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Mega Long-Shot. Medical Billing Question...

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Mega Long-Shot. Medical Billing Question...

Old 10-17-2016, 03:01 PM
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Anyone with specific knowledge regarding doing a breast ultrasound instead of a mammogram for the "wellness visit"? I'm reading that there is some "code" and/or "language" to make this happen... but I can't get any help from her doctor or the insurance company.

Thanks,
Pete
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Old 10-17-2016, 04:10 PM
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I forget where I found it, but there is a published list of all of the new revised billing codes. It was on a gov web site. If you can find the listing, or the listing for your insurance provider (you can call them to get that list) you'll be able to find the options and stand a chance at getting them to bill under that code.

For instance, getting a lipid test that checked for 3 items (cholesterol, triglycerides, whatever) was one code, or it could be listed under the three individual codes. The 3 individual tests added up to about 2x the cost of the one combo test, so it was all in how it was billed. I'm sure I have the jargon wrong, and someone will correct me, but hopefully that helps.

ETA: Ins company won't help you find a specific billing code, but they can direct you to the spot on their web site where the list is stashed.
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Old 10-17-2016, 06:04 PM
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Originally Posted by jobowker View Post
I forget where I found it, but there is a published list of all of the new revised billing codes. It was on a gov web site. If you can find the listing, or the listing for your insurance provider (you can call them to get that list) you'll be able to find the options and stand a chance at getting them to bill under that code.

For instance, getting a lipid test that checked for 3 items (cholesterol, triglycerides, whatever) was one code, or it could be listed under the three individual codes. The 3 individual tests added up to about 2x the cost of the one combo test, so it was all in how it was billed. I'm sure I have the jargon wrong, and someone will correct me, but hopefully that helps.

ETA: Ins company won't help you find a specific billing code, but they can direct you to the spot on their web site where the list is stashed.
Thanks! I'm going to search now!
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Old 10-17-2016, 06:49 PM
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If it's not part of the CMS preventive guidelines, then I'd be shocked if the insurance company covers it at no cost to you as part of wellness.
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Old 10-17-2016, 06:59 PM
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Mammography is the standard for routine screening, if anything is seen or the breast is very dense then an ultrasound may be ordered for further diagnostics. I've been out of the field for about 10 years solely focused on MRI now but unless things have changed the insurance company won't pay for a screening ultrasound unless there are specific indications following a mammogram. You may have some luck calling an imaging center and speaking to their billing department. You really need the mammogram though to map out any areas that need checked by ultrasound.
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Old 10-17-2016, 07:35 PM
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If it's preventative then it should be covered; if there's an underlying reason that triggered the need then it's diagnostic and falls under you co-pay/deductibles. You need to be talking to her doctor about how they are coding this and why.
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Old 10-17-2016, 07:50 PM
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Ultrasound and mammography are different procedures. If this was, or will be done at a radiology office ask to speak to someone in their billing/coding dept. There is a code for the procedure which is linked to a diagnostic code. Generally the request for the study must be made by the referring physician, i.e. if the radiologist sees something on a mammogram and feels that an ultrasound would help clarify the interpretation of the images the referring physician must sign off on that request. An additional code (something like dense breast tissue) to justify the need for the supplemental procedure.
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Old 10-17-2016, 09:26 PM
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ICD-10 codes...
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Old 10-18-2016, 03:49 AM
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Thanks guys... wife handled it. The doctor and her staff are useless. Wife found a 3D place that is going to do reasonably.
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Old 10-18-2016, 04:29 AM
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Holly found the new Holy Cross imaging center out on Hillsboro Blvd west of Military Trail had good prices.
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Old 10-18-2016, 04:59 AM
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Often US will be paid if done for "palpable abnormality" in other words I feel a breast lump. That usually will get mammo and then US covered.
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Old 10-18-2016, 07:07 AM
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Originally Posted by tabascoT View Post
Often US will be paid if done for "palpable abnormality" in other words I feel a breast lump. That usually will get mammo and then US covered.
Is that "palpable abnormality" the buzz word to get it covered during the wellness visit or just "covered" overall? The situation is that they didn't do a very good mammogram, and they want to do "more". We were trying to get the "more" as part of the wellness.

Right now she's got a 3D place set up... from what we've read they tend to be more detailed.

Thanks for the help guys. We lost our insurance again (Obamacare) and wife is a little upset and wants to get this done before we risk not having any.

I won't turn this into another Obamacare thread...
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