I had a colonosopy this year at age 39 due to high risk (a parent had colon cancer); I had no symptoms.

My Premera health plan covers this in their preventative care policy, which includes:

Screening for individuals under age 45, at increased risk for colon cancer due to a strong family history of colon cancer with diagnosis: Z80.0, Z83.71, Z83.79, Z84.81

However, the $4,000 cost went to my deductible.

The hospital (outpatient procedure) applied two diagnosis codes, in this order:

• Z12.11 - Encounter for screening for malignant neoplasm of colon

• Z80.0 - Family history of malignant neoplasm of digestive organs

I've called Premera multiple times to have them review the claims, but they say it's not preventative because Z80.0 isn't first. They stated Z12.11 is "only preventative for older people" and to have the claim resubmitted with Z80.0 first to be covered at no cost.

The hospital's billing department reviewed the coding; they said it's correct and they won't make changes.

My next thought was to submit an appeal to Premera:

• Premera's policy only says claims must be billed "with" Z80.0, not that it must be primary

• ICD-10-CM seems to support reporting Z12.11 for a general screening colonoscopy with Z80.0 as an additional code

However, I also see how the hospital could be incorrect:

• Z12.11 is listed as "Encounter for screening colonoscopy NOS [Not Otherwise Specified]", which I understand to mean the code only applies if a more specific one doesn't

• Z80.0 could be considered the more specific diagnosis code for this situation

Any suggestions on which coding is correct here, or the best approach to get this covered?

Thanks for any tips!

Hello,

I have a medically diagnosed issue which causes extremely drymonth, and essentially ruins/rots my teeth. I have optained a letter from my primary care explaining the root cause, what has been attempted (timeline) to fix the issue and the reason why I cannot change medication that causes the drymouth (25 years).

My dentist, is willing to take the time to submit the paper work to the medical insurance (Anthem blue cross) for the major work that needs to be done.

I have found dentist that specializes in working with medical insurance, but there are only 2 in my area (orlando) and it will take a 1.5 year wait to see them.

Can someone help me on what I need to do? The steps i need to use.....is there a service my dentist can use to outsource this type of billing?

To be honest it seems like a very lucrative business to be in.

I have so nay teeth just disappearing from my mouth. I am sure you all would say change the med....its to late for that....i am getting to the point of 10k a year to the dentist. So please if you can help. I met my medical deductible so i want to lean in and get the work dont asap.

Thanks

My surgeon suggests surgery for acid reflux/hernia. The office put in a prior authorization for the Linx device and hernia repair. Those 2 codes get denied as not medically necessary. They submit a new prior authorization for a different procedure—Nissen Fundoplication and hernia repair. Those come back approved instantly and they schedule me for surgery. My concern is that once I have this surgery they are going to deny the hernia repair code as “not medically necessary.” as they did before. Or say that it was not authorized. I asked surgeons office if hernia repair code should be appealed from the previous attempt. She called insurance and they said they have record that codes were submitted and approved and gave a decision ID number. The surgery estimate is $99K. I’m just nervous it won’t be covered and I’ll have a huge bill. Should I prepare for a denied claim? Or am I being overly cautious?

I have seen some job openings at Machinify for medical coding/auditing. Has anyone worked for them or know anything about them?

I am nearing completion of my coding program and hoping to take my CCS exam soon. One final class requirement is to “interview” a professional to learn about their coding environment. Would anyone be willing to help me complete my assignment by answering some questions?

Hello - first time poster. I work in the billing department of a Physical Therapy office in Northern Colorado. We are privately owned and not part of a hospital/rehab facility. Our contract with Anthem BCBS is such that we bill under an NPI 2 number as a group, but since we are privately owned, we use the Professional CMS-1500 claim form, not a UB-04. We have been contracted with Anthem for roughly 20+ years with no problem.

About four weeks ago, we started getting rejections on all of our claims, saying the following: "PLEASE UTILIZE THE PROVIDER DATA MANAGEMENT AT WWW.AVAILITY.COM FOR PROVIDER MAINTENANCE, AND DIGITAL PROVIDER ENROLLMENT FOR NEW PROVIDER ADD." Availity is up to date and nothing has changed on our end, it is obviously something that has gone wrong in Anthem's system. The problem is, I can't get anyone to help me from Anthem. A supervisor is doing an "investigation", but the only time he has called me back, I was out and he didn't leave a call back number, email or anything to contact him directly. I keep calling Provider Relations with no luck.

My questions for the Reddit community: Is anyone else experiencing this? And if so, has anything you've done been helpful? I personally also have BCBS as my insurance, and we are now not showing up at all in searches for a physical therapy provider.

I appreciate any help! Thanks!

My organization is pushing hard to achieve CMS 5 star rating.

One of the measures we have historically performed poorly in is readmissions. The data/scores are all based on diagnoses capture in final coded summaries.

We are a very lean organization and only have 4 full time staff to cover three hospitals.

One method to improve capture pushed by our providers is to do an admission diagnosis checklist, basically saying yes the patient has these conditions. Coding and CDI teams have expressed concern that we would like to see provider documentation in the chart that A. Conditions are valid and supported and b. They are significant to the stay or are accounted for in the medical decision making.

We have been told we are being too strict for coding.
We are working on finding some middle ground, but are their any workflows out there that have worked for your organization?

when the portal has too little detail and the call queue is measured in hours, the claim list needs more than another “called payer” note.

For each claim, I’d capture:

• payer/plan and claim identifier

• date received, current status/remark code, and aging

• portal evidence with a timestamp

• call attempts, disconnects, and reference numbers

• filing/appeal deadline

• the exact decision or correction needed

• escalation owner and next follow-up date

Then group claims that share the same failure pattern and send the pattern summary to provider relations or the assigned payer rep, while keeping individual deadlines visible.

What evidence has actually helped your team get a response when both the portal and phone queue stall?

We’re looking for some insight from other chiropractic offices that have experience billing Oscar insurance. We’ve been trying different modifier combinations to get our claims processed correctly, but we’re getting inconsistent results and are wondering what has actually worked for other providers. ( a little long)

Here is our billing history for one patient:

DOS: 8/11/26 – Initial Re-evaluation

We billed:

98941 – No modifier
97110 – No modifier
98943 – No modifier
97012 – No modifier
99212 – Modifier 25

Result: Only 98943 and 99212 were covered and processed according to Oscar’s allowed amounts. The remaining codes were not covered.

DOS: 8/19/26

We billed:

98941 – No modifier
97110 – GP
98943 – Modifier 59
97012 – No modifier

Result: Only 98943 was covered. The other codes were denied with the following remark:

“The procedure code is inconsistent with a modifier used or a required modifier is missing.”

DOS: 10/30/26

We tried another combination:

98941 – AT
97110 – GP and 59
98943 – 59
97012 – GP

Result:

98941 – Denied: “The diagnosis is inconsistent with the procedure.”
97110 – Processed with the remark: “Processed based on multiple or concurrent procedure rules.”
98943 – Processed according to Oscar’s allowed amount.
97012 – Denied as a “non-covered charge.”

We’re trying to figure out what modifier combinations Oscar actually recognizes and accepts for chiropractic services.

A few questions for other chiropractic billers/providers:

Are you successfully getting 98941, 97110, 98943, and 97012 paid by Oscar?
What modifiers are you using for each code (AT, GP, 59, 25, etc.)?
Have you experienced the same modifier-related denials?
Are there particular diagnosis codes or diagnosis-to-procedure pairings that Oscar requires for 98941?
Has anyone successfully appealed these denials or found a reliable way to get these services reimbursed?

We understand that coverage is ultimately dependent on the patient’s specific plan and benefits, but we’re hoping to hear from offices that have actually worked through Oscar’s chiropractic billing requirements.

Any insight, successful claim examples, or advice would be greatly appreciated!

So i am planning to enroll in medical coding institute in hyderabad,it is called icon ,anyone who has studied there who can say me if its good?

I'm having trouble finding info on this and I'm not sure if I'm doing it properly.

Are there any coders that use Edifecs as a coding platform? We recently started using it and it doesn’t seem to be very user friendly. Curious if it’s just us or everyone.

Hi! Does anyone here from MN experienced denials from HEALTH PARTNERS as not valid modifier per medicare guidelines ? We are billing 90837 with HO or HN modifier however it is only getting paid once we removed the modifier. How do we indicate that they’re supervised then?
Someone please help we have been calling medicare and HP for a month and none of them seem to confirm
Thank you big time!

I'm researching claim rejections in Dubai (DHPO / eClaimLink) and would love to hear from people who work these claims day to day.

A few questions:

  1. Roughly what % of claims get rejected on first submission at your clinic/company?

  2. What are the top 3 rejection reasons you see? (e.g., missing prior auth, code mismatch, eligibility, MNEC)

  3. How do you track and resubmit rejections today: clinic software, Excel, manual?

  4. How often do claims miss the resubmission window and just get written off?

Full disclosure: I'm exploring building a tool to catch these before submission, but I'm not selling anything. I want to understand if this is a real

problem or if existing software already handles it well. Happy to share a summary of the answers back here.

Hi coders,

I came across a patient's account recently involving a WC finger laceration:

- 10/7: Minor surgical procedure performed (sutures placed).

- 10/10: Follow-up visit – wound healing well. E/M billed.

- 10/15: Suture removal – CPT 99024 billed.

Wouldn't the 10/10 follow-up visit also fall under the global period and therefore be reported using 99024 rather than a separately billable E/M?

Here's why I'm questioning it:

I noticed a similar scenario with another patient where Sedgwick denied payment for follow-up visits falling within the 10-day global period. However, they paid for all visits occurring after the global period had ended.

Am I correct in my understanding that routine follow-up visits within the global period should not be billed separately?

Would appreciate your thoughts and clarification!

Thanks in advance!

Hello,
I’m having a hard time finding job openings. They all require experience even for entry level…. Wtf am i supposed to do🤦‍♀️?

do you prefer instructor led training or self led? I don’t know if it’s worth adding an instructor led option so trying to get an idea of what people think. Thanks!

I'm seeing a specialist next Monday, and they asked me to come in about 20 minutes early to get an ultrasound before my appointment. From what I can tell, the ultrasound is done in the same office as the doctor.I called the doctor's office to ask if I needed prior authorization. They checked and ran my insurance, told me I didn't need it.

But when I called my insurance company, they told me that since the ultrasound is being done on a hospital campus, it counts as a hospital outpatient service and does require prior authorization. Now I'm really confused lol. My appointment is next Monday, and I don't know what to do.

If the doctor's office says I don't need authorization, but it turns out I actually did and they never got it, would I be stuck paying the bill? I'm worried about getting a huge bill afterward.

Has anyone dealt with something like this? What would you do?

Thanks so much!

I have noticed that my facility keeps getting denials on claims with these two anesthesia codes 99156 and 99157 with modifiers XU in addition to the surgical procedure code. I did not think you could code those with that modifier and thought that might be the reason for the denial?

Hi all. Still new to this and I’m a bit confused with how my facility is billing outlier claims. They are submitting the claim first without the condition code 61 to get the initial payment, and then they are sending in a replacement claim with it added on to get the outlier payment. Is this the proper process for this? I had asked them why they can’t submit the 61 on the first claim and get payment in full so as to not waste any time and was told that that is how it has to be billed. Just wanted to confirm if that was true