Guides to insurance billing rules, payer policies, prior authorization requirements, and coordination of benefits for US medical billing professionals.
A coder posted this question in a billing community forum: what CPT code is everyone using for injections of Juvederm Ultra XC to bilateral breasts? They had done their homework and landed on the 11950 to 11954 range based on the volume injected. Their instinct on the code family was correct. But the real answer … Read more
Short answer: CPT 27599 (unlisted femur/knee procedure) is the more technically accurate code for patellofemoral arthroplasty (PFA). But across three commercial payers I contacted directly, 27438 processes and pays without a flag while 27599 routes into manual pricing at 60–80% of the 27447 allowable. The right code depends on your payer, your documentation, and whether … Read more
What Are Unlisted CPT Codes and Why Do They Exist Every CPT code in the AMA’s procedural terminology system describes a specific, defined service. Most of the time, a provider can find a code that accurately fits what was performed. But medicine moves faster than codebooks. New surgical techniques, emerging technologies, and rare procedures regularly … Read more
Why This Decision Matters More Than Most Billers Realize When a provider performs a procedure that has no obvious home in the standard CPT code set, two options appear on the table. The first is a Category III CPT code, sometimes called a T-code because the fifth character is always the letter T. The second … Read more
Why Box 19 Is the First Thing a Reviewer Reads When a claim lands on a payer reviewer’s desk with an unlisted procedure code in Box 24D, the reviewer does not open the attached operative report first. They read Box 19. That single field, labeled Additional Claim Information on the current version of the CMS-1500 … Read more
What a MAC Prepayment Review Actually Is A Medicare Administrative Contractor prepayment review is a formal medical record audit that occurs before Medicare pays a claim rather than after. When a claim is selected for prepayment review, payment is suspended while the MAC requests clinical documentation to verify that the service meets Medicare’s coverage, coding, … Read more