, you can pay up to 6 months w/o the pp on file
Daily Double
Cierra was in a car accident and her PCP advised that she should start chiropractic care to help her with recovery. She goes to Spine Reset Chiropractor and they perform XRAYS to see what type of treatment plan she would need. How would the xrays and visit from the Spine Reset chiropractor be coded? How many visits can she have per dx or injury since her plan doesn't explicitly state?
95C/20 visit rule applies
Stratton has been feeling pretty tired lately and his labs indicated that his thyroid levels were low. His PCP recommends that he gets additional labs done by an endocrinologist to rule out haishimoto's disease. Stratton's employer group has a specific BC for specialist labs. What BC code would the specialist lab claim be coded with?
6U
Daily Double
Oakhill ER billed an emergent facility claim with rev code 0981 which was for the professional charges for the day. What BC would we apply to this line on the claim? What BC would we use for all other lines?
95E for the professional charges billed on a UB, 3E for all other lines
You receive a claim for a DME item. Precert is not required for your item and your item is eligible and not a plan exclusion. There is also an RX on file, and the total eligible amount of what we allowed so far for this DME HCPC is nowhere near the Purchase Price of the Equipment. Before we verify the claim, what else do we need to ensure is not required by Meritain per the DME Coverage Table?
A Medical Review
DAILY DOUBLE
You receive a DME claim for a CPAP machine. Where are the 4 places the PP can possibly be found? IF you don't find the pp, and we've already allowed 6 months of charges, what should your next steps be for an Aetna provider? and a non-Aetna Provider? (Hint: Use your DME Workflow in the Training Manual)
Claim Image
MRV Tech Review
Dependent comments (Patient Front Screen)
Member Comments (EE comments)
Due to weakened knee muscles, Sheila sees her specialist to receive injections for her knee which are coded under J7321. How should this Jcode injection be coded on her place of service 11 claim?
90A-Jcodes on office visit POS 11 claims are coded using MISC BC's.
Meritain received an outpatient facility claim on a UB that is billing for labs alone. What BC would we use for these labs billed on a UB?
6X, or the procedure specific 6 BC. If neither, then 6
What range of rev codes will I see on my claim to imply that it's probably from the ER?
450-459
Daily Double
Open your Remark Code Spreadsheet. What RC would we use to indicate that the claim would go over the Purchase Price of the DME?
22 and 376
Daily Double
PP=400
TOTAL ELIGIBLE SO FAR= 380
PPO ALLOWED ON CLAIM=45
What should the new ppo allowed be?
New PPO allowed= 20