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PRP Presentation - Bonafide

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Wayne Bailey
Wayne Bailey

This document provides guidance on insurance coverage and billing procedures for various medical treatments. It notes that PRP and stem cell treatments are typically self-pay, while Botox, joint injections, and nerve blocks may be covered by insurance with the proper documentation and codes. It emphasizes establishing policies for self-pay procedures and pricing based on costs. The document also addresses evaluation and management documentation, billing rules, and providing ABN forms for non-covered services like PRP.

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Michelle Tohill AAPC Certified Coder & Auditor Welcome!
PRP - Typically not covered by insurance and considered experimental. Some insurance policies will cover due to the patients plan provisions. Otherwise procedure is self-pay. Medicare now prices the PRP, but it is based on Medical necessity. Medical records will need to be sent in for review. When pricing prp for self-pay. Review the guidelines for proper billing protocols. Stem cell - Self pay procedures, an extension of the Prp and more expensive. Botox - self pay procedure, but may be covered by insurance. Will require research ICD-10 for DME BusinessesInjections
Synvisc, Euflexxa, & Orthovisc - Patient may obtain meds through pharmacy or office can obtain approval to buy and bill meds. It all depends on the patient insurance policy. Tenotomy - typically covered by insurance. There may be some place of service provisions. These codes have a global period. Joint and trigger & point injections - Prolotherapy - Self pay procedure. This procedure is deemed experimental. Nerve block - typically covered by insurance. Ultrasound may deny as inclusive to nerve block codes ICD-10 for DME BusinessesInjections - Continued
Common Ultrasound Codes: 76881, 76882, 76972, & 76970 Coverage - This all depends on the actual insurance. Each insurance seems to have their own ultrasound policy. However, they are almost always covered. ICD-10 for DME BusinessesUltrasounds
May require medical records review - when billing ultrasounds some insurance may require a review. This is a common occurrence with Aetna HMO. Documenting the ultrasounds and treatment plan is very important when billing these codes. Joint injections & Ultrasound - These codes are now bundled with Medicare. New codes include 20611, 20604, 20606. These codes are required for Medicare and Federal Carefirst policies and may eventually dwindle down to all insurance. ICD-10 for DME BusinessesUltrasounds - Continued
Establish polices and rules when performing the above procedures. This will give the patient an idea of what to expect as an out of pocket fee and what is billed to insurance. Each procedures bills a minimum of about 4-5 codes and sometimes patient do not understand this especially when they have co-insurance and deductibles. ICD-10 for DME BusinessesOffice Recommendations
Establish a strict self-pay policy. This should be mandatory across the board. Especially with the non-covered procedures Make sure procedures are priced based on supply costs and insurance reimbursement. This will help with the AR and write off amounts. Stay up to date with the major insurance policies on common procedures. This will help to reduce denials. ICD-10 for DME BusinessesOffice Recommendations
1995 vs 1997 Documentation New vs. Established Billing according to documentation HPI/CC, ROS, PFSH, Examination & MDM ICD-10 for DME BusinessesEvaluation & Management
Familiarize your staff with MUEs, NCCI Edits Bundling/Unbundling Contractual Adjustments vs. Residual account balances Fee Schedules ICD-10 for DME BusinessesBilling
Box 2 of the ABN pertains to NON-Covered services. PRP is considered a covered service which is priced by Medicare. References are available on our website at the following links: ABN Form Instructions PRP Price List CMS LCD Designations ICD-10 for DME BusinessesBilling ABN Guidelines
Michelle Tohill Revenue Officer/Billing Director 805-777-7666 x 1497 Office 805-907-1615 Cell 805-777-7661 Fax mtohil@bonafide.com www.bonafide.com Contact Info

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PRP Presentation - Bonafide

  • 1. Michelle Tohill AAPC Certified Coder & Auditor Welcome!
  • 2. PRP - Typically not covered by insurance and considered experimental. Some insurance policies will cover due to the patients plan provisions. Otherwise procedure is self-pay. Medicare now prices the PRP, but it is based on Medical necessity. Medical records will need to be sent in for review. When pricing prp for self-pay. Review the guidelines for proper billing protocols. Stem cell - Self pay procedures, an extension of the Prp and more expensive. Botox - self pay procedure, but may be covered by insurance. Will require research ICD-10 for DME BusinessesInjections
  • 3. Synvisc, Euflexxa, & Orthovisc - Patient may obtain meds through pharmacy or office can obtain approval to buy and bill meds. It all depends on the patient insurance policy. Tenotomy - typically covered by insurance. There may be some place of service provisions. These codes have a global period. Joint and trigger & point injections - Prolotherapy - Self pay procedure. This procedure is deemed experimental. Nerve block - typically covered by insurance. Ultrasound may deny as inclusive to nerve block codes ICD-10 for DME BusinessesInjections - Continued
  • 4. Common Ultrasound Codes: 76881, 76882, 76972, & 76970 Coverage - This all depends on the actual insurance. Each insurance seems to have their own ultrasound policy. However, they are almost always covered. ICD-10 for DME BusinessesUltrasounds
  • 5. May require medical records review - when billing ultrasounds some insurance may require a review. This is a common occurrence with Aetna HMO. Documenting the ultrasounds and treatment plan is very important when billing these codes. Joint injections & Ultrasound - These codes are now bundled with Medicare. New codes include 20611, 20604, 20606. These codes are required for Medicare and Federal Carefirst policies and may eventually dwindle down to all insurance. ICD-10 for DME BusinessesUltrasounds - Continued
  • 6. Establish polices and rules when performing the above procedures. This will give the patient an idea of what to expect as an out of pocket fee and what is billed to insurance. Each procedures bills a minimum of about 4-5 codes and sometimes patient do not understand this especially when they have co-insurance and deductibles. ICD-10 for DME BusinessesOffice Recommendations
  • 7. Establish a strict self-pay policy. This should be mandatory across the board. Especially with the non-covered procedures Make sure procedures are priced based on supply costs and insurance reimbursement. This will help with the AR and write off amounts. Stay up to date with the major insurance policies on common procedures. This will help to reduce denials. ICD-10 for DME BusinessesOffice Recommendations
  • 8. 1995 vs 1997 Documentation New vs. Established Billing according to documentation HPI/CC, ROS, PFSH, Examination & MDM ICD-10 for DME BusinessesEvaluation & Management
  • 9. Familiarize your staff with MUEs, NCCI Edits Bundling/Unbundling Contractual Adjustments vs. Residual account balances Fee Schedules ICD-10 for DME BusinessesBilling
  • 10. Box 2 of the ABN pertains to NON-Covered services. PRP is considered a covered service which is priced by Medicare. References are available on our website at the following links: ABN Form Instructions PRP Price List CMS LCD Designations ICD-10 for DME BusinessesBilling ABN Guidelines
  • 11. Michelle Tohill Revenue Officer/Billing Director 805-777-7666 x 1497 Office 805-907-1615 Cell 805-777-7661 Fax mtohil@bonafide.com www.bonafide.com Contact Info
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